Introduction
Objective
Methods
Search strategy
Paper selection
Population | Patients ≥ 16 years of age diagnosed radiologically with an incidental asymptomatic intracranial meningioma/s. Neurofibromatosis type II associated and radiation-induced meningiomas were excluded | |||||
Intervention | Active monitoring, surgery, SRS, fRT, or hospital discharge after the first inpatient/outpatient appointment | |||||
Comparator | Not required |
Outcomes | Primary | Secondary | ||||
---|---|---|---|---|---|---|
Active monitoring | Surgery | SRS | fRT | Hospital discharge | All treatment options | |
Progression and time to progression (clinical and radiological) | Treatment-related morbidity | Treatment-related morbidity | Treatment-related morbidity | Meningioma-related readmissions | Neurocognitive function | |
Intervention and time to intervention | Meningioma grade | Recurrence | Recurrence | Quality of life | ||
Recurrence | ||||||
Study design | Randomized controlled trials and retrospective and prospective case series and cohort studies with ≥ 10 adult patients. Case reports were excluded |
Data extraction
Data synthesis
Statistical analysis
Simple pooled analysis
Meta-analysis
Multivariable regression analysis
Quality and bias assessment
Results
Literature search and study characteristics
Baseline characteristics
No. of studies informing characteristic | No. of valid cases informing characteristic (%) | Characteristics | Total | Surgery | SRS | Active monitoring | P | |
---|---|---|---|---|---|---|---|---|
18 | 2050 | No. of patients (%) | 2050 | 560 (27.3) | 450 (22.0) | 1040 (50.7) | ||
12 | 803 (39.2) | Mean age, years (SD) | 63.1 (6.9) | 61.5 (4.7) | 54.9 (NR)b | 64 (6.9) | < 0.001 | |
17 | 1919 (93.6) | Sex, N (%) | Female | 1526 | 294 (19.3) | 375 (24.6) | 857 (56.2) | < 0.001 |
Male | 393 | 164 (41.7) | 75 (19.1) | 154 (39.2) | ||||
16 | 1465 (71.5) | Location, N (%)a | Non-skull base | 1012 | 269 (26.6) | 233 (23.0) | 510 (50.4) | < 0.001 |
Convexity | 484 | 129 | 86 | 269 | ||||
Parafalcine | 247 | 55 | 71 | 121 | ||||
Parasagittal | 153 | 40 | 36 | 77 | ||||
Tentorial | 61 | 11 | 28 | 22 | ||||
Intraventricular | 24 | 3 | 12 | 9 | ||||
Skull base | 453 | 113 (24.9) | 153 (33.8) | 187 (41.3) | ||||
Anterior midline | 113 | 30 | 43 | 40 | ||||
Sphenoid wing | 100 | 24 | 11 | 62 | ||||
Posterior fossa—lateral and posterior | 48 | 22 | 12 | 14 | ||||
Posterior fossa—midline | 143 | 18 | 87 | 34 | ||||
15 | 888 (43.3) | Mean diameter, cm (SD) | 2.14 (0.61) | 2.11 (0.42) | 1.73 (NR)b | 2.19 (0.66) | < 0.001 | |
10 | 615 (30.0) | Calcification, N (%) | No | 380 | 55 (14.5) | NR | 325 (85.5) | 0.774 |
Yes | 235 | 36 (15.3) | NR | 199 (84.7) | ||||
5 | 298 (14.5) | Tumor signal intensity, N (%) | Hyperintense | 120 | 40 (33.3) | NR | 80 (66.6) | 0.237 |
Iso/hypointense | 178 | 48 (27.0) | NR | 130 (73.0) | ||||
12 | 1097 (53.5) | Peritumoral edema, N (%) | Yes | 231 | 57 (24.7) | 19 (8.2) | 155 (67.1) | < 0.001 |
No | 866 | 135 (15.6) | 370 (42.7) | 361 (41.7) |
