Fractionated stereotactic radiotherapy in patients with benign or atypical intracranial meningioma: Long-term experience and prognostic factors

doi:10.1016/j.ijrobp.2004.07.669

International Journal of Radiation OncologyBiologyPhysics

Volume 61, Issue 3, 1 March 2005, Pages 809-816

https://doi.org/10.1016/j.ijrobp.2004.07.669 Get rights and content

Purpose

To analyze our long-term experience and prognostic factors after fractionated stereotactic radiotherapy (FSRT) in patients with benign or atypical intracranial meningioma.

Methods and materials

Between January 1985 and December 2001, 317 patients with a median age of 55.7 years were treated with FSRT for intracranial meningioma. The tumor distribution was World Health Organization (WHO) Grade 1 in 48.3%, WHO Grade 2 in 8.2%, and unknown in 43.5%. Of the 317 patients, 97 underwent RT as their primary treatment, 79 underwent postoperative RT (subtotal resection in 38 and biopsy only in 41), and 141 were treated for recurrent disease. The median target volume was 33.6 cm³ (range, 1.0–412.6 cm³). The median total dose was 57.6 Gy at 1.8 Gy/fraction five times weekly.

Results

The median follow-up was 5.7 years (range, 1.2–14.3 years). The overall local tumor control rate was 93.1% (295 of 317). Of the 317 patients, 72 had a partial response on CT/MRI and 223 (70.4%) remained stable. At a median of 4.5 years after FSRT, 22 patients (6.9%) had local tumor progression on MRI. Local tumor failure was significantly greater in patients with WHO Grade 2 meningioma (p <0.002) than in patients with WHO Grade 1 or unknown histologic features. Patients treated for recurrent meningioma showed a trend toward decreased progression-free survival compared with patients treated with primary therapy, after biopsy, or after subtotal resection (p <0.06). Patients with a tumor volume >60 cm³ had a recurrence rate of 15.5% vs. 4.3% for those with a tumor volume of ≤60 cm³ (p <0.001). In 42.9% of the patients, preexisting neurologic deficits improved. Worsening of preexisting neurologic symptoms occurred in 8.2%. Eight patients developed new clinical symptoms, such as reduced vision, trigeminal neuralgia, and intermittent tinnitus located at the side of the irradiated meningioma after FSRT.

Conclusion

These data have demonstrated that FSRT is an effective and safe treatment modality for local control of meningioma with a low risk of significant late toxicity. We identified the tumor volume, indication for FSRT, and histologic features of the meningioma as statistically significant prognostic factors.

Introduction

Meningiomas are the most common non–glial primary brain tumors, accounting for approximately 14–20% of all brain tumors (1, 2). Most meningiomas are histologically benign and typically slow-growing lesions arising from the arachnoidal cap cells (3). In the literature, the 5-year survival rates for patients with benign meningioma range from 90% to 100% in the era of modern imaging and treatment modalities (4). Patients with malignant meningioma have had 5-year survival rates of 50–60% (5). The treatment of choice for benign meningioma is radical surgical resection (6). Long-term local control rates of 33–60% after surgical resection of benign meningiomas have been reported. High local control rates can be achieved by more radical tumor resection (7, 8). Most meningiomas can be completely resected, but they have a high tendency for local recurrence, especially after subtotal surgical intervention. Postoperative radiotherapy (RT) has prolonged the time to recurrence and prevented tumor regrowth in several cases. Whether postoperative RT is also capable of improving the survival of patients with incompletely resected meningiomas is still controversial. After complete resection, long-term disease-free survival has been achieved in 81% of patients, with a local tumor control rate of 96%. Relapses occurred 4–17 years after the initial surgical intervention. In patients with inoperable or incompletely resected meningioma, postoperative RT may improve local tumor control comparable to that after complete resection (8, 9, 10). The aim of RT is to shrink the existing tumor burden and prevent regrowth (3, 4).

In this article, we report our analysis of our own long-term experience with fractionated stereotactic RT (FSRT) in the treatment of benign intracranial meningiomas with respect to local tumor control, radiation-induced side effects, and overall survival. We also analyzed our results with respects to prognostic factors after FSRT.

