Meningiomas in children: A study of 18 cases

Meningioma grading via diagnostic imaging: A systematic review and meta-analysis

PURPOSE

Meningioma is the most common intracranial tumor, graded on pathology using WHO criteria to predict tumor course and treatment. However, pathological grading via biopsy may not be possible in cases with poor surgical access due to tumor location. Therefore, our systematic review aims to evaluate whether diagnostic imaging features can differentiate high grade (HG) from low grade (LG) meningiomas as an alternative to pathological grading.

METHODS

Three databases were searched for primary studies that either use routine magnetic resonance imaging (MRI) or computed tomography (CT) to assess pathologically WHO-graded meningiomas. Two investigators independently screened and extracted data from included studies.

RESULTS

24 studies met our inclusion criteria with 12 significant (p < 0.05) CT and MRI features identified for differentiating HG from LG meningiomas. Cystic changes in the tumor had the highest specificity (93.4%) and irregular tumor-brain interface had the highest positive predictive value (65.0%). Mass effect had the highest sensitivity (81.0%) and negative predictive value (90.7%) of all imaging features. Imaging feature with the highest accuracy for identifying HG disease was irregular tumor-brain interface (79.7%). Irregular tumor-brain interface and heterogenous tumor enhancement had the highest AUC values of 0.788 and 0.703, respectively.

CONCLUSION

Our systematic review highlight imaging features that can help differentiate HG from LG meningiomas.

Pediatric intraparenchymal meningioma in the basal ganglia treated with gross total resection: a case report and review of the literature

INTRODUCTION

Intraparenchymal meningiomas in the basal ganglia are extremely rare, and to the best of our knowledge, only three case reports have been published to date. Owing to concerns regarding major vessels, gross total resection (GTR) is difficult to achieve; therefore, subtotal resection and radiation therapy are often chosen as treatment options. We present a pediatric case with an intraparenchymal meningioma in the left basal ganglia that was successfully treated with GTR. We also reviewed the relevant literature to discuss the pathogenesis, radiological findings, and treatment methods of this rare disease.

CASE REPORT

A 4-year-old girl presented with progressive right facial paralysis, aphasia, and right incomplete hemiplegia. Imaging revealed a mass lesion in the left basal ganglia and unilateral obstructive hydrocephalus. Neuroendoscopic septostomy, tumor biopsy, and cerebrospinal fluid reservoir placement were performed, and the initial pathological diagnosis was suspected glioma. Thus, craniotomy was performed to remove the tumor, which was white, elastic, and well-defined. Intraoperative rapid pathology revealed a meningioma. Postoperatively, the patient experienced transient worsening of the right incomplete hemiplegia, which subsequently improved. The final pathological diagnosis was a fibrous meningioma.

CONCLUSION

Surgery for intraparenchymal meningiomas in the basal ganglia is challenging owing to the proximity of major blood vessels; however, GTR may be preferable to subtotal resection, considering the possibility of recurrence. Even in cases of intraparenchymal tumors, it is important to consider meningioma as a differential diagnosis and to carefully plan the appropriate treatment.

Stereotactic Radiosurgery for Meningiomas in Children and Adolescents: An International Multi-Institutional Study

BACKGROUND AND OBJECTIVES

Meningiomas in children are uncommon, with distinct characteristics that set them apart from their adult counterparts. The existing evidence for stereotactic radiosurgery (SRS) in this patient population is limited to only case series. The objective of this study was to evaluate the safety and efficacy of SRS in managing pediatric meningiomas.

METHODS

Children and adolescents who had been treated for meningioma with single-fraction SRS were included in this retrospective, multicenter study. The assessment included local tumor control, any complications related to the tumor or SRS, and the emergence of new neurological deficits after SRS.

RESULTS

The cohort included 57 patients (male-to-female ratio 1.6:1) with a mean age of 14.4 years who were managed with single-fraction SRS for 78 meningiomas. The median radiological and clinical follow-up periods were 69 months (range, 6-268) and 71 months (range, 6-268), respectively. At the last follow-up, tumor control (tumor stability and regression) was achieved in 69 (85.9%) tumors. Post-SRS, new neurological deficits occurred in 2 (3.5%) patients. Adverse radiation effects occurred in 5 (8.8%) patients. A de novo aneurysm was observed in a patient 69 months after SRS.

CONCLUSION

SRS seems to be a safe and effective up-front or adjuvant treatment option for surgically inaccessible, recurrent, or residual pediatric meningiomas.

Quality of Life, Clinical, and Patient-Reported Outcomes after Pencil Beam Scanning Proton Therapy Delivered for Intracranial Grade WHO 1-2 Meningioma in Children and Adolescents

PURPOSE

The purpose of this study was to report the clinical and patient-reported outcomes of children and adolescents with intracranial meningioma treated with pencil beam scanning proton therapy (PBS-PT).

MATERIAL AND METHODS

Out of a total cohort of 207 intracranial meningioma patients treated with PBS-PT between 1999 and 2022, 10 (4.8%) were children or adolescents aged < 18 years. Median age was 13.9 years (range, 3.2-17.2). Six (60%) children were treated as primary treatment (postoperative PT, n = 4; exclusive PT, n = 2) and four (40%) at the time of tumor recurrence. Acute and late toxicities were registered according to Common Terminology Criteria of Adverse Events (CTCAE). Quality of life (QoL) before PBS-PT was assessed using PEDQOL questionnaires. Educational, functional, and social aspects after PT were assessed through our in-house developed follow-up surveys. Median follow-up time was 71.1 months (range, 2.5-249.7), and median time to last questionnaire available was 37.6 months (range, 5.75-112.6).

