Anaplastic meningioma: an analysis of the National Cancer Database from 2004 to 2012

Prognostic role of extent of resection and adjuvant radiotherapy in de novo anaplastic meningiomas

PURPOSE

Grade 3 meningiomas, although rare, are associated with high morbidity and mortality. The respective impacts of extent of surgical resection and adjuvant radiotherapy are still debated. Moreover, anaplastic meningiomas are studied in heterogenous cohort of de novo and progressive anaplastic tumors.

METHODS

We conducted a retrospective multicentric study on patients operated from a de novo anaplastic meningioma between 1999 and 2021. A centralized pathological review using 2016 WHO criteria was performed for all cases. Patients with history of radiotherapy or NF2-related Schwannomatosis were excluded.

RESULTS

Sixty-five patients were included in the study. Median progression free survival was 23 months and median overall survival was 2 years. Neither quality of resection nor adjuvant radiotherapy alone were predictive of better overall survival. Progression free survival were impacted by combination of gross-total resection and adjuvant radiotherapy (HR = 0.47 CI95% = [0.24-0.92], p = 0.027) and age at diagnosis (HR = 2.92 CI95% = [1.38-6.21], p = 0.005) in univariate analyses. Within anaplastic tumors, those graded on mitosis number had a poorer prognosis than those graded on overt anaplasia. Among anaplastic tumors with high mitotic score (> 20/10HPF), progression free survival were impacted by postoperative radiotherapy (HR = 0.44 CI95% = [0.22-0.88], p = 0.020) and gross total resection and adjuvant radiotherapy association (HR = 0.44 CI95% = [0.21-0.90], p = 0.024) in univariate analyses.

CONCLUSION

Simpson grade didn't show any impact on overall survival. Gross total resection + adjuvant radiotherapy favorably impacted progression free survival in our cohort of de novo anaplastic meningiomas.

Mathematical modeling of meningioma volume change after radiation treatment

OBJECTIVE

Meningiomas are the most common primary central nervous tumor and are often treated with radiation therapy. This study examines the long-term volumetric changes of intracranial meningiomas in response to radiation therapy. The objective is to analyze and model the volumetric changes following treatment.

METHODS

Data from a retrospective single-institution database (2005-2015) were used, with inclusion criteria being patients with a diagnosis of meningiomas, along with additional inclusion criteria consisting of treatment with radiation, having at least three magnetic resonance imaging (MRI) scans with one or more before and after radiation treatment, and the patients following up for at least eighteen months. Exclusion criteria consisted of patients less than 18 years old, patients receiving surgery and/or adjuvant chemotherapy following radiation, and patients without any available details regarding radiation treatment parameters. Tumor volumes were measured via T1-weighted post-contrast MRI and calculated using the ABC/2 ellipsoidal approximation, a method allowing for the measurement of non-linear growth volume reduction.

RESULTS

Of 48 meningioma patients considered, 10 % experienced post-radiation growth, while 75 % witnessed a ≥50 % decrease in volume over a follow-up period of 0.3-14.9 years. Median decay rate was 0.81, and within 1.17 years, 90 % achieved the predicted volume reduction. Predicted vs. actual volumes showed a mean difference of 0.009 ± 0.347 cc. Initial tumor volumes strongly correlated (Pearson's R=0.98, R-squared=0.96) with final asymptotic volumes, which had a median of 1.50 cc, with interquartile range (IQR) = [0.39, 3.67].

CONCLUSION

90 % of patients achieved tumor-volume reduction at 1.17 years post-treatment, reaching a non-zero asymptote strongly correlated with initial tumor volume, and 75 % experienced at least a 50 % volume decrease. Individual volume changes for responsive meningiomas can be modeled and predicted using exponential decay curves.

The role of adjuvant radiotherapy for intracranial malignant meningiomas: analysis of a nationwide database

PURPOSE

This study aimed to examine the effect of postoperative radiotherapy on survival outcomes in patients with malignant meningiomas.

METHODS

We identified patients with malignant meningioma diagnosed between 2007 and 2018 using the Taiwan Cancer Registry and followed them up using the death registry. Survival was compared between patients with and without adjuvant radiotherapy. The potential confounding factors evaluated in this study included age, sex, comorbidities, and the Charlson Comorbidity Index (CCI).

RESULTS

The analysis included 204 patients; 94 (46%) received adjuvant radiotherapy. The two groups had similar sex distributions (p = 0.53), mean age (p = 0.33), histologic subtype (p = 0.13), and CCI (p = 0.62). The prognosis of malignant meningioma was poor, with a median overall survival (OS) of 2.4 years. The median OS was 3.0 years (interquartile range (IQR) [1.4-6.1], and 2.0 years (IQR [0.5-3.9]) in the radiotherapy and non-radiotherapy groups, respectively (p = 0.001). However, Kaplan-Meier curves with the log-rank test showed no significant difference in OS between the two groups (p = 0.999). Controlling for age group, sex, histologic subtype, treatment, comorbidities, and CCI, adjuvant radiotherapy did not impart a survival benefit (hazard ratio [HR] = 0.87; 95% confidence interval [CI]: 0.6‒1.26); however, only factor of higher comorbidity score (HR = 2.03, 95%CI: 1.04‒3.94) was associated with unfavorable survival.

