Long-term follow up of children with meningiomas in Denmark: 1935 to 1984

Is location more determining than WHO grade for long-term clinical outcome in patients with meningioma in the first two decades of life?

OBJECTIVE

To identify factors for tumor relapse and poor outcome in patients with meningiomas in the first two decades of life.

METHODS

All patients ≤ 21 years of age who underwent resection of a meningioma at the department of neurosurgery, Medical University of Vienna between 1989 and 2022 were included in this retrospective study. Clinical and radiological data were extracted from the medical records. Outcome and tumor relapse were analyzed for tumor location, histological findings and extent of resection.

RESULTS

In this study 18 patients were included, 6 meningiomas were located in the skull base, 5 in the convexity and 7 in other locations including intraventricular and spine (2 patients each), falx, intraparenchymal and optic nerve sheath. Most frequent symptoms were seizures and cranial nerve palsy. In total 56% of the meningiomas were World Health organization (WHO) grade 1, 39% grade 2 and 5% grade 3. Gross total resection was achieved in 67%. The overall relapse rate was 61% and 50% underwent repeat surgery. All patients with convexity meningiomas became seizure free and had a favorable outcome. Relapse and clinical outcome were independent of WHO grade among the whole cohort but the outcome significantly depended on the WHO grade when patients with skull base meningiomas were analyzed as a subgroup. The relapse rate was significantly higher in cases of skull base location (100% vs. 42%, p = 0.038) and after subtotal resection (100% vs. 42%, p = 0.038). Clinical outcome was also significantly worse and the rate of complications was higher in patients with skull base meningiomas.

CONCLUSION

Patients with convexity meningiomas in the first two decades of life have a good outcome due to high chance of gross total resection. Patients with skull base meningioma are at high risk of relapse and poor outcome, particularly those with WHO grades 2 and 3. Subtotal resection in patients with skull base location is probably the main reason for this difference.

Quality of Life, Clinical, and Patient-Reported Outcomes after Pencil Beam Scanning Proton Therapy Delivered for Intracranial Grade WHO 1-2 Meningioma in Children and Adolescents

PURPOSE

The purpose of this study was to report the clinical and patient-reported outcomes of children and adolescents with intracranial meningioma treated with pencil beam scanning proton therapy (PBS-PT).

MATERIAL AND METHODS

Out of a total cohort of 207 intracranial meningioma patients treated with PBS-PT between 1999 and 2022, 10 (4.8%) were children or adolescents aged < 18 years. Median age was 13.9 years (range, 3.2-17.2). Six (60%) children were treated as primary treatment (postoperative PT, n = 4; exclusive PT, n = 2) and four (40%) at the time of tumor recurrence. Acute and late toxicities were registered according to Common Terminology Criteria of Adverse Events (CTCAE). Quality of life (QoL) before PBS-PT was assessed using PEDQOL questionnaires. Educational, functional, and social aspects after PT were assessed through our in-house developed follow-up surveys. Median follow-up time was 71.1 months (range, 2.5-249.7), and median time to last questionnaire available was 37.6 months (range, 5.75-112.6).

RESULTS

Five (50%) children developed local failure (LF) at a median time of 32.4 months (range, 17.7-55.4) after PBS-PT and four (80%) were considered in-field. One patient died of T-cell lymphoma 127.1 months after PBS-PT. Estimated 5-year local control (LC) and overall survival (OS) rates were 19.4% and 100.0%, respectively. Except for one patient who developed a cataract requiring surgery, no grade ≥3 late toxicities were reported. Before PT, patients rated their QoL lower than their parents in most domains. During the first year after PT, one child required educational support, one needed to attend to a special school, one had social problems and another three children required assistance for daily basic activities (DBA). Three years after PT, only one child required assistance for DBA.

CONCLUSIONS

The outcome of children with intracranial meningioma treated with PBS-PT is in line with other centers who have reported results of radiation therapy delivered to this particular patient group. This therapy provides acceptable functional status profiles with no high-grade adverse radiation-induced events.