RESULTS

Five (50%) children developed local failure (LF) at a median time of 32.4 months (range, 17.7-55.4) after PBS-PT and four (80%) were considered in-field. One patient died of T-cell lymphoma 127.1 months after PBS-PT. Estimated 5-year local control (LC) and overall survival (OS) rates were 19.4% and 100.0%, respectively. Except for one patient who developed a cataract requiring surgery, no grade ≥3 late toxicities were reported. Before PT, patients rated their QoL lower than their parents in most domains. During the first year after PT, one child required educational support, one needed to attend to a special school, one had social problems and another three children required assistance for daily basic activities (DBA). Three years after PT, only one child required assistance for DBA.

CONCLUSIONS

The outcome of children with intracranial meningioma treated with PBS-PT is in line with other centers who have reported results of radiation therapy delivered to this particular patient group. This therapy provides acceptable functional status profiles with no high-grade adverse radiation-induced events.

Hemostasis in a giant intraventricular tumor using a saline-cooled radiofrequency bipolar coagulator: technical note

BACKGROUND

Meningiomas are relatively rare in children and tend to be intraventricular and cystic, with often malignant behavior. Complete excision is associated with the most favorable outcome; moreover, the size and extent of these lesions often make complete excision in one step impossible because of the risk of intraoperative death from uncontrollable hemorrhage.

CASE PRESENTATION

A 10-year-old girl was admitted for headache in the last 3 months and was found to have a giant left intraventricular lesion with a volume of 166.63 cm3, which caused hydrocephalus and significant mass effect. Very large draining veins were evident within the tumor, draining into the thalamostriates and internal cerebral veins. Cerebral angiography showed multiple feeders originating mainly from branches of the posterior left choroidal artery with distal afferents that could not be embolized. Therefore, a left parietal transcortical approach was chosen. Given the vascularity of the tumor, saline-cooled radiofrequency coagulation (Aquamantys®) was used to reduce blood loss intraoperatively. Gross total resection (GTR) was achieved with an estimated blood loss of 640 mL. Pathology analysis was consistent with WHO grade 1 transitional meningioma. Postoperatively, the patient was neurologically intact, and MRI confirmed complete resection.

CONCLUSION

Aquamantys® is a novel bipolar coagulation device that employs a new bipolar coagulation technique combining radiofrequency energy and saline to achieve hemostatic sealing by denaturing collagen fibers. This offers the possibility of achieving adequate hemostasis even in giant intraventricular tumors in infants to obtain GTR resection with minimal blood loss.

The clinical and genomic features of seizures in meningiomas

Meningiomas are the most common central nervous system tumors. Although these tumors are extra-axial, a relatively high proportion (10%-50%) of meningioma patients have seizures that can substantially impact the quality of life. Meningiomas are believed to cause seizures by inducing cortical hyperexcitability that results from mass effect and cortical irritation, brain invasion, or peritumoral brain edema. In general, meningiomas that are associated with seizures have aggressive features, with risk factors including atypical histology, brain invasion, and higher tumor grade. Somatic NF2 mutated meningiomas are associated with preoperative seizures, but the effect of the driver mutation is mediated through atypical features. While surgical resection is effective in controlling seizures in most patients with meningioma-related epilepsy, a history of seizures and uncontrolled seizures prior to surgery is the most significant predisposing factor for persistent postoperative seizures. Subtotal resection (STR) and relatively larger residual tumor volume are positive predictors of postoperative seizures. Other factors, including higher WHO grade, peritumoral brain edema, and brain invasion, are inconsistently associated with postoperative seizures, suggesting they might be crucial in the development of an epileptogenic focus, but do not appear to play a substantial role after seizure activity has been established. Herein, we review and summarize the current literature surrounding meningioma-related epilepsy and underscore the interaction of multiple factors that relate to seizures in patients with meningioma.

Case of a WHO Grade II Atypical Meningioma in a 16-Year-Old Female

Meningiomas have a high frequency of occurrence as primary intracranial tumors. We report the case of a 16-year-old female who presented with a three-week history of persistent headache, vomiting, and photophobia. Imaging studies revealed the presence of a meningioma in the right occipital lobe of the brain. The patient underwent surgical resection, and histopathological analysis confirmed the diagnosis of an atypical WHO grade 2 meningioma. The patient experienced a significant improvement in her symptoms postoperatively and had no evidence of recurrence on follow-up imaging. This case highlights the importance of considering meningioma in the differential diagnosis of relatively young patients presenting with chronic headaches, and the favorable prognosis associated with atypical WHO grade 2 meningiomas following complete surgical resection.