CONCLUSION

This population-based retrospective analysis suggests that the role of radiotherapy remains unclear and underscores the need for randomized clinical trials to assess the usefulness of adjuvant radiotherapy in malignant meningioma.

A nomogram to predict cancer-specific mortality in adult patients with malignant meningioma: a competing risk analysis

BACKGROUND

Comprehensive investigations of the prognosis factors and treatment strategies with adjustment of competing causes of death for patients with malignant meningioma (MM) is still lacking.

PATIENT AND METHOD

The surveillance, Epidemiology, and End Results (SEER) database were used to include adult patients with this rare disease between 2004 and 2018. The probability of MM-caused mortality (MMCM) and non-MM-caused mortality (non-MMCM) were presented by cumulative incidence function curves. Then, the association between variates with non-MMCM was evaluated by the cox proportional hazard model, and the prognostic factors of MMCM were identified by Fine-Gray competing risk regression model. Furthermore, a nomogram was developed to predict the 1-year, 2-year, and 5-year MMCM and the performance was tested by a time-dependent area under the receiver operating characteristic (ROC) curve and calibration.

RESULT

577 patients were included, with a median age of 62 (18-100) years old and a median overall survival time of 36 (0-176) months. The percentage of non-MMCM was 15.4% (n = 89) in the entire population and 21.7% (n = 54) in elderly patients. The multivariable Cox proportional hazard regression model revealed that older age and other tumor(s) before or after MM had an independently significant association with higher non-MMCM. After adjustment of competing causes of death, the multivariable Fine-gray regression model identified age group ≥ 65 year, tumor size > 5.3 cm, recurrent MM, and histologic type 9530/3 (Meningioma, malignant) had an independently significant association with higher MMCM. Compared with gross total (GTR) of tumor, subtotal resection of tumor (HR 1.66, 95%CI 1.08-2.56, P = 0.02), partial resection of lobe (HR 2.26, 95%CI 1.32-3.87, P = 0.003), and gross total resection of lobe (HR 1.69, 95%CI 1.12-2.51, P = 0.01) had an independently significant association with higher MMCM.

CONCLUSION

The competing risk nomogram including age group, tumor size, initial status, histologic type, and extent of resection is discriminative and clinically useful. This study emphasized the importance of the GTR of tumor in the treatment of MM patients, which had a significantly lower incidence of MMCM compared with biopsy, STR of tumor, partial resection of lobe, and GTR of lobe.

Atypical and anaplastic meningiomas in the later decades of life: A national cancer database analysis

PURPOSE

We conducted a National Cancer Database (NCDB) study to investigate the epidemiological characteristics and identify predictors of outcomes associated with geriatric meningiomas.

METHODS

The NCDB was queried for adults aged 60-89 years diagnosed between 2010 and 2017 with grade 2 and 3 meningiomas. The patients were classified into three age groups based on their age: 60-69 (hexagenarians), 70-79 (septuagenarians), and 80-89 (octogenarians). The log-rank test was utilized to compare the differences in overall survival (OS). Univariate and multivariate Cox proportional hazards regressions were used to evaluate the mortality risk associated with various patient and disease parameters.

RESULTS

A total of 6585 patients were identified. Hexagenerians were the most common age group (49.8%), with the majority of meningiomas being classified as grade 2 (89.5%). The incidence of high-grade meningiomas increased in all age groups during the study period. Advanced age, male sex, black race, lower socioeconomic status, Charlson-Deyo score ≥ 2, and higher tumor grade were independent factors of poor survival. Among the modes of treatment, the extent of surgical resection, adjuvant radiotherapy, and treatment at a noncommunity cancer program were linked with better outcomes.

CONCLUSION

In geriatric patients with high-grade meningiomas, the greater extent of surgical resection and radiotherapy are associated with improved survival. However, the management and outcome of geriatric patients with higher-grade meningiomas are also associated with several socioeconomic factors.

Surgical Management of High-Grade Meningiomas

Maximal resection with the preservation of neurological function are the mainstays of the surgical management of high-grade meningiomas. Surgical morbidity is strongly associated with tumor size, location, and invasiveness, whereas patient survival is strongly associated with the extent of resection, tumor biology, and patient health. A versatile microsurgical skill set combined with a cogent multimodality treatment plan is critical in order to achieve optimal patient outcomes. Continued refinement in surgical techniques in conjunction with directed radiotherapeutic and medical therapies will define future treatment.

Anaplastic Transformation of Sphenoid Wing Meningioma With Orbital and Cavernous Sinus Invasion: Unveiling the Aggressive Nature

Primary tumors in the central nervous system, known as meningiomas, are frequently found and constitute a substantial proportion of tumor cases. Although generally benign, there are occasional cases where they might exhibit malignant characteristics. Anaplastic meningioma is a rare subtype of malignant meningiomas, representing only a small proportion of cases. We present the case of a 70-year-old female patient who presented to the Neurosurgery Clinic of University Hospital "Saint George" with clinical manifestations of monocular vision and blurry vision in the right eye for three months. On physical examination, unilateral ptosis and mydriasis were noted in the left eye. MRI revealed an extra-axial mass located supratentorial in the left temporopolar region affecting the wing of the left sphenoidal bone, invading the cavernous sinus, suppressing the left and right optic nerves, and involving the left orbit. Operative treatment was performed through a left pterional craniotomy and resection of the tumor mass by microsurgical technique. The subdural, epidural, and intraorbital mass were resected. Total removal of the tumor was not achievable and subtotal resection was performed. Pathology results showed that the tumor mass was anaplastic meningioma. Surgery-related complications were not observed. Postoperatively, the patient was mobilized on the day after intervention and the control CT scan showed no ischemic or hemorrhagic events. The patient experienced relief in her symptoms and was discharged on the fifth day. The patient underwent radiation therapy, resulting in the complete removal of the left tumor in the cavernous sinus. After six months, no tumor recurrence was found, and a long-term follow-up is planned to monitor for possible recurrence.