Treatment groups and outcomes
Active monitoring
Follow-up regimens
Study | Protocol | Growth definition | |
---|---|---|---|
Timing of scan following diagnosis | Measurement | Definition | |
Olivero et al. (1995) [13] | 3 months → 9 months → 1–2 yearly | NR | NR |
Go et al. (1998) [14] | NR | Diameter | ≥ 0.5 cm |
Niiro et al. (2000) [16] | NR | Diameter | ≥ 0.5 cm |
Yoneoka et al. (2000) [17] | NR | Volume | > 1 cm3/year |
Nakamura et al. (2003) [18] | 6 months → 1 yearly | NR | NR |
Sonoda et al. (2004) [19] | 3 months → 6 monthly | NR | NR |
Hashiba et al. (2009) [22] | NR | Volume | > 15% |
Jo et al. (2010) [23] | 6 months → 1–2 yearly | Volume | > 25% |
Jadid et al. (2014) [26] | 1 yearly for a minimum of 10 years | Diameter | > 0.2 cm |
Liu et al. (2015) [27] | 3–12 monthly | NR | NR |
Radiological and clinical progression
Intervention endpoints and timeframe for treatability
Baseline radiological characteristics, growth dynamics and symptom development
Factor | Mean AGR (cm3/year) | P | Mean RGR (%/year) | P | Symptom development, yes/total (%) | OR (95% CI) | MLR P | |
---|---|---|---|---|---|---|---|---|
Location | Non-skull base | 2.14 | 0.942 | 53.8 | 0.213 | 12/64 (18.8) | 0.927 | |
Skull base | 1.79 | 30.5 | 5/25 (20.0) | |||||
Diameter | ≥ 3.0 cm | 4.00 | < 0.001 | 28.4 | 0.863 | 15/27 (56.6) | 34.90 (5.17–160.40) | 0.001 |
< 3.0 cm | 0.62 | 27.3 | 2/62 (3.2) | |||||
Calcification | No | 2.42 | 0.499 | 38.0 | 0.093 | 10/47 (21.3) | 0.879 | |
Yes | 1.35 | 60.6 | 6/25 (24.0) | |||||
Tumor signal intensity | Hyperintense | 2.04 | 0.988 | 53.0 | 0.262 | 11/41 (26.8) | 0.866 | |
Iso/hypointense | 2.02 | 36.1 | 4/27 (14.8) | |||||
Peritumoral edema | Yes | 0.34 | 0.301 | 55.4 | 0.727 | 5/10 (50.0) | 8.72 (0.35–14.90) | 0.027 |
No | 2.32 | 44.7 | 12/63 (19.0) |
Surgery
Extent of resection
Post-operative morbidity and mortality
Histopathology and recurrence
Stereotactic radiosurgery
Treatment parameters
Post-SRS complications
Response rates
Meningioma specific mortality
QoL and NCF outcomes
Quality and bias assessment results
Management | Outcome | Pooled risk (95% CI)a | No. of studies (no. of patients) | Quality assessment | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Type of evidence | Risk of bias | Heterogeneity | Directness | Precision | Reporting bias | Overall | ||||
Active monitoring | Symptom development | 8.1% (2.7–16.1) | 12 (608) | + 2 | − 1 | − 1 | 0 | 0 | 0 | ⨁◯◯◯ Very low |
Intervention | 24.8% (7.5–48.0) | 13 (971) | + 2 | − 1 | − 1 | 0 | − 1 | 0 | ⨁◯◯◯ Very low | |
Surgery | Morbidity | 11.8% (3.7 23.5) | 5 (533) | + 2 | − 1 | − 1 | 0 | 0 | 0 | ⨁◯◯◯ Very low |
WHO grade I | 94.0% (88.2–97.9) | 9 (316) | + 2 | − 1 | 0 | − 1b | 0 | 0 | ⨁◯◯◯ Very low | |
Recurrence | 0.3% (0.2–2.2) | 2 (105) | + 2 | − 1 | + 1 | 0 | 0 | 0 | ⨁⨁◯◯ Low | |
SRS | Morbidity | 32.0% (10.6–70.5) | 2 (389) | + 2 | 0 | − 1 | 0 | − 1 | NAc | ⨁◯◯◯ Very low |
Recurrence | 1.5% (0.1–4.3) | 2 (389) | + 2 | 0 | − 1 | 0 | 0 | NAc | ⨁◯◯◯ Very low |