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Cancer Medicine :: Meningioma

Meningioma

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of tumor. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options.

Treatment overview

In meningioma care, different types of doctors often work together to create a patient's overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. This team may include neuro-oncologists, medical oncologists, radiation oncologists, surgeons, rehabilitation therapists, and other specialists.

People diagnosed with a CNS tumor usually need treatment as soon as possible. The pressure caused by a growing CNS tumor can cause severe symptoms, including a backup of cerebrospinal fluid and problems with blood circulation, which can damage delicate nerves and deprive cells of nutrients.

Descriptions of the most common treatment options for meningioma are listed below, and may include surgery and radiation therapy, and occasionally chemotherapy. Treatment options and recommendations depend on several factors, including the type and grade of the tumor, possible side effects, and the patient's preferences and overall health.

Treating brain and spinal cord tumors can be challenging. Surgery is the most common type of treatment, but it can be difficult if the tumor is near a delicate portion of the brain or spinal cord. The blood-brain barrier, which normally serves to protect the brain and spinal cord from damaging chemicals, also keeps out many types of chemotherapy. Meningioma grows outside the blood-brain barrier, so some drugs do reach these tumors; however, they are very resistant to currently available chemotherapy.

More refined surgeries, a better understanding of the tumors that can be treated with chemotherapy, and precise delivery of radiation therapy have helped more patients with CNS tumors live longer and have a better quality of life.

Active surveillance

Because a grade I meningioma grows slowly, active surveillance may be recommended for some patients. This approach is also called watchful waiting or watch-and-wait. During active surveillance, the tumor is monitored and treatment would begin if it started causing any symptoms or problems. This approach may be used for much older patients or for those with a tumor that was discovered accidently and is not causing any symptoms.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. For meningioma, it is the most common type of treatment and is often the only treatment needed for benign tumors that are able to be completely removed by surgery. For patients with a cancerous tumor or a tumor that cannot be fully removed with surgery, the treatment plan often includes radiation therapy and/or chemotherapy after surgery (see below).

Blocking the blood vessels that feed the tumor may be performed before surgery to reduce bleeding. Surgery to the brain is done by removing part of the skull, a procedure called a craniotomy. A neurosurgeon is a doctor who specializes in surgery of the brain and spinal cord. After the surgeon removes the tumor, the patient's own bone will be used to cover the opening in the skull.

In addition to removing or reducing the meningioma, surgery can be used to obtain a sample of tumor for analysis under a microscope. The results of the analysis can show if additional treatments, such as radiation therapy, will be necessary.

There have been rapid advances in surgery for brain tumors, including cortical mapping to identify the areas of the brain that control the senses, language, and motor skills and enhanced imaging methods to give surgeons more tools to plan and perform the surgery. Talk with your doctors to learn about the specific techniques that your surgery will include, including the possible side effects.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill tumor cells. A doctor who specializes in giving radiation therapy to treat tumor is called a radiation oncologist. Doctors may recommend radiation therapy along with surgery to slow the growth of aggressive tumors. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. Radiation therapy can be given in several ways. External-beam radiation therapy techniques use a machine outside the body to target the tumor. These techniques are becoming better able to direct radiation to the tumor while avoiding healthy tissue. For example, a linear accelerator is a special x-ray machine that moves around the body to direct pencil-thin beams of radiation to the brain tumor at different angles and intensities. This helps to reduce the amount of healthy tissue exposed to the radiation.  

Internal radiation therapy or brachytherapy is the use of tiny pellets or rods containing radioactive materials that are surgically implanted in or near the tumor. This approach is only used for meningioma in clinical trials.

The following external-beam radiation therapy techniques may be used:

Conventional radiation therapy. In this procedure, where the radiation is directed is determined by features of the brain and skull and by x-rays. When a person's entire brain needs to receive radiation therapy, this technique is appropriate. For more precise targeting, different techniques are needed.

