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Medical care for meningiomas has been disappointing. It is restricted either to perioperative drugs
or to medications that are used after all other means of treatment have failed. [23]
The use of corticosteroids preoperatively and postoperatively has significantly decreased the
mortality and morbidity rates associated with surgical resection.
Antiepileptic drugs should be started preoperatively in supratentorial surgery and continued
postoperatively for no less than 3 months.
The current experience with chemotherapy is disappointing.
This modality of treatment is reserved for malignant cases after failure of surgery and
radiotherapy to control the disease.
The main drugs studied include temozolomide, which had no effect against recurrent
meningiomas in a phase 2 study[24] , and hydroxyurea (ribonucleotide reductase inhibitor); RU-486
(synthetic antiprogestin); and interferon-alpha. The last 3 drugs also showed disappointing results. A
recently published prospective phase 2 study of irinotecan (CPT-11) also failed to demonstrate any
efficacy.
The combination of interferon alpha and 5-fluorouracil synergistically reduces
meningioma cell proliferation in culture and warrants further investigation.
Some studies have shown a possible role of COX-2 inhibitors in the treatment of
recurrent meningiomas.[8]
The role of targeted chemotherapy to block the tumorogenic pathways of meningiomas at
specific sites is being extensively investigated.[25]
Molecules to block specific growth factors or enzymes are being developed. Atypical
meningioma (WHO grade II) and anaplastic meningioma (WHO grade III) showed increased fatty acid
synthase (FAS) expression. FAS inhibitor (cerulein) decreased meningioma cell survival in vitro. Thus,
increased FAS expression in human meningiomas represents a novel therapeutic target for the
treatment of unresectable or malignant meningiomas.[26]
Although most meningiomas grow slowly and have a low mitotic rate, clinical benefit has been
reported in many case series with either tumor regression or stasis after radiotherapy; however, these
results have not been confirmed in randomized trials. Oya et al reported on the natural history of
meningiomas. [27] The prospect of benign meningioma growth is an important factor to consider in their
proper management. Approximately 40% of 273 meningiomas (in 244 patients) grew within a 4-year
period. Lack of calcification, hyperintensity in T2 MRI, and peritumoral edema were predictors of growth
in follow up. In addition, age younger than 60 years and tumor size larger than 25 mm (diameter) were
also associated with a greater risk.
Radiotherapy is mainly used as adjuvant therapy for incompletely resected, high-grade and/or
recurrent tumors. It can also be used as primary treatment in some cases ( optic nerve
meningiomas [28] and some unresectable tumors). [29, 30]
In general the ideal treatment of a benign meningioma is surgical resection if possible. Hasegawa
et al treated 46 patients with gamma knife radiation (GKR) as the initial treatment modality. [31] The
lesions were falcine, convexity, or parasagittal. The study found GKR to be effective. The main caveat
was tumor size. Large tumors had the possibility of severe postirradiation edema. This was actually
more likely to occur with significant, baseline peritumoral edema. GKR may be selected over surgery in
patients with significant medical comorbidities.
Stereotactic radiosurgery has been shown to provide excellent local tumor control with minimal
toxicity. [32, 33]
It is mainly used for small (< 3 cm in diameter) residual or recurrent lesions when surgery
is considered to carry a significantly high risk of morbidity.
It has been advocated as an effective management strategy for small meningiomas and
for meningiomas involving the skull base or the cavernous sinus.
It is used primarily to prevent tumor progression.
In a recently published series, the long-term follow up after radiosurgery was reported; a
tumor control rate of 94% was found after an average of 103 months.