Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

good surgical candidate

1st line – observation

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ACUTE
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good surgical candidate
|
asymptomatic or incidental
1st line – 

observation

Asymptomatic, incidental lesions may be monitored for growth before considering treatment.[43] The majority of tumors <2.5 cm have a stable course and do not show growth over a follow-up period of 5 years.[66] The findings that correlate most consistently with tumor growth are: hyperintensity on T2-weighted imaging; larger tumor size; and younger age at presentation. Tumor calcification has been a relatively consistent finding in tumors exhibiting no growth.[65][67][68][69][70][71][72]

Guidance on monitoring frequency varies. The European Association of Neuro-Oncology (EANO) recommends annual magnetic resonance imaging (MRI) scans for suspected meningiomas for 5 years, with the interval doubling thereafter.[50] For patients with unresected meningiomas, the National Comprehensive Cancer Network recommends an MRI at 3, 6, and 12 months, then every 6 to 12 months for 5 years, and then every 1 to 3 years as clinically indicated.[43] In pediatric patients under observation, the Children’s Cancer and Leukemia Group advises initial surveillance imaging within 3 months for meningiomas of any grade.[45]

Serial imaging plans should be tailored to each patient's case, as some incidental meningiomas have higher risk for growth. Lesions with associated parenchymal edema should also be monitored closely if not treated.

Emerging tools are available to help identify incidental meningiomas at higher risk, including the IMPACT calculator, which can be used to inform monitoring strategies.[73][74] IMPACT Calculator Opens in new window

1st line – surgical resection

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ACUTE
|
good surgical candidate
|
symptomatic at any size
1st line – 

surgical resection

Surgery should be considered the treatment of choice.[43][50]

An open surgical approach is usually indicated. Endoscopic transnasal approaches may be used for anterior skull base tumors or those involving the region of the sella, but one review has indicated that the extent of resection may be better with open surgical techniques.[60] Visual improvement has been noted to be superior in some studies of endonasal removal of tuberculum sellae meningiomas, although a higher rate of cerebrospinal fluid leak is noted.[61]

The efficacy of surgery is related to the extent of surgical resection. Complete resection of the tumor, its dural and bone attachment, together with a margin of normal dura (>1 cm if possible) should be attempted to decrease the incidence of recurrence. In cases in which surgical resection would be associated with unacceptable neurologic deficit, consideration should be given to subtotal resection and radiosurgery.

The risk of recurrence after surgical resection is related directly to the extent of resection of the tumor and the World Health Organization (WHO) grade. The optimal aim is complete removal of tumor, its dural attachment and a margin of normal dura. If this is not possible anatomically, resection should include the tumor resection and its attachment as completely as is feasible. With incompletely resected tumors, or those of higher grade than WHO grade 1, radiation therapy may be used as an adjuvant to surgical resection.[43][75] Whether this is given after surgical resection or at growth of residual is not uniform.

Primary treatment for meningiomas in younger patients is with surgical resection.[45] One analysis based on individual patient data found that the extent of initial surgical resection was the strongest independent prognostic factor for child and adolescent meningioma.[62]

Consider – stereotactic radiosurgery

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ACUTE
|
good surgical candidate
|
symptomatic at any size
Consider – 

stereotactic radiosurgery

Treatment recommended for SOME patients in selected patient group

Stereotactic radiosurgery (SRS) is a technique whereby high-dose single-fraction or hypofractionated radiation treatment is delivered with great accuracy to small targets using specialized computerized radiation-delivery devices.

Surgery may be combined with SRS in patients in whom complete surgical resection is not possible.[76] Radiation therapy is also often administered postoperatively following the complete surgical resection of World Health Organization (WHO) grade 2 and 3 meningiomas.

Radiation therapy may be used as a primary therapy in some tumor locations, such as the cavernous sinus, where associated morbidity from cranial neuropathies is high with attempted surgical resection.[77][78][79]

Consider – fractionated stereotactic radiation therapy

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ACUTE
|
good surgical candidate
|
symptomatic at any size
Consider – 

fractionated stereotactic radiation therapy

Treatment recommended for SOME patients in selected patient group

Fractionated stereotactic radiation therapy (FSRT) involves the delivery of low-dose multiple-fraction radiation treatments to targets of any size using specialized computerized radiation-delivery devices.

