by ROBERT G. OJEMANN, M.D.
© Congress of Neurological Surgeons Honored Guest Presentation
Originally Published Clinical Neurosurgery, Volume 40, Chapter 17, Pages 321-383, 1992
Used with permission of the Congress of Neurological Surgeons.
HTML Editor: Stephen B. Tatter, M.D., Ph.D.

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Contents

• Introduction to the therapy of Meningiomas (File 1)
• General Considerations in Management of Meningiomas (File 1)
  • Surgery of Meningiomas (File 1)
  • Radiation Therapy of Meningiomas (File 1)
  • Observation of Meningiomas (File 1)
• Summary of Dr. Ojemann's Meningioma Series (File 1)
  • MALIGNANT MENINGIOMAS (This File)
• References (File 22)

MALIGNANT MENINGIOMAS

(Meningioma Management, File 21)

In most patients a preoperative diagnosis of malignant meningioma is not made. Therefore, the initial management decisions are the same as outlined for each location of tumor. The most important surgical consideration is to make as wide an excision as possible of the dura and/or falx around the tumor. Some patients have required multiple operations.

TABLE 17.20 Malignant Meningioma Locations
Location	Number
Sphenoid wing-cavernous sinus	1
Parasagittal	10
Convexity	3
Tentorial	1
Cerebellopontine angle	3
Spine	1

Radiation therapy is used at some point in the management of most of these patients. When to give the therapy has not been defined. When I thought there was a gross total removal I usually postponed radiation therapy and carefully observed the patient. When there was recurrence and the findings on the scan suggested that another total removal could be done, surgery was performed.

In this series there were 19 patients (5.1% of the series) who were classified as having a malignant meningioma. Patients with hemangiopelicytoma are not included. There were 10 women and nine men, ranging in age from 17 to 77 years, with five over 70 years of age. The histological criteria used to define malignant meningiomas have been described by the World Health Organization (57). Six criteria are considered: hypercellularity, loss of architecture ("sheeting"), nuclear pleomorphism, mitotic index, focal necrosis, and brain invasion. I have considered these tumors separately because of the difference in clinical behavior, compared with benign and atypical meningiomas. The locations of the malignant meningiomas are recorded in Table 17.20 and the results of treatment in Table 17.21. Eleven patients are alive 1-10 years after treatment. Seven have no evidence of tumor (three received radiation therapy), three have a stable residual tumor (two received radiation therapy), and one has a progressive growth of tumor in spite of surgery and radiation therapy.

TABLE 17.21 Malignant Meningioma Outcomes
Results	Number	Radiation Therapy
Alive
No evidence of tumor	7	3
Stable tumor	3	2
Tumor growing	1	1
Dead
From tumor	7	5
Other cause	1	0

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