Asymptomatic Meningioma Treatment [Neurosurgery Wiki]

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====== Asymptomatic Meningioma Treatment ======

//J.Sales-Llopis//

//Neurosurgery Service, Alicante University General Hospital, Alicante, Spain.//


===== Latest Asymptomatic Meningioma Treatment Pubmed Related Articles =====



{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/123Q1E1Q18WCxrULrm2rdG3KfqSyP2KpirWNk_eB3qmGiB2Qpy/?limit=15&utm_campaign=pubmed-2&fc=20230525021934}}


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Although optimal [[management]] is unclear, clinicians recommend a [[conservative]] approach, which preserves [[quality of life]] and limits unnecessary [[intervention]]. Several [[risk factor]]s have been investigated for their potential utility in the development of [[prognostic model]]s for [[risk assessment]]
((Mahgerefteh N, Mozaffari K, Teton Z, Malkhasyan Y, Kim K, Yang I. Incidental Meningiomas: Potential Predictors of Growth and Current State of Management. Neurosurg Clin N Am. 2023 Jul;34(3):347-369. doi: 10.1016/j.nec.2023.02.009. Epub 2023 Apr 12. PMID: 37210125.)).

===== Natural history =====

[[Asymptomatic meningioma natural history]].



===== Age =====


Among patients older than [[age]] 70 years who underwent operation for [[asymptomatic meningioma]], the neurological [[morbidity]] rate was 23.3%; it was 3.5% among younger patients. This indicates that the advisability of surgery in elderly patients with asymptomatic meningiomas must be considered very carefully
((Kuratsu J, Kochi M, Ushio Y. Incidence and clinical features of asymptomatic
meningiomas. J Neurosurg. 2000 May;92(5):766-70. PubMed PMID: 10794289.
)).

For the treatment of elderly patients with [[asymptomatic meningioma]]s, it is important to determine the [[intracranial meningioma natural history]].

[[GKS]] can control tumors clinically and radiologically with high probability. Although the risk of transient adverse events exists, proactive GKS may be a reasonable treatment option when there are no comorbidities limiting life expectancy
((Kim KH, Kang SJ, Choi JW, Kong DS, Seol HJ, Nam DH, Lee JI. Clinical and
radiological outcomes of proactive Gamma Knife surgery for asymptomatic
meningiomas compared with the natural course without intervention. J Neurosurg.
2018 May 18:1-10. doi: 10.3171/2017.12.JNS171943. [Epub ahead of print] PubMed
PMID: 29775154.
)).

===== Calcification =====

A comprehensive search in 2015 of [[PubMed]], [[Embase]], and the ISI [[Web of Science]] was performed. Using a [[metaanalysis]] with nine subsidiary studies including 777 patients.

They analyzed the correlation of the growth pattern of meningioma with patient gender, tumor location, tumor calcification, [[T2 weighted image]] [[signal intensity]] in magnetic resonance imaging (MRI), and [[Meningioma peritumoral edema]]. 

The growth rate of meningioma was negatively correlated with tumor calcification (odds ratio [OR]: 0.23; 95% confidence interval (CI), 0.11-0.46; p < 0.001) but positively associated with MRI T2 signal intensity (OR: 2.75; 95% CI, 1.75-4.33; p < 0.001). No correlations were found between tumor growth and other factors such as gender (OR: 1.29; 95% CI, 0.84-1.99; p = 0.24), skull base location (OR: 0.80; 95% CI, 0.25-2.58; p = 0.70), and peritumoral brain edema (OR: 1.24; 95% CI, 0.29-5.27; p = 0.77).  

Two factors, tumor calcification and low MRI T2 signal intensity, indicate the possibility of a slow growth meningioma. In such cases of asymptomatic meningioma, a follow-up strategy can be preferentially considered
((Zeng L, Liang P, Jiao J, Chen J, Lei T. Will an Asymptomatic Meningioma Grow
or Not Grow? A Meta-analysis. J Neurol Surg A Cent Eur Neurosurg. 2015 Mar 23.
[Epub ahead of print] PubMed PMID: 25798801.
)).

===== MRI T2 signal intensity =====

A comprehensive search in 2015 of [[PubMed]], [[Embase]], and the ISI [[Web of Science]] was performed. Using a [[metaanalysis]] with nine subsidiary studies including 777 patients.

