Patterns of Care and Outcomes of Adjuvant Radiotherapy for Meningiomas: A Surveillance, Epidemiology, and End Results and Medicare Linked Analysis

The multiomic landscape of meningiomas: a review and update

PURPOSE

Meningiomas are the most common primary brain tumor in adults. Traditionally they have been understudied compared to other central nervous system (CNS) tumors. However over the last decade, there has been renewed interest in uncovering the molecular topography of these tumors, with landmark studies identifying key driver alterations contributing to meningioma development and progression. Recent work from several independent research groups have integrated different genomic and epigenomic platforms to develop a molecular-based classification scheme for meningiomas that could supersede histopathological grading in terms of diagnostic accuracy, biological relevance, and outcome prediction, keeping pace with contemporary grading schemes for other CNS tumors including gliomas and medulloblastomas.

METHODS

Here we summarize the studies that have uncovered key alterations in meningiomas which builds towards the discovery of consensus molecular groups in meningiomas by integrating these findings. These groups supersede WHO grade and other clinical factors in being able to accurately predict tumor biology and clinical outcomes following surgery.

RESULTS

Despite differences in the nomenclature of recently uncovered molecular groups across different studies, the biological similarities between these groups enables us to likely reconciliate these groups into four consensus molecular groups: two benign groups largely dichotomized by NF2-status, and two clinically aggressive groups defined by their hypermetabolic transcriptome, and by their preponderance of proliferative, cell-cycling pathways respectively.

CONCLUSION

Future work, including by our group and others are underway to validate these molecular groups and harmonize the nomenclature for routine clinical use.

Male sex and presence of preoperative symptoms are associated with early recurrence of WHO grade I meningiomas after surgical resection: analysis from the nationwide Brain Tumor Registry of Japan

This study aimed to assess the risk factors for the recurrence of WHO grade I intracranial meningiomas using the Brain Tumor Registry of Japan (BTRJ) database. We extracted the data of 4641 patients with intracranial WHO grade I meningiomas treated only by surgical resection between 2001 and 2008. We conducted complete data analysis (n = 3690) and multiple imputation analysis (n = 4641) to adjust for missing data on tumor size. The influence of factors including age, sex, size, extent of resection, location, and preoperative symptoms on PFS was assessed. Univariate analyses of the complete data set showed that age did not affect PFS; however, male sex (p < 0.001), tumor size ≥ 30 mm (p < 0.001), low extent of resection, tumor location at the skull base (p < 0.001), and the presence of preoperative symptoms (p < 0.001) were risk factors for a significantly shorter PFS. Multivariate analysis demonstrated that male sex (p < 0.001) and presence of preoperative symptoms (p = 0.027) were independent risk factors for shorter PFS alongside large tumor size (p < 0.001) and non-gross total resection (p < 0.001). These results were confirmed for the imputed dataset. While most previous large nationwide studies of meningiomas have evaluated overall survival, progression-free survival has yet to be thoroughly examined. This study suggests that even histologically benign meningiomas may have a sex difference in postoperative behavior. This observation may provide clues to understanding the mechanism of meningioma cell proliferation.

Does the Timing of Radiosurgery after Grade 1 Meningioma Resection Affect Long-Term Outcomes?

BACKGROUND

Meningiomas are the most common benign intracranial tumors. Gamma Knife® stereotactic radiosurgery (GKSRS) has become a preferred management for recurrent or residual meningiomas. This study focuses on the relationship between tumor control and the time interval between resection of a World Health Organization (WHO) grade 1 meningioma and GKSRS.

METHODS

This single institution retrospective analysis reviewed our experience in 238 patients who underwent GKSRS after a pathologically confirmed WHO grade 1 meningioma resection. The median follow-up was 7.4 years. The median aggregate tumor volume at GKSRS was 6 cm3 and a median margin dose of 13 Gy was utilized. Neurological symptoms were evident in 60% of patients at the time of procedure.

RESULTS

Overall actuarial tumor control rates achieved were 91.3% at 5 years, 83.4% at 10 years, and 76% at 15 years. There were 35 patients (15%) who developed tumor progression within or directly adjacent to the GKSRS treatment field. The median time until progression was 6.3 years. The duration between surgical intervention and GKSRS did not show statistical significance at 3 months (p = 0.9), 6 months (p = 0.8), 12 months (p = 0.5), or 24 months (p = 0.9). Fifteen patients (6%) had tumor progression at an anatomically distinct location outside the GKSRS target volume. Neurological symptomatic improvement was more likely with early radiosurgery intervention (p = 0.007).

