[The role of radiotherapy in the treatment of malignant meningiomas]

Outcome After Protontherapy for Progression or Recurrence of Surgically Treated Meningioma

Background

To assess the outcome after meningioma surgery and protontherapy (PT).

Methods

We processed the French Système National des Données de Santé database to retrieve appropriate cases of meningiomas operated and irradiated between 2008 and 2017. Survival methods were implemented.

Results

One hundred ninety-three patients who received PT after meningioma surgery over a 10-year period were identified. Of the 193 patients, 75.6% were female. Median age at surgery was 50 years (interquartile range [IQR] 41–62). The median number of PT fractions was 31 (IQR 30–39) given over a median duration of 52 days (IQR 44–69). Fourteen patients (7.3%) also received photon radiotherapy and six patients (3.1%) stereotactic radiosurgery. Median follow-up was 4.4 years (IQR 3.86–4.71). Five-year progression-free survival (PFS) rate was 69% (95% confidence interval [CI] 62.1–76.6). For benign, atypical, and malignant meningioma, 5-year PFS rates were 71.5% (95% CI 64.4–79.4), 55.6% (95% CI 32.5–95), and 35.6% (95% CI 12.8–98.9), respectively (p<0.01). In the adjusted regression, tumour location (hazard ratio [HR]=0.1, 95% CI 0.05–0.22, p<0.001), aggressive meningioma (HR=2.26, 95% CI 1.1–4.66, p=0.027), and the need of cerebrospinal fluid (CSF) insertion for hydrocephalus (HR=3.51, 95% CI 1.32–9.31, p=0.012) remained significantly associated to the PFS. All grades considered, 5-year overall survival (OS) rates was 89.7% (95% CI 84.6–95.1). For benign, atypical, and malignant meningioma, 5-year OS rates were 93% (95% CI 88.7–97.4), 76.4% (95% CI 51.4–100), and 44.4% (95% CI 16.7–100), respectively (p<0.01). In the multivariable regression, an older age above 70 years (HR=5.95, 95% CI 2.09–16.89, p<0.001) associated to a high level of comorbidities (HR=5.31, 95% CI 1.43–19.78, p=0.013) and a malignant meningioma (HR=5.68, 95% CI 1.54–20.94, p=0.009) remained significantly associated to a reduced OS.

Conclusion

Five-year PFS and OS after meningioma surgery and PT is favourable but impaired for older patients with high level of morbidities, tumour of the convexity, malignant histopathology and for those requiring CSF shunting. Further inclusion and prolonged follow-up is required to assess other predictors such as sex, tumour volume, or given dose.

Meningiomas: knowledge base, treatment outcomes, and uncertainties. A RANO review

Evolving interest in meningioma, the most common primary brain tumor, has refined contemporary management of these tumors. Problematic, however, is the paucity of prospective clinical trials that provide an evidence-based algorithm for managing meningioma. This review summarizes the published literature regarding the treatment of newly diagnosed and recurrent meningioma, with an emphasis on outcomes stratified by WHO tumor grade. Specifically, this review focuses on patient outcomes following treatment (either adjuvant or at recurrence) with surgery or radiation therapy inclusive of radiosurgery and fractionated radiation therapy. Phase II trials for patients with meningioma have recently completed accrual within the Radiation Therapy Oncology Group and the European Organisation for Research and Treatment of Cancer consortia, and Phase III studies are being developed. However, at present, there are no completed prospective, randomized trials assessing the role of either surgery or radiation therapy. Successful completion of future studies will require a multidisciplinary effort, dissemination of the current knowledge base, improved implementation of WHO grading criteria, standardization of response criteria and other outcome end points, and concerted efforts to address weaknesses in present treatment paradigms, particularly for patients with progressive or recurrent low-grade meningioma or with high-grade meningioma. In parallel efforts, Response Assessment in Neuro-Oncology (RANO) subcommittees are developing a paper on systemic therapies for meningioma and a separate article proposing standardized end point and response criteria for meningioma.

Linac-based stereotactic radiotherapy and radiosurgery in patients with meningioma

BACKGROUND

It was our purpose to analyze long-term clinical outcome and to identify prognostic factors after Linac-based fractionated stereotactic radiotherapy (Linac-based FSRT) and stereotactic radiosurgery (SRS) in patients with intracranial meningiomas.

