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Journal of Integrative Oncology Fotakopoulos, et al.

, J Integr Oncol 2015, 4:2
http://dx.doi.org/10.4172/ 2329-6771.1000135

Review Open Access

New Developments in Management of Meningioma
George Fotakopoulos1*, Eleni Tsianaka1, Vasilios Panagiotopoulos2 and Kostas Fountas1
1Department of Neurosurgery, University Hospital of Thessaly, University Hospital of Larissa, Biopolis, 41110 Larissa, Thessaly, Greece
2Department of Neurosurgery, University Hospital of Patras medical school, Patra, Greece
*Corresponding author: George Fotakopoulos, Pyrgou, Ilias, 27100, Greece, Tel: +30 2621051828; E-mail: gfotakop@yahoo.gr
Received date: May 11, 2015; Accepted date: May 17, 2015; Published date: May 25, 2015
Copyright: © 2015 Fotakopoulos G, et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Introduction: The incidence of Meningiomas, indicating of the population-based studies, is approximately
13-26% of all primary intracranial tumors.

Methods: We searched PubMed for studies related to meningiomas published over the last 6 years (from May
2009) and retrieved 2104.

Results: Surgery remains the main choice of treatment at meningiomas and the combination with the
endovascular treatment and/or Stereotactic radiosurgery provide a better and safer therapeutic strategy. In atypical
and subtotal excised or recurrent meningiomas, conventional radiotherapy should be performed. Chemotherapeutic
agents also, should be used in specific cases, because of questionable effectiveness and considerably side effects.

Conclusion: Even the recent technological developments, which give rise to better therapeutic options, the "gold
standard" of meningiomas treatment, still remain challenging.

Keywords: Meningioma; Surgery; Chemotherapy radiotherapy; Although meningioma is typically benign and slow growing in
Endovascular treatment; Management approximately 92%, appearing mostly in the later decades of life, they
can be exhibit an anaplastic (1.0 to 2.8%) or atypical (4.7 to 7.2%)
Introduction behavior [19,20], with more common appearance in men [21].

The incidence of Meningiomas, indicating of the population-based However, more than 9% of all meningiomas are characterized by
studies, is approximately 13-26% of all primary intracranial tumors aggressive clinical behavior with increased risk of tumor recurrence
[1,2]. Has been estimated that the asymptomatic meningiomas [20], with 1,3 - 14,7% recurrence rate at the spinal cord meningiomas
account 2-3% of the population [3-6], although at some cases [11].
incidence approaches the 59,6% [7]. A Magnetic Resonance Imaging While asymptomatic meningiomas are traditionally managed
(MRI) study in the general population by Vernooij et al. reported a conservatively until symptoms develop or lesion growth occurs, it is
prevalence of 0,9% [8]. Their occurrence increases with age (peaks likely that patients at high risk for symptom development – most
after the fifth decade of life) and affects women more frequently with common young people because of the higher growth potential, may
2:1 female:male ratio [1,3]. Contrary to commonly opinions, there is benefit from earlier clinical and radiological follow-up in order to
no evidence of an increased prevalence of meningiomas in cancer decrease this possibility [4,6]. Also, many measurements are useful to
survivors [9]. Spinal meningiomas represents 25-46% of spinal tumors, determine the extent of the increase of meningiomas, such as the
affecting more commonly middle-aged women and having thoracic calcification evidence on CT scans and T2-weighted MRI, the
laterality [10,11]. depending of patient’s age to the decision of operation, the
Meningiomas most common arise from the arachnoid cap cells symptomatology and comorbidities [17,21,22]. Furthermore, in
imbedded in the arachnoid vill [3], optic nerve sheath, choroids plexus surgical treatment of asymptomatic meningiomas, the morbidity rate
and rare from unknown and progenitor cells origin [12,13]. According was 4.4% in patients younger than 70 years of age and 9.4% in those 70
to Word Health Organization (WHO), they classified on the basis of years of age or older [17,23].
the tissues involvement, dural site origin and histological type [14]. The “gold standard” for symptomatic patients, is the complete
The vast majority of spinal meningiomas have thoracic localization tumor resection, although in elderly population the complications are
80%, with benign behavior and intradural extramedullary lateral more frequent [24,25]. Some studies proposed a stereotactic
appearance, whereas in 15-27% of cases have anterior manifestation radiotherapy as an alternative method, with low toxicity and the lack
and their surgical removal is difficult [15]. Meningiomas are the most of treatment-associated mortality [26]. In order to reduce the surgical
common calcified intradural spinal tumors on CT scans and with low complications in more aged patients with symptomatic meningiomas,
signal intensity on T2-weighted MRI associated with slower growth Sacko et al. proposed a grading system to standardize the surgical
rate, but exhibit an uncommon totally ossification in only 1-5% of indications [27]. On the other hand, for subtotal resected and
cases and more difficult resection than the usual type [16-18]. recurrent meningiomas, radiotherapy (conventional or stereotactic)
may be proposed. When all treatments (surgery and radiotherapy)

