Meningioma+(Adult)

a) Increased cellularity b) Small cells c) Necrosis d) Prominent Nuclei e) Sheeting architecture with a peak at 3 years[2] Radiosurgery Side Effects – are dependent on the treatment location and radiation dose. || However add a 2cm margin around the target volume based on the modified volume defined by the neurosurgeons location of residual tumor location the neurosurgeons’ location of residual tumor location Field arrangement [11]﻿ || **Shun** Epidemiology and Etiology **Eric** Signs and Symptoms, Diagnostic procedures **Lisa** Histology and Metastatic spread **Curtis** Lymph node drainage, Prognosis and TD 5/5 **Kim** Grading and Staging <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**LaDonna** Side effects and Treatment
 * Epidemiology: || <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">The most common brain tumor is meningioma, which is approximately 33.8 percent of all primary brain and central nervous system tumors. Meningioma tumors usually appear in patients that are middle-aged and older. This tumor is also predominant in females with a 2 to 1 ratio. “Meningioma is estimated to be approximately 97.5/100,000 in the United States with over 170,000 individuals currently diagnosed with this tumor.” Meningioma appears slightly higher for Blacks than for white and Hispanics. The incidence rate also increases as age increases. [1] ||
 * Etiology: || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">A mutation in the neurofibromatosis gene (NF2) increases the likelihood of developing meningioma cancer. According to Wiemels, “ Deletion and inactivation of NF2 on chromosome 22 is a predominant feature in sporadic meningiomas, and biallelic deletions are common.” Ionizing radiation exposure is also another risk factor for developing meningioma. For example atomic bomb survivors showed higher risk of developing meningioma. Low dose levels of radiation also showed evidence of this tumor. Other risk factors may be hormones and head trauma. Some also question whether cell phone use has an effect of brain tumor, but there is very little evidence to support this idea. [1] ||
 * Signs & Symptoms: || [[image:meningioma[1].jpg width="560" height="273"]] ||
 * Diagnostic Procedures: || * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Complete History and Work up [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">General Physical exam [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Complete Blood work (CBC & chemistries)
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Complete Neurologic examination- Assess mental status, coordination, reflexes, & motor and cranial nerves [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Opthalmoscopy – check for papilladema associated with ↑ cranial pressure [2]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">CT Scan of brain with/without contrast shows bony extension for disease if present [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">MRI – T1 weighted for anatomy delineation and T2 weighted for edema and tumor localization [2,3]
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Biopsy – when and where possible depending on location and size. Either stereotactic with needle or open craniotomy.
 * <span style="color: #cc0000; font-family: 'Times New Roman','serif'; font-size: 16px;">Post Fossa Tumors – Indicate CSF spinal axis staging, (CSF cytology, preoperative Myelogram / MRI) [2,3] ||
 * Histology: || <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">Histology: The World Health Organization defines the meningiomas into three categories; these are: Grade I (benign), meinogothelial, fibrous, transitional, psammomatous, angioblastic which is the most aggressive. The grade I tumors are approximately 90% of all cases. Grade II (atypical), choroid, clear cell, atypical which infiltrates the brain), grade II tumors account for 7% of all cases. Grade III (anaplastic/malignant), papillary, rhabdoid, anaplastic, which make up 2% of the meningiomas. [5] ||
 * Lymph Node Drainage: || ** <span style="color: #4f6228; font-family: 'Times New Roman',Times,serif; font-size: 120%;">There are no lymphatic channels in the brain and therefore do not metastasize through the lymphatic system [6] ||
 * Metastatic Spread: || <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-decoration: none; vertical-align: auto;">Meningiomas are considered to be neoplastic growth that derived from the leptomeninges. Malignant meningiomas are rare. The development of metastatic spread from meningiomas is less than 1 per 1,000. In an 18 year study seven of 396 meningiomas were labeled as malignant. Out of the seven, three of them spread to extracranial tissues. Overall, the metastatic spread infiltrated the vertebral bodies, liver, pelvis, long bones, and the spinal cord. There is a 0.76% chance of metastases when including all meningiomas and 43% chance of metastasis when malignant meningiomas are considered. [7] ||
 * Grading: || <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> Classification of meningiomas is based upon the WHO classification system. [8] * Grade I - (Benign) - does not fulfill criteria for grades II (atypical) or III (anaplastic)
 * <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%; margin-bottom: 6pt;">Grade II - (Atypical) – Any of the following criteria:
 * 1) <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Four or more mitoses per 10 high-power fields
 * 2) <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Brain invasion
 * 3) <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Three or more of the following:
 * <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%; margin-bottom: 6pt;">Grade III - (Anaplastic) – Either if the following criteria:
 * 1) <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Twenty or more mitoses per high-power fields
 * 2) <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Obviously malignant cytologic characteristics such that the tumor cell resembles carcinoma, sarcoma, or melanoma. [9] ||
 * Staging: || <span style="color: #800080; font-family: 'Times New Roman','serif'; font-size: 110%; margin: 6pt 0in 6pt 0.25in;">There is no formal staging system for Meningiomas since CNS tumors cannot be staged the same way as other types of tumors. In the past the TMN system was used for staging brain tumors. [2] ||
 * Radiation Side Effects: || * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Alopecia
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Headaches
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Seizures
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Short term memory deficiency
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Difficulty with problem solving
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Loss of balance and/or trouble walking
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Otitis externa
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Serous otitis media
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Dermatitis
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Decreased visual acuity
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Decreased visual field
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Retinopathy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Cataract
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Blindness
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Hormone insufficiency
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">High tone hearing loss
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Vestibular damage
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Nausea and vomiting
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Fatigue
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Secondary tumor
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Death [2]
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Neurologic deterioration Can begin 6-12 months following radiation treatment.