CONCLUSION

Postoperative GKSRS was associated with excellent long-term tumor control for WHO grade 1 meningiomas, regardless of the interval after initial surgery. In addition, earlier radiosurgery was associated with superior symptom improvement.

Outcomes following upfront radiation versus monitoring in atypical meningiomas: 16-year experience at a tertiary medical center

Background

The role of postoperative upfront radiotherapy (RT) in the management of gross totally resected atypical meningiomas remains unclear. This single-center retrospective review of newly diagnosed histologically confirmed cases of World Health Organization (WHO) Grade II atypical meningioma at Weill Cornell Medicine from 2004 to 2020 aims to compare overall survival (OS) and progression-free survival (PFS) of postoperative upfront RT versus observation, stratified by resection status (gross total resection [GTR] vs subtotal resection [STR]).

Methods

Ninety cases of atypical meningioma were reviewed (56% women; median age 61 years; median follow-up 41 months).

Results

In patients with GTR, hazard ratio (HR) of PFS was 0.09 for postoperative upfront RT versus observation alone (95% confidence interval [CI] 0.01–0.68; P = .02), though HR for OS was not significant (HR 0.46; 95% CI 0.05–4.45; P = .5). With RT, PFS was 100% at 12 and 36 months (compared to 84% and 63%, respectively, with observation); OS at 36 months (OS36) was 100% (compared to 94% with observation). In patients with STR, though PFS at 36 months was higher for RT arm versus observation (84% vs 74%), OS36 was 100% in both arms. HR was not significant (HR 0.76; 95% CI 0.16–3.5; P = .73).

Conclusions

This retrospective study suggests postoperative upfront RT following GTR of atypical meningioma is associated with improved PFS compared to observation. Further studies are required to draw conclusions about OS.

Effect of adjuvant radiotherapy after subtotal resection for WHO grade I meningioma: a propensity score matching analysis of the Brain Tumor Registry of Japan

PURPOSE

This study aimed to improve the understanding of the role of adjuvant radiotherapy (AR) after subtotal resection (STR) of World Health Organization (WHO) grade I meningiomas.

METHODS

We retrospectively reviewed the Brain Tumor Registry of Japan database. Among 7341 patients diagnosed with intracranial meningioma during 2001-2008, we identified 406 patients with WHO grade I meningioma treated with STR as initial treatment. Data on progression-free survival (PFS) were assessed for their relevance to clinical factors including age, sex, tumor location and size, presence of preoperative symptoms, and AR.

RESULTS

AR was administered for 73 patients (18.0%). Regrowth occurred in 90 cases (22.2%) during the median follow-up period of 6.0 years (interquartile range, 2.7-7.7 years). Multivariate Cox regression analysis of the entire cohort showed that no AR was associated with significantly shorter PFS (hazard ratio [HR] 2.52, 95% confidence interval [CI] 1.33-5.42, p = 0.004). The therapeutic effect of AR was confirmed for skull base, but not non-skull base, meningiomas (p = 0.003 and 0.69, respectively). Propensity score matching analysis balanced the influence of confounding factors to generate AR+ and AR- cohorts of 73 patients each. PFS was significantly longer in the AR+ cohort than in the AR- cohort (HR 3.46, 95% CI 1.53-8.59, p = 0.003). Subgroup analysis demonstrated the favorable effect of AR only for skull base meningiomas.

CONCLUSIONS

Our study revealed that AR improves tumor control after STR in WHO grade I meningiomas. However, this beneficial effect might be limited to skull base meningiomas.

Individual-patient prediction of meningioma malignancy and survival using the Surveillance, Epidemiology, and End Results database

Meningiomas are known to have relatively lower aggressiveness and better outcomes than other central nervous system (CNS) tumors. However, there is considerable overlap between clinical and radiological features characterizing benign, atypical, and malignant tumors. In this study, we developed methods and a practical app designed to assist with the diagnosis and prognosis of meningiomas. Statistical learning models were trained and validated on 62,844 patients from the Surveillance, Epidemiology, and End Results database. We used balanced logistic regression-random forest ensemble classifiers and proportional hazards models to learn multivariate patterns of association between malignancy, survival, and a series of basic clinical variables-such as tumor size, location, and surgical procedure. We demonstrate that our models are capable of predicting meaningful individual-specific clinical outcome variables and show good generalizability across 16 SEER registries. A free smartphone and web application is provided for readers to access and test the predictive models (www.meningioma.app). Future model improvements and prospective replication will be necessary to demonstrate true clinical utility. Rather than being used in isolation, we expect that the proposed models will be integrated into larger and more comprehensive models that integrate imaging and molecular biomarkers. Whether for meningiomas or other tumors of the CNS, the power of these methods to make individual-patient predictions could lead to improved diagnosis, patient counseling, and outcomes.

