Meningioma and the SSS

[Haybrant]

64 yo man history of psychiatric issues with increasing forgetfulness over the last year had an MRI that showed left parasag vertex extraaxial mass (picture attached). Was taken for surgery With path showing atypical meningioma, low Ki67 but high mitoses. Considered subtotal due to wrapping around and invasion of the sup sag sinus. Surgeon was worried about RT hastening CVST (cerebral venous sinus thrombosis) and wanted to know if we would recommend RT. Don’t see many of these, is concern for RT leading to CVST enough to not offer RT in a subtotal resection? Do you boost the area of residual if treating? Thanks

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[Palex80]

Argument in favor of adjuvant RT is that repeat resection in case of progression appears highly unlikely, thus local control may be higher if you treat now after maximal possible surgery was performed.

Argument against RT is the localization, which can be easily followed up and won’t cause immediate symptoms in case of progression.

The ROAM trial recently fully accrued, comparing observation vs. adjuvant after Simpson I-III. Results pending.

The ROAM/EORTC-1308 trial: Radiation versus Observation following surgical resection of Atypical Meningioma: study protocol for a randomised controlled trial - Trials

Background Atypical meningiomas are an intermediate grade brain tumour with a recurrence rate of 39–58 %. It is not known whether early adjuvant radiotherapy reduces the risk of tumour recurrence and whether the potential side-effects are justified. An alternative management strategy is to...

trialsjournal.biomedcentral.com

I don‘t boost residual disease in atypical. 60/2 is my standard dose, one volume.

 

[Haybrant]

Argument in favor of adjuvant RT is that repeat resection in case of progression appears highly unlikely, thus local control may be higher if you treat now after maximal possible surgery was performed.

Argument against RT is the localization, which can be easily followed up and won’t cause immediate symptoms in case of progression.

The ROAM trial recently fully accrued, comparing observation vs. adjuvant after Simpson I-III. Results pending.

The ROAM/EORTC-1308 trial: Radiation versus Observation following surgical resection of Atypical Meningioma: study protocol for a randomised controlled trial - Trials

Background Atypical meningiomas are an intermediate grade brain tumour with a recurrence rate of 39–58 %. It is not known whether early adjuvant radiotherapy reduces the risk of tumour recurrence and whether the potential side-effects are justified. An alternative management strategy is to...

trialsjournal.biomedcentral.com

I don‘t boost residual disease in atypical. 60/2 is my standard dose, one volume.

Thanks palex - since he had residual at the SSS I presume this would be considered subtotal resection so he falls into a high risk group by rtog 0539 so seems like it would be standard to recommend adjuvant RT?

Bc of proximity to the SSS can it be argued that early recurrence can lead to more significant complication? Perhaps the surgeon is not concerned that RT hastens thrombosis but that tumor recurrence hastens Thrombosis it is that correct RT can lead to thrombosis? If so perhaps anticoagulation can be considered and proceed to RT?

 

[Neuronix]

NRG BN003 is asking the same question on RT vs. observation in gross totally resected atypical meningioma, and it is also nearing full accrual.

This is not that case. This is subtotal resection of atypical meningioma. I would treat for sure. This would be considered high risk under RTOG 0539.

I would use NRG BN003 fields though. RTOG 0539 fields are too large in my opinion. I often do 54 Gy to cavity + 5 mm and 60 Gy to disease + 5 mm in 30 fractions. CTV only extends into brain in case of brain invasion. This is kind of a hybrid of BN003 and RTOG 0539 and my own personal style.

I'd keep SRS in my back pocket for recurrence.

I don't believe that RT contributes to central venous sinus thrombosis. I have never seen any data on this one way or the other. I'm happy to be educated on this if someone has published data on it. If patient has symptomatic thrombosis, needs anticoagulation. If not, just move forward. I treat a lot of meningiomas and RT thrombosis risk has never come up as a concern from our surgeons. I don't see this as a concern elsewhere in the body either.

 

[Palex80]

Oh yes, you are right! ROAM only included gross total resection. That’s certainly an argument in favor of adjuvant RT.

 

[jondunn]

yeah this is not a BN003 case - SOC for subtotal is RT for a grade 2.

 

[Mandelin Rain]

NRG BN003 is asking the same question on RT vs. observation in gross totally resected atypical meningioma, and it is also nearing full accrual.

This is not that case. This is subtotal resection of atypical meningioma. I would treat for sure. This would be considered high risk under RTOG 0539.

I would use NRG BN003 fields though. RTOG 0539 fields are too large in my opinion. I often do 54 Gy to cavity + 5 mm and 60 Gy to disease + 5 mm in 30 fractions. CTV only extends into brain in case of brain invasion. This is kind of a hybrid of BN003 and RTOG 0539 and my own personal style.