Intensity modulated radiation therapy (IMRT). IMRT is a type of external-beam radiation therapy that can more directly target a tumor, further sparing normal tissue from radiation therapy. In IMRT, the radiation beams are broken up into smaller beams and the intensity of each of these smaller beams can be changed. This means that the more intense beams, or the beams giving more radiation, can be directed only at the tumor. It is most useful to treat a tumor that is near critical parts of the brain, such as the brain stem and areas that control sight.

Three-dimensional conformal radiation therapy. Based on CT and MRI images, a three-dimensional model of the tumor and normal tissues is created on a computer. Beam size and angles are determined that deliver more radiation to the tumor and less to the normal tissue.

Stereotactic radiosurgery. Stereotactic radiosurgery delivers a single, high dose of radiation directly to the tumor and not healthy tissues. It works best for a tumor that is only in one area of the brain and some benign tumors, including most meningiomas. There are many different types of stereotactic radiosurgery equipment, including:

A modified linear accelerator, which is a machine that creates high-energy radiation by using electricity to form a stream of fast-moving particles that help kill tumor cells.

A gamma knife is another form of radiation therapy that concentrates highly focused beams of gamma radiation on the tumor. A gamma knife can only be used for meningioma in the brain, not meningioma on the spine.

A cyber knife is a robotic device used in radiation therapy to guide radiation to the tumor—particularly tumors in the brain, head, and neck.

Fractionated stereotactic radiation therapy. Radiation therapy is delivered as directly as stereotactic radiation therapy, but the dose is divided into small, daily doses over several weeks using a relocatable head frame instead of in a single day. This technique is best for tumors close to complex or sensitive structures, such as the optic nerves or brain stem.

Proton radiation therapy. Proton therapy (also called proton beam therapy) is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy tumor cells. 

With these different techniques, doctors are trying to better target only the tumor and reduce the dose to the surrounding normal tissue. Depending on the size and location of the tumor, the radiation oncologist may choose any of the above radiation therapy techniques. In certain situations, a combination of two or more techniques may be used.

Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and neurologic symptoms. Most side effects go away soon after treatment is finished. Also, radiation therapy is usually not recommended for children younger than five because of the high risk of damaging their developing brains.

There are long term side effects that may occur years after treatment. A person may experience cognitive problems, including memory loss and a slow decline in intellectual performance. If the pituitary gland (a small gland near the brain that releases may hormones that control bodily functions) received radiation, there may be changes in hormonal levels that need to be evaluated by an endocrinologist (a doctor who specializes in hormonal conditions). How severe these side effects are depends on how much radiation was given and where in the brain. While these side effects have become less severe with better technology and precision in radiation therapy, you should speak with your radiation therapist before treatment begins if you have any questions or concerns about the possible long-term side effects of radiation therapy. 

Chemotherapy

Chemotherapy is the use of drugs to kill tumor cells, usually by stopping the tumor cells' ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach tumor cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating a tumor with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

The goal of chemotherapy can be to destroy any tumor remaining after surgery, slow the tumor's growth, or reduce symptoms. However, chemotherapy is rarely used to treat meningioma, although researchers are studying this form of treatment. It is also important to keep in mind that a treatment plan may change over time if it is no longer working.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

The medications used to treat any type of tumor are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Palliative/supportive care

A tumor and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the tumor, an important part of care is relieving a person's symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the tumor and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. Common types of supportive care for people with a brain tumor include:

Steroids. Steroids occur naturally in the body in tiny amounts. In larger amounts, they are very powerful anti-inflammatories (drugs that reduce swelling). Most patients with a brain tumor will be prescribed steroids to help relieve swelling of the brain. You will most likely receive steroids when you are first diagnosed, before and after surgery, before and after radiation therapy, and if you have an advanced brain tumor. Steroids have many side effects, which include weight gain and water retention, increased appetite, difficulty sleeping, changes in mood, and stomach irritation. After successful treatment for the brain tumor, your doctor may slowly reduce the amount of steroids you need to take over time.