They analyzed the correlation of the growth pattern of meningioma with patient gender, tumor location, tumor calcification, [[T2 weighted image]] [[signal intensity]] in magnetic resonance imaging (MRI), and [[Meningioma peritumoral edema]]. 

The growth rate of meningioma was negatively correlated with tumor calcification (odds ratio [OR]: 0.23; 95% confidence interval (CI), 0.11-0.46; p < 0.001) but positively associated with MRI T2 signal intensity (OR: 2.75; 95% CI, 1.75-4.33; p < 0.001). No correlations were found between tumor growth and other factors such as gender (OR: 1.29; 95% CI, 0.84-1.99; p = 0.24), skull base location (OR: 0.80; 95% CI, 0.25-2.58; p = 0.70), and peritumoral brain edema (OR: 1.24; 95% CI, 0.29-5.27; p = 0.77).  

Two factors, tumor calcification and low MRI T2 signal intensity, indicate the possibility of a slow growth meningioma. In such cases of asymptomatic meningioma, a follow-up strategy can be preferentially considered
((Zeng L, Liang P, Jiao J, Chen J, Lei T. Will an Asymptomatic Meningioma Grow
or Not Grow? A Meta-analysis. J Neurol Surg A Cent Eur Neurosurg. 2015 Mar 23.
[Epub ahead of print] PubMed PMID: 25798801.
)).

===== Size =====

The effect of tumor size on future lesion growth or
symptom development has been addressed in several studies.
Sughrue et al. systematically reviewed the natural history of untreated meningiomas.  

They identified 22 studies
comprising 675 patients who were followed up by serial
MRI for a median period of 4.6 years. The authors found
that approximately three-quarters of untreated meningiomas
2.5 cm or smaller demonstrated no growth (51%)
or grew 10% or less per year (26%). Patients with initial
tumor diameters smaller than 2 cm (approximately 2%)
rarely demonstrated new or worsening symptoms. Patients
with initial tumor diameters of 2–2.5 cm had a marked
difference in the rate of symptom progression based on
whether their tumors grew more than or less than 10% per
year (42% vs 0%). Patients with initial tumor diameters
of 2.5–3 cm had new or worsening symptoms 17% of the
time. These findings suggest that the majority of tumors
smaller than 2.5 cm in diameter will not cause symptoms
over the 5-year period following their discovery and that
close observation with serial imaging is reasonable in
these patients. On the other hand, larger lesions may be
considered for early intervention
((Sughrue ME, Rutkowski MJ, Aranda D, Barani IJ, McDermott
MW, Parsa AT: Treatment decision making based on the published
natural history and growth rate of small meningiomas. A
review and meta-analysis. J Neurosurg 113:1036–1042, 2010)).
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===== Asymptomatic meningioma radiosurgery =====

[[Asymptomatic meningioma radiosurgery]].

===== Monitoring =====

Overdiagnosis and excessive follow-up are potential pitfalls in the management of incidental meningioma. An MRI after 6-12 months could be reasonable to rule out rapid growth and differential diagnoses. Using the available prognostic models, one might later suggest more active monitoring for certain patient groups harboring specific radiological features predictive of growth. However, detecting growth may not necessarily be clinically significant as all larger non-growing meningiomas have at one point been small. Too much follow-up may place an unnecessary burden on patients and the health-care system and could be a driver toward overtreatment. It must be contemplated whether growth is an acceptable primary outcome measure or if there are other factors more relevant to consider in this often benign tumor entity
((Näslund O, Strand PS, Skoglund T, Solheim O, Jakola AS. Overview and recent advances in incidental meningioma. Expert Rev Anticancer Ther. 2023 Apr;23(4):397-406. doi: 10.1080/14737140.2023.2193333. Epub 2023 Mar 27. PMID: 36951191.))
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Active monitoring seems a safe and appropriate first-line management of incidental meningiomas. Intervention was avoided in > 40% with indolent tumors in a cohort. Treatment was not compromised by [[meningioma growth]]. Clinical follow-up seems sufficient beyond 5 years if self-limiting growth is established. Steady or accelerating growth warrant monitoring until they reach a stable state or intervention is initiated
((Strømsnes TA, Lund-Johansen M, Skeie GO, Eide GE, Behbahani M, Skeie BS. Growth dynamics of incidental meningiomas: A prospective long-term follow-up study. Neurooncol Pract. 2022 Nov 12;10(3):238-248. doi: 10.1093/nop/npac088. PMID: 37188168; PMCID: PMC10180371.))