J Integr Oncol Volume 4 • Issue 2 • 1000135
ISSN:2329-6771 JIO, an open access journal

(CFRT). Parasagittal meningiomas constitute a challenge for the control [62]. Recurrence rate has very well established and have been showed a The function of the facial nerve was preserved in 91% of cases with depending on tumor’s WHO grade and the extent of resection by total resection. because of diaphragma sella meningioma. may be opened tumor for surgery and many base approaches can be used with good and a total tumor resection could be proposed. surgeon. is a Radiotherapy (SFRT). giving a quick access. The restore of flow. management of tuberculum sellae meningiomas can include pterional usually offer very good results. Stereotactic for surgical resection. having a low recurrence rate (<1%) [60]. selective intra-arterial injection of more favorable visual outcome and overall prognosis.55]. cerebellopontine angle (CPA) meningiomas. is a common and safe Single Photon Emission Computed Tomography (SPECT) has showed surgical procedure [60]. the need of preoperative meningiomas. an early surgery using the subfrontal latest approaches.47]. an alternative plan is the outside of sinus a satisfactory approach regardless of tumor size [64]. safe and totally resection of the imaging techniques also. retrosigmoidal for petroclival [30] or skull size is associated with better outcome [57]. during surgical removal of the tumor [38]. Also. the effectiveness of radiotherapy has been improved. recurrence [46. Other challenged J Integr Oncol Volume 4 • Issue 2 • 1000135 ISSN:2329-6771 JIO. The retrosigmoid approach for the management of the avoid vascular events. If meningiomas invasion of the lateral aspect of the optic canal. The new Sylvian fissure. the retrolabyrinthine approach described in 1972 by Many meningiomas cannot be totally resected because of their Hitselberger and Pulec. a complete tumor involve the optic canal. removal of the tumor. For the olfactory more clear view to the vascular blood supply of the meningiomas.Citation: Fotakopoulos G. the tumors without cavernous sinus involvement had a Angiography and more recently. In tumor excision and coagulation of remnants or the use of radiation the current study we reviewed the available treatment modalities for treatment [44]. followed by venous results [63]. including the decompression of the optic nerve [50]. mainly when they arise from the middle. Hormonal manipulation is also under review in cases embolization and shorted resection times [52].40] and Computed Tomography Venography (CTV) combined retrosigmoid–transpetrosal–transcochlear approach can can provide a significant assistance at meningiomas located close to provide wide exposure to the CPA and easier surgical resection of the Superior Sagittal Sinus (SSS) [41]. by venous reconstruction and meningioma treatment.4172/ 2329-6771. can compress the promise for the differentiation between anaplastic and benign brainstem and may have a vascular and neuronal attachment. Panagiotopoulos V. Radiotherapy (RT). complete resection is the goal [51]. Parasagittal meningiomas constitute a challenge for the of the visual function) [49]. the tissues. which tumor followed by irradiation is advocated in order to reduce are quite rare. Large meningiomas of CPA. allows an easier exposure in anatomical involving with vital neural. A meningiomas [39. the base approach for giant anterior clinoidal meningiomas [31-33]. only 154 article were eligible. when postoperative neurological injuries [56]. Surgical resection of spheno-orbital en plaque meningiomas is symptomatic. Tsianaka E. If the sinus is partially or completely occluded. For parasellar and posterior fossa meningiomas. usual excision of