Associations of race and socioeconomic status with outcomes after intracranial meningioma resection: a systematic review and meta-analysis

PURPOSE

Social determinants of health broadly affect healthcare access and outcomes. Studies report that minorities and low socioeconomic status (SES) patients undergoing intracranial meningioma resection demonstrate worse outcomes and higher mortality rates. This systematic review and meta-analysis summarizes the available research reporting racial and SES disparities in intracranial meningioma resection outcomes.

METHODS

A systematic review was conducted using PRISMA guidelines and included peer-reviewed, English-language articles from the United States between 2000 and 2022 that reported racial and SES disparities in meningioma outcomes. Outcomes included overall survival (OS), extent of resection (EOR), hospitalization costs, length of stay (LOS), 30-day readmission, recurrence, and receipt of surgery and adjuvant radiotherapy. A quantitative meta-analysis was performed only on survival outcomes by race. All other variables were summarized as a systematic review.

RESULTS

633 articles were identified; 19 studies met inclusion criteria. Black or low SES patients were more likely to have increased hospitalization costs, rates of 30-day readmission, LOS, recurrence and less likely to undergo surgery, gross total resection, and adjuvant radiotherapy for their tumors. Six studies were used for the quantitative meta-analysis of race and OS. Compared to White patients, Black patients had significantly worse survival outcomes, and Asian patients had significantly better survival outcomes.

CONCLUSION

Disparities in outcomes exist for patients who undergo surgery for meningioma, such that Black and low SES patients have worse outcomes. The literature is quite sparse and contains confounding relationships not often accounted for appropriately. Further studies are needed to help understand these disparities to improve outcomes.

Impact of a cell cycle and an extracellular matrix remodeling transcriptional signature on tumor progression and correlation with EZH2 expression in meningioma

OBJECTIVE

The authors searched for genetic and transcriptional signatures associated with tumor progression and recurrence in their cohort of patients with meningiomas, combining the analysis of targeted exome, NF2-LOH, transcriptome, and protein expressions.

METHODS

The authors included 91 patients who underwent resection of intracranial meningioma at their institution between June 2000 and November 2007. The search of somatic mutations was performed by Next Generation Sequencing through a customized panel and multiplex ligation-dependent probe amplification for NF2 loss of heterozygosity. The transcriptomic profile was analyzed by QuantSeq 3' mRNA-Seq. The differentially expressed genes of interest were validated at the protein level analysis by immunohistochemistry.

RESULTS

The transcriptomic analysis identified an upregulated set of genes related to metabolism and cell cycle and downregulated genes related to immune response and extracellular matrix remodeling in grade 2 (atypical) meningiomas, with a significant difference in recurrent compared with nonrecurrent cases. EZH2 nuclear positivity associated with grade 2, particularly with recurrent tumors and EZH2 gene expression level, correlated positively with the expression of genes related to cell cycle and negatively to genes related to immune response and regulation of cell motility.

CONCLUSIONS

The authors identified modules of dysregulated genes in grade 2 meningiomas related to the activation of oxidative metabolism, cell division, cell motility due to extracellular remodeling, and immune evasion that were predictive of survival and exhibited significant correlations with EZH2 expression.

Histone deacetylase inhibitors enhance oncolytic herpes simplex virus therapy for malignant meningioma

Approximately 20% of meningiomas are not benign (higher grade) and tend to relapse after surgery and radiation therapy. Malignant (anaplastic) meningioma (MM) is a minor subset of high-grade meningioma that is lethal with no effective treatment options currently. Oncolytic herpes simplex virus (oHSV) is a powerful anti-cancer modality that induces both direct cell death and anti-tumor immunity, and has shown activity in preclinical models of MM. However, clinically meaningful efficacy will likely entail rational mechanistic combination approaches. We here show that epigenome modulator histone deacetylase inhibitors (HDACi) increase anti-cancer effects of oHSV in human MM models, IOMM-Lee (NF2 wild-type) and CH157 (NF2 mutant). Minimally toxic, sub-micromolar concentrations of pan-HDACi, Trichostatin A and Panobinostat, substantively increased the infectability and spread of oHSV G47Δ within MM cells in vitro, resulting in enhanced oHSV-mediated killing of target cells when infected at low multiplicity of infection (MOI). Transcriptomics analysis identified selective alteration of mRNA processing and splicing modules that might underlie the potent anti-MM effects of combining HDACi and oHSV. In vivo, HDACi treatment increased intratumoral oHSV replication and boosted the capacity of oHSV to control the growth of human MM xenografts. Thus, our work supports further translational development of the combination approach employing HDACi and oHSV for the treatment of MM.