Meningioma Related Epilepsy- Pathophysiology, Pre/postoperative Seizures Predicators and Treatment

Meningiomas are the most common primary brain tumors accounting for about 30% of all brain tumors. The vast majority of meningiomas are slow-growing and of benign histopathology rendering them curable by surgery alone. Symptomatic lesions depend on the location with signs of mass effect or neurological deficits. Seizures are the presenting symptoms in approximately 30% of cases, which negatively affect quality of life, limit independence, impair cognitive functioning, as well as increase the risk for psychiatric comorbidities including depression. Although surgical resection may offer seizure freedom in 60-90% of meningiomas, seizures persist after surgical resection in approximately 12-19% of patients. Anti-seizure medications (ASMs) are employed in management, however, are limited by adverse neurocognitive side-effects and inefficacy in some patients. The potential predictors of pre- and post-operative seizures in meningioma patients have been identified in the literature. Understanding various factors associated with seizure likelihood in meningioma patients can help guide more effective seizure control and allow for better determination of risk before and after surgery.

Distribution of Primary Brain Tumor Subtypes in Lebanon: A Multicenter Eleven-Year Study of 695 Patients

Background

Brain tumors are associated with relatively high mortality and morbidity in comparison with their low incidence. Little is known about primary brain tumors in Lebanon, as well as in the Arab world. This study aims to analyze the epidemiology of brain tumors across the Lebanese population.

Methods

Data from pathology reports of patients diagnosed with malignant and non-malignant primary brain tumors were collected retrospectively in an eleven-year period (2007-2017) from four medical centers in Lebanon. A total of 695 primary brain tumor cases (61% malignant and 39% non-malignant) were retrieved from different regions across the country.

Results

Meningiomas were the most common histology in this sample (29.6%), followed by glioblastomas (25.5%) and oligodendrogliomas (5.9%). Pituitary tumors were only 3.5% of brain tumors. Besides, the most common anatomical locations in malignant and non-malignant tumors were cerebral meninges (29.6%), the "other brain" category (21.3%), and the frontal lobe (11.2%). In children and adolescents, embryonal tumors (21%) were the most common histologies, while glioblastomas and meningiomas accounted for 14.8% and 13.6%, respectively.

Conclusion

Lebanon presented a low rate of pituitary tumors and an unusually high percentage of malignant tumors, as well as pediatric glioblastomas and meningiomas. This should raise major concerns for policymakers to detect the possible underlying causes.

Clinical features and long-term outcomes of pediatric meningiomas

OBJECTIVE

Pediatric meningiomas are relatively rare and have atypical clinical features compared to adults. The purpose of this work is to report our 15-year experience in the management of pediatric meningiomas and assess their clinical characteristics, pathological features, and prognostic factors.

METHODS

A total of 40 children (age ≤ 15 years) who were diagnosed as pediatric meningiomas were enrolled in this study. Patient information including clinical presentation, gender, age at time of diagnosis, histopathological features, tumor location, tumor volume, treatment methods, and follow-up data were extracted and analyzed.

RESULTS

The mean age at diagnosis was 10.78 ± 3.50 years (range 2-15 years) in 40 patients with a male to female ratio of 1:1.11. Headache, epilepsy, visual disturbance, and limb weakness are common clinical manifestations. Two patients had multiple intracranial meningiomas. Fourteen (33.3%) of pediatric meningiomas were high grade meningiomas. Seven patients (17.5%) were treated with STR, while GTR was achieved in 33 patients (82.5%). The mean follow-up period was 82.1 months (range 9-173 months). Recurrence occurred in 9 patients (22.5%), and 5 patients (12.5%) passed away.

CONCLUSION

The incidence of pediatric meningiomas increases with advancing age. In pediatric patients, the percentage of high-grade tumors is higher than adults. Younger children were more likely to have high-grade meningiomas, while patients with tumors located in skull base or parasagittal/falx tend to have low-grade meningiomas. The WHO grade III meningiomas were significantly correlated with poor prognosis. Adjuvant radiotherapy after surgery can improve prognosis and may be a potential treatment strategy in children with malignant meningiomas.

Histopathological Mapping of Meningiomas: A 10-year Retrospective Analysis

Background Meningiomas are a group of neoplasms showing a spectrum of histopathological variants, mostly corresponding to World Health Organization (WHO) grade I. However, certain histologic variants correspond histologically to WHO grades II and III. In this study, the histopathological spectrum of the meningiomas received in our department over the past 10 years is being revisited, with the aim to analyze the various histopathological variants, in order to assess their grade as per WHO 2016 criteria and also assess their epidemiology and localization.

Materials and Methods A retrospective analysis of the histopathology records and clinical case files was done in 302 cases of histopathologically diagnosed cases of intracranial/intraspinal meningiomas (WHO grade I, II and III) received over a period of 10 years in our department. Hematoxylin and eosin (HE) staining was done for histological typing and grading of the tumors, and the cases were analyzed as per WHO 2016 criterion. Age and sex distribution along with the localization of the 302 cases was also analyzed.

Results Among these, grade I meningiomas (93.05%) were the most common. According to histopathological type, transitional meningioma (76.50%) was the most common. Maximum cases were located at the cerebral convexities, reported in the fifth decade with a female preponderance.

Conclusion As per WHO 2016, grade I meningiomas are associated with low-risk of recurrence and aggressive behavior, while WHO grade II and III meningiomas are associated with greater likelihood of recurrence and aggressive behavior. This classification itself summarizes the importance of accurate typing and grading of meningiomas on histopathology.

