Background and recommendations

Question 1

What is the median age?

Answer 1

50-60s

Question 2

Which NF syndrome is associated with meningioma?

Answer 2

NF 2

Question 3

What histologic features are common with meningiomas?

Answer 3

Psammoma bodies

Calcifications

Question 4

What are negative prognostic features for meningiomas?

Answer 4

1. High grade
2. Young age
3. Chromosomal alterations
4. Poor performance status
5. STR

Question 5

What are the grades for meningiomas?

Answer 5

Grade I: benign
Grade II: Atypical
Grade III: Anaplastic/malignant

Question 6

Median OS for patients with grade III meningiomas?

Answer 6

3.2 years

Question 7

What are the history elements to capture at work up?

Answer 7

Hx: headaches, neurologic deficits

Physical: CN exam, gait, extremity exam for strength and sensation

Question 8

Dose constraint for optic chiasm after SRS?

Answer 8

8 Gy max

Question 9

LC rate of meningiomas after SRS?

Answer 9

5 year LC: 98%

Question 10

If observes when should patients return for exam and MRI?

Answer 10

At 3 months, 9 months and then yearly if stable

Question 11

What are the treatment options for meningiomas?

Answer 11

1. Observation
2. Surgery
3. Fractionated RT
4. SRS

Question 12

For which sites is RT the preferred treatment modality?

Answer 12

Meningiomas involving the optic nerve sheath or cavernous sinus

Question 13

What is the appearance of meningiomas on MRI?

Answer 13

Homogenously enhancing on T1, well circumscribed with a dural tail
Isointense on T1
Hyperintense on T2

Question 14

DDx for tumors having a dural tail

Answer 14

Chloroma
Lymphoma
Sarcoidosis

Question 15

Which lesions should observation be considered?

Answer 15

1. Incidental lesions, asymmtomatic
2. Not in a high risk area
3. Reliable patients
4. Older patients

Question 16

Indications for adjuvant RT after surgery?

Answer 16

1. Atypical or anaplastic histology
2. STR
3. Recurrent tumors

Question 17

What are the recurrence rates after surgery?

Answer 17

10 year:
GTR: 10%
STR: 30-40%

Question 18

What doses should be used for Grade I meningiomas?

Answer 18

Fractionated: 50.4 Gy at 1.8 Gy/fx
SRS: 12.5

Question 19

What doses should be used for Grade II-III meningiomas?

Answer 19

60 Gy at 2 Gy/fx

Question 20

How are patients with optic nerve sheath/cavernous sinus meningiomas followed?

Answer 20

Serial MRIs
Neuropthalmology exam
Endocrine labs

Question 21

RT volume for Grade II-III tumors?

Answer 21

GTV is gross tumor seen on MRI including dural tail

CTV=GTV+1 cm

Question 22

What histologic features define each grade?

Answer 22

1. WHO Grade I (80%): Mitoses <4/10 hpf
2. WHO Grade II(20%):Mitoses 4/10 or more per hpf chondroid, clear cell, brain invasion
3. WHO Grade II(20%):Mitoses 20/10 or more per hpf or papillary, rhabdoid

Question 23

RT volume for Grade II-III tumors?

Answer 23

GTV+ 3 mm = CTV

Question 24

What is the treatment paradigm for Grade II-III tumors?

Answer 24

Maximal safe resection

Adjuvant RT

Question 25

What is the LC for tumors treated with STR + fractionated RT?

Answer 25

UF data published by Kellie Condra

10 year LC of 87%

Question 26

What RT dose to provide after STR?

Answer 26

54 Gy at 1.8 Gy/fx

Question 27

What are the toxicities of RT for meningiomas?

Answer 27

Alopecia
Nausea
Headache
Seizure

Question 28

What special study do you need for diagnosis of an optic nerve meningioma?

Answer 28

MR T1 + contrast and fat suppression