Aggressive meningioma Robert M. Koffie Neurosurgery sub-intern July 19, 2012 Department of Neurosurgery Massachusetts General Hospital Harvard Medical School Case Presentation HPI: 62 RHF 6 yrs ago p/w headaches, personality changes, & difficulty concentrating, and was found to have 7-cm parasagittal extra-axial enhancing lesion c/w meningioma. Multiple recurrence s/p surgery x4, several cycles of radiotherapy. Oncological course: 2006: GTR, benign meningioma 2007: Recurrence, GTR, benign meningioma w/ atypical features Post-op fractionated radiotherapy 2009: Local recurrence, GTR, atypical meningioma 2010: Multifocal recurrence, proton SRS x3 2011: Recurrence, GTR, atypical meningioma w/ anaplastic features 2012: Multifocal recurrence, ant. skull base invasion Case Presentation T1 post gad: Multifocal parasagittal enhancing mass lesion with dura tail; another component centered in nasal cavity, filling ethmoid sinus, & bilateral orbits; contiguous anterior cranial fossa component Part 1 pre-op scans Part 1 Bifrontal craniotomy for resection of parasagittal tumor 125 I brachytherapy seed placement Part 2 Endonasal resection of tumor (ENT) Bifrontal craniotomy for skull base tumor Biorbital decompression (ENT/Oculoplastics) Titanium + free flap skull base reconstruction (Plastics) Operative plan T1 post gad: Enhancing mass lesion centered in nasal cavity, filling ethmoid sinus, & bilateral orbits; contiguous anterior cranial fossa component with dura tail, severe proptosis Non-contrast CT: Destruction of cribriform plate and surrounding bone, Brachytherapy seeds in place Part 1 post-op scans (Part 2 pre-op) Intraoperative findings EndonasalSubfrontal Post-op scans T1 post gad: s/p extensive cranial facial resection of tumor flap placement for skull base repair no residual tumor WHO grades II and III meningioma Pathology Design: Retrospective, 108 patients Goal: Define the long-term recurrence rate after GTR, role of radiation, factors predicting recurrence Results: Recurrence rates 7% (1 year), 41% (5 years), and 48% (10 years). Age, men, prominent nucleoli & high mitosis increases risk Recurrence rate (Atypical) Aghi MK et al, Neurosurgery, 2009 Recurrence rate (Atypical) Design: Retrospective, 63 patients. Results: Survival after initial operation 82% (2y), 61%(5y) 40%(10y) +Survival benefit with repeat operation (53 vs 25 months) Surgery for recurrence Sughrue ME et al, J Neurosurg, 2010 Pathogenesis of Aggressive Meningioma BenignAtypicalAnaplastic Choy BA, Neurosurg Focus, 2011 Pathogenesis of Aggressive Meningioma BenignAtypicalAnaplastic Atypical Anaplastic Krayenbuhl N et al., Neurosurgery, 2007 WHO grade II WHO grade III De novo vs. transformed aggressive meningioma Agar et al., Anal. Chem Imaging Meningioma Progression: MALDI-MSI POD8: Tension pneumocephalus s/p decompression POD10: Thrombosed free flap, CSF Leak s/p repair POD11: Lumbar drain POD15: Trach/PEG POD22: Doing well, transfer to rehab Hospital course MGH Faculty William T. Curry, M.D. David N. Louis, M.D. MGH House staff Gavin P. Dunn, M.D., Ph.D. Peter E. Fecci, M.D., Ph.D. Daniel A. Mordes, M.D., Ph.D Staff Sylvia Weld Neuro Nurses/NPs Acknowledgements Thank you