Pineal Region Meningioma in a Very Young Child

INTRODUCTION

Meningiomas in childhood are infrequently seen. Furthermore, they are extremely rare at a pineal location with few reported cases above 5-years of age. We present a very young child with a large pineal region meningioma which mimicked the usually occurring pathologies at this site.

CASE PRESENTATION

A 2.5-year-old child presented with symptoms of raised intracranial pressure. MRI demonstrated a homogenously enhancing pineal lesion with small cystic areas. After an initial cerebrospinal fluid evaluation for germ cell tumors, the child underwent excision of the lesion by the Krause approach. The tumor showed no definitive dural attachment, had well-defined arachnoid interface, and was completely excised. The final histopathology was meningioma.

CONCLUSION

Although unusual, we highlight the importance of considering meningiomas among the childhood pineal region lesions, given their good outcome with total resection. Also, pertinent brief literature of the pediatric pineal region meningiomas has been provided. An assessment of preoperative and intraoperative features (clear arachnoid plane) along with adjuncts such as frozen studies can help discern various entities of this region, and decide the extent of excision.

A Treatise on Pediatric Meningiomas: Single-center Retrospective Cohort Experience and Review of Literature

Background

Pediatric meningiomas are infrequently encountered in clinical practice. In comparison to adults, they have a distinct pathophysiology and clinical presentation. They are benign but locally aggressive tumors. Radical excision often culminates in good outcome.

Aim

The aim of this study was to study the demographic profile, clinico-radiological features, pathophysiology, and surgical outcome of childhood meningiomas.

Materials and Methods

The case records of patients <18 years of age operated for meningiomas in our institute from 1985 to 2015 were retrieved. The demographic profile, clinical and radiological features, surgical approach, extension of resection, and surgical outcome were recorded and subsequently analyzed.

Results

Among 37 patients, 20 were males and 17 were females. The mean age was 13 years. Predisposing etiologies such as neurofibromatosis and radiation exposure were identified in 20% of the study population. There were 31 intracranial and 6 spinal meningiomas. Headache associated with vomiting was the most common presenting complaint. Majority were supratentorial tumors. A safe maximal excision was attempted in each case. Recurrence was noted in five patients. Average follow-up was approximately 24 months. Two patients succumbed to the illness. Approximately, 30% of patients were rendered morbid.

Conclusion

Although rare, pediatric meningiomas are biologically different from their adult counterparts. They have a male predominance, common in intraventricular region and cystic in nature. Radical excision is associated with good prognosis. Although benign, they are aggressive in nature and have a tendency to recur. The response to adjuvant therapy is modest. Further molecular research and genetic studies are necessary to understand the biology of pediatric meningiomas, which will help in the identification of targeted molecular therapy.

Pediatric meningiomas: 10-year experience with 39 patients

OBJECTIVE

The purpose of this article was to study the characteristics of pediatric meningiomas, including the clinical symptom, anatomic location, radiological finding, treatment approaches, and long-term surgical outcome as well as the possible influence factors of the prognosis.

METHODS

We retrospectively reviewed the medical records and follow-up data of 39 pediatric patients who were treated by operation for intracranial meningiomas in West-China Hospital between 2009-2019.

RESULTS

The incidence of pediatric meningioma was 0.74%. The mean age at surgery was 12.2 years and the ratio of male to female was 1.3. Three cases (7.7%) were related to neurofibromas. WHO grade I was found in 26 patients (66.7%) and higher grades was seen in 13 (33.3%). The most common location sites were convexity (35.9%). Gross total excision was achieved in 28 patients (71.8%). The mean follow-up period was 54.4 months. The recurrence rate was 41.9%. By survival analysis, only gross total resection (p = 0.028) was associated with favorable outcome.

CONCLUSION

Meningiomas in children are very rare and have a slight male predominance. Pediatric meningiomas are more commonly located in intraventricular and have higher incidence rate of high-grade than that in adults. Although being challenging, the gross total excision should be underdone to achieve a better prognosis.

Intracranial calcifications in childhood: Part 2

This article is the second of a two-part series on intracranial calcification in childhood. In Part 1, the authors discussed the main differences between physiological and pathological intracranial calcification. They also outlined histological intracranial calcification characteristics and how these can be detected across different neuroimaging modalities. Part 1 emphasized the importance of age at presentation and intracranial calcification location and proposed a comprehensive neuroimaging approach toward the differential diagnosis of the causes of intracranial calcification. Pathological intracranial calcification can be divided into infectious, congenital, endocrine/metabolic, vascular, and neoplastic. In Part 2, the chief focus is on discussing endocrine/metabolic, vascular, and neoplastic intracranial calcification etiologies of intracranial calcification. Endocrine/metabolic diseases causing intracranial calcification are mainly from parathyroid and thyroid dysfunction and inborn errors of metabolism, such as mitochondrial disorders (MELAS, or mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes; Kearns-Sayre; and Cockayne syndromes), interferonopathies (Aicardi-Goutières syndrome), and lysosomal disorders (Krabbe disease). Specific noninfectious causes of intracranial calcification that mimic TORCH (toxoplasmosis, other [syphilis, varicella-zoster, parvovirus B19], rubella, cytomegalovirus, and herpes) infections are known as pseudo-TORCH. Cavernous malformations, arteriovenous malformations, arteriovenous fistulas, and chronic venous hypertension are also known causes of intracranial calcification. Other vascular-related causes of intracranial calcification include early atherosclerosis presentation (children with risk factors such as hyperhomocysteinemia, familial hypercholesterolemia, and others), healed hematoma, radiotherapy treatment, old infarct, and disorders of the microvasculature such as COL4A1- and COL4A2-related diseases. Intracranial calcification is also seen in several pediatric brain tumors. Clinical and familial information such as age at presentation, maternal exposure to teratogens including viruses, and association with chromosomal abnormalities, pathogenic genes, and postnatal infections facilitates narrowing the differential diagnosis of the multiple causes of intracranial calcification.