Anaplastic Meningioma: Clinical Characteristics, Prognostic Factors and Survival Outcome

BACKGROUND

Anaplastic meningioma is very rare and is generally known to have a poor prognosis. However, due to its rarity, the relationship between clinical prognosis and prognostic factors is not clear. We analyzed the prognostic factors influencing survival outcomes of patients with anaplastic meningioma. Moreover, we analyzed on the progression pattern and the response to treatment about anaplastic meningioma.

METHODS

Retrospective review of 48 patients with diagnosis of World Health Organization (WHO) grade 3 meningioma was performed. According to diagnosis type, primary anaplastic meningioma was included in 28 cases and secondary anaplastic meningioma in 20 cases. Gross total resection was performed in 36 patients (75.0%), and 32 patients (66.7%) received adjuvant radiotherapy after tumor resection with confirmed WHO grade 3 meningioma. Kaplan-Meier survival curve and Cox proportional hazards modeling were used for outcome analysis.

RESULTS

The median progression-free survival (PFS) and overall survival (OS) were 13.9 months (95% confidence interval [CI], 8.8 to 19.1) and 56.9 months (95% CI, 24.1 to 89.7), respectively. Adjuvant radiotherapy was a robust prognostic factor for PFS and OS. Extent of resection and diagnosis type which appeared to be significant prognostic factors in univariate analysis were failed to prove statistical significance in multivariate analysis.

CONCLUSION

Adjuvant radiotherapy is an essential treatment arm in patients with anaplastic meningiomas. Stereotactic radiosurgery seems to play an important role as a salvage treatment. But chemotherapy seems to have limited efficacy. Because of the disseminated nature of the disease, further investigations to improve survival outcome are needed.

Diagnostic and Therapeutic Strategy in Anaplastic (Malignant) Meningioma, CNS WHO Grade 3

Simple Summary

Only 1% of all meningioma diagnosis is classified as malignant (anaplastic) meningioma. Due to their rarity, clinical management of these tumors presents several gaps. In this review, we investigate current knowledge of anaplastic meningioma focusing on their pathological and radiological diagnosis, molecular assessment, and loco-regional and systemic management. Despite the current marginal role of systemic therapy, it is possible that the increasing knowledge of molecular altered pathways of the disease will lead to the development of novel effective systemic treatments.

Abstract

Background: Meningiomas are the most common primary central nervous system malignancies accounting for 36% of all intracranial tumors. However, only 1% of meningioma is classified as malignant (anaplastic) meningioma. Due to their rarity, clinical management of these tumors presents several gaps. Methods: We carried out a narrative review aimed to investigate current knowledge of anaplastic meningioma focusing on their pathological and radiological diagnosis, molecular assessment, and loco-regional and systemic management. Results: The most frequent genetic alteration occurring in meningioma is the inactivation in the neurofibromatosis 2 genes (merlin). The accumulation of copy number losses, including 1p, 6p/q, 10q, 14q, and 18p/q, and less frequently 2p/q, 3p, 4p/q, 7p, 8p/q, and 9p, compatible with instability, is restricted to NF2 mutated meningioma. Surgery and different RT approaches represent the milestone of grade 3 meningioma management, while there is a marginal role of systemic therapy. Conclusions: Anaplastic meningiomas are rare tumors, and diagnosis should be suspected and confirmed by trained radiologists and pathologists. Despite the current marginal role of systemic therapy, it is possible that the increasing knowledge of molecular altered pathways of the disease will lead to the development of novel effective systemic treatments.

Prognostic Factors and Treatment Strategies for Elderly Patients with Malignant Meningioma: A SEER Population-Based Study

OBJECTIVE

Malignant meningioma (MM) is a relatively rare disease with poor survival. Few studies had focused on MM in the elderly population. This study aims to explore the prognostic factors and optimal therapeutic strategy in elderly patients with MM.

METHODS

We took advantage of the Surveillance, Epidemiology, and End Results (SEER) database to include 275 adult patients with histologically confirmed MM between 2011 and 2018. The Kaplan-Meier curves were plotted by different covariates to reveal the survival probability. Univariate and multivariable Cox proportional hazard regression analyses were applied to identify prognostic factors for cancer-specific survival (CSS).

RESULTS

The multivariable analysis in the elderly group revealed that when compared with patients receiving gross total resection (GTR), patients receiving biopsy had significantly worse CSS (HR = 3.72; 95% CI: 1.35-10.21; P = 0.011), whereas patients receiving subtotal resection (STR) had nearly the same CSS (HR = 0.83; 95% CI: 0.37-1.86; P = 0.653). Meanwhile, postoperative radiotherapy (PORT) showed no significant association with CSS in the elderly patient group (HR = 0.94; 95% CI: 0.42-2.12; P = 0.888).

CONCLUSION

Surgical resection is recommended for elderly patients with MM in the absence of surgical contraindications, but GTR does not present survival benefit in the elderly patients compared with STR. Additional large-scale clinical studies are needed to explore the survival benefit of PORT applied in patients with MM.

Clinical factors and outcomes of malignant meningioma: a population-based study

OBJECTIVE

We aimed to investigate prognostic factors and outcomes of malignant meningioma and to construct a nomogram model of survival.

