Long-term survival in patients with long-segment complex meningiomas occluding the dural venous sinuses: illustrative cases

Abstract

Background: Invasive sagittal sinus meningiomas are difficult tumors to cure by resection alone. Stereotactic radiosurgery (SRS) can be used as an adjuvant management strategy to improve tumor control after incomplete resection.

Observations: The authors reported the long-term retrospective follow-up of two patients whose recurrent parasagittal meningiomas eventually occluded their superior sagittal sinus. Both patients underwent staged radiosurgery and fractionated radiation therapy to achieve tumor control that extended to 20 years after their initial surgery. After initial subtotal resection of meningiomas that had invaded major cerebral venous sinuses, adjuvant radiosurgery was performed to enhance local tumor control. Over time, adjacent tumor progression required repeat SRS and fractionated radiation therapy to boost long-term tumor response. Staged multimodality intervention led to extended survival in these patients with otherwise unresectable meningiomas.

Lessons: Multimodality management with radiosurgery and fractionated radiation therapy was associated with long-term survival of two patients with otherwise surgically incurable and invasive meningiomas of the dural venous sinuses.

Keywords: GK = Gamma Knife; IMRT = intensity-modulated radiation therapy; MRI = magnetic resonance imaging; SRS = stereotactic radiosurgery; SSS = superior sagittal sinus; WHO = World Health Organization; dural venous sinuses; radiation therapy; stereotactic radiosurgery.

FIG. 1.

Patient history timeline, GK SRS treatment plans, and tumor response to SRS for case 1. A: A 55-year-old woman underwent initial resection of a parasagittal meningioma. The residual tumor in the sagittal and transverse sinuses was treated with adjuvant volume-staged SRS and fractionated radiation therapy. The patient developed trigeminal neuralgia (TGN) 24 months after her craniotomy and was treated with SRS for management of her facial pain. She underwent repeat SRS 120 months after the initial craniotomy for recurrent tumor. Repeat trigeminal GK SRS was performed three times for recurrent pain. At 243 months after the initial craniotomy, her tumor and facial pain were stable. B: The radiosurgery dose plan projected on the axial, coronal, and sagittal views for stages 1, 2, and 3 of the first and second SRS. The 214-month follow-up MRI after first GK shows stable tumor.

FIG. 2.

Patient history timeline, GK SRS treatment plans, and tumor response to SRS for case 2. A: A 49-year-old woman underwent initial resection of a left frontal meningioma. The residual and recurrent tumors in the SSS were treated with four SRS procedures and boosted with radiation therapy over an interval of 216 months. The patient was neurologically and functionally stable 216 months after her initial craniotomy. B: The radiosurgery dose plans projected on the axial, coronal, and sagittal views of the four SRS procedures. Follow-up images 191 months after the first SRS show stable tumor. The patient’s status was stable without neurological deficits.