Paediatric meningiomas in Singapore - Case series of a rare entity

Paediatric meningiomas are extremely rare. These tumours constitute only 2 to 3% of all childhood brain tumours. Despite similarities in histological features between PMs and their adult counterparts, there are important distinctions between them. In this case series, the authors describe their experience in paediatric meningiomas in Singapore's 2 children's hospitals from 1998 to 2018. The primary aim of this retrospective study is to evaluate the clinical, radiological and pathological characteristics, and associated outcomes of paediatric patients diagnosed with meningioma managed in our local institutions. Following that, the study's findings are secondary aims are corroborated with published literature. A total of 10 patients (4 males and 6 females) were identified for this study within the period of 01 January 1998 to 31 December 2018. Their ages ranged from 1 year old to 18 years old (median age 10.5 years old). Two of the patients had NF1 and NF2 respectively. There were 9 intracranial and 1 intraspinal paediatric meningiomas. Seven patients achieved gross total resection and 3 patients had subtotal resection. Eight patients did not have tumour recurrence or increase in size of tumour remnant during the course of their follow-up. In congruency with the literature, up to 40% of our patients had higher grade meningiomas and 55.6% had large tumour volumes more than 30 cm³. Owing to the paucity of knowledge for this unusual tumour, the authors emphasize the need for closer surveillance and in-depth genomic studies to identify novel therapies for this challenging condition.

Pediatric meningiomas: a report of 5 cases and review of literature

PURPOSE

The purpose of this paper is to provide novel insight into the rare pediatric meningiomas.

METHODS

We retrospectively analyzed pediatric surgical cases of meningioma during 2002 to 2017 in our institution. The preoperative, intraoperative, and the postoperative status were collected to find any unique features that has not reported in the past.

RESULTS

Nine surgeries out of 5 patients were identified. The mean age was 7 years old (range 1-14 years old). Four patients were females. The mean tumor diameter was 52 mm (range 23-81 mm). The tumor locations were optic nerve sheath, Sylvian fissure, parasagittal, trigone of the lateral ventricle, and cerebellopontine angle. The Sylvian fissure meningioma without dural attachment (MWODA) was found in a 15-month-old female. A relapsed parasagittal meningioma showed regression in histological grade and residual tumor demonstrated spontaneous regression. In the initial surgeries, Simpson grade 1 resection was achieved in 2 cases. The pathological diagnoses were 1 meningothelial, 1 metaplastic, 2 atypical, and 1 clear cell meningiomas. The mean postoperative follow-up period was 71 months. Three patients experienced recurrence of the tumor. At the latest follow-up, all patients were free of radiological tumor recurrence or regrowth with a mean follow-up of 4 years (range 1-6.9 years). All patients were in the modified Rankin scale of 0-1.

CONCLUSIONS

MWODA is not considered to be rare in pediatric meningioma and should be included in the differential diagnosis. We presented a histologically regressed relapsed meningioma, which spontaneously regressed after subtotal resection. In the case of recurrent meningioma, surgical resection and adjuvant radiation therapy could be effective for long-term control of the tumor.

Management of pediatric CNS meningiomas: CCHE-57357 experience in 39 cases

PURPOSE

Our aim is to present our experience in the management of pediatric meningiomas in the largest referral center in Egypt for pediatric tumors focusing on variables including clinical picture, anatomic location, histopathology, treatment strategies, and outcome together with their possible correlation to prognosis.

METHODS

We retrospectively reviewed the medical records of 39 pediatric patients who were treated for CNS meningiomas in Children's Cancer Hospital-Egypt (CCHE-57357) 2007-2017.

RESULTS

The prevalence of pediatric meningioma was 1.42%. Four cases had type 2 neurofibromatosis (NFII). The mean age was 8.19 years. The presence of NFII was associated with challenging multiple lesions, older age of presentation and poorer prognosis and functional outcome. Convexity was the commonest location. Gross total resection (GTR) was achieved in 28 cases, subtotal resection (STR) in 8 cases, and biopsy was decided in 3 patients. Histopathological examination revealed WHO grade I in 16 patients and higher grades in 23 patients (59%). The 5-year overall survival (OS) rate was 87.8% while the 5-years event-free survival (EFS) rate was 85.6%. Tumor location, histopathology, and clinical presentation were not statistically correlated to prognosis.

CONCLUSIONS

Pediatric CNS meningiomas are uncommon pediatric tumors but of an aggressive clinical and pathological behaviors as compared to adult meningiomas. The presence of NFII is associated with a poorer prognosis and functional outcomes. Although being challenging, the maximum and safe surgical excision should be exercised even in recurrent cases in order to achieve the best outcome. Adjuvant radiotherapy provides good tumor control for inoperable residual atypical or anaplastic meningiomas.

