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Atypical and aggressive meningiomas:
Is there a role for radiologists in
guiding treatment?
#EP-53
Anthony Galinato MD, Feras Mossa-Basha MD, Ishani Dalal MD
Department of Radiology, Henry Ford Hospital
Detroit, MI
Disclosures
The authors have no financial interest or other
relationship with any commercial organization
that may have an interest in the content
presented.
Purpose
• Describe difficulties with current treatments for
atypical and aggressive meningiomas.
• Analyze potential use of somatostatin receptor
blockers in treating meningiomas in cases of
residual or recurrent disease following surgical
resection.
• Demonstrate the radiologist’s role in guiding
treatment of atypical and aggressive
meningiomas with the use of octreoscans.
Background
• Meningiomas are the most common primary
intracranial neoplasm.
• WHO classification organizes meningiomas into 3
distinct grades based on cell type, mitotic activity,
cellularity, necrosis, and brain invasion.
– WHO Grade I – benign
• Most common - 80% of cases
– WHO Grade II – atypical
• 15-20% of cases
– WHO Grade III – anaplastic
• 1-3% of cases
Background
• Axial and coronal T1 weighted post contrast images demonstrate a large
enhancing extra-axial lesion in the right paramedian frontoparietal
region. There is invasion of the superior sagittal sinus and extension
across midline which makes complete surgical resection difficult.
• Pathology demonstrated atypical meningioma (WHO Grade II).
Background
• Patients with meningiomas can have complicated
clinical courses with poor clinical outcomes.
• The standard treatment of choice for
meningiomas historically has been compete
surgical resection.
• Resection of meningiomas are often debilitating
with extensive recoveries.
• Complete resection is often difficult to achieve
secondary to difficult locations such as at the
skull base, near the sagittal sinus, or in close
proximity to cranial nerves.
Background
• Complete resection is achieved in less than 50%
of patients.
• Even in cases where there is complete
macroscopic resection, recurrence has been
shown to occur in up to 32% of cases after 15
year follow up.
• Higher recurrence rates are seen in both atypical
and anaplastic meningiomas.
• Hence, physicians have been looking toward
alternative medical therapies.
Background
Pre-operative
6 months
post-operative
• Post-operative MRI performed 6 months after
surgical resection demonstrates residual atypical
meningioma along the superior sagittal sinus.
Background
• Some meningiomas, may express somatostatin
receptors.
• Somatostatin is a neuropeptide that is normally
synthesized by the hypothalamus and helps to
regulate GI motility, endocrine functions, and
exocrine functions.
– Somatostatin is also involved in cancer pathways as it
affects angiogenesis and apoptosis.
• Treatment with somatostatin receptor blockers
has the potential for inhibiting meningioma cell
growth.
Background
• Nuclear medicine indium-111 pentetreotide
scintigraphy (octreoscans) can identify
meningiomas that express these somatostatin
receptors.
• Octreoscans utilize a radiolabeled
somatostatin analog (pentetreotide) which
binds to somatostatin receptors.
Background
•
•
•
Coronal T1 weighted post contrast imaging (left) demonstrates a residual
meningioma following surgery and radiation at the left parietal vertex and along
the left temporal lobe.
Planar octreoscan image (middle) demonstrates area of increased radiotracer
uptake in the regions of residual meningioma, consistent with meningioma with
significant expression of somatostatin receptors.
SPECT-CT image (right) confirms location of residual meningioma with significant
expression of somatostatin receptors in the regions seen on prior MRI.
Background
• Treatment in the form of somatostatin
receptor blockers may represent an
alternative or adjunctive treatment to the
complex and often grueling course of multiple
surgical procedures.
Materials and Methods
• A retrospective database search was done to
identify patients with a history of meningioma
who had octreoscans that were positive for
somatostatin receptors within the Henry Ford
Health System during the period of January 2005
to November 2014.
• Relevant medical records and radiologic imaging
were reviewed to categorize the patients’
symptomatology, surgical history, pathology
results, imaging findings, and treatment plans.
Materials and Methods
• MRI examinations before and after
somatostatin receptor blocker treatment were
reviewed to assess for progression of disease
following initiation of somatostatin receptor
blocker treatment.
Results
• A total of seven patients were identified
including 4 females and 3 males.
• In all seven of the cases, the octreoscans were
performed after there was MRI evidence of
residual or recurrent disease following surgical
resection.
Results
• Pathology
– 29% of the patients identified had pathology
results consistent with meningiomas without
atypical features (WHO Grade I).
– 57% of the patients had pathology results
consistent with meningiomas with atypical
features (WHO Grade II).
– 14% of the patients had pathology results
consistent with anaplastic meningioma (WHO
Grade III).
Results
• 14% of the patients had residual or recurrent
disease in close proximity to cranial nerves, which
limited further surgical resection.
• In 71% of the cases, medical therapy with a
somatostatin receptor blocker was initiated.
– One of the patients decided to forgo somatostatin
receptor blocker treatment secondary to the patient’s
history of diabetes and possible complication of
worsening blood sugar levels while on the therapy.
– Another patient decided to forgo somatostatin
receptor blocker treatment with no clear reason given
in the clinical notes.
Results
• In 40% of the patients who underwent therapy
with somatostatin receptor blocker therapy, there
was no evidence of recurrence or progression of
disease after initiation of treatment.
• The remaining 60% showed progression of
disease on MRI following initiation of
somatostatin receptor therapy with either
increased size of exisiting lesions or the
development of new lesions.
Results
• MRI after surgical resection and prior to initiation of Sandostatin therapy
(left) demonstrates post-operative changes with no evidence of residual
disease.
• MRI obtained after initiation of Sandostatin therapy (right) demonstrates
new enhancing mass in the right subfrontal region consistent with new
meningioma and disease progression.
Conclusion
• This study shows that somatostatin receptor
blocker therapy can lead to progression-free
survival in a certain subset of patients and
thus may act as an amenable alternative or
adjunct to complicated and possibility
debilitating surgical resections in patients with
meningiomas expressing somatostatin
receptor.
Conclusion
• Radiologists can play a role in guiding treatment
of these meningiomas through octreoscans.
• This can enable the identification of the subset of
patients that may benefit from somatostatin
receptor blocker therapy, specifically in the
population of patients that have undergone
multiple surgical resections or in which the
meningiomas demonstrate aggressive features
which preclude complete surgical resection.
References
• Wiemels J, Wrensch M, Claus EB. Epidemiology and
etiology of meningioma. J Neurooncol 2010 Sep; 99:307314.
• Simo M, Argyriou AA, Macia M, et al. Recurrent high-grade
meningioma: a phase II trial with somatostatin analogue
therapy. Cancer Chemother Pharmacol. 2014 May; 73(5)
919-923.
• De La Garza-Ramos R, Flores-Rodriguez JV, MartinezGutierrez JC, et al. Current standing and frontiers of gene
therapy for meningiomas. Neurosurg Focus. 2013 Dec;
35(6): E4.
• Mozzam AA, Wagle N, Zada G. Recent developments in
chemotherapy for meningiomas: a review. Neurosurg
Focus. 2013 Dec; 35(6): E18.