Surgery the tumor followed by irradiation is advocated in order to reduce Surgery constitutes the first choice of treatment. Results If meningioma involves the optic canal. There are reports. mainly when they arise from the middle and posterior third Anterior clinoidal meningiomas constitute a more challenging of SSS. offer a very useful collateral drainage [45]. hand. the proposed management includes pterional approach postoperative neurological injuries. optimize visual recovery and prevent tumor We found differences therapeutic strategies including surgery. with more radical excision.43]. Fountas K (2015) New Developments in Management of Meningioma . with less morbidity rate and Discussion better access in bifrontal and frontolateral approaches [54. meningiomas. surgery with radical excision. microsurgical operation [58] or frontolateral approach with microsurgical dissection of the has given grate results and an effective resection [34-36]. meningioma. When meningiomas are [48]. maintenance of cortical veins. Stereotactic Fractioned with diffuse orbital tumors and invasion of the optic canal. in two stages (first treating the most impaired Radiosurgery (SRS) or Gamma Knife SRS constitute a supplementary side). Direct intratumoral hydrogen Traditional chemotherapeutic agents are not very effective against peroxide injection may reduce blood loss. an open access journal . At sphenoid wing with untreatable tumors or those who are inappropriate for surgery. showed that the pterional craniotomy is reconstruction [32]. doi:10. can be offer a better understanding and tumors presenting cavernous sinus involvement [53]. the use of dorsolateral approach for foramen approach with better preoperative visual function and smaller tumor magnum meningioma [29]. When and effective management to a surgery and conventional radiotherapy cavernous sinus infiltration coexists. usual excision of the the cases of bilateral hyperostotic sphenoorbital meningiomas. constitutes the first choice effective and safe (low morbidity and in about 2/3 of cases improving of treatment. the decompression and After investigation of 2104 articles. allows a better preoperative planning. radiation therapy can be added treatment. In a case of a small residual tumor. hormonal therapy or chemotherapy can be applied [28]. location. Furthermore. J Integr Oncol 4: 135. it can be managed with radiosurgery for a long period free of tumor recurrence. compared with dilute MR contrast media. the decompression and removal of the tumor resection offers good decompression of the optic nerve (via a less inside optimize visual recovery and prevent tumor recurrence. For parasellar and posterior fossa meningiomas. vascular (central veins) structures or are en entities at this region with a better tumor resection and lateral sinus plaque. The management of spheno-orbital meningiomas Radiotherapy Stereotactic radiosurgery (SRS). groove meningiomas many approaches have been used depend on tumor size. On the other Simpson criteria [42. origin and extension. large meningiomas [61]. Intensity-Modulated Radiotherapy (IMRT). By the development of 3D Conformal Radiotherapy [50]. Moreover.1000135 Page 2 of 9 have failed. supraorbital-pterional approach and wide opening of the optic canal Chemotherapy and Endovascular treatment. In tuberculum and meningiomas are symptomatic. Thus. where the high-dose suits the target and avoids normal For lateral sphenoid wing and olfactory groove meningioma. For lateral intraorbital tumors with surgeon. For invasive lateral orbitocranial approach without craniotomy) [48]. with improvement of the vision and reduction of the Meningiomas are well MR perfused tumors [37] and 3D-CTA helps to morbidity [59].

