EANO guideline on the diagnosis and management of meningiomas

Abstract

Meningiomas are the most common intracranial tumors. Yet, only few controlled clinical trials have been conducted to guide clinical decision making, resulting in variations of management approaches across countries and centers. However, recent advances in molecular genetics and clinical trial results help to refine the diagnostic and therapeutic approach to meningioma. Accordingly, the European Association of Neuro-Oncology (EANO) updated its recommendations for the diagnosis and treatment of meningiomas. A provisional diagnosis of meningioma is typically made by neuroimaging, mostly magnetic resonance imaging. Such provisional diagnoses may be made incidentally. Accordingly, a significant proportion of meningiomas, notably in patients that are asymptomatic or elderly or both, may be managed by a watch-and-scan strategy. A surgical intervention with tissue, commonly with the goal of gross total resection, is required for the definitive diagnosis according to the WHO classification. A role for molecular profiling including gene panel sequencing and genomic methylation profiling is emerging. A gross total surgical resection including the involved dura is often curative. Inoperable or recurrent tumors requiring treatment can be treated with radiosurgery, if the size or the vicinity of critical structures allows that, or with fractionated radiotherapy (RT). Treatment concepts combining surgery and radiosurgery or fractionated RT are increasingly used, although there remain controversies regard timing, type, and dosing of the various RT approaches. Radionuclide therapy targeting somatostatin receptors is an experimental approach, as are all approaches of systemic pharmacotherapy. The best albeit modest results with pharmacotherapy have been obtained with bevacizumab or multikinase inhibitors targeting vascular endothelial growth factor receptor, but no standard of care systemic treatment has been yet defined.

Keywords: meningioma; molecular pathology; neuropathology; radiosurgery; surgery.

Fig. 1

PET-CT after injection of ⁶⁸Ga-DOTATATE. (A) PET-gamma-scan in coronar plane, (B) PET-gamma-scan in axial plane, (C) computed tomography in axial plane, (D) fusion of computed tomography and PET-scan in axial plane, (E) MRI T1-weighted with CM in coronar plane, and (F) MRI T1-weighted with CM in axial plane. Abbreviations: ⁶⁸Ga-DOTATATE, 68-gallium DOTA-D-Phe1-Tyr3-octreotate; CM, contrast medium; MRI, magnetic resonance imaging; PET-CT, positron emission tomography-computed tomography.

Fig. 2

Recommendations for the therapeutic management of WHO grade 1-3 meningiomas.