METHODS

Patients with malignant meningioma were collected from the Surveillance, Epidemiology, and End Results database. The nomogram was developed for the 3-, 5-, and 8-year prediction of overall survival (OS) and cancer-specific survival (CSS). Harrell's concordance index (C-index) and decision curve analysis (DCA) were used to verify the predicted effect of the nomogram.

RESULTS

Between 1998 and 2016, 806 adult patients with histologically confirmed malignant meningioma were included. The mean age at diagnosis was 61.0 years (median 61.0 years), with a range of 19-104 years. Univariate analysis revealed that male gender, distant metastasis, and age ≥ 80 years as significant adverse factors for OS and CSS. These factors remained significance in the multivariate analysis. The nomogram demonstrated satisfactory discrimination, with a C-index value of 0.663 for OS and 0.654 for CSS, respectively. For both OS and CSS, the DCA curves indicated that the nomogram model performed better than other clinical variables.

CONCLUSION

Older age, male gender, distant metastasis, and radiotherapy were significantly related to poor prognosis; and extent of resection did not affect survival.

High-grade meningiomas in octogenarian and elderly patients: A population-based SEER analysis

Knowledge on high-grade meningiomas in octogenarian and elderly patients is limited. We aimed to analyze the outcomes and identify factors that influence overall survival (OS) in this population, using data from the Surveillance, Epidemiology, and End Results (SEER) database.Patients (≥80 years old) diagnosed with high-grade meningiomas between 1990 and 2016 were retrieved from the SEER database. According to treatments received, patients were classified into three groups: observation, radiation only, and surgery (with or without radiation). A Cox proportional hazards regression model was used for univariate and multivariate analyses. Based on the inclusion criteria, 678 patients with high-grade meningiomas were included.Surgery was the most common treatment modality. The median OS was 32 months for patients who received surgery, compared with 20 months for observation (p = 0.001).The factors significantly associated with OS on multivariate analysis included increasing age (hazard ratio [HR] 1.353, p < 0.001), diagnosis after 2008 (HR 0.693, p = 0.022), and surgical treatment (HR 0.807, p = 0.028). Further analysis revealed increasing age (HR 1.451, p = 0.003), and subtotal resection (HR 1.275, p = 0.043) were significantly associated with worse OS following surgery. This is the largest clinical study of high-grade meningiomas in octogenarian and elderly patients conducted thus far. Age, treatment modality, and year of diagnosis were associated with OS in octogenarian and elderly patients with high-grade meningiomas. Patients who received subtotal resection had a worse prognosis than gross total resection.

Papillary meningioma of the central nervous system: a SEER database analysis

Papillary meningioma (PM) is a rare central nervous system tumor. We aimed to analyze the characteristics and outcomes of patients with PM (WHO grade III) and identify risk factors that influence survival using the Surveillance, Epidemiology, and End Results (SEER) database. Clinical characteristics, tumor features, and outcomes of 108 PM patients included in the SEER database between 1990 and 2016 were retrieved. Risk factors related to prognosis of PM were assessed by Kaplan-Meier curves and the Cox proportional hazards model. All 108 patients, including 65 males and 43 females (1.5:1), with a median age of 52 years (range, 9 to > 85 years) had undergone surgical resection. Gross total resection (GTR) was achieved in 50%, and 50% underwent subtotal resection (STR). While 55.6% underwent postoperative radiation therapy, 48% did not. The median disease-specific survival (DSS) was 128 months, and the 5-year DSS rate was 77%. In multivariate analysis, age ≤ 52 years and GTR were both independently associated with higher probability of DSS (p = 0.033 and p = 0.029, respectively). Stratification analysis showed that postoperative radiotherapy had no significant impact on the DSS, irrespective of resection extent (p = 0.172). Our SEER analysis showed that age and extent of resection were prognostic factors for PM, but race, tumor size, gender, chemotherapy, and postoperative radiotherapy did not significantly impact DSS of PM patients. There was no significant improvement in survival of patients who underwent radiotherapy and GTR, or radiotherapy and STR, compared with GTR or STR alone.

Analysis of Prognostic Factors of World Health Organization Grade Ⅲ Meningiomas

Objective

WHO grade III meningiomas are highly aggressive and lethal. However, there is a paucity of clinical information because of a low incidence rate, and little is known for prognostic factors. The aim of this work is to analyze clinical characteristics and prognosis in patients diagnosed as WHO grade III meningiomas.

Methods

36 patients with WHO grade III meningiomas were enrolled in this study. Data on gender, age, clinical presentation, preoperative Karnofsky Performance Status (KPS), histopathologic features, tumor size, location, radiologic findings, postoperative radiotherapy (RT), surgical treatment, and prognosis were retrospectively analyzed. Progression-free survival (PFS) and overall survival (OS) were evaluated using the Kaplan-Meier method. Univariate and multivariate analysis were conducted by the Cox regression model.

Results

Median PFS is 20 months and median OS is 36 months in 36 patients with WHO grade III meningiomas. Patients with secondary tumors which transformed from low grade meningomas had lower PFS (p=0.0014) compared with primary group. Multivariate analysis revealed that tumors location (PFS, p=0.016; OS, p=0.013), Ki-67 index (PFS, p=0.004; OS, p<0.001) and postoperative radiotherapy (PFS, p=0.006; OS, p<0.001) were associated with prognosis.