Concerning atypical meningiomas. used evoked beneficial for skull base meningiomas. in approach. They should be treated with neurological deficits [73]. Gamma Knife J Integr Oncol Volume 4 • Issue 2 • 1000135 ISSN:2329-6771 JIO. The less invasive posterior approach allows an incomplete neurological morbidity [66]. using orbital osteotomies. such as an intraoperative leg- [85. a localization. In meningiomas at the upper anterior third of the 3.93]. it can be offer a wide exposure of meningioma by [31]. can be used the transthoracic approach with a better tumor visualization. respectively [94]. SRS allows smaller doses of radiation. with difficulties in management [68]. mainly Spinal meningiomas have more frequently intradural-extramedullar when they have anterolateral localization [65]. the treatment is conservative. In cases with large 2. Either as initial or adjuvant excision it’s too difficult [76]. parasagittal. J Integr Oncol 4: 135. better clinical outcome and early diagnosis [82-84]. only if there was brain involvement. in order to reduce potentials. but For giant meningiomas of the anterior cranial fossa.Citation: Fotakopoulos G. it can enhanced Magnetic Resonance Venography (MRV). Stereotactic radiosurgery (SRS) posterior fossa. good results with radical improved the possibility of gross-total tumor removal with minimal resection. brain invasion and the craniectomy [70]. mainly when therapy. can be achieved total surgical excision. anterior skull base approaches. improving [75]. In a small study of IVM. mainly if incomplete surgical transcortical parieto-occipital approach. after a total resection. Microsurgical techniques and MRI can be helpful for a elderly population with mild symptoms. control rates of 38% and 52%. the surgical resection can result Radiotherapy (RT) recommended as an additional therapy in in hydrocephalus. Severe concomitant disease or high American Society of Anesthesiology (ASA) score advice not to undergo surgical therapy Radiosurgery. For meningiomas of the foramen magnum. have an anterior to the spinal cord offers very good results [65]. In patients with high-grade the lateral ventricular IVM were accessed by the posterior middle atypical meningiomas.86].78]. is a good option for convexity. fourth ventricular IVM were accessed via midline suboccipital p53 overexpression. The aim of 3D contrast. proposed. Radiotherapy Intraventricular Meningiomas (IVM).3-14% [84]. and the transnasal endoscopic approach have been achieved a better outcome [74]. temporal and transcallosal excision is performed [87.100]. Radiotherapy has meningiomas [99. In posteriorly. Fountas K (2015) New Developments in Management of Meningioma . convensional radiotherapy treatment. with risk of likelihood for further surgery [90. rates for recurrent and 93% for residual disease [105]. An approximately When they are small (<30 mm) and asymptomatics. and the survival. In difficult cases. has a significant or superior petrosal sinus and patent sinus should be protected during improvement in malignant meningiomas [94].88]. RT can be postoperative neurological morbidity. when they are asymptomatic. and with poor outcome. The extent of resection. with difficult exposure [15]. malignant progression. High dose RT also. a transcavernous approach with exposure of the lateral Stereotactic radiosurgery (SRS) or Gamma Knife SRS constitute a wall of the cavernous sinus and removal of the anterior clinoid supplementary and effective management to a surgery and process. with residual tumor either diagnosed or recurrent meningiomas [98]. using the malignant or atypical meningiomas. because of the delayed tumor growth and the reduces of Petroclival meningiomas are other demanding tumors. radiosurgery 15-27% of spinal meningiomas.97]. In benign meningiomas adjuvant radiotherapy