Anti-seizure (convulsant) medication. A person with a CNS tumor may experience seizures , and this type of medication helps to control the frequency of them.

Shunt. If fluid begins to build up in the brain, it may become necessary for a surgeon to place a shunt (a device used to bypass or divert fluid from one place to another) to drain the excess fluid.

Anti-depressants. Depression can be common in people with a CNS tumor, but it is often undiagnosed. However, this does not mean that all people with a CNS tumor are depressed. For those who have symptoms of depression, the health care team may decide to prescribe an anti-depressant medication to help with the symptoms. 

Recurrent meningioma

A remission is when the tumor cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the tumor will come back. While many remissions are permanent, it's important to talk with your doctor about the possibility of the tumor returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the tumor does return. 

If the tumor does return after the original treatment, it is called a recurrent tumor. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, radiation therapy, and chemotherapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent tumor. The most common treatment for recurrent meningioma is additional surgery. If surgery cannot be performed, radiation therapy is generally used. In addition, a patient can still receive care to manage the symptoms caused by the tumor. Symptom management (see Palliative/supportive care above) is always important since the symptoms of meningioma can interfere with a person's quality of life.

People with a recurrent tumor often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic meningioma

If the tumor has spread to another location in the body, it is called a metastatic tumor. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating metastatic meningioma, because there can be different opinions about the best treatment plan. 

For many patients, a diagnosis of metastatic meningioma can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Coping with Side Effects

Fear of treatment side effects is common after a diagnosis of meningioma, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for meningioma are described in detail within the Treatment section. Side effects depend on a variety of factors, including the tumor's grade, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with meningioma. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. 

After Treatment

After treatment for meningioma ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.

People treated for benign meningioma typically have annual follow-up visits with a neurosurgeon or neuro-oncologist. Because meningioma may recur, people are routinely monitored for new symptoms with regular MRI scans as well as physical examinations. The frequency of the checkups and scans varies widely from patient to patient; your plan will be determined by your oncologist or neuro-oncologist. More aggressive tumors may require more frequent checkups and ongoing medical care after recovery from surgery. If radiation therapy was given to the pituitary gland, evaluations of hormone levels may be needed. 

As described in previous sections, meningioma and its treatments can affect the functioning of the brain as well as the well-being of the patient. For this reason, it is sometimes helpful for the health care team to evaluate the patient's cognitive (thought-process) abilities through specialized tests, often given by a neuropsychologist (a psychologist who studies causes of brain disorders and specializes in diagnosing and treating these disorders using mostly a medical approach), and also to monitor the quality of life of the patient. These evaluations could identify certain problems that may benefit from specific therapies, such as speech or occupational therapy, counseling with a social worker, or prescription medications that can help to reduce fatigue or improve memory. Whenever possible, participation in a support group with other people diagnosed with a CNS tumor is highly encouraged.

In addition, people with difficulties moving or performing daily physical functions, such as weakness or imbalance, may benefit by talking with a doctor who specializes in rehabilitation medicine, because the specialist may be able to recommend specific strategies for recovery.

Latest Research 

Doctors are working to learn more about meningioma, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Hyperfractionization radiation therapy. This is the use of smaller doses of radiation therapy given more often.

Hormonal drugs. Research has shown a possible link between meningioma and hormone levels.

New treatments. New treatments that target the proteins that a tumor uses to grow are being studied in clinical trials. These types of treatments include the following:

Immunotherapy boosts the body's natural defenses to fight the tumor. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function.

Anti-angiogenesis therapy focuses on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to starve the tumor.

Drugs affecting other functions inside of tumor cells, including those that help tumor cells divide.

Gene therapy seeks to correct faulty genes that are causing tumor growth.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current meningioma treatments in order to improve patients' comfort and quality of life.

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