Conclusion

WHO grade III meningiomas which progressed from low grade meningiomas were more prone to have recurrences or progression. Tumors location and Ki-67 index can be employed to predict patient outcomes. Adjuvant radiotherapy after surgery can significantly improve patient prognosis.

Prognostic Value of Histopathological Features and Loss of H3K27me3 Immunolabeling in Anaplastic Meningioma: A Multicenter Retrospective Study

The diagnosis of anaplastic meningioma (AM) (WHO grade III) is based on the presence of a high mitotic index (MI) and/or overt anaplasia. Only few data exist about the reproducibility and prognostic value of overt anaplasia. Additionally, the prognostic value of H3K27me3 loss in AM has not yet been demonstrated. Our objectives were to evaluate the reproducibility and prognostic value of WHO criteria and H3K27me3 loss in a multicenter series of 66 AM. Interobserver reproducibility was good for the determination of WHO grade (Kappa = 0.671) and MI (intraclass correlation coefficient [ICC] = 0.649), and fair for assessment of overt anaplasia (Kappa = 0.366). Patients with meningiomas showing high MI had significantly shorter overall survival (OS) than patients with meningiomas showing overt anaplasia without high MI (p = 0.009). OS was significantly lower in case of overt anaplasia with low MI (<20/1.6 mm2) than in atypical meningiomas (p = 0.008). H3K27me3 loss was present in 10/47 (21%) of AM and independently associated with shorter OS (p = 0.036; Cox multivariate analysis), with a good reproducibility (Kappa = 0.643). In conclusion, the presence of overt anaplasia could give additional prognostic information in tumors lacking high MI. Finally, loss of H3K27me3 is an easy-to-use and reproducible marker of poorer prognosis.

High Tumor Mitochondrial DNA Content Correlates With an Improved Patient's Outcome in WHO Grade III Meningioma

Background: Studies have shown mitochondrial genome content (mtDNA content) varies in many malignancies. However, its distribution and prognostic values in high-grade meningioma remain largely unknown. In this retrospective study, we sought to assess a putative correlation between the mtDNA content and clinical characteristics. Methods: Mitochondrial DNA was extracted from 87 World Health Organization grade III meningioma samples using a qPCR method. The distribution of mtDNA content in WHO grade III meningioma and its correlations with clinical variables were assessed. Furthermore, we prognostic values were also determined. Results: Mean mtDNA content was 617.7 (range, 0.8-3000). There was no mtDNA distribution difference based on the histological subtypes (P = 0.07). Tumors with preoperative radiation were associated with lower mtDNA content (P = 0.041), whereas no correlations with other clinical variables were observed. A high mtDNA content was associated with significantly better PFS (P = 0.044) and OS (P = 0.019). However, in patients who received postoperative radiotherapy, low mtDNA content was associated with better PFS (P = 0.028), while no difference in OS was observed (P = 0.272). Low mtDNA content was also associated with better OS and PFS in subgroups of patients with ER negative status (PFS, P = 0.002; OS, P = 0.002). Conclusions: Consistent with other tumors, high mtDNA content was associated with better outcome in WHO grade III meningioma in our cohort. However, for patients who received post-operative radiation therapy, low mtDNA content was associated with better PFS. These findings suggest that mtDNA content may further be explored as a potential biomarker for high-grade meningioma patients and for those who received postoperative radiation therapy.

Management trends for anaplastic meningioma with adjuvant radiotherapy and predictors of long-term survival

OBJECTIVEThe purpose of this study was to describe effects of adjuvant radiotherapy (RT) for anaplastic meningiomas (AMs) on long-term survival, and to analyze patient and RT characteristics associated with long-term survival.METHODSThe authors queried a retrospective cohort of patients with AM from the National Cancer Database (NCDB) diagnosed between 2004 and 2015 to describe treatment trends. For outcome analysis, patients with at least 10 years of follow-up were included, and they were stratified based on adjuvant RT status and propensity matched to controls for covariates. Survival curves were compared. A data-driven approach was used to find a biologically effective dose (BED) of RT with the largest difference between survival curves. Factors associated with long-term survival were quantified.RESULTSThe authors identified 2170 cases of AM in the NCDB between 2004 and 2015. They observed increased use of adjuvant RT in patients treated with higher doses. A total of 178 cases met the inclusion criteria for outcome analysis. Forty-five percent (n = 80) received adjuvant RT. Patients received a BED of 80.23 ± 16.6 Gy (mean ± IQR). The median survival time was not significantly different (32.8 months for adjuvant RT vs 38.5 months for no RT; p = 0.57, log-rank test). Dichotomizing the patients at a BED of 81 Gy showed maximal difference in survival distribution with a decrease in median survival in favor of no adjuvant RT (31.2 months for adjuvant RT vs 49.7 months for no RT; p = 0.03, log-rank test), but this difference was not significant after false discovery rate correction. Age was a significant predictor for long-term survival.CONCLUSIONSAMs are aggressive tumors that carry a poor prognosis. Conventional adjuvant RT improves local control. However, the effect of adjuvant radiation on overall survival is unclear. Further investigation into this area is warranted.