Section snippets

Methods and materials

Between January 1985 and December 2001, 317 patients with a median age of 55.7 years (range, 11–86 years) were treated with FSRT for benign or atypical intracranial meningioma at the German Cancer Research Center, Heidelberg, Germany. Our institutional review board approved this study. The male/female ratio was 1:2.7 (86 men and 231 women). The median Karnofsky performance score was 90%. Of the 317 patients, 179 (56.5%) had a histologically proven diagnosis of meningioma and 138 had clinical

Results

The median follow-up was 5.7 years (range, 1.2–14.3 years), and all patients were followed for >12 months; 264 patients (83.2%) were followed for >36 months. The median target volume was 33.6 cm³ (range, 1–412.6 cm³).

Discussion

These data indicate that FSRT is safe and feasible in the treatment of intracranial meningiomas with a low risk of significant chronic late toxicity. The indications for RT have included residual tumors after subtotal resection, disease recurrence, and inoperable tumors because of the proximity to critical structures or comorbid patient conditions.

In our analysis, the overall survival rate of patients with benign or atypical intracranial meningiomas was 94.7% at 5 years and 90% at 10 years. The

Conclusion

These data demonstrate that FSRT is an effective and safe treatment modality for local control of intracranial meningiomas with low risk of significant late toxicity. We identified tumor volume, the indication for FSRT, and the histologic type of meningioma as statistically significant prognostic factors.