This is used primarily instead of stereotactic radiosurgery (SRS) in tumors that are larger in size or involve critical structures, such as the optic nerve, which may be less tolerant to a single, large dose of radiation as delivered by SRS. The tumor-control rates using stereotactic radiation therapy are comparable with those from SRS, although the fractionation of dose requires multiple patient treatments. Although this is an adjunctive therapeutic option in patients in whom complete surgical resection has not been possible, it is preferred that younger patients are not radiated using FSRT. Radiation therapy is also often administered postoperatively following the complete surgical resection of World Health Organization (WHO) grade 2 and 3 meningiomas.

Radiation therapy may be used as a primary therapy in some tumor locations, such as the cavernous sinus, where associated morbidity from cranial neuropathies is high with attempted surgical resection.[77][78][79]

Consider – preoperative endovascular embolization

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ACUTE
|
good surgical candidate
|
symptomatic at any size
Consider – 

preoperative endovascular embolization

Treatment recommended for SOME patients in selected patient group

Some large tumors can also be considered for preoperative endovascular embolization to decrease vascularity and aid in resection of the tumor.[43] Due to increased risk of potential complications, preoperative embolization is not recommended for most meningiomas.[50] However, in select cases where the treating surgeons are concerned that a tumor is highly vascular, it can be a useful preoperative adjunct to surgical care.

poor surgical candidate

1st line – observation

Back
ACUTE
|
poor surgical candidate
|
asymptomatic
1st line – 

observation

Asymptomatic, incidental lesions may be monitored for growth before considering treatment.[43] The majority of tumors <2.5 cm have a stable course and do not show growth over a follow-up period of 5 years.[66] The findings that correlate most consistently with tumor growth are: hyperintensity on T2-weighted imaging; larger tumor size; and younger age at presentation. Tumor calcification has been a relatively consistent finding in tumors exhibiting no growth.[65][67][68][69][70][71][72]

Guidance on monitoring frequency varies. The European Association of Neuro-Oncology (EANO) recommends annual magnetic resonance imaging (MRI) scans for suspected meningiomas for 5 years, with the interval doubling thereafter.[50] For patients with unresected meningiomas, the National Comprehensive Cancer Network recommends an MRI at 3, 6, and 12 months, then every 6 to 12 months for 5 years, and then every 1 to 3 years as clinically indicated.[43] In pediatric patients under observation, the Children’s Cancer and Leukemia Group advises initial surveillance imaging within 3 months for meningiomas of any grade.[45]

Serial imaging plans should be tailored to each patient's case, as some incidental meningiomas have higher risk for growth. Lesions with associated parenchymal edema should also be monitored closely if not treated. Emerging tools are available to help identify incidental meningiomas at higher risk, including the IMPACT calculator.[73][74] IMPACT Calculator Opens in new window

1st line – stereotactic radiosurgery or fractionated stereotactic radiation therapy

Back
ACUTE
|
poor surgical candidate
|
symptomatic: tumor <3 cm
1st line – 

stereotactic radiosurgery or fractionated stereotactic radiation therapy

If a decision is made to treat, stereotactic radiosurgery or fractionated stereotactic radiation therapy (FSRT) should be considered.[50][76] Management decisions are nuanced, based on the severity of the patient’s symptoms, tumor location, and severity of the patient’s comorbidities.

Both of these radiation modalities use a stereotactic technique to focus the radiation on the tumor and spare surrounding normal structures. FSRT is delivered in a fractionated manner (e.g., many treatments, typically 4-6 weeks) rather than as a single treatment.

1st line – surgical resection

Back
ACUTE
|
poor surgical candidate
|
symptomatic: tumor <3 cm
1st line – 

surgical resection

If the decision is made to treat, surgical resection may be considered as an option, particularly if the tumor progresses. Even poor surgical candidates who are very symptomatic may need surgery; management decisions are nuanced, based on the severity of the patient’s symptoms, tumor location, and severity of comorbidities.

The goal of surgery will be a complete resection. If this is not possible without inducing a new neurologic deficit, then a subtotal resection will be performed with subsequent observation or stereotactic radiosurgery.

An open surgical approach is usually indicated. Endoscopic transnasal approaches have been used for anterior skull base tumors or those involving the region of the sella, but one review has indicated that the extent of resection may be better with open surgical techniques.[60] Visual improvement has been noted to be superior in some studies of endonasal removal of tuberculum sellae meningiomas, although a higher rate of cerebrospinal fluid leak is noted.[61]

Consider – fractionated stereotactic radiation therapy

Back
ACUTE
|
poor surgical candidate
|
symptomatic: tumor <3 cm
Consider – 

fractionated stereotactic radiation therapy

Treatment recommended for SOME patients in selected patient group

Fractionated stereotactic radiation therapy may be used as adjunctive therapy in cases in which the tumor is not resectable without incurring a new deficit and the residual tumor involves radiation-sensitive structures, such as the optic nerve, which would not tolerate a single, large fraction of radiation therapy.

