Meningiomas are also known to have high somatostatin生长抑素 receptor 受体density 密度allowing for the use of octreotide奥曲肽 brain scintigraphy闪烁扫描技术 to help delineate extent of disease and to pathologically病理地 define an extra-axial超出轴向 lesion.198-200
脑膜瘤也被认为有高生长抑素受体密度可以使用奥曲肽脑闪烁扫描技术来帮助描绘病变范围以及病理上定义一个超过中线轴向的病灶。
Octreotide imaging with radiolabeled indium or more recently, gallium, may be particularly useful in distinguishing residual tumor from post-operative scarring in subtotally resected/recurrent tumors.
放射性铟元素或者较新的、镓元素标记的奥曲肽成像，或许特别有益于区分在完整切除残余肿瘤还是手术后的瘢痕，或者复发的肿瘤
Treatment Overview 治疗综述
Observation 观察
Studies that examined检查 the growth rate生长速度 of incidental偶发 偶然 meningiomas in otherwise 另外的symptomatic有症状的 patients suggested建议 that many asymptomatic无症状的 meningiomas may be followed safely with serial连续 brain imaging until either the tumor enlarges增大 significantly明显 or becomes symptomatic.201, 202 研究 检查偶发的另外的有症状的脑膜瘤病人生长速度在建议许多无症状性脑膜瘤使用连续脑成像后可能安全地,直到任何肿瘤明显增大或变得有症状。
These studies confirm the tenet that many meningiomas grow very slowly and that a decision not to operate is justified 合理地in selected asymptomatic patients.
这些研究证实的原则 许多脑膜瘤生长非常缓慢,这决定在挑选出的无症状的病人不进行操作是合理的。 As the growth rate is unpredictable in any individual, repeat brain imaging is mandatory to monitor an incidental asymptomatic meningioma.
但是任何个体的生长速度是不可预知的，反复强制性进行脑成像来监测偶发的雾症状的脑膜瘤 Surgery
The treatment of meningiomas is dependent upon both patient-related factors (age, performance status, medical co-morbidities) and treatment-related factors (reasons for symptoms, resectability and goals of surgery). 脑膜瘤的治疗取决于与患者相关的因素 (年龄、性能状况、医学 联合发病率)和治疗相关的因素(症状原因,resectability可治愈性和外科手术的目标)。
Most patients diagnosed with surgically-accessible symptomatic meningioma undergo surgical resection to relieve neurological symptoms.
大多数病人被诊断为可手术的有症状的脑膜瘤经历手术切除缓解神经症状。 Complete surgical resection may be curative and is therefore the treatment of choice. 完成手术切除可能治愈的,所以是治疗的首选。
Both the tumor grade and the extent of resection impact the rate of recurrence. 肿瘤分级和切除的范围影响复发的几率。
In a cohort同期组群 of 581 patients, 10-year progression-free survival was 75% following GTR(gross total resection ) but dropped to 39% for patients receiving subtotal resection.203
在一个581个病人的同期组群中，接受完全切除的患者10年无进展生存率是75%，但接受次全切除的病人下降到39%。
Short-term recurrences reported for grade I, II, and III meningiomas were 1% to 16%, 20% to 41%, and 56% to 63%, respectively.204-206
据报道短期的复发率 在1、2、3级脑膜瘤分别是1% to 16%, 20% to 41%, and 56% to 63%,
The Simpson classification scheme that evaluates meningioma surgery based on extent of resection of the tumor and its dural attachment (grades I to V in decreasing degree of completeness) correlates with local recurrence rates.207 辛普森分类方案,评估脑膜瘤手术基于肿瘤切除范围及硬脑膜的附件(1至V级在减少的完全程度)与局部复发率的关系
First proposed in 1957, it is still being widely used by surgeons today. 在1957年首次提出, 今天它仍被外科医生广泛使用。 Radiation therapy 放疗
Safe GTR is sometimes not feasible due to tumor location. 因为肿瘤位置 安全的完整切除有时候是不可行的
In this case, subtotal resection followed by adjuvant EBRT（external beam radiation therapy） has been shown to result in long-term survival comparable to GTR (86% vs. versus 88%, respectively),compared to only 51% with incomplete resection alone.208
在这种情况下，次全切除,然后行辅助外放射治疗已被证明导致与完全切除相近的长期生存(分别是86%比88%),而单纯的不完整切除只有51%。
Of 92 patients with grade I tumors, Soyuer and colleagues found that radiation following subtotal resection reduced progression compared to incomplete resection alone, but has no effect on overall survival.209
92位1级肿瘤的患者，Soyuer和他的同事们发现,次全切除后放疗相比单纯不完全切除减少肿瘤进展,但不影响总的生存
Because high grade meningiomas have a significant probability of recurrence even following GTR,210 postoperative high-dose EBRT (above 54 Gy) has become the accepted standard of care for these tumors to improve local control.211 因为高级别脑膜瘤甚至在完全切除后仍有很高的复发几率，手术后大剂量的外放射治疗（超过54GY）已经成为改善肿瘤局部控制率的公认的标准
A review of 74 patients showed that adjuvant radiotherapy improves survival in patients with grade III meningioma and in those with grade II disease with brain invasion.212
一项74名患者的回顾研究显示辅助放疗改善了3级脑膜瘤患者的生存，这些患者存在2级的脑浸润病变 The role of post-GTR radiotherapy in benign cases remains controversial. 完全切除之后的放射治疗的角色良性情况下存在争议
Technical advances have enabled stereotactic administration of radiotherapy by linear accelerator (LINAC), Leksell Gamma Knife or Cyberknife radiosurgery.