ADC values of benign and high grade meningiomas and associations with tumor cellularity and proliferation - A systematic review and meta-analysis

INTRODUCTION

The aim of the present systematic review and meta-analysis was to compare the reported ADC values in different meningiomas and to analyze associations between ADC and cell count and proliferation activity in this tumor entity.

METHOD

MEDLINE library and SCOPUS database were screened for papers investigating ADC values of meningiomas up November 2019. The first primary endpoint of the systematic review was the reported ADC mean value of the meningioma groups. The second primary endpoint was the correlation coefficient between ADC values and proliferation index Ki 67 and cellularity.

RESULTS

For the discrimination analysis between benign and high grade meningioma 17 studies were suitable. There were 766 grade I tumors and 289 high grade meningiomas. The calculated mean ADC value of the benign grade I tumors was 0.93 × 10^-3mm²/s [95%-Confidence interval 0.84;1.03] and the mean value of the high-grade tumors was 0.77 × 10^-3mm²/s [95%-Confidence interval 0.73-0.80]. The pooled correlation coefficient between ADC and the proliferation index Ki 67 was r = -0.36 [95% CI -0.43; -0.28]. The pooled correlation coefficient between ADC and cellularity was r = -0.43 [95% CI -0.61; - 0.26].

CONCLUSION

No validated ADC threshold can be recommended for distinguishing benign from high grade meningiomas. Only a moderate inverse correlation was identified between ADC values and tumor microstructure in meningiomas and, therefore, ADC might not accurately enough to predict proliferation potential and cellularity in this entity.

Malignant Meningioma: An International Multicentre Retrospective Study

BACKGROUND

In contrast to benign meningiomas, malignant meningiomas (MM) are rare and associated with an unfavourable prognosis. Reports on MM concern fairly small cohorts, often comprising less than 30 cases.

OBJECTIVE

To describe the outcome MM and identify factors that may influence survival.

METHODS

Pathology reports and clinical data of 178 patients treated between 1989 and 2017 for a MM at 6 different international institutions were retrospectively reviewed. Seventy-six patients (42.7%) had a previous history of grade I or grade II meningioma. The patients underwent a total of 380 surgical resections and 72.5% received radiotherapy. Median follow-up was 4.5 yr.

RESULTS

At data collection, 111 patients were deceased (63.4%) and only 23 patients (13.7%) were alive without any residual tumor on the most recent scan. Median overall survival was 2.9 yr, 95% confidence interval [CI; 2.4, 4.5]. Overall survival rates at 1, 5, and 10 yr, respectively, were: 77.7%, 95% CI [71.6, 84.3], 40%, 95% CI [32.7, 49], and 27.9%, 95% CI [20.9, 37.3]. In the multivariable analysis, age at MM surgery <65 yr (hazard ratio [HR] = 0.44, 95% CI [0.29, 0.67], P < .001), previous benign or atypical meningioma surgery (HR = 1.9, 95% CI [1.23, 2.92], P = .004), completeness of resection (HR = 0.51, 95% CI [0.34, 0.78], P = .002), and adjuvant radiotherapy (HR = 0.64, 95% CI [0.42, 0.98], P = .039) were established as independent prognostic factors for survival.

CONCLUSION

This large series confirms the poor prognosis associated with MM, the treatment of which remains challenging. Patients under 65-yr-old with primary MM may live longer after complete resection and postoperative radiotherapy. Even with aggressive treatments, local control remains difficult to achieve.

Survival impacts of extent of resection and adjuvant radiotherapy for the modern management of high-grade meningiomas

PURPOSE

We aim to investigate the impacts of extent of resection and adjuvant radiotherapy on survival of high-grade meningiomas (WHO grade II-III) according to modern diagnosis and management.

METHODS

Patients with high-grade meningiomas were identified in the Surveillance Epidemiology and End Results (SEER) database between 2000 and 2015 and used for survival analysis. Propensity score matching (PSM) was conducted to reduce selection bias. Another 92 patients from Sun Yat-sen University Cancer Center (SYSUCC) were used for validation.

RESULTS

530 patients were enrolled from SEER. Patients with gross total resection (GTR) had no significantly different overall survival (OS) compared with those with subtotal resection (STR), even after performing PSM between these two groups. Multivariable analysis found that age ≥ 65 years (HR 2.22, P < 0.001), tumor diameter > 6 cm (HR 1.59, P = 0.004) and grade III tumor (HR 4.31, P < 0.001) were associated with worse OS. Stratification analysis showed that adjuvant radiotherapy conferred significantly improved OS for grade III meningiomas, but not for grade II meningiomas, regardless of resection extent. In SYSUCC cohort, resection extent was also not significantly associated with OS. However, patients with GTR (Simpson grade I-III) had distinctly increased progression-free survival (PFS) than those with STR (P < 0.001). Additionally, for grade II meningiomas after GTR, radiotherapy was unable to improve OS and PFS.

CONCLUSION

On modern management of high-grade meningiomas, GTR does not improve OS, but seems to be associated with increased PFS. Radiotherapy is reasonable as a supplement for treating grade III meningiomas, whereas its effect for grade II meningiomas remains uncertain and needs further validation by prospective study.

