Meningiomas in the Elderly: A Growing Challenge

Meningiomas represent 21% of all intracranial tumors, and their incidence increases with age; the incidence in persons older than 70 years is 3.5 times higher than in persons younger than 70 years (7). In the last 2 decades, life expectancy in industrial nations has increased, and every day neurosurgeons encounter more and more elderly patients with a meningioma. Surgical management of intracranial meningiomas is now considered a valid treatment option in elderly patients. Many preoperative factors that have been proposed as predictors of a good prognosis influence the treatment decision-making process. These factors can be divided into three major categories: patient-related, tumor-related, or a combination of both. The contradictory results of some articles and the multitude of proposed scales contribute equally to confound neurosurgeons, patients, and family members ( [3], [4] and [9]). The result is that the criteria adopted to choose among different treatment options for elderly patients are determined subjectively by the individual surgeon and are not evidence-based. The question arises concerning the identification of elderly patients who would benefit from surgery in terms of overall survival and quality of life. Age is not unanimously considered a risk factor for postoperative morbidity and mortality ( [1] and [3]). The patient's chronologic age is no longer important in the decision-making process in the management of meningiomas; it may be reasonable to consider patients with less than 10–15 years of remaining life expectancy to be “elderly.” This different point of view moves the center of discussion from the chronologic age to the biologic age (ie, the age determined by physiology rather than chronology), which would surely have much more of an influence on outcome. How should the biologic age of a patient be calculated? The Charlson Comorbidity Score proposed by Grossman et al. could be an easy and reliable option. If the surgical risk is not greater with advancing age, all recent published series agree with the assumption that more symptomatic lesions carry a higher risk of a worse prognosis ( [4] and [5]). Location of the tumor is another important consideration: Parasagittal, posterior fossa, and skull base lesions are considered negative prognostic factors (2), but recently Roser et al. (9) showed that skull base meningiomas can be treated with results comparable to young patients. In my opinion, symptomatic lesions should always be treated, even in elderly patients with skull base or parasagittal meningiomas. Surgery should be the first choice, but a willing patient with a high American Society of Anesthesiologists classification could be an indication for radiosurgery for lesions of suitable size. Careful observation is often my first-line management for patients with asymptomatic meningiomas. Only large tumors (>3 cm) should be surgically treated in elderly patients to avoid unnecessary neurologic deterioration leading to a worst prognosis after surgery. The studied natural history of asymptomatic meningiomas shows that two thirds of patients with asymptomatic lesions do not show tumor growth for several years. The following factors were identified as predictive of future tumor growth: Calcified meningiomas usually do not grow, whereas large tumors (>3 cm) show a propensity to become larger (8), and hyperintensity of meningiomas on T2-weighted magnetic resonance imaging (MRI) has a fairly strong correlation with the growth rate and can be considered an indicator of further tumor size progression ( [8] and [10]). Hyperintensity on MRI probably is related to the histologic subtype (6). Timing of neuroradiologic examinations is another important factor. In accord with most authors, I suggest a detailed examination 2–3 months after initial diagnosis to rule out rapidly growing lesions and yearly MRI examinations thereafter (8). This imaging protocol is particularly important because some authors consider meningioma in elderly patients as a separate clinical entity characterized by slow progression and reduced aggressive behavior owing to different cellular proliferation, vascularity, and intratumoral hormonal profile (9). Grossman et al. report an interesting study on the value of preoperative Charlson Comorbidity Score in predicting outcome in elderly (>65 years old) patients with meningioma who undergo surgical treatment. They analyzed the Nationwide Inpatient Sample identifying 5717 patients according to ICD-9 coding. In multivariate analysis, they found that Charlson score and patient age older than 65 years were independent factors associated with worse outcome. The Charlson score was associated with greater odds of all major postoperative complications. As mentioned earlier, the number of older patients who are candidates for surgical resection of an intracranial meningioma is increasing continuously. Knowledge of the role of a simple and reliable preoperative score, such as the Charlson Comorbidity Score proposed by Grossman et al., can help neurosurgeons and patients to make an appropriate decision. The article by Grossman et al. deserves high consideration in the neurosurgical literature because the proposed scale represents a simple and reliable variable in the decision-making process for older patients harboring an intracranial meningioma.