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Management of Meningiomas. DIAGNOSTIC TOOLS. MRI Dural tail, edema CT SCAN : Hyperostosis, intratumoral calcifications ANGIOGRAPHY: embolization is a consideration tumor blush. DIAGNOSTIC TOOLS. HISTOLOGY Globular, well demarcated Wide dural attachment - PowerPoint PPT Presentation
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Management of Meningiomas
DIAGNOSTIC TOOLS
• MRI– Dural tail, edema
• CT SCAN: – Hyperostosis, intratumoral calcifications
• ANGIOGRAPHY: – embolization is a consideration– tumor blush
DIAGNOSTIC TOOLS
• HISTOLOGY– Globular, well demarcated– Wide dural attachment– Invaginated into underlying
brain with no invasion– Cut surface: translucent
pale, homogenously reddish brown,
– Gritty– Meningioma en plaque:
occur as sheet- like extension that covers dura; does not invaginate parenchyma
WHO
GRADE HISTOLOGICAL SUBTYPE
HISTOLOGIC FEATURES
I MENINGOTHELIAL, FIBROBLASTIC, TRANSITIONAL, ANGIOMATOUS, MICROCYSTIC, SECRETORY, LYMPHOPLASMACYTIC, PSAMMOMATOUS
Does not fulfill criteria for grade II or grade III
II (ATYPICAL) CHORDOID, CLEAR CELL 4 or more mitotic cells/ 10 hpf3 or more of ff: -increased cellularity -small cells, necrosis -prominent nucleoli, sheeting -brain invasion in an otherwise Grade 1 tumor
III (ANAPLASTIC) PAPILLARY, RHABDOID 20 or more mitosis/ 10 hpfTumor cells resemble carcinoma, sarcoma or melanoma
IMMUNOCHEMISTRY
(+) Epithelial membrane antigen
(-) anti- Leu 7 antibodies
(+) progesterone, somatostatin receptors
TREATMENT OPTIONS
• SURGERY– Objective: total removal of the meningioma, dural
attachment and bone involved with the tumor– Priority: preserve and improve neurological function
• RADIOTHERAPY– Indications:
• Residual tumor left at operation• Recurrence• Tumors could not be treated surgically• Malignant histology
• OBSERVATION– Asymptomatic patients with little or no edema
in the adjacent brain areas– Patients with mild or minimal symptoms– Older patients with seizure or very slowly
progressing symptoms– Patients in whom treatment carries a
significant risk
FOLLOW- UP
• Multidisciplinary approach for patients with disabilities (e.g. diplopia, dysphasia, dysphagia)
• Regular follow-up with enhanced MRI to check for possible recurrences
• Patients who are discharged home with antiepileptic agents should be monitored
OPERATIVE MEASURES
– Steroids for at least 48 hours; longer with significant brain edema; postoperatively, tapered off over 5 days or longer
– Intravenous antibiotics before operation; 24 hours after the procedure
– Anti- convulsant medications (phenytoin, carbamazepine, valproic acid) for supratentorial operations
TYPES OF RADIATION THERAPY
• EXTERNAL- BEAM RADIATION THERAPY– 5000- 5500 cGy– Daily fractions: 180-200 cGy over 5-6 weeks– Particular care near optic nerves and
brainstem• Radiosurgery: Co- gamma unit
– Dose delivered to margin of tumor : 15-18 Gy– Proximal to optic nerves and chiasm: 9 Gy