is necessarily been associated with postoperative visual deficits [71]. Subtotal resection or WHO grade III atypical and anaplastic meningiomas produced 5-year actuarial local tumors are in need of close observation [79. Heparin (LMWH) (there were no elevated risk of post-operative hemorrhage). is such as typical ones [101-103]. a total tumor survival and tumor control [96. Additional. beneficial for high surgical risk or advanced age patients. but elevation. an open access journal . constitute the prognostic factors for anaplastic ventricular meningiomas is a safe surgical approach which may not meningiomas [89]. In case also. Three-dimensional conformal radiotherapy for no benefit as initial treatment. is a more secure be helpful in cases with meningioma located in eloquent or surgical resection. Panagiotopoulos V. in patients with brain tumors Furthermore. with the majority of them to be extended laterally or subtotal resection can be proposed. early (on the day of surgery) Low-Molecular-Weight the recurrence rate is 1. Most of the patients operation [72]. Tsianaka E.1000135 Page 3 of 9 managing tumors are the foramen magnum meningiomas. the parietooccipital route for lateral adjuvant RT. For elderly patients or asymptomatic with anterolateral falcine meningiomas as a primary or adjuvant therapy [104]. Recently. Furthermore. In a young patient. Many techniques also. mainly when the cavernous sinus drains into either inferior inaccessible areas [92. Furthermore. In this region the near total tumor resection. with few same reports with gross total resected tumors without RT. doi:10. Results removal with maintenance of vascular and neurological structures is were better for small to medium-sized symptomatic and newly now a most acceptable management. position. 50% in Grade II and 17% in Grade III tumors) and infarction after a forceful excision is very high. application of Intermittent Pneumatic Compression (IPC) and regular compression stockings [67]. with 68% in 5-year local control rate in atypical gross-total resection as first choice initial treatment. the extended is more invasive procedure and there is a need for verbectomy. In these challenging cases. In order to limit the side effects of radiation. surgeon’s manipulations may damage the spinal cord thromboembolic events during surgery. and [81]. recurrence rate after 5 years was 28% [88]. adjuvant radiotherapy improves patients’ temporal gyrus or the superior parietal lobule approach.4172/ 2329-6771. are spacialy resection. Moreover. the decision for operating or not. the risk of brain Grade I tumors. leads to a better control to the upper basilar region. SRS is safe and effective treatment option for radio-induced meningiomas In the elderly patients also. considerably reduce the positivity of recurrence and the postoperative suffer of permanent morbidity. without intraoperative monitoring. SRS achieved a high rate tumor control (98% with WHO the sinus is totally occluded [77]. especially in removal of the posterior clinoid process and the petroclival osseous meningiomas. with Tentorial Fold (TF) meningiomas (TFM). The use of SRS in patients observed by serial imaging or treated with radiation [68. the neurological deficits and no recurrence [69]. individual. Total exposure usually offers a neurological improvement. the use of computer-aided surgery radiotherapy [95]. Also. have Postero-lateral approach offers also.80]. conservative treatment is the parasagittal meningioma radiosurgery resulted in 60% 5-year control recommendation [65]. The subtotal tumor only in 5% after radiosurgery was necessary an extra resection.91]. with recurrent or residual atypical and malignant meningiomas can The management of meningiomas in children includes aggressive improve survival. with sinus cavernosous involvement.

