Salvage therapy outcomes for atypical meningioma

Abstract

Atypical menginomas demonstrate increased clinical aggressiveness characterized by recurrence and diminished survival. The optimal management of atypical meningioma in the recurrent setting is especially not well defined. To characterize outcomes following salvage treatment of recurrent atypical meningioma and to identify risk factors for further recurrence. Retrospective chart review was performed on 65 patients who underwent salvage treatment of atypical meningioma at a single institution. Data were analyzed using the Kaplan-Meier method and Cox proportional hazards modeling. Sixty-five patients with recurrent atypical meningioma and median imaging follow-up of 4.0 years (range 1.9-6.6 years) underwent 62 surgeries and 114 radiation treatments (RT) for salvage therapy. Salvage modality was surgery (21%), surgery/RT (25%), or RT alone (54%), associated with 2 year local freedom from recurrence (LFFR) of 36, 59, and 73%, respectively (P = 0.01). Twenty percent of patients experienced CTCAE grade ≥ 3 toxicity with salvage therapy. Thirty-nine percent of patients experienced ≥ 3 recurrences. The median disease-free survival intervals after first and second salvage treatments were 2.9 and 1.3 years, respectively. On univariate Cox analysis, prior subtotal resection, prior RT, tumor diameter > 2.5 cm, and multifocal local recurrence were associated with recurrence after salvage therapy. On multivariate logistic regression, only multifocal local recurrence was associated with further recurrence. Recurrent atypical meningioma is clinically and pathologically more aggressive than primary atypical meningioma, and the likelihood of durable local control with salvage therapy is lower. Future efforts should identify patients at risk of recurrence, and aggressive upfront treatment should be employed.

Integrative assessment of brain and bone invasion in meningioma patients

“…WHO grading, MIB-1 proliferation activity, initial versus salvage treatment and the localization showed significant prognostic values in univariate analysis. These prognostic factors are well in line with several previous reports [15–17]. However, better prognosis of skull base and optic nerve sheath meningiomas in our study appears contrary to other publications.…”

Multiplatform genomic profiling and magnetic resonance imaging identify mechanisms underlying intratumor heterogeneity in meningioma

“…Due to the intrinsic morbidity of salvage surgery and radiotherapy for recurrent meningioma 53 – 55 , there is an urgent, unmet need for new therapies to treat patients with high grade or recurrent tumors 4 , 5 . We have shown that meningiomas with elevated ADC are at risk for high grade and recurrence 45 , 46 , and have identified molecular signatures associated with high ADC values in vivo (Fig.…”

Radiotherapy for meningiomas

“…Pontoriero et al [ 50 ] in 2022 reported use of a stereotactic radiosurgery boost in addition to IMRT to achieve an equivalent dose in 2 Gy fractions of 72.5 Gy to areas of gross residual WHO grade 2 meningiomas, reporting no serious toxicities among 16 patients. All 7 patients with primary WHO grade 2 meningioma and gross residual tumors after surgery achieved local control, but 4 of 9 patients with recurrent WHO grade 2 tumors developed in-field failures, underlining the fact that recurrent meningiomas are biologically more aggressive [ 51 ] and may frequently encode genetic and epigenetic alterations leading to treatment resistance [ 52 ]. Finally, historical series have also noted trends towards improved local control of high grade meningiomas with doses greater than 60 Gy in Boskos et al [ 53 ] and Hug et al [ 54 ], and greater than 53 Gy in Goldsmith et al [ 13 ].…”