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Outcomes and predictors of response to fractionated radiotherapy as primary treatment for intracranial meningiomas
2023, Clinical and Translational Radiation Oncology
Surgery is the primary treatment for most meningiomas. However, primary fractionated radiotherapy (fRT) remains an option for patients with larger meningiomas in challenging anatomic locations or patients at prohibitively high surgical risk. Outcome prediction for these patients is uncertain and cannot be guided by histopathology without available tumor tissue from surgery. Therefore, we aimed to assess the clinical factors that contribute to treatment failure in a large cohort of meningiomas consecutively treated with fRT as primary therapy, with the goal of identifying predictors of response.
Patients treated with primary fRT for intracranial meningiomas from 1998 to 2017 were reviewed. Those who received primary surgical resection, radiosurgery, previous fRT, or had <6 months of clinical follow-up were excluded. We applied logistic regression and Cox regression modeling to ascertain key predictors of treatment failure, progression-free survival (PFS), and adverse events (AE) following fRT.
Our cohort included 137 meningiomas, 21 of which progressed after fRT (median PFS 3.45 years). Progressive meningiomas had a larger median gross tumor volume (GTV) compared to those that remained stable (19.1 cm³ vs 9.6 cm³, p = 2.86 × 10⁻²). GTV > 11.27 cm³ was independently predictive of progression and larger GTV was associated with higher risk of significant (grades 3/4) AE following fRT. Cavernous sinus and optic nerve sheath meningiomas had overall excellent outcomes post-fRT.
We present a large cohort of meningiomas treated with primary fRT and find GTV and anatomic location to be key predictors of outcome, adding to the complex treatment considerations for this heterogeneous disease.
Atypical meningiomas
2020, Handbook of Clinical Neurology
Meningiomas are the most common primary CNS tumor in adults, representing a third of brain lesions. Their clinical presentation varies greatly, ranging from asymptomatic incidental tumor to fatal tumor. The majority of meningiomas are benign, and gross total resection can achieve very low recurrence rates, with radiation therapy or radiosurgery reserved for recurrences or residual tumor that grows during serial imaging. At the other end of the spectrum, malignant meningiomas, although comprising just 1% of meningiomas, have been recognized to exhibit aggressive behavior that ultimately proves lethal regardless of the extent of resection or whether adjuvant radiation and chemotherapy are utilized. Over the past 2 decades, there has been pathologic recognition of a third type of meningioma known as “atypical,” with borderline histologic and clinical features between benign and malignant meningioma. Here we review the clinical features, treatment, and outcomes of atypical meningiomas, with a focus on the impact of extent of resection and radiation therapy on the long-term recurrence rate of completely and incompletely resected atypical meningiomas.
External beam radiation therapy for meningioma
2020, Handbook of Clinical Neurology
Radiation therapy (RT) plays an important role in the management of meningioma. Surgery often remains the initial treatment of choice as it reduces mass effect and confirms the diagnosis and grade. However, RT has frequently been successful in the primary setting and is commonly employed as adjuvant therapy for incompletely resected tumors as well as for high-grade meningiomas regardless of resection extent. Some meningiomas develop in locations less amenable to resection or in patients who are poor surgical candidates, in which circumstances RT is particularly appropriate as primary treatment. Recent cooperative group studies including RTOG 0539 have better established the role of RT for meningioma. These studies suggest a role for adjuvant RT for completely resected Grade II meningioma, which was less clear historically. Ongoing clinical trials such as NRG BN 003 and ROAM will further clarify this. This chapter reviews the role of fractionated external beam RT for various grades of meningioma.
Meningiomas in the elderly
2020, Handbook of Clinical Neurology
Citation Excerpt :
Cons: Some problems with radiosurgery include that the older population is at risk for radiation toxicity given their poorer general health and comorbidities depending on the amount of radiation needed for the meningioma (Kaul et al., 2015). Optic pathway toxicity can also occur for meningiomas treated with radiation in the proximity of the optic pathway, causing transient visual impairment (Milker-Zabel et al., 2005). Intracranial meningiomas pose a challenge in regard to the proper choice of a treatment in the elderly population that has significant comorbidities.
Meningiomas are benign tumors that arise from the meningo-epithelial cells of the arachnoid dura and account for approximately one-third of all adult intracranial tumors. With the evolution of diagnostic imaging and the average life span increasing, meningiomas are being detected more frequently in an older population. In the elderly population, defined by patients aged 60 years or older, meningiomas are the most incidentally detected benign primary brain tumor. As a patient ages, the rate of growth of the meningioma decreases, while comorbidities increase, making the elderly population a unique group when it comes to decision-making for treatment. Treatment options for intracranial meningiomas in the elderly include surgery, radiosurgery, or observation. Although age may have some part in treatment considerations, comorbidities, overall state of health, and tumor characteristics play a more significant role in patient outcome. This chapter will investigate the incidence, evaluation, treatment, and outcomes of intracranial meningiomas in the elderly population.
Skull base meningioma: Clinical and radiological efficacy based on a quantitative volumetric analysis
2019, Cancer/Radiotherapie