Clinicopathological Characteristics of Meningiomas: Experience from a Tertiary Care Hospital in the Kashmir Valley

Background:

Meningiomas comprise 15%–20% of all primary intracranial tumors. They are generally benign tumors, and most patients are cured after surgery and remain free of recurrence. However, some tumors behave in an aggressive manner, and patients develop local recurrence or metastasis. Overall prognosis is good.

Patients and Methods:

This is an 11-year retrospective study conducted in the Departments of Pathology and Neurosurgery at Sheri-I-Kashmir Institute of Medical Sciences, Kashmir, India. Besides the demographic profile, the parameters analyzed were location of tumor on imaging, histopathological subtype, and grade of tumor according to the 2007 WHO classification and recurrence at follow-up.

Results:

A total of 254 patients were included in our study, of which 205 (80.7%) were brain meningiomas and 49 (19.3%) were spinal, with an overall female: male ratio of 2:1. Female: male ratio was more in spinal meningiomas, 15.3:1. Most of our patients were in the 4–6^th decade of life with a mean age of 48 years (range: 5–73 years). Meningothelial meningioma was the most common histological type. Of ten patients who showed recurrence, seven cases showed only recurrence, but no progression to higher grade and three cases showed recurrence with progression by one WHO-grade. We also noticed that recurrence was higher in Simpson Grades II and III.

Conclusion:

Meningiomas are common in females and most of the meningiomas do well after surgery. The recurrence rate was 3.93% in our study and Simpson grade of tumor excision and histopathological grade contribute significantly to the recurrence of the tumor.

A comparison of clinicopathological features and surgical outcomes between pediatric skull base and non-skull base meningiomas

OBJECT

The purpose of this study is to analyze and compare the clinicopathological characteristics and surgical outcomes between skull base and non-skull base meningiomas in pediatric population.

METHODS

We retrospectively analyzed a total of 140 cases of pediatric meningiomas surgically treated in our department from January 2005 to July 2015 and compared the clinicopathological characteristics and surgical outcomes between skull base and non-skull base meningiomas.

RESULTS

Of all the pediatric meningiomas, 50 (35.8 %) were located at the skull base and 90 (64.2 %) were located at the non-skull base. Skull base and non-skull base meningiomas had a similar sex distribution (male/female = 1:1 in skull base meningiomas and male/female = 1.5:1 in non-skull base meningiomas) (P = 0.288) and high-grade meningioma occurrence rate (P = 0.569). In addition, the mean age of non-skull base meningiomas was 12.5 years which was younger than that of skull base meningiomas (14.2 years) (P = 0.019), and the preoperative tumor size was smaller in skull base (mean size = 4.7 cm in skull base meningiomas and mean size = 5.7 cm in non-skull base meningiomas) (P = 0.020). Gross total resection was achieved in 64 non-skull base patients (73.9 %) and 26 skull base patients (52 %) (P = 0.046). Patients with gross total resection had better progression free survival (PFS) than those with subtotal resection.

CONCLUSION

Pediatric skull base and non-skull base meningiomas are similar in sex distribution and high-grade meningioma occurrence rate. In comparison with non-skull base ones, pediatric skull base meningiomas occur at elder age and are smaller in size and they are more likely to be incompletely resected. Gross total resection and early treatment are recommended to prolong PFS of pediatric patients.

Genomic diagnostics leading to the identification of a TFG-ROS1 fusion in a child with possible atypical meningioma

Meningiomas are rare in children. They are highly complex, harboring unique clinical and pathological characteristics, and many occur in patients with neurofibromatosis type 2. Hereby, we present a case of a two-year-old boy presented with a diagnostically challenging intraventricular tumor. It was incompletely resected 6 times over 14 months but kept progressing and was ultimately deemed unresectable. Histologically, the tumor was initially classified as schwannoma, but extensive international review concluded it was most likely an atypical meningioma, WHO grade II. Comprehensive genomic profiling revealed a TFG-ROS1 fusion, suggesting that ROS1-signaling pathway alterations were driving the tumor growth. In light of this new information, the possibility of a diagnosis of inflammatory myofibroblastic tumor was considered; however the histopathological results were not conclusive. This specific molecular finding allowed the potential use of precision medicine and the patient was enrolled in the AcSé phase 2 trial with crizotinib (NCT02034981), leading to a prolonged partial tumor response which is persisting since 14 months. This case highlights the value of precision cancer medicine in children.

Pediatric meningiomas an aggressive subset: a clinicopathological and immunohistochemical study

BACKGROUND

Meningiomas are uncommon neoplasms in the pediatric age group and differ in various aspects from their adult counterparts. They account for 0.4-4.6% of all primary brain tumors.

AIMS

To retrospectively analyze the clinicopathological and immunohistochemical features of pediatric meningiomas.