Molecular profiling of pediatric meningiomas shows tumor characteristics distinct from adult meningiomas

In contrast to adults, meningiomas are uncommon tumors in childhood and adolescence. Whether adult and pediatric meningiomas differ on a molecular level is unclear. Here we report detailed genomic analyses of 37 pediatric meningiomas by sequencing and DNA methylation profiling. Histologically, the series was dominated by meningioma subtypes with aggressive behavior, with 70% of patients suffering from WHO grade II or III meningiomas. The most frequent cytogenetic aberrations were loss of chromosomes 22 (23/37 [62%]), 1 (9/37 [24%]), 18 (7/37 [19%]), and 14 (5/37 [14%]). Tumors with NF2 alterations exhibited overall increased chromosomal instability. Unsupervised clustering of DNA methylation profiles revealed separation into three groups: designated group 1 composed of clear cell and papillary meningiomas, whereas group 2A comprised predominantly atypical meningiomas and group 2B enriched for rare high-grade subtypes (rhabdoid, chordoid). Meningiomas from NF2 patients clustered exclusively within groups 1 and 2A. When compared with a dataset of 105 adult meningiomas, the pediatric meningiomas largely grouped separately. Targeted panel DNA sequencing of 34 tumors revealed frequent NF2 alterations, while other typical alterations found in adult non-NF2 tumors were absent. These data demonstrate that pediatric meningiomas are characterized by molecular features distinct from adult tumors.

How Important Is to Know the Psychosocial Performance in an Operated Child of Meningioma? Devil Is in the Details

Background:

Meningioma constitutes only 0.4%–4.1% of all the pediatric tumors. This article aims to find the impact of the pediatric meningioma surgery on the developmental and scholastic performance among these children over long-term follow-up.

Materials and Methods:

This study is a retrospective analysis of all the histopathological proven pediatric meningioma and a cross-sectional analysis to study the functional outcome, using Malin’s Intelligence Scale for Indian children (MISIC); scholastic performance was assessed from behavioral checklist for screening the learning disabled (BCSLD) and subjective self-filled questionnaire to know parent satisfaction.

Results:

Twenty-eight patients (mean age 14.52 ± 0.722 years) (M:F = 16:12) were analyzed (6 [21.4%] were grade-schooler and 22 [78.5%] were teenage), with most common symptom being headache (n = 20, 71.4%) and mean duration of symptoms was 11.19 ± 16.25 days. The mean intelligent quotient (IQ) of grade-schooler was 83.4 ± 9.072 compared to 75.69 ± 9.903 among teenage group. The BCSLD analyses showed that the postoperative score was poorer. Similarly, an average change in BCSLD was observed among the patients with complications (10) compared to the patients without complication (8).

Conclusion:

The discontinuation in schooling or lack of alternative education may lead to poor MISIC scores, wrongly categorizing the children in poor IQ group. In pediatric benign disease such as meningioma, the holistic approach should be opted from the time of first visit to neurological care team.

[Intracranial meningiomas in children]

Meningiomas are rare in children and distinguished from the tumors in adults by clinical and biological aspects. Moreover, some histological forms and localizations are even casuistic in adults. There were 178 patients younger 18 years old with brain tumors. All patients underwent surgery at the pediatric department for 5-year period. Meningiomas were diagnosed in 5 cases that accounted for 2.8% of the total number of brain tumors in children. The authors reported children with intracranial meningiomas and discussed certain features of the course of disease in these patients.

Morbidity in survivors of child and adolescent meningioma

BACKGROUND

The extent of initial surgical resection has been identified as the strongest prognostic indicator for survival in child and adolescent meningioma. Given the paucity of data concerning long-term outcome, the authors undertook a meta-analysis to analyze morbidity in survivors of this disease.

METHODS

Individual patient data were obtained from 19 case series published over the last 23 years through direct communication with the authors. Ordinal logistic regression models were used to assess the influence of risk factors on morbidity.

RESULTS

Of 261 patients, 48% reported a completely normal life with no morbidity, and 25% had moderate/severe meningioma-associated morbidity at last follow-up. Multivariate analysis identified relapse as the only independent variable associated with an increased risk of morbidity (odds ratio, 4.02; 95% confidence interval, 2.11-7.65; P ≤ .001). Univariate analysis also revealed an increased risk for patients with neurofibromatosis (odds ratio, 1.90; 95% confidence interval, 1.04-3.48; P = .04). Subgroup analysis identified a higher incidence of morbidity among patients who had intracranial tumors with a skull base location compared with a nonskull base location (P ≤ .001). Timing at which morbidity occurred was available for 70 patients, with persistence of preoperative tumor-related symptoms in 67% and as a result of therapy in 20%.

CONCLUSIONS

The majority of survivors of child and adolescent meningioma had no or only mild long-term morbidity, whereas 25% had moderate/severe morbidity, with a significantly increased risk in patients with relapsed disease. In the majority, morbidity occurred as a consequence of the tumor itself, justifying aggressive surgery to achieve gross total resection. However, for patients with neurofibromatosis and skull base meningioma, a more cautious surgical approach should be reserved.