MATERIALS AND METHODS

Between 10/1995 and 03/2009, 297 patients with a median age of 59 years were treated with FSRT for intracranial meningioma. 50 patients had a Grade I meningioma, 20 patients had a Grade II meningioma, 12 patients suffered from a Grade III tumor, and in 215 cases no histology was obtained (Grade 0). Of the 297 patients, 144 underwent FSRT as their primary treatment and 158 underwent postoperative FSRT. 179 patients received normofractionated radiotherapy (nFSRT), 92 patients received hypofractionated FSRT (hFSRT) and 26 patients underwent SRS. Patients with nFSRT received a mean total dose of 57.31 ± 5.82 Gy, patients with hFSRT received a mean total dose of 37.6 ± 4.4 Gy and patients who underwent SRS received a mean total dose of 17.31 ± 2.58 Gy.

RESULTS

Median follow-up was 35 months. Overall progression free survival (PFS) was 92.3% at 3 years, 87% at 5 years and 84.1% at 10 years. Patients with adjuvant radiotherapy showed significantly better PFS-rates than patients who had been treated with primary radiotherapy. There was no significant difference between PFS-rates of nFSRT, hFSRT and SRS patients. PFS-rates were independent of tumor size. Patients who had received nFSRT showed less acute toxicity than those who had received hFSRT. In the Grade 0/I group the rate of radiologic focal reactions was significantly lower than in the atypical/malignant histology group.

CONCLUSION

This large study showed that FSRT is an effective and safe treatment modality with high PFS-rates for intracranial meningioma. We identified "pathological grading" and and "prior surgery" as significant prognostic factors.

Fractionated proton radiotherapy for benign cavernous sinus meningiomas

PURPOSE

To evaluate the efficacy of fractionated proton radiotherapy for a population of patients with benign cavernous sinus meningiomas.

METHODS AND MATERIALS

Between 1991 and 2002, 72 patients were treated at Loma Linda University Medical Center with proton therapy for cavernous sinus meningiomas. Fifty-one patients had biopsy or subtotal resection; 47 had World Health Organization grade 1 pathology. Twenty-one patients had no histologic verification. Twenty-two patients received primary proton therapy; 30 had 1 previous surgery; 20 had more than 1 surgery. The mean gross tumor volume was 27.6 cm(3); mean clinical target volume was 52.9 cm(3). Median total doses for patients with and without histologic verification were 59 and 57 Gy, respectively. Mean and median follow-up periods were 74 months.

RESULTS

The overall 5-year actuarial control rate was 96%; the control rate was 99% in patients with grade 1 or absent histologic findings and 50% for those with atypical histology. All 21 patients who did not have histologic verification and 46 of 47 patients with histologic confirmation of grade 1 tumor demonstrated disease control at 5 years. Control rates for patients without previous surgery, 1 surgery, and 2 or more surgeries were 95%, 96%, and 95%, respectively.

CONCLUSIONS

Fractionated proton radiotherapy for grade 1 cavernous sinus meningiomas achieves excellent control rates with minimal toxicities, regardless of surgical intervention or use of histologic diagnosis. Disease control for large lesions can be achieved by primary fractionated proton therapy.

Stereotactic radiosurgery and radiotherapy in benign intracranial meningioma

PURPOSE

To investigate the role of stereotactic radio surgery (SRS) and hypo-fractionated stereotactic radiotherapy (SRT) in treatment of benign intracranial meningioma.

PATIENTS AND METHODS

Between 2003 and 2010, 32 patients with a median age of 44 years (range 21-67 years) were treated with SRS (n=19), and hypo-fractionated SRT (n=13) for intracranial meningioma. Fourteen patients underwent SRS or SRT as their primary treatment, while 18 patients underwent post operative SRS or SRT (PORT). Cumulative progression free survival, overall cumulative survival, toxicity and symptomatology were evaluated.

