The diagnosis of a brain tumor can be life-changing for a patient and their family. The good news is that not all tumors that originate in the brain are malignant. Approximately 1/3 of primary brain tumors are meningiomas. Usually, these are benign. Depending on their location, they can often be cured with surgery and in many cases, the patient can return to their work and normal activities.
Meningiomas arise from cells in the protective membrane covering the brain called the dura mater. As they enlarge slowly over time, they will compress the adjacent brain and can cause headache, weakness of the limbs or face, tingling, numbness, seizures, double vision, or other symptoms depending on functions of the adjacent brain and tissue.
Meningiomas are frequently quite slow in their rate of growth. While some grow as slowly as 5 – 7% /yr or sometimes less, others can grow more rapidly. A slow-growing meningioma originating beside a relatively neurologically silent area of the brain can often grow to a dramatic size (for instance, a citrus fruit) before being symptomatic. Frequently, meningiomas may be diagnosed as incidental findings on MR scans of the brain being done for investigations for other conditions.
Meningiomas are graded based on microscopic appearances and characteristics. This can predict their growth, tendency to invade adjacent tissues and their recurrence risk after treatment. Approximately 85% are Grade I and benign; 5-15% are Grade II or atypical; less than 1-2% are Grade III or malignant.
Treatment depends on numerous factors including size and location of the tumor, and general medical condition of the patient and the presence of other serious illnesses. The location plays a large role in determining the complexity of surgery required to remove the tumor. Some locations can be very difficult, and sometimes it is not possible or advisable to remove all of the tumor, and another treatment modality such as stereotactic irradiation may be used after surgery for a remaining portion. However, if a meningioma can be completely removed surgically then it will usually be cured.
The most ideal treatment of meningiomas is complete surgical removal if possible, as this offers the most predictable chance of long term cure. Stereotactic irradiation alone can offer long term control in many but not all cases, however, this is not suitable treatment for very large tumors. In other cases, management might be as simple repeated follow-up with serial imaging studies.
Today, many excellent technical aids are available to enhance the safety of microsurgery for brain tumors. This includes operating microscopes, exoscopes, endoscopes, computerized image-guided navigation, brain mapping, and intraoperative electrophysiological studies that give dynamic functional information about the function of the brain and nervous system while the patient is under anesthesia. The goal in treating a meningioma is to eliminate the risk of the tumor to the patient hopefully by complete surgical removal with as minimal or no risk to brain and nerve function as possible and with subsequent return to full activities and work duties.
It is important to choose a neurosurgeon who is experienced and skilled in brain tumors microsurgery. While all neurosurgeons may learn this as part of training, many neurosurgeons do not routinely do this in their practice. It is very acceptable to ask your neurosurgeon how many brain tumors they operate on, and more specifically how many of them are like your tumor. Just like a pianist, the neurosurgeon who is most technically capable of safely removing your tumor is the one that practices those specific technical skills regularly.
It is important to feel comfortable communicating with your neurosurgeon. Neurosurgery is a team sport. You and your neurosurgeon are the most important players on the team and you need to be able to trust and communicate well together. When mutual trust and communication are established you can then focus on getting well. In most situations, meningiomas do not require emergent care and if you are not comfortable, a second opinion can often help to increase your knowledge, understanding, and confidence in your choice of surgeon and your treatment.
Michael T. Stechison, MD, PhD, Neurosurgery Atlanta
1700 Tree Lane, Suite 470
Snellville, GA 30078