Pediatric meningiomas: a single-center experience with 15 consecutive cases and review of the literature

OBJECTIVE

The goal of this study was to determine the epidemiology, clinical presentation, associated factors, pathological features, and treatment outcome of pediatric meningiomas in a single-center institution.

METHODS

Clinical data of 15 patients under 18 years of age operated on for meningiomas from January 1994 to December 2010 were reviewed.

RESULTS

The study group included nine males and six females (mean age of 13 years at surgery). The most common symptoms at presentation were headaches in 6 out of 15 (40 %), raised intracranial pressure in 3 out of 15 (20 %), and seizures in 3 out of 15 (20 %). Sole operated tumors were found in 12 out of 15 (80 %), whose location is as follows: parasagittal in 4 out of 12 (33.3 %), 2 in the convexity (16.6 %), 2 at the skull base (16.6 %), and 4 in other sites (33.3 %). Six children presented with radiation-induced (RT) meningiomas and five had evidence of neurofibromatosis type 2 (NF2). Three patients had multiple meningiomas (all of them had NF2). Simpson's grade I excision was achieved in 12 out of 15 (80 %). On histopathology, 11 out of 15 (73.3 %) were grade I and 4 out of 15 (26.6 %) were grade II (all of them atypical). Five tumors (33.3 %) recurred, four of which had RT or NF2. During the mean follow-up period of 5 years, 12 out of 15 (80 %) had a good outcome (GOS=5).

CONCLUSIONS

Childhood meningiomas are uncommon lesions with a slight male predominance. Absence of large series with long follow-up precludes any definite conclusions on the clinical course and outcome of these tumors. Associated factors (such as RT and NF2), location, and extent of excision appear to be more important than histopathological grade in predicting outcome.

Meningiomas and neurofibromatosis

Neurofibromatosis type 2 (NF2) is a rare genetic disorder predisposing to multiple benign tumors of the nervous system. Meningiomas occur in about half of NF2 patients, and are often multiple. Patients harboring seemingly isolated multiple meningiomas should be investigated to diagnose NF2 by careful familial history collection, detailed clinical examination (skin lesions and slit lamp examination of the lens), audiovestibular testing, and fine cranio-spinal Magnetic Resonance Imaging. Somatic mosaicism is frequent in NF2 and may explain a mild phenotype as, e.g. isolated multiple meningiomas. Neurofibromatosis type 1 is not associated with an increased risk of meningioma. Whether meningiomas are part of the schwannomatosis tumor phenotype or not remains debated. Meningiomas in NF2 patients are associated with a higher risk of mortality, and their treatment is challenging, but data about natural history of meningiomas in NF2 patients in the literature are sparse. Thus, knowledge of tumor behavior is essential in slow growing tumors like meningiomas, to balance the risk of treatment against the natural history of the disease, and to evaluate the efficiency of alternative therapeutics (radiation therapy or new drugs).

Childhood and juvenile meningiomas

PURPOSE

The purpose of this paper was to study the clinical characteristic, treatment, and prognosis of childhood meningioma.

MATERIALS AND METHODS

Fifty-four meningioma cases below the age of 18 have been treated in Huashan Hospital in the last 15 years (from 1993 to 2008), their sex and age distribution, clinical manifestation, radiological finding, pathological subtype, treatment, and prognosis are retrospectively analyzed, and the results are compared with those reported in the literature.

RESULTS

The ratio of male to female was 1.16:1 (29:25) and mean age was 13.14 years (ranging from 2.75 to 18 years). Five patients in this series were associated with neurofibromatosis-2. The most common symptoms and signs were the signs of increased intracranial pressure including headache, papilledema, and vomiting. The most common radiological finding was homogeneous enhancement with contrast. The most common locations of meningiomas in this series were intraventricular and anterior/middle fossa. All of these patients were surgically treated; resection both in Simpson grades I and II could be achieved in 39 out of 54 patients. Perioperative mortality was 3.7% (2 out of 54); the most common postoperative complications were intracranial infection and injury of cranial nerve. Fibroblastic meningiomas were the most common pathological subtype, and malignant and atypical meningiomas (both of grades II and III according to WHO classification) accounted for 18.5% of the whole series.

CONCLUSION

Childhood meningiomas are scarce in clinical practice, which are characterized with its male predominance, large size, distinctive radiological features, and high rate of atypical/malignant histological subtypes; favorable outcome is accessible with total removal.