Radiation therapy is also often administered postoperatively following the surgical resection of grade 2 and 3 meningiomas.

1st line – observation

Back
ACUTE
|
poor surgical candidate
|
symptomatic: tumor <3 cm
1st line – 

observation

Observation is not standard of care for symptomatic tumors, but it may be considered for select patients, such as in older people.[50]

Observation may continue as long as the tumor remains stable in size, although serious consideration should still be given to surgery after frank discussion with the patient and family of the risk versus benefit. Management decisions should be nuanced, based on the severity of the patient’s symptoms, tumor location, and presence of comorbidities.

Guidance on monitoring frequency varies. The European Association of Neuro-Oncology (EANO) recommends annual magnetic resonance imaging (MRI) scans for suspected meningiomas for 5 years, with the interval doubling thereafter.[50] For patients with unresected meningiomas, the National Comprehensive Cancer Network recommends an MRI at 3, 6, and 12 months, then every 6 to 12 months for 5 years, and then every 1 to 3 years as clinically indicated.[43]

Serial imaging plans should be tailored to each patient's case. The follow-up interval would be shortened if the patient develops progressive symptoms.

1st line – surgical resection

Back
ACUTE
|
poor surgical candidate
|
symptomatic: tumor ≥3 cm
1st line – 

surgical resection

Surgical resection may be necessary to reduce mass effect and critical compression of neural structures, and, if required, is performed with as complete a resection as possible.

An open surgical approach is usually indicated. Endoscopic transnasal approaches have been used for anterior skull base tumors or those involving the region of the sella, but one review has indicated that the extent of resection may be better with open surgical techniques.[60] Visual improvement has been noted to be superior in some studies of endonasal removal of tuberculum sellae meningiomas, although a higher rate of cerebrospinal fluid leak is noted.[61]

Consider – stereotactic radiosurgery or fractionated stereotactic radiation therapy

Back
ACUTE
|
poor surgical candidate
|
symptomatic: tumor ≥3 cm
Consider – 

stereotactic radiosurgery or fractionated stereotactic radiation therapy

Treatment recommended for SOME patients in selected patient group

Surgical resection may be combined with adjuvant radiation therapy (stereotactic radiosurgery or fractionated stereotactic radiation therapy) in cases of residual unresectable tumor.[83]

Radiation therapy is also often administered postoperatively following the complete surgical resection of grade 2 and 3 meningiomas.

1st line – observation

Back
ACUTE
|
poor surgical candidate
|
symptomatic: tumor ≥3 cm
1st line – 

observation

Observation is not standard of care for symptomatic tumors, but it may be considered for select patients, such as in older people.[50]

Serial tumor observation with magnetic resonance imaging (MRI) may be performed if the patient has minimal symptoms (i.e., not progressing or causing significant impact on activities of daily living) and the tumor remains stable in size. If neurologic deterioration occurs, treatment should be considered. Management decisions should be nuanced, based on the severity of the patient’s symptoms, tumor location, and presence of comorbidities.

Guidance on monitoring frequency varies. The European Association of Neuro-Oncology (EANO) recommends annual MRI scans for suspected meningiomas for 5 years, with the interval doubling thereafter.[50] For patients with unresected meningiomas, the National Comprehensive Cancer Network recommends an MRI at 3, 6, and 12 months, then every 6 to 12 months for 5 years, and then every 1 to 3 years as clinically indicated.[43]

Serial imaging plans should be tailored to each patient's case. The follow-up interval would be shortened if the patient develops progressive symptoms.

ONGOING

recurrent or progressive tumor following initial treatment

1st line – salvage therapy

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ONGOING
|
recurrent or progressive tumor following initial treatment
1st line – 

salvage therapy

Patients should be considered for referral to centers that offer clinical trials for meningioma, or that have neuro-oncology expertise in considering targeted off-label medical therapies with biologic rationale, as there are currently no approved medical therapies.[43][80]

For patients who are good surgical candidates, salvage surgery may be performed following initial failed treatment.[43] This should be combined with radiation therapy if a patient has not been initially irradiated.[50] However, re-irradiation may be considered in patients already treated with this modality. Specialized centers may also offer intracranial brachytherapy at the time of repeat surgery.[81][82] If salvage surgery is not an option, radiation therapy alone may be considered. Treatment with systemic therapy is indicated where radiation therapy is not possible. Where treatment is not clinically indicated in any case, an observation-only approach is warranted.[43]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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