Recherche d’une corrélation entre efficacité clinique et radiologique basée sur un suivi volumétrique quantitatif après irradiation de méningiomes de la base du crâne.
Les données de 35 patients pris en charge, soit par tomothérapie hélicoïdale (45,7 %), soit par radiothérapie fractionnée en conditions stéréotaxiques (54,3 %), ont été rétrospectivement analysées. Il s’agissait principalement de femmes (94 %) de 59 ans (43–81) avec des lésions du sinus caverneux (60 %). Il y avait une médiane de 2 (1–4) symptômes par patient, principalement des troubles visuels (39 %), des déficits des nerfs crâniens (23,4 %) et les céphalées (17,2 %).
Le volume tumoral avait significativement diminué (p < 0,05) passant d’une médiane de 9,6 mL (0,3–36,6) à 6,8 mL (0,1–26,5) après un suivi médian de 44 mois (24–77). Une amélioration d’au moins un symptôme a été retrouvée chez 63 % des patients. En analyse unifactorielle, l’efficacité clinique (p < 0,05), la technique de radiothérapie (p < 0,05), la topographie tumorale (p < 0,05) et le volume tumoral initial (p < 0,05) étaient des facteurs prédictifs de la réponse radiologique. En analyse multifactorielle, seule la corrélation inverse entre réponse radiologique et volume tumoral initial demeurait significative (ρ : −0,47 ; intervalle de confiance à 95 % : −3,2–5,7 ; p < 0,05).
Le suivi volumétrique quantitatif permet de mettre en évidence une efficacité radiologique majeure de la radiothérapie. Cependant, aucune corrélation franche entre efficacité clinique et radiologique n’a été retrouvée.
To date, no correlation has been found between clinical and radiological efficacy after irradiation of skull base meningiomas. However, the evaluation of the radiological response was most often made by questionable methods that may have underestimated the radiological effectiveness of radiotherapy. The objective of this work is to verify this hypothesis by quantitative volumetric analysis.
Data from 35 patients treated with either helical tomotherapy (45.7%) or fractionated stereotactic radiotherapy (54.3%) were retrospectively analysed. These were mainly women (94%) aged 59 (43–81) with lesions mainly of the cavernous sinus (60%). There was a median of 2 (1–4) symptoms and the main symptoms were visual impairment (39%), cranial nerve deficits (23.4%) and headaches (17.2%).
Median tumour volume decreased significantly (P < 0.05) from 9.6 mL (0.3–36.6) to 6.8 mL (0.1–26.5) after median follow-up of 44 months (24–77). Sixty-three percent of patients had an improvement of at least one symptom. In univariate analysis, clinical efficacy (P < 0.05), radiotherapy technique (P < 0.05), tumor topography (P < 0.05) and initial tumor volume (P < 0.05) were predictive factors for radiological response. In multivariate analysis, only the inverse correlation between radiological response and initial tumor volume remained significant (ρ: −0.47 95% CI −3.2 to 5.7; P < 0.05).
The quantitative volumetric monitoring demonstrates a major radiological efficiency of radiotherapy. However, no clear correlation between clinical and radiological efficacy was found.
A retrospective case series on the usefulness of fractionated stereotactic radiotherapy for benign intracranial tumors
2019, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Conventional radiation therapy has been progressively replaced by fractionated stereotactic radiotherapy (FSRT) and single fraction radiosurgery for dealing with benign intracranial lesions. Purpose of our study is to investigate the safety and efficacy of FSRT in a series of patients with benign intracranial tumors.
31 patients with benign intracranial lesions treated with FSRT between 2006 and 2014 were retrospectively reviewed. Indications for treatment included post-operative residual tumor growth or symptomatic exacerbation in patients in whom surgery was not indicated. A clinical and radiological outcome evaluation was performed. Univariate analysis was executed to identify predictors for post-treatment neurological function and radiological tumor control.
Median age was 62 years (range 22–82). The lesions treated included 20 meningiomas, 2 vestibular schwannomas, 7 pituitary adenomas, 1 craniopharyngioma, 1 jugular-tympanic paraganglioma. Median clinical target volume was 14.59 cm³ (range 0.43–159.06) and median planning treatment volume was 18.16 cm³ (range 0.81–217.24). Median total dose was 45 Gy (range 25–54), and median daily fraction 4 Gy (range 1.8–9). At a median follow-up of 78 and 50 months, respectively clinical and neuroradiological, no tumor had larger dimensions, and only one lesion changed in a way other than size determining a concomitant clinical worsening. Other three patients deteriorated without evidence of radiological progression. Conversely, 12 patients improved clinically. No significant predictor for post-treatment neurological function or radiological tumor control was found.
FSRT may represent, when indicated, a safe and effective treatment modality for benign intracranial tumors, especially for large/irregular lesions.

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Clinical investigationBrainFractionated stereotactic radiotherapy in patients with benign or atypical intracranial meningioma: Long-term experience and prognostic factors

Purpose

Methods and materials

Results

Conclusion

Introduction

Section snippets

Methods and materials

Results

Discussion

Conclusion

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Cancer Radiother

Clin Oncol (R Coll Radiol)

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Pathology of tumors of the central nervous system

The role of radiation therapy in the treatment of subtotally resected benign meningiomas

J Neurooncol

Meningioma: Analysis of recurrence and progression following neurosurgical resection

J Neurosurg

Long-term follow-up of patients with meningioma involving the cavernous sinus: Recurrence, progression and quality of life

Neurosurgery

Clinical investigation
Brain
Fractionated stereotactic radiotherapy in patients with benign or atypical intracranial meningioma: Long-term experience and prognostic factors