I'd keep SRS in my back pocket for recurrence.

I don't believe that RT contributes to central venous sinus thrombosis. I have never seen any data on this one way or the other. I'm happy to be educated on this if someone has published data on it. If patient has symptomatic thrombosis, needs anticoagulation. If not, just move forward. I treat a lot of meningiomas and RT thrombosis risk has never come up as a concern from our surgeons. I don't see this as a concern elsewhere in the body either.

All of this. I treat the same way (with slightly larger margin).

I believe that most of the concern regarding these cases is SRS, as parasagittal meningiomas may be at risk for greater treatment related edema. Never heard about it with traditionally fractionated XRT.

 

[seper]

I'd treat now. Check post MR - there is invariably a large residium.
Tumor will cause thrombosis if left untreated.

 

[evilbooyaa]

Have also not heard any reports or seen any data suggesting RT worsens cerebral venous sinus thrombosis. If you have a collegial relationship with the NSG, I'd ask him what makes him think that RT worsens CVST. If you don't, then don't bother and say "I would recommend RT".

 

[Haybrant]

Wanted to come back to this case. I treated him with fractionated RT 54 and boost to 60 in 30 fractions he finished in October ‘22. He tolerated things fine until the last week of treatment complained of right lower extremity clumsiness causing loss of balance. Remained mild but more pronounced about a week post RT. Did a low dose 2 weeks steroid taper, helped a little but change was still present but mild. Looking back he did say he had similar sxs post surgery but it did seem worse by end of RT. About a month later he had more weakness and had a couple falls. He was being followed by neuroonc and neurology. Two MRIs post RT were unrevealing, standard post op RT change. Neuro did a bunch of testing that I don’t even understand including EEGs and an amyloid PET, said he might have early Parkinson’s.

Then 1 week ago came in with profound confusion and right hemiplegia. MRI showed mild increase in edema up in the vertex but it’s a pretty low amount, otherwise stable but it was non con bc he couldn’t tolerate. Contrast head ct without any enhancement. Chalked up to RT necrosis. Started on steroids 10mg bolus and had been on 4bid. Confusion improves considerably but not change in the right sided weakness. NeuroRad says the sinus thrombus has not changed in size and there is no evidence of an infarction

Appreciate thoughts, nsurg/onc/neuro not really sure where to go.

 

[gvsudew]

Wanted to come back to this case. I treated him with fractionated RT 54 and boost to 60 in 30 fractions he finished in October ‘22. He tolerated things fine until the last week of treatment complained of right lower extremity clumsiness causing loss of balance. Remained mild but more pronounced about a week post RT. Did a low dose 2 weeks steroid taper, helped a little but change was still present but mild. Looking back he did say he had similar sxs post surgery but it did seem worse by end of RT. About a month later he had more weakness and had a couple falls. He was being followed by neuroonc and neurology. Two MRIs post RT were unrevealing, standard post op RT change. Neuro did a bunch of testing that I don’t even understand including EEGs and an amyloid PET, said he might have early Parkinson’s.

Then 1 week ago came in with profound confusion and right hemiplegia. MRI showed mild increase in edema up in the vertex but it’s a pretty low amount, otherwise stable but it was non con bc he couldn’t tolerate. Contrast head ct without any enhancement. Chalked up to RT necrosis. Started on steroids 10mg bolus and had been on 4bid. Confusion improves considerably but not change in the right sided weakness. NeuroRad says the sinus thrombus has not changed in size and there is no evidence of an infarction

Appreciate thoughts, nsurg/onc/neuro not really sure where to go.

Had a very similar patient and symptoms gradually improved over 12-18 months with fairly persistent need for steroids over much of that time. At this point 4 years out has LC and feels fairly well.

 

[Neuronix]

Contrast head ct without any enhancement.

Contrast head CT useless, should be MRI. I would try to repeat asap. Could be RT necrosis, treatments start with dex, can consider Vit E + Trental, then the other options are hyperbaric oxygen or Avastin.

If it's just one sided sounds like a focal process like RT injury or tumor recurrence, don't know how Parkinson's or any other neurodegeneration would do that.

It's odd though that a mild amount of edema is causing so much confusion. Maybe there's something entirely different going on. In the elderly there are a million causes of confusion, though that doesn't explain the hemiplegia. I mean... How's his neck? Atypicals can be multifocal in the spine. Heck, had a lady one time who had progressive cervical spinal stenosis during treatment and I sent her for a laminectomy right after treatment. Just thinking broadly here. Any other symptoms like sensation change that might point to something elsewhere?

 

[Palex80]

It's a bit early for necrosis and after 54/60 Gy rather unlikely, wouldn't you say?
Perhaps some vascular issue?