技术进步使立体定向放射治疗实施由直线加速器(直线加速器),立体定向伽玛刀或射波刀放射外科。
The use of stereotactic radiotherapy (either single fraction or fractionated) in the management of meningiomas continues to evolve. Advocates have suggested this therapy in lieu of EBRT for small (<35 mm) recurrent or partially resected tumors. 使用立体定向放射治疗(无论是单部分或分组)在脑膜瘤的治疗中得以持续发展。这一疗法的倡导者建议代替外放射治疗对于小(< 35毫米)复发或部分切除的肿瘤。
In addition, it has been used as primary therapy in surgically inaccessible tumors (i.e. base of skull meningiomas) or in patients deemed poor surgical candidates because of advanced age or medical co-morbidities.
此外,作为无法手术的肿瘤的主要治疗(例如头盖骨为基础脑膜瘤)或在病人认为因为高龄老人和医疗共病难以手术。 A study of about 200 patients compared surgery with SRS as primary treatment for small meningiomas.213 一项关于200例患者手术相比与SRS作为主要治疗小脑膜瘤
The SRS arm had similar 7-year progression-free survival compared to GTR and superior survival over incomplete resection. SRS组相比完全切除具有相似的7年雾进展生存，相比不完全切除有较高生存
In another study, Kondziolka and colleagues followed a cohort of 972 meningioma patients managed by SRS over 18 years.214
在另一项研究中,Kondziolka及其同事追踪了一组972名SRS治疗的脑膜瘤患者超过18年。
Half of the patients have undergone previous surgery. 一半的病人之前接受过手术。
SRS provided excellent tumor control (93%) in patients with grade I tumors. SRS为一级肿瘤患者提供了卓越的肿瘤控制(93%)。
For grade II and III meningiomas, tumor control was 50% and 17%, respectively. 对于等级II和III脑膜瘤,肿瘤控制分别是50%和17%。
These results suggest that stereotactic radiation is effective as primary and salvage treatment for meningiomas smaller than 3.5 cm.
这些结果表明,立体定向放射治疗对于小于3.5厘米脑膜瘤的初始及抢救性治疗是有效的。 Systemic therapy 全身治疗
Notwithstanding limited data, hydroxyurea has been modestly successful in patients with recurrent meningiomas.215 虽然数据有限,羟基脲都类治疗复发性脑膜瘤患者是成功的。
Targeted therapies that have shown partial efficacy in refractory meningiomas are somatostatin analogues and alpha interferon.
靶向治疗已经表明在难治性脑膜瘤中有部分效果的是生长抑素类似物和α干扰素。 NCCN Recommendations 推荐
Initial treatment初始治疗
Meningiomas are typically diagnosed by CT or MRI imaging. 脑膜瘤通常由CT或MRI成像诊断。
Biopsy or octreotide scan may be considered for confirmation. 活检或奥曲肽扫描可以被当成证据。
For treatment planning, multidisciplinary panel consultation is encouraged. 为制定治疗计划、多学科小组会诊是被鼓励的。
Patients are stratified by the presence or absence of symptoms and the tumor size.
Most asymptomatic patients with small tumors (< 30 mm) are best managed by observation.
If neurologic impairment is imminent, surgery (if accessible) or radiotherapy (EBRT or SRS) is feasible.
Asymptomatic tumors 30 mm or larger should be surgically resected or observed.
Symptomatic disease requires active treatment by surgery whenever possible.
Non-surgical candidates should undergo radiation.
Regardless of tumor size and symptom status, all patients with surgically resected grade III meningioma (even after GTR) should receive adjuvant radiation to enhance local control.
Following subtotal resection, radiation should be considered for small, asymptomatic grade II tumors and for large grade I and II tumors.
SRS may be used in lieu of conventional radiation as adjuvant or primary therapy in asymptomatic cases.
Follow-up and recurrence
In the absence of data, panelists have varying opinions on the best surveillance scheme and clinicians should follow patients based on individual clinical conditions.
Generally, malignant or recurrent meningiomas are followed more closely than grades I and II tumors.
A typical schedule for low grade tumors is MRI every 3 months in year 1, then every 6 to 12 months for another 5 years.
Less frequent imaging is required beyond 5-10 years.
Upon detection of recurrence, the lesion should be resected whenever possible, followed by radiation.
Non-surgical candidates should receive radiation.