with a relatively use of chemotherapy or targeted therapy for intracranial meningioma. 9. but recurrence evidence [115]. The In a study where compared the effectiveness and limitations of restricted radiation tolerance of the visual pathways lesions is a great Stereotactic Arc Therapy (SRS/T). J Integr Oncol Volume 4 • Issue 2 • 1000135 ISSN:2329-6771 JIO. Chemotherapy treatment.1000135 Page 4 of 9 surgery can be used safely in small.93]. In 317 patients with intracranial meningiomas. Carbon ion plans offered intradural spinal meningiomas. Hormonal manipulation is also under review in cases alternative to surgery or a primary treatment. on patients with benign There are also reports. an meningiomas.91. IMPT has the potential to overcome the lack of a Radiosurgery also. IMRT and Dynamic Arcs (DA) for skull not reduce the effectiveness of the method [110]. progress or are Linear accelerator (LINAC) fractionated RT using the multiple inoperable. IMRT is the most lesions and the radiosurgery related complications occurred in 3% of advanced form of CFRT. SRS provided effective tumor control in patients shaped tumors and too large for stereotactic radiotherapy. target coverage was similar. and effective in the management of symptomatic Cavernous Sinus Meningiomas (CSMs) [125]. noncoplanar dynamic rotation conformal paradigms can be offered to Traditional chemotherapeutic agents are not very effective against patients with meningiomas at the anterior visual pathways. For that suffering cavernous sinus meningiomas. Results are better for small meningiomas under the condition base meningiomas IMRT leads to long-term tumor control with of using higher doses and greater marginal [114].3% benign meningiomas. the toxicity is minimal [128]. On the other hand. in cases of benign intracranial meningiomas [121]. suggesting that multisession therapy can be an brain tumors. with very low local tumor failure and ophthalmologic deficits. the margins (CTV + PTV) ≤1 cm. but also with preservation of quality of life [130]. Furthermore. The development of 3D conformal radiotherapy (CFRT). including 5 meningiomas.9%) had local tumor progression. SFRT improves disease-free period after subtotal developed new symptoms in only six patients [132]. cyberknife and Intensity- The use is more meaningful before severe visual problems settle [119]. lesions immediately adjacent to short segments of the optic apparatus and between AMOA and IMRT. It is also useful and safe to use in residual tumors. reported that IMRT was more effective when the target volume was larger than 25 cm3. A number of challenges are apparent with respect to the Furthermore. inclusive of surgery and/or depending of histology and tumor volume as prognostic factors [122]. LINAC is effective and safe method. is tissue sparing into the brain stem or temporal lobe [126. high local tumor control and low morbidity. A study that compared neuralgia. the optimal medical therapies are yet to be elucidated. demonstrates efficacy and low risk of use of radiosurgery in non-benign meningiomas is not effective marginal failure with reduced margins [129]. taking into account organs at risk. 22 patients (6. for optic nerve sheath meningiomas. but [120]. Improved understanding of the molecular mechanisms driving meningioma tumorigenesis and malignant transformation has resulted in the targeted development of more specific agents for chemotherapeutic intervention in patients with nonresectable. Helical Tomotherapy (HT). choice. In patients with skull enough. possible to preserve cranial nerve function [111]. This technique is useful for irregularly patients [107. while subtotal tumor resection does static Conformal Field (CF). has been for typical meningiomas. has been beneficial for the treatment of framework for skull base tumors. but does not improve reason meningiomas are an ideal candidate. standard therapy of meningiomas. Panagiotopoulos V. and worsened or Furthermore. proof from which to establish appropriate treatment and there are a small number of clinical trials for patients with Combined Stereotactic Radiosurgery and FSRS are both equally safe recurrent meningiomas [134]. the differences were not clinically significant with traditional dose recommendation concepts [131]. While strong evidence exists for the 4. aggressive. with results similar to with untreatable tumors or those which are inappropriate for surgery those reported for other stereotactic RT techniques [123]. 39. minimal side effects. all techniques provided good effective alternative to either surgery or radiotherapy for selected organs at risk sparing. Fountas K (2015) New Developments in Management of Meningioma . Tsianaka E.2% anaplastic) the use of IMRT as primary treatment or Stereotactic Fractionated Radiotherapy (SFRT) is the treatment of postoperative for residual disease and treatment after local recurrence. (IMRT). reducing post-surgical lesions of the optic nerve [118]. where the In skull base meningiomas. J Integr Oncol 4: 135. because of a limited normal The use of SRS in cerebellopontine angle (CPA) meningiomas.Citation: Fotakopoulos G.4172/ 2329-6771. after subtotal excision or biopsy and for recurrence disease.108]. radiation therapy.6% atypical and 4. neurologic deficits improved. base meningiomas. resection and offers excellent help in management of the skull base lesions.5 years after SFRT. 49% for atypical and 0% for malignant improved the effectiveness of radiotherapy. In low morbidity and satisfactory long-term results [116. minimally symptomatic or 5. for those tumors which recur.117]. Intensity-Modulated Radiotherapy challenge and SFRS improves or stabilize visual deficit. in most patients [109]. FSRS was used as primary 6. after microsurgical removal [106]. the 5-year actuarial control rate was 87% high-dose suits the target and avoids normal tissues. an open access journal . at incompletely resected There is very limited published literature that provides persuasive or recurrent malignant meningiomas [124]. Additionally. In a study with complex-shaped 4. with a reduction of radiographic considerably better dose distributions than proton plans in IMPT. treatment toxicity [91]. AMOA was considerably preferable [133].127]. [42. and malignant meningiomas [135]. Other reports mentioned an 89% 5-year tumor The use of IMRT to treat grade II meningiomas with total initial control rate and 5% complication rate [113]. doi:10. HT providing the best combination of indices. It is a safe option with was an effective and safe cure modality for long-term local control. Gamma Knife radiosurgery shows satisfactory results in long-term disease control of IMRT is an effective method for treating meningiomas causing benign meningiomas [112]. A single-fraction Stereotactic Radiosurgery provides a high rate tumor control. in 89% of cases. Stereotactic Fractioned Radiotherapy (SFRT) meningiomas of the skull base (54. Modulated Multiple Arc Therapy (AMOA). Intensity-modulated radiotherapy (IMRT) growing Foramen Magnum Meningiomas (FMMs).8% of the patients.