Biopsy proven metastatic meningioma: A case report and review of the literature

Meningiomas are the most common type of benign tumor found in the brain and are typically benign, slow-growing lesions. The current standard of care consists of surgical resection and subsequent postoperative radiotherapy to prevent local recurrence. Because of their indolent nature, meningiomas are rarely found to spread extracranially and develop distant metastases. We present the clinical, imaging, and pathologic features of a patient who had meningioma with multiple local recurrences, who was incidentally found to have metastatic disease in the lungs. In addition, we discuss details of this case in the context of the previously reported literature.

Immortal Time Bias in National Cancer Database Studies

PURPOSE

In studies evaluating the benefit of adjuvant therapies, immortal time bias (ITB) can affect the results by incorrectly reporting a survival advantage. It does so by including all deceased patients who may have been planned to receive adjuvant therapy within the observation cohort. Given the increase in National Cancer Database (NCDB) analyses evaluating postoperative radiation therapy (PORT) as an adjuvant therapy, we sought to examine how often such studies accounted and adjusted for ITB.

METHODS AND MATERIALS

A systematic review was undertaken to search MEDLINE and EMBASE from January 2014 until May 2019 for NCDB studies evaluating PORT. After appropriate exclusion criteria were applied, 60 peer-reviewed manuscripts in which PORT was compared with postoperative observation or maintenance therapy were reviewed. The manuscripts were reviewed to evaluate whether ITB was accounted for, the method with which it was adjusted for, impact factor, year of publication, and whether PORT was beneficial.

RESULTS

Of the 60 publications reviewed, 23 studies (38.3%) did not include an adjustment for ITB. Most studies that did adjust for ITB employed a single landmark (LM) time (n = 31), 4 used a sequential landmark analyses, and 2 used a time-dependent Cox model. In 23 of 31 studies (74.2%) that did adjust for ITB via a single LM time, the rationale behind why the specified LM time was chosen was not clearly explained. There was no relationship between adjusting for ITB and year of publication (P = .074) or whether the study was published in a high-impact journal (P = .55).

CONCLUSIONS

Studies assessing adjuvant radiation therapy by analyzing the NCDB are susceptible to ITB, which overestimates the effect size of adjuvant therapies and can provide misleading results. Adjusting for this bias is essential for accurate data representation and to better quantify the impact of adjuvant therapies such as PORT.

Effectiveness of Postoperative Radiotherapy on Atypical Meningioma Patients: A Population-Based Study

Purpose: It is controversial whether atypical meningioma patients undergoing gross-total resection (GTR) can benefit from postoperative radiotherapy (PORT). This study aimed to investigate the effectiveness of PORT on atypical meningioma patients.

Methods: Patients diagnosed with atypical meningioma from 2008 to 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The Kaplan–Meier survival curves were generated, and the log-rank test was used to compare the differences among groups. Univariable and multivariable COX regressions were conducted for survival analyses.

Results: A total of 1,014 patients were enrolled. The 5-years survival rate of the overall patients was 79.0%. PORT was performed in 315 (31.1%) patients. The utilization rates of PORT in patients undergoing GTR and undergoing subtotal resection (STR) were 26.7% and 42.2%, respectively. For patients undergoing STR, log-rank test showed that overall survival (OS) time was significantly longer in patients receiving PORT than those not (p = 0.026). For patients undergoing GTR, OS time did not show significant association with PORT (p = 0.339). In addition, patients undergoing STR with PORT had no significantly different OS time compared with those undergoing GTR with PORT (p = 0.398). Multivariable Cox regression analysis showed that receipt of PORT (p = 0.187) was not an independent predictor of OS after adjustment.

Conclusion: PORT may not prolong the OS in atypical meningioma patients undergoing GTR. However, patients undergoing STR may benefit from PORT and achieve similar OS to those undergoing GTR.

Primary management of atypical meningioma: treatment patterns and survival outcomes by patient age

PURPOSE

The initial management of atypical meningiomas poses a distinct clinical challenge in that treatment protocols have not been fully established, and outcomes, especially differences by patient age, have not been broadly measured. The National Cancer Database (NCDB) allows for analysis of a large, diverse patient population to determine clinical parameters and survival outcomes based on the initial treatment of patients with atypical meningiomas.

METHODS

Analysis of the NCDB yielded 3611 atypical meningioma patients treated between 2008 and 2012. Principal treatment paradigms included surgery with or without radiation. Survival estimates were calculated using Kaplan-Meier curves stratified by age at diagnosis for each treatment paradigm. Subset analysis was performed for socio-economic factors.

RESULTS

Overall 5-year survival rate was 77.6% and declined with increasing patient age (p < 0.0001). Five-year survival for patients ≤ 45 years undergoing surgery alone was 89.3 vs. 44.4% for those > 75 years (p < 0.0001). For patients undergoing surgery with adjuvant radiation, 5-year survival was 93.7% in those ≤ 45 years and 54.1% in those > 75 years (p < 0.0001). Use of adjuvant radiation was stable over time. Private-insured patients were more likely to receive adjuvant radiation (p = 0.0001).

CONCLUSIONS

Patients treated for atypical meningioma have high rates of 5-year survival. A marginal survival benefit of adjuvant radiation was observed for patients < 55 and > 75 years, while patients between 55 and 75 years tended to have slightly improved survival with surgery alone. Though surgery remains the standard of care in the primary treatment of atypical meningioma, the decision to administer radiation post-operatively has remained controversial.