MATERIALS AND METHODS

Meningiomas in patients under 18 years of age diagnosed between January 2001 to December 2011 were analyzed retrospectively. The hematoxylin and eosin stained sections and Ki 67 labelling index (LI) were reviewed for all the cases Results: The pediatric meningiomas accounted for 1.52% of total meningiomas (15/983). The mean age at presentation was 12 years with male to female ratio of 1.5:1. The presenting symptoms were headache, seizures, and motor deficits. The histology included 9 cases (60%) of atypical meningioma (WHO grade II) followed by 4 cases (26.67%) of WHO grade-I and 2 cases (13.33%) of anaplastic meningioma (WHO grade III). Five cases had a recurrence. Ki67 LI ranged from 0.5% to 1.5% in grade I, 0.5% to 15% in grade II and 13% to 24% in grade III meningiomas.

CONCLUSION

Meningiomas are rare in children and show a male preponderance. There was a higher incidence of atypical and anaplastic meningiomas in pediatric population.

The importance of microsurgery in childhood meningioma: a case report

INTRODUCTION

Although meningiomas are frequently diagnosed in adults, it is a rare (intracranial) tumor in the pediatric population, with an incidence of 0.06/100,000. The pathology and treatment of meningiomas in adulthood has been a topic of increasing investigation. So far, the treatment of pediatric meningiomas has been extrapolated from these results. The question remains, however, whether translation of adult meningioma data into the childhood population is legitimate.

METHODS

We present the case of a 3-year-old girl diagnosed with an intraventricular malignant meningioma and type 2 neurofibromatosis. She was operated on multiple times to achieve complete resection and received adjuvant chemotherapy. Since, she has been stable with no neurological sequelae and/or recurrence of the meningioma.

CONCLUSION

Pediatric meningiomas are rare tumors and differ from their adult counterparts in various aspects. We believe that gross total resection of meningioma in the pediatric population, when possible, is the treatment of choice. In the event of a subtotal resection, repeat resection is recommended. Any adjuvant treatment with chemotherapy or radiation therapy should be carefully considered during multidisciplinary meetings.

Morbidity in survivors of child and adolescent meningioma

BACKGROUND

The extent of initial surgical resection has been identified as the strongest prognostic indicator for survival in child and adolescent meningioma. Given the paucity of data concerning long-term outcome, the authors undertook a meta-analysis to analyze morbidity in survivors of this disease.

METHODS

Individual patient data were obtained from 19 case series published over the last 23 years through direct communication with the authors. Ordinal logistic regression models were used to assess the influence of risk factors on morbidity.

RESULTS

Of 261 patients, 48% reported a completely normal life with no morbidity, and 25% had moderate/severe meningioma-associated morbidity at last follow-up. Multivariate analysis identified relapse as the only independent variable associated with an increased risk of morbidity (odds ratio, 4.02; 95% confidence interval, 2.11-7.65; P ≤ .001). Univariate analysis also revealed an increased risk for patients with neurofibromatosis (odds ratio, 1.90; 95% confidence interval, 1.04-3.48; P = .04). Subgroup analysis identified a higher incidence of morbidity among patients who had intracranial tumors with a skull base location compared with a nonskull base location (P ≤ .001). Timing at which morbidity occurred was available for 70 patients, with persistence of preoperative tumor-related symptoms in 67% and as a result of therapy in 20%.

CONCLUSIONS

The majority of survivors of child and adolescent meningioma had no or only mild long-term morbidity, whereas 25% had moderate/severe morbidity, with a significantly increased risk in patients with relapsed disease. In the majority, morbidity occurred as a consequence of the tumor itself, justifying aggressive surgery to achieve gross total resection. However, for patients with neurofibromatosis and skull base meningioma, a more cautious surgical approach should be reserved.

Management of pediatric intracranial meningiomas: an analysis of 31 cases and review of literature

OBJECTIVE

The purpose of this study is to understand the epidemiology, clinical features, behavior, and the prognostic factors that influence the outcome of intracranial meningiomas in children.

METHODS

Thirty-one patients with age less than 18 years who underwent surgery for intracranial meningiomas during the period of at 1988-2012 at Voluntary Health Services Hospital, Chennai, India were studied. These formed 3.7 % of the total 831 cases of intracranial meningiomas operated at the institute.

RESULTS

The study group included 22 (71 %) males and 9 (29 %) females. The mean age of presentation was 15 years, with the youngest being 9 months old. Two (6 %) had evidence of neurofibromatosis type 2 (NF2). The most common symptoms at presentation were seizures in 11 (35.5 %), weakness of limbs in 11 (35.5 %), and raised intracranial pressure in 10 (32 %). Convexity meningiomas were seen in 16 (51 %) and skull base in 15(49 %). Multiple meningiomas was seen in two (6 %) of the patients and intraventricular location was found in one patient (3 %). Two (6 %) had evidence of NF2. Gross total excision was achieved in 26 (83 %) and subtotal excision in 5 (17 %). WHO grade I was found in 20 (64 %) and higher grade was seen in 11 (36 %). The mean follow-up was 46.2 months. Recurrence was seen in 20 patients (64 %). In patients with higher grade or with recurrence resurgery and radiotherapy was given. Three (9 %) had multiple recurrences. On a mean follow-up of 46.2 months, 25 patients (81 %) were neurologically intact, 5 (16 %) were having moderated disability, and 1 (3 %) patient died.

CONCLUSIONS

Childhood meningiomas are uncommon lesions with a slight male predominance. They can have a varied clinical presentation. Higher grade is found more frequently compared with adults. Gross total resection is the goal and in higher grade meningiomas radiotherapy helps as a good adjuvant. Though the rate of recurrence is high, resurgery and radiotherapy gives a good outcome.