Jo KW. Whittle IR. The exact search was done using the term – those involving the dural venous sinuses. Navoo P. age of the study and biochemical hypothyroidism [142]. Endovascular treatment hoc. any study of dilute MR contrast media. non-English [143]. In atypical and subtotal excised or recurrent 8. provide a better and safer therapeutic analysis of asymptomatic and symptomatic meningiomas. Nam DH. Heros RC (2013) Asymptomatic meningiomas. selective intra-arterial injection speaking publications and reports not related to humans. McGuire VM. in order to decrease the volume of the tumor and the surgical blood loss [146]. the major complications. Longstreth WT Jr. and details on the definitions of all reported analyses. J post-embolization cranial nerve palsy [153]. such as hemiparesis and tumor swelling [146]. Sheehan J (2013) Gamma Knife sinus is demanding more carefulness. or supplementary transfusion during operation [145]. hydroxyurea and somatostatin. PubMed searches were performed using a wide array of terms large residual tumors [91]. Angiography and more recently. with good results and tumor shrinkage in most cases [151].150]. after total or subtotal resection and RT. Nozaki K (2011) Growth curve endovascular treatment. Dennis LK. et al. Panagiotopoulos V. journal.139]. Further. The combination with the 7. offer an excellent results and in Neurochir (Wien) 153: 62-67. Smith C. Nakasu S. Vernooij MW.1000135 Page 5 of 9 Some studies analyze the potentials benefits from because of questionable effectiveness and considerably side effects. eliminating the postoperative complications and Committee of the Institution within which this work was undertaken shortening the operative time [148]. Mifepristone can be also performed for prolonged periods in patients Data extraction and definitions with nonresectable meningioma. The malignant recurrent meningiomas [138. Fukami T. as an alternative (effective and safe) 639-648. chemotherapeutics. Tanghe HL. Nagaraja TG. The rapid technological developments in endovascular materials. parasagittal and temporal base 3. J Neurooncol 29: 197-205. Most data is about therapeutic options. Jito J. conventional radiotherapy should be performed. On the other hand. (2007) Incidental findings on brain MRI in the general population. Drangsholt MT. Ligon BL (1996) Epidemiology and etiology of intracranial meningiomas: a review. Stereotactic radiosurgery can be used as an alternative 102: 303-310. benign meningiomas of the skull base or pertinent to meningiomas. Methods Hydroxyurea is a modestly active agent against recurrent meningiomas and can induce long-term stabilization of Search strategy for identification of studies disease in some patients [137]. which give rise to better targeted molecular agents and hormonal agents. Thus. 6. most cases a completely therapy. design.Citation: Fotakopoulos G. in many meningiomas and therapy. including cytotoxic agents. Levy C. Kong DS.4172/ 2329-6771. 5. However. arteries run posteromedially toward the petrous apex or cavernous 4. should be used in specific cases. figures. Even the recent technological developments. patients also. Fountas K (2015) New Developments in Management of Meningioma . Ikram MA. doi:10. material. References On the other hand. has been used. method for very large convexity. There are reports also. the “gold standard” of meningiomas treatment. adjuvant scrutinized. adriamicin and vincristine retrieved articles and disagreements were solved by consensus after (CAV). Nakasu Y. preventing the atypical histological This study has been approved by a suitably constituted Ethics changes [147]. Elhammady MS. J Integr Oncol Volume 4 • Issue 2 • 1000135 ISSN:2329-6771 JIO. whether analyses had been adjusted for multiple comparisons. such as an irregular vaginal bleeding. Seol HJ. but have been reported many side This is a review study. J Conclusion Neurosurg 119: 482-486. Acta in benign and total resected tumors. combination and targeted molecular therapies are still underway [136]. Neurosurg 119: 487-493. Chemotherapeutic agents also. We reports mentioned a limited effect of this agent. although further trials with still remain challenging. since they are at increased risk of surgery for the treatment of patients with asymptomatic meningiomas. From each eligible study we extracted the effects. N Engl J Med 357: 1821-1828. racial descent. tables. (2011) Treatment Surgery remains the main choice of treatment at meningiomas and modalities and outcomes for asymptomatic meningiomas. may be beneficial in Ethics Statement benign (grade I) meningiomas. Collie D (2004) Meningiomas. Hofman A. can be offer a better understanding and with less than four cases with spinal ependymomas. Embolization is recommended. Tsianaka E. biologic agents. year. the application or not of preoperative embolization in meningiomas. endometrial thickening following information: author. It has been used for untreatable tumors. an open access journal . Lancet 363: meningiomas [152]. years) [140]. treatment to surgery. meningiomas. in patients whose tumor-feeding 1535-1543. Cancer 72: clipping of external carotid artery. Two independent investigators for eligibility evaluated chemotherapy with cyclophosphamide. et al. allowed a micro catheterization and embolization of meningiomas we excluded case reports analyzing less than four cases. is still remaining controversial. J Integr Oncol 4: 135.(last updated on January 2015). Kim CH. Xu Z. performed the used of the temporary 2. combinations of andriamycin and dacarbazine or isosfamide and mensa provide a more effective treatment [141]. angiographic embolization reduces the need of any level of detail in the text. population. Furthermore. Bondy M. Vincent AJ. Information was more clear view to the vascular blood supply of the meningiomas captured on all analyses performed and reported in any format and in [144]. From the 2104 related articles retrieved from the PubMed search. Koepsell TD (1993) Epidemiology of intracranial meningioma. due to 1. J Neurooncol strategy. embolization can be used as an alternative treatment [149. in atypical or included studies published over the last 6 years (from May 2009). Salvetti DJ. whether analyses were acknowledged to be post 7. As for malignant reference lists of eligible articles and pertinent reviews were meningioma.3 discussion with a third investigator. with very good outcome (median survival 5. At inappropriate for surgery and conforms to the provisions of the Declaration of Helsinki.

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