Childhood and adolescent meningiomas: a report of 38 cases and review of literature

BACKGROUND

The aim is to study the clinical, radiological and pathological features of childhood and adolescent meningiomas and analyse outcome prognosticators.

METHOD

A retrospective analysis of the case records of patients less than 20 years of age operated for a meningioma in our institute since 1982 was performed. The variables analysed included age, sex, presentation, associated neurofibromatosis (NF), imaging characteristics, extent of resection and histopathology.

RESULTS

The study group included 20 males and 18 females with a mean age of 15.53 years. Eleven children (28.9%) had evidence of NF of whom three had NF2 with bilateral vestibular schwannomas. The common presenting symptoms were seizures (76.3%), raised intracranial tension (71%), and focal neurological deficits (39.4%). The location of the operated tumours were as follows: ten skull base (24.4%), ten falx/parasagittal (24.4%), eight spinal (19.5%), five convexity (12.2%), three posterior fossa (7.3%), three intraventricular (7.3%) and two optic nerve sheath (4.9%). Two children (4.9%) had cystic meningiomas. Grade I excision was achieved only in twenty tumours (48.8%). On histopathology, thirty (73.2%) were grade I, nine (21.9%) were grade II and two (4.9%) were grade III meningiomas. Seven tumours recurred of which six were located at the skull base. During the mean follow up period of 4.74 years, the majority, 32 (84.2%) had a good outcome and five (13.2%) had a poor outcome. One child (2.6%) expired due to post-operative sepsis.

CONCLUSION

Childhood meningiomas are uncommon but not rare lesions with a marginal male predominance. Absence of large series with long follow up precludes any definite conclusions on the clinical course and outcome. Uniform observations made in different series including ours, include a higher incidence of the skull base location and tumours with atypical histopathology. Favourable prognostic factors include younger age (< than 10 years), superficial location, total excision and absence of neurofibromatosis. Location and extent of excision appear to be more important than histopathology grade in predicting outcome.

Anaplastic meningioma in an adolescent: a report of a rare case and brief review of literature

OBJECTIVE

Anaplastic meningioma is an uncommon neoplasm in childhood and adolescence. Due to the rarity, treatment options for anaplastic meningioma in this age group are not clearly outlined.

CASE

A 15-year-old boy presented with a left forehead swelling with a history of a left frontal tumor. Radiological investigations revealed a dura-based tumor with a large extracranial and a smaller intracranial component. Craniotomy with near-total excision of the tumor was performed. Histopathological examination of the tumor showed features of an anaplastic meningioma. The patient is currently receiving radiotherapy and chemotherapy. However, he has developed scalp swellings while on radiotherapy.

CONCLUSION

Anaplastic meningioma is extremely rare in children. Extensive sampling is required to recognize the meningothelial nature of the tumor and immunohistochemistry helps in making an accurate diagnosis in such cases. Therapeutic interventions in such cases need to be closely monitored due to the aggressive behavior of this tumor.

Meningioma with dural venous sinus invasion and jugular vein extension

Meningiomas represent the most common benign intracranial neoplasm in adults, with a considerably lower incidence in children. The authors present the case of an intracranial meningioma with invasion of, and intraluminal extension into, the transverse and sigmoid sinuses, jugular bulb, and internal jugular vein, resulting in venous occlusion in a 14-year-old girl. Computed tomography scanning, MR imaging, and conventional angiography were performed preoperatively. The patient underwent a 2-stage resection: the supratentorial component was resected first, and the infratentorial and venous sinus and jugular vein components were subsequently removed using a combined skull base approach. Gross-total resection was achieved by opening the lateral dural sinus and removing the meningioma from within the transverse and sigmoid sinuses, the jugular bulb, and the internal jugular vein. The patient remained neurologically intact after the staged tumor resections. Postoperative imaging confirmed the gross-total resection. This case illustrates the unusual property of an intracranial meningioma to invade the intrasinusoidal space and extend into the jugular vein without adherence to the underlying venous endothelium of the jugular vein.

Primary intra-diploic meningioma in a child

BACKGROUND

Primary intra-diploic meningiomas are uncommon in childhood and, at the clinical onset, may be confused with other and more frequent bone tumours because they lack specific clinical and radiological characteristics. Surgery is indicated not only to remove the lesion but also to obtain an accurate histological diagnosis.

CASE REPORT

We report the case of a young girl who presented with a recently developed subcutaneous hard mass in the left pterional region. Neuroradiological investigations revealed an intra-osseous lytic mass with a sclerotic reaction. Diagnosis was possible only after the total removal of the tumour and its histological examination.