RESULTS

The median follow up period was 39 months (range 6-72 months). The 5 year overall survival and progression free survival were 90 ± 5% and 94 ± 4% after SRT or SRS respectively. Symptoms were improved or stable in 94% of patients. Acute toxicity was mild, and was seen in 41% of patients. Clinically significant late morbidity or new cranial nerve palsies did not occur.

CONCLUSION

Stereotactic radio surgery (SRS) and hypo-fractionated stereotactic radiotherapy (SRT) are effective and safe treatment modality for local control of meningioma with low risk of significant late toxicity. In case of large tumor size and adjacent critical structures, hypo-fractionated SRT is highly recommended.

Combined proton and photon conformal radiotherapy for intracranial atypical and malignant meningioma

PURPOSE

To evaluate retrospectively the efficacy of conformal fractionated radiotherapy combining proton and photon beams after primary surgery for treatment of atypical and malignant meningiomas.

PATIENTS AND METHODS

Between September 1999 and October 2006, 24 patients (12 male, 12 female) with histopathologically proven meningioma (atypical 19, malignant 5) received postoperative combined radiotherapy with a 201-MeV proton beam at the Centre Protontherapie d'Orsay and a high-energy photon beam. Six patients underwent gross total resection and 18 a subtotal resection. Median gross tumor volume and clinical target volume were 44.7 cm(3) and 153.3 cm(3), respectively. Mean total irradiation dose was 65.01 CGE (cobalt gray equivalent), with a mean proton total dose of 34.05 CGE and a mean photon total dose 30.96 CGE.

RESULTS

The median (range) follow-up interval was 32.2 (1-72) months. The overall mean local relapse-free interval was 27.2 (10-50) months, 28.3 (10-50) months for atypical meningioma and 23 (13-33) months for malignant meningioma. Ten tumors recurred locally. One-, 2-, 3-, 4-, 5-, and 8- year local control rates for the entire group of patients were 82.9% +/- 7.8%, 82.9% +/- 7.8%, 61.3% +/- 11%, 61.3% +/- 11%, 46.7% +/- 12.3%, and 46.7% +/- 12.3%, respectively. One-, 2-, 3-, 4-, 5-, and 8- year overall survival rates were 100%, 95.5% +/- 4.4%, 80.4% +/- 8.8%, 65.3% +/- 10.6%, 53.2% +/- 11.6%, and 42.6% +/- 13%, respectively. Survival was significantly associated with total dose. There was no acute morbidity of radiotherapy. One patient developed radiation necrosis 16 months after treatment.

CONCLUSIONS

Postoperative combination of conformal radiotherapy with protons and photons for atypical and malignant meningiomas is a well-tolerated treatment producing long-term tumor stabilization.

Prolonged Oral Hydroxyurea and Concurrent 3d-Conformal Radiation in Patients with Progressive or Recurrent Meningioma: Results of a Pilot Study

PURPOSE

Treatment of recurrent and progressive meningiomas remains a challenge in clinical neurooncology. This study was designed to evaluate the efficacy of the simultaneous application of 3d-conformal radiotherapy and chemotherapy with hydroxyurea (HU).

PATIENTS AND METHODS

Twenty-one patients with recurrent or progressive meningiomas (13 benign, 4 atypical and malignant, 4 with unproven histology) received treatment by fractionated 3d-conformal radiation (55.8-59.4 Gy) and concurrent HU, administered for a median time of three months with a daily dosage of 20 mg/kg. Response was evaluated using clinical and neuro-imaging data.

RESULTS

Disease stabilization was achieved in 14/21 patients (pts). Three pts had significant improvement of tumor associated neurological symptoms with imaging criteria of minor response. Progression free survival rates 1 year and 2 years after the initiation of radio-chemotherapy were 84% and 77%, respectively. At the time of analysis a total of 6/21 pts presented with progressive disease with a median time to progression of 59 weeks. Documented radio- and chemotherapy associated toxicity was minimal; only one patient discontinued HU treatment due to gastrointestinal symptoms such as anorexia and weight loss.

CONCLUSION

Results obtained in this study indicate that treatment with HU and simultaneous radiotherapy is safe and effective with disease stabilization in the majority of patients. Randomized trials comparing radiosurgery versus radiochemotherapy versus fractionated radiotherapy are warranted.