Surgical resection of pediatric skull base meningiomas

PURPOSE

Meningiomas in children are rare, especially those located at the skull base. In this study, we report our experience of meningioma surgery in the pediatric population and compare our findings of skull base (SB) versus non-skull base (NSB) meningiomas.

METHODS

From our database of 724 surgically treated meningioma patients at the University Hospital, Zurich between 1995 and 2010, 12 patients under 18 years of age were identified. Data for those patients was retrospectively collected through chart review. A descriptive comparison between SB and NSB meningiomas was undertaken to determine statistical significance.

RESULTS

In all 12 children (seven males, five females; mean age 12.2 ± 4.3 years), surgical removal of the meningioma was performed microsurgically with a mean follow-up of 53 months (range 12-137 months). Of the 12 tumors, six were located in the SB and six in the NSB. Comparing SB to NSB lesions, the mean age was 11 ± 3.8 versus 14 ± 4.6 years, male/female gender distribution was 5:1 compared to 1:5, mean tumor size was 7.5 ± 6.2 versus 26 ± 15.8 cm(2) (p = 0.03), and mean surgery time was 347 versus 214 min. While WHO grade was similar for both groups, the Simpson grade revealed more extensive resection for NSB meningiomas. The Glasgow Outcome Scale at last follow-up was favorable for both groups.

CONCLUSIONS

Meningioma surgery was safe with favorable outcomes. SB meningiomas were significantly smaller in size, were less likely to undergo complete resection, and had a predilection for younger, male patients.

Pediatric meningiomas: a single-center experience with 15 consecutive cases and review of the literature

OBJECTIVE

The goal of this study was to determine the epidemiology, clinical presentation, associated factors, pathological features, and treatment outcome of pediatric meningiomas in a single-center institution.

METHODS

Clinical data of 15 patients under 18 years of age operated on for meningiomas from January 1994 to December 2010 were reviewed.

RESULTS

The study group included nine males and six females (mean age of 13 years at surgery). The most common symptoms at presentation were headaches in 6 out of 15 (40 %), raised intracranial pressure in 3 out of 15 (20 %), and seizures in 3 out of 15 (20 %). Sole operated tumors were found in 12 out of 15 (80 %), whose location is as follows: parasagittal in 4 out of 12 (33.3 %), 2 in the convexity (16.6 %), 2 at the skull base (16.6 %), and 4 in other sites (33.3 %). Six children presented with radiation-induced (RT) meningiomas and five had evidence of neurofibromatosis type 2 (NF2). Three patients had multiple meningiomas (all of them had NF2). Simpson's grade I excision was achieved in 12 out of 15 (80 %). On histopathology, 11 out of 15 (73.3 %) were grade I and 4 out of 15 (26.6 %) were grade II (all of them atypical). Five tumors (33.3 %) recurred, four of which had RT or NF2. During the mean follow-up period of 5 years, 12 out of 15 (80 %) had a good outcome (GOS=5).

CONCLUSIONS

Childhood meningiomas are uncommon lesions with a slight male predominance. Absence of large series with long follow-up precludes any definite conclusions on the clinical course and outcome of these tumors. Associated factors (such as RT and NF2), location, and extent of excision appear to be more important than histopathological grade in predicting outcome.

Meningioma in a 20-month-old boy

A 20-month-old boy presented with a intraparenchymal mass in the right frontoparietal area manifesting as complex partial seizure, secondary generalization and left hemiparesis. Magnetic resonance images (MRI) of the brain showed inhomogeneously enhancing mass in the right frontoparietal area which has irregular margin and perilesional edema. Based on the radiological findings, a preoperative diagnosis was an intraaxial tumor, such as pilocytic astrocytoma or dysembryoplastic neuroepithelial tumor. The patient underwent a surgery including frontal craniotomy. The tumor had a partially extreme adherence to the surrounding brain tissue but it showed no dural attachment. Gross-total resection of the tumor was achieved. Postoperative follow-up computed tomography scans showed no residual tumor. The pathological findings confirmed the tumor as a WHO grade I meningioma, transitional type. Nine months after the surgery, follow-up brain MRI showed no recurrence of the tumor, porencephaly in site where the tumor was resected; the patient's symptoms had fully recovered. We report the case of a meningioma in a 20-month-old boy.

Intraventricular meningioma: case report and literature review

In this article we describe the clinical course of a child with an intraventricular meningioma and review the relevant literature. A 7-year-old girl with a several-month history of headaches had a CT scan that demonstrated a large, enhancing, intraventricular tumor. The tumor was completely excised via a superior parietal approach. Pathological examination revealed a pleomorphic meningioma. Postoperative scans demonstrated no residual tumor. Pediatric intraventricular tumors are rare. The surgical objective is complete resection, which appears to be associated with excellent outcomes.

Collision tumor of meningioma and malignant astrocytoma

The authors report a 12-year-old boy who was presented with headache, nausea, vomiting and seizure. His magnetic resonance imaging showed 2 adjacent tumors in the region of the left ventricular trigone. The pathology of tumors reported collision tumors composed of meningioma and malignant astrocytoma.