Questions from membership
Answers from Shabbar F. Danish, MD
Director, Stereotactic and Functional Neurosurgery
Assistant Professor
Robert Wood Johnson Medical School
New Brunswick, New Jersey USA

***Please note that these are general answers and are not specific to your individual case.
See your own specialist with any concerns.***

Question: My meningioma is in a risky location. It’s in the middle to median sphenoid wing. I heard that I may experience stroke-like symptoms and/or other problems if surgery becomes necessary. I do not want to have surgery and would like to try alternatives that may halt growth or shrink the tumor. Can you recommend anything other than surgery?

Answer: There are many options for the treatment of meningiomas. Depending on its size, location, and proximity to adjacent structures the following options may apply: surgery with or without embolization, radiation treatment or laser ablation. There is also the option to watch it. If it is not symptomatic, there may not be a need for immediate intervention.

Question: I have a meningioma. I heard that it can become cancer. Is that true? I have also been told that a DCA may be helpful -- is there any reason I should be weary of trying it?

Answer: A small number of meningiomas can either transform, or may have atypical features that predispose them to be more aggressive. DCA refers to a radiation delivery technique. Its pros and cons versus other techniques such as IMSRT or GammaKnife are physics related. It would depend on where the meningioma is, the size, and proximity to critical structures.

Question: Can any of the treatments used for higher grade brain tumors (malignant) be used for lower grade brain tumors (benign)?

Answer: Yes. All the techniques available for malignant tumors can be applied to lower grade tumors. In most instances it is unnecessary. Those options need to be discussed with your neurosurgeon.

Question: I have symptoms and side effects from my brain tumor. How can I determine whether my symptoms/side effects are due to my brain tumor, the surgery and treatment, or my medications?

Answer: That can be a very difficult question to answer. The complete picture has to be put together by the physician who knows your case best, the appropriate images, and inspecting your current medication profile.

Question: My cerebellar hemangioblastoma was removed last June. Should I be genetically tested for Von Hippel-Lindau as a precaution? It shows in 20% of the tumours like what I had. I am thinking that my pancreas and kidneys should be checked out as well. What do you think?

Answer: VHL itself is extremely rare with an incidence of 1/36000. However, 20% of patients with VHL have no family history. It is easy enough to get screened if you are concerned. Screening can include an eye exam, and abdominal ultrasound, and a 24 hour urine test. If these are negative, VHL is unlikely.

Question: There are many new brain tumor treatments out there, both procedures and medications. How do we weigh the pros/cons of these treatment options (gamma knife/ cyber knife radiation, etc.) when the long term side effects are unknown? I still want to preserve my body the best that I can and want to minimize the long-term side effects.

Answer: It is difficult to quantitatively weight pros/cons when there are some unknowns that exist. One way to approach it is to understand the natural history of the brain tumor. If the most likely scenario is a tumor that will NOT grow, or cause symptoms, then treatment may not be necessary at all. If the tumor is likely to grow rapidly or is malignant, then the risk of any intervention is outweighed by the potential benefit of control, granted it can be done safely and that you want to fight it.

Question: I read that fiber optics are being used to basically cook the tumor. Fiber optics is inserted in a small hole in the brain and the tumor is cooked. Have you heard of this? When do you think this will be an option in the US?

Answer: This is a technique called laser assisted thermal ablation. This is available at a handful of institutions around the country. A well-informed neurosurgeon should be able to direct you to an institution in proximity that has this option available.

Question: I had two craniotomies and received radiation treatment in 1986 for a brainstem glioma. I still have follow-up MRIs and the results have always been "no significant interval change". I do have either remaining tumor or scar tissue that shows on the scans, but, I've never investigated further. Although it's been two decades since my treatments, I worry that my "tumor" might grow. What would be my options now if it does grow?

Answer: That would depend on how it grows and where within the brainstem it is located. All of the options still exist i.e. craniotomy, radiation, laser-assisted ablation but need to be weighed carefully in terms of the risk/benefit profile. Given that it has not grown in two decades, there is a good chance you have beat it.

Question: Why does it seem like most physicians downplay the diagnosis of Meningiomas? Is it because it’s benign? Several other individuals that I know seem to have this problem, too.

Answer: You need to see a physician whose special interest and/or seek.

Question: What kinds of surgery are used to remove brain tumors, in general, and a meningioma, specifically? What are the pros and cons of each?

Answer: A comprehensive answer to this question is beyond the scope of this forum. There are many different kinds of approaches, each with their benefits and risks. If a specific kind and location of meningioma is disclosed, we may be able to provide a more detailed answer.

Question: I had a meningioma – please briefly explain a surgical procedure, which involves using sound waves to vaporize the meningioma.

Answer: You may be referring to MRIgFUS which is a technique used in recurrent gliomas. This is a high intensity focused ultrasound that is used to apply thermocoagulation to intracranial lesions. It’s the use of “sound waves” to kill tumors by the heat that is generated. You might also be referring to the use of a cavitron ultrasound aspirator which is a surgical tool used during open surgery to help in tumor resections. This technology allows us to “vaporize” tumors with ultrasound with extreme precision.

Question: Are there any innovative surgical techniques available, both newly approved and not yet approved?

Answer: Surgical techniques are always evolving. This would be a good discussion to have with your neurosurgeon. Techniques not FDA approved are experiemental and usually be accessed only within the confines of a trial.

Question: Why does my MRI show an area of necrosis (scar)? I had a meningioma removed via procedure and do not understand why there would be a scar.

Answer: A scar can result from any intervention. This is the body’s natural reaction to the healing process and inflammation from an intervention. It does not mean that anything is specifically damaged.

Question: Why do some patients have major neurological effects from a craniotomy and others do not for a brain tumor in the same location?

Answer: Every brain tumor and every patient is slightly different. Outcomes after surgery depend on many variables.

Question: How is the age of a brain tumor determined? I have heard two differing estimates for the same size meningioma. One said that a 6x6x6 cm brain tumor is 8 years and another said 15 years.

Answer: This is almost always a guess by physicians. The most accurate answer for the age of a grade I meningioma is many years.

Question: When is an awake craniotomy recommended and why?

Answer: Awake craniotomies are recommended for surgeries in eloquent areas of the brain. This is usually recommended for tumors near the language cortex or very close to the motor cortex in which the approach will change based on the patients response. With awake, patient resection can be much safer as the surgery can be carried out while directly monitoring the patient’s response.

Question: What are the pros and cons for “watch and wait” and for surgery (or other treatment)?

Answer: If there is a suspicion that the tumor is not growing and it is not causing symptoms, then watching it is reasonable. It is extremely rare for a benign meningioma to grow fast. Surgery is always an option. The pros/cons depend on the individual patient and tumor, and can also depend on the patient’s personality and their attitude towards the tumor. Some patients cannot bear the thought of having a tumor in their brain and want it out regardless of whether its symptomatic.

Question: Can benign brain tumors be treated with a vaccine similar to the vaccine treatment being studied for malignant brain tumors? Is this a potential treatment option? Are there clinical trials underway to develop/study vaccines for treatment of benign brain tumors?

Answer: Currently, there are no vaccines with proven efficacy for malignant brain tumors. There are currently many trials in various phases attempting to show a benefit in survival and control. There are ongoing trials investigating drug options that may halt the growth of meningiomas, but currently not a specific vaccine trial.

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