Geographical Differences in Intracranial Meningioma Management: Examining 65,973 Patients across the United States

Background  Age, tumor size and location, overall health, and patient preference are primary considerations driving treatment decision-making for intracranial meningiomas. However, even for the same individual patient, treatment recommendations may vary between centers and providers. Objective  To study associations between geography, disease presentation, and management of intracranial meningioma in the United States. Methods  The population-based Surveillance, Epidemiology, and End Results(SEER) data were queried between 2004 and 2014 for cases of intracranial meningioma. Results  A total of 65,808 patients with intracranial meningioma were identified. Univariate analyses demonstrated strong associations between geographic location, age, and size of tumor at presentation. The mean age for all registries was 64.2 years, with a range from 62.0 (Utah registry) to 66.6 (Detroit registry). The greatest proportion of small tumors (<1 cm) were identified in the Utah registry (13.9% of tumors), while the greatest proportion of large tumors (> 4cm) were noted in the Hawaii registry (30.7% of tumors). Multivariable analysis demonstrated that the impact of geography on treatment selection was just as important as other established variables. For example, the distribution in tumor size between New Mexico and Greater California registries is nearly identical; however, the odds ratio for surgery was 1.5 times greater for the New Mexico population. Conclusion  These data suggest that disease presentation and treatment are significantly influenced by regional referral patterns, provider or institutional treatment preferences, and regional availability of subspecialty expertise. Understanding such biases is important for patients, referring physicians, and treatment providers in an effort to provide balanced counseling and treatment.

Adjuvant treatment of meningioma with stereotactic radiation surgery and hypofractionated stereotactic radiation surgery: Patterns of care and survival in a large, hospital database

OBJECTIVES

Stereotactic radiation surgery (SRS) and hypofractionated stereotactic radiation surgery (HF-SRS) have become an alternative to external beam radiation therapy (EBRT) in the adjuvant treatment of meningiomas. The purpose of this study was to identify national treatment patterns and survival outcomes for meningiomas on the basis of radiation treatment modality in the adjuvant setting.

METHODS AND MATERIALS

The National Cancer Database was queried for patients with meningioma diagnosed between 2010 and 2012. World Health Organization grade I disease with subtotal resection and all cases of grade II disease regardless of the extent of the resection were included. Logistic regression was used to determine factors that were associated with receipt of SRS/HF-SRS compared with EBRT. Cox regression was used to determine covariables associated with differences in overall survival (OS).

RESULTS

A total of 802 patients met the inclusion criteria of which 173 patients received SRS/HF-SRS (22%) and 629 patients (78%) received EBRT. The 3-year OS rate was 97.3% for the SRS/HF-SRS group and 93.4% for the EBRT group (P = .018). On subgroup analysis by grade, for grade I the 3-year OS rate was 98.3% for the SRS/HF-SRS group versus 96.7% for the EBRT group (P = .117). For grade II disease, the 3-year OS rate was 94.4% in the SRS/HF-SRS group versus 92.4% in the EBRT group (P = .199). On multivariable analysis, World Health Organization grade II histology (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.21-0.56; P < .001) and gross total resection (OR: 0.29; 95% CI, 0.15-0.57; P < .001) were associated with a decreased likelihood of receiving SRS/HF-SRS but private insurance (OR: 8.89; 95% CI, 1.15-68.47; P = .036) and Medicare (OR: 10.03; 95% CI, 1.28-78.69; P = .028) were associated with an increased likelihood of receiving SRS/HF-SRS. Year of diagnosis was not associated with receipt of SRS/HF-SRS. The multivariable Cox regression demonstrated a trend toward improved OS for treatment with SRS/HF-SRS (hazard ratio: 0.24; 95% CI, 0.06-1.03; P = .055).

CONCLUSIONS

SRS and HF-SRS are associated with similar survival as EBRT; however, SRS/HF-SRS is used infrequently and usage has not increased over time.