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Radiation necrosis Can appear after 6 months following radiation treatment
 * Prognosis: || ** <span style="color: #4f6228; font-family: 'Times New Roman',Times,serif; font-size: 120%;">Location of the lesion, extent of surgical resection, and whether the tumor is malignant or benign are the most important prognostic factors . ||
 * Treatments: || __<span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Treatment __
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Radiosurgery alone: Smaller meningioma
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Surgery alone: Benign total resection
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">No chemo
 * //<span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Benign //**
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Subtotal resection or recurrent follow surgery with radiation therapy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Radiation dose: 180-200 cGy per fraction to a total dose of 50-54 Gy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Target volume
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Define by CT or MRI initially,
 * //<span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Malignant //**
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Radiation dose: 180-200cGy per fraction to a total dose of 60 Gy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Surgery followed by radiation therapy
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">PTV 3cm margin around the target volume based on the modified volume defined by
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Wedged Multifield
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">Rotational
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">3D conformal
 * <span style="color: #0070c0; font-family: 'Times New Roman','serif'; font-size: 16px;">IMRT [2,10]
 * TD5/5: || [[image:5_table[1]_(2).jpg width="675" height="246"]][11] ||

<span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">**__References__** <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;">[1] Wiemels J, Wrensch M, Claus EB. Epidemiology and Etiology of Meningioma. // J Neurooncol //. September 2010. <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: normal; margin: 0in 0in 0pt;">[2] Chao KS, Perez CA, Brady LW, //Radiation Oncology Management Decisions.// 2nd edition. Philadelphia: Lippincott, Williams & Wilkins. 2002 <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: normal; margin: 0in 0in 0pt;">[3] National Cancer Institute at the National Institutes of Health. Available at: [] Accessed on June 1, 2011 <span style="color: #cc0000; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: normal; margin: 0in 0in 0pt;">[4] American Cancer Society. //Brain and spinal cord tumors in adults.// Available at: [] Accessed June 1, 2011 <span style="font-family: 'Times New Roman',Times,serif; font-size: 120%;"> [5] Wikipedia.org. Meningioma. Available at: [] Accessed June 3, 2011. <span style="background-color: transparent; color: #76923c; font-family: 'Times New Roman',Times,serif; font-size: 120%; line-height: 115%; text-decoration: none; vertical-align: auto;">[6]Washington, Charles, and Dennis Leaver. Principles and Practices of Radiation Therapy. St. Louis, Missouri: Mosby Elsevier, 2010. Print <span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-decoration: none; vertical-align: auto;">[7] Enam SA, Abdulrauf S, Mehta B, Malik GM, Mahmood A. Metastasis in meningioma. //<span style="background-color: transparent; color: #ff0066; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Department of Neurosurgery, Henry Ford Hospital 1996; 138 (10):1172-7. // <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[8]Wikipedia. //Meningioma//. Available at [|http://en.wikipedia.org/wiki/Meningioma. Accessed 6/2/11]. <span style="color: purple; font-family: 'Times New Roman',Times,serif; font-size: 120%;">[9] Hoppe R, Phillips T, Roach M, //Leibel and Phillips textbook of Radiation Oncology.//3rd edition. Philadelphia: Saunders. 2010. Chapter 21: Central Nervous System: 447-448 <span style="color: #115c92; font-family: 'Times New Roman','serif'; font-size: 16px;">[10]Halperin E, Perez CA, Brady LW. //Perez and Brady's Principles and Practice of Radiation Oncology//. 5th edition. Philadelphia: Lippincott, Williams & Wilkins. 2008 <span style="color: #115c92; font-family: 'Times New Roman','serif'; font-size: 16px;">[11] Kahn, F. Treatment planning in radiation oncology. 2nd edition. //Chapter 25//, Cancers of the central nervous system. 2nd ed. Philadelphia, PA; Lippincott, Williams and Wilkins; 2007.