Meningiomas: genetics, malignancy, and the role of radiation in induction and treatment

The Richard C. Schneider Lecture

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✓ The author reviews the molecular genetics, pathology, and cell kinetics of meningiomas and the role that regional multiplicity in the dura mater may play in their recurrence. Malignant and radiation-induced meningiomas are discussed, with summaries of series of 60 patients with frankly malignant lesions treated over a period of 22 years at the University of California, San Francisco, and of 10 patients with meningiomas induced by high-dose radiation therapy. Reviewing a 23-year series of 140 patients with subtotally removed meningiomas who were treated postoperatively with radiation, the author recommends that, with meticulous technique, irradiation is effective in preventing the regrowth of subtotally removed benign meningiomas and of all malignant meningiomas. Adoption of both the microscopical cytological grading system proposed by Jääskeläinen's group in Helsinki and the classification of operations proposed by Donald Simpson is also recommended. Wide removal of dura adjacent to meningioma reduces the risk of recurrence, and determination of the bromodeoxyuridine labeling index provides a valid basis for planning treatment and follow-up evaluations. Increased awareness is necessary for early recognition of radiation-induced meningiomas in patients at risk for developing such tumors. For meningiomas in such sites as the parasellar region and the posterior fossa, conservative removal of tumor followed by irradiation is advocated in preference to a radical operation that may cause neurological injury without being curative.

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Address reprint requests to: Charles B. Wilson, M.D., Department of Neurological Surgery, c/o The Editorial Office, 1360 Ninth Avenue, Suite 210, San Francisco, California 94122.

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Figures

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    Distribution of the volume doubling time within each of three histological grades as proposed by the Helsinki group8 (Grade I, benign; Grade II, atypical; Grade III, anaplastic). Based on this distribution, the group proposed the following limits for classifying meningiomas according to their volume doubling time (Td): very fast, Td less than 50 days; fast, Td 50 to 200 days; intermediate, Td 200 to 500 days; and slow, Td more than 500 days. (Reproduced with permission from Jääskeläinen J, Haltia M, Laasonen E, et al: The growth rate of intracranial meningiomas and its relation to histology. An analysis of 43 patients. Surg Neurol 24:165–172, 1985.)

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    A: Axial T2-weighted magnetic resonance (MR) image (TR 2500 msec, TE 80 msec) showing a relatively isointense mass with surrounding gray matter. The mass displaces the falx to the left. Note the central hyperintensity, indicative of necrosis (arrows). B: Axial T1-weighted MR image (TR 2500 msec, TE 80 msec). Note the axial nature of this frontal lobe mass, with displacement of the falx to the left. A low signal intensity area in the center of the mass represents necrosis. C: Contrast-enhanced axial T1-weighted MR image (TR 500 msec, TE 11 msec) showing a diffusely enhancing frontal lobe meningioma. Note, in the central portion of the tumor, the area of more intense signal enhancement surrounding a region of poor enhancement representing necrosis. This feature is rather atypical for benign meningioma. D: Contrast-enhanced coronal T1-weighted MR image (TR 600 msec, TE 11 msec) showing a homogeneously enhancing mass in the right frontal lobe with a central area of necrosis (arrows).

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    Contrast-enhanced coronal T1-weighted magnetic resonance image (TR 600 msec, TE 15 msec) showing an enhancing meningioma with an atypical lobulated margin that invades the falx, superior sagittal sinus, and both parietal lobes.

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    Left: Contrast-enhanced axial T1-weighted magnetic resonance (MR) image (TR 600 msec, TE 16 msec) showing a homogeneously contrast-enhancing lobular mass involving the right sphenoid wing and the right anterior temporal lobe. The lobular nature of this mass is somewhat atypical for a benign meningioma. Right: Axial T2-weighted MR image (TR 2500 msec, TE 80 msec) obtained at a level several centimeters above the meningioma showing the marked amount of edema (arrows) generated by this mass and tracking up the white-matter fibers throughout the right hemisphere.

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    Left: Contrast-enhanced axial T1-weighted magnetic resonance (MR) image (TR 500 msec, TE 11 msec) showing an extra-axial contrast-enhancing mass involving the right frontal convexity. Note the tremendous edema, with a shift of the midline structures generated by this relatively small meningioma. Right: Axial T2-weighted MR image (TR 2500 msec, TE 80 msec) showing the peripherally based meningioma (closed arrows) surrounded by a marked amount of edema (open arrows) that shifts the midline ventricular structures to the left. This amount of edema, although it is occasionally seen with benign meningiomas, should raise a suspicion of a malignant process.

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    Contrast-enhanced T1-weighted magnetic resonance image (TR 600 msec, TE 15 msec) in an axial (left) and coronal (right) projection showing a malignant meningioma. In its pattern of growth, the tumor “mushrooms” as it extends peripherally from the central or primary tumor mass.

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    Contrast-enhanced T1-weighted coronal magnetic resonance image (TR 500 msec, TE 11 msec) showing a parasellar meningioma that was treated by means of a biopsy followed by irradiation in 1980. There was no change in the size of the tumor until year 12 after the end of radiation therapy, when an annual radiological examination indicated a 10% shrinkage of the tumor. Note the encased carotid artery and invasion of the cavernous sinus. The patient is asymptomatic except for preoperative impaired vision in the right eye.

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