Meningiomas – Benign Brain Tumours of the Meninges: Prof. Makoto Nakamura on the PRIMO MEDICO Expert Physician Talk

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00:00:36: Meningeomas found in the head are typically benign tumors that originate from the brain's protective membranes, nevertheless depending on their location and size they can have considerable impact.

00:00:50: I am very pleased to welcome Professor Dr Nakamura as our guest on this important topic.

00:00:56: Professor Doctor Makoto Nakamura is a specialist in neurosurgery and the chief physician of the Neurosurgical Clinic at The City Of Cologne Hospitals, in Mayerheim.

00:01:07: Furthermore professor Nakamura holds a distinguished professorship At the University of Witten Herdecker.

00:01:14: Professor Nakamura what exactly is a meningioma?

00:01:18: And how does it differ from other brain tumors?

00:01:21: Well yes, meningiomas are typically benign tumors of the brain which originate from what is known as arachnoid capsules of the meninges.

00:01:31: This means that the crucial distinction between other types of brain tumours... ...is this particular tumor does not actually arise form the brain tissue itself!

00:01:41: This also an advantage because meningiomers grow more by displacement and not by infiltration.

00:01:49: They don't grow by infiltration of the brain.

00:01:52: It is extremely rare for meningiomas to do that, and they displace their brain tissue.

00:01:58: so it's not primarily destroyed right away from these tumors.

00:02:03: So this is a big difference compared with other brain tumors like gliomas or similar ones where common perception is that brain tumors are very malignant and essentially destroy the brain through growth and infiltration.

00:02:19: meningiomas do this only very rarely and mostly they have a displacing growth.

00:02:27: How often do meningiomas occur in the cranial region?

00:02:30: And which individuals are typically affected by them?

00:02:34: Well, meningioma make up approximately one third of all primary brain tumors.

00:02:38: however it's crucial to understand that incidents meaning the annual occurrence and yearly diagnosis of meningiomer remains quite rare within the general population.

00:02:48: Specifically, it's found in about seven to nine cases per one hundred thousand people.

00:02:53: So if we were to project this onto Cologne a city with approximately one million inhabitants that would mean seventy to ninety new diagnosis each year.

00:03:04: This is considerably rarer than many other illnesses.

00:03:08: They grow very slowly and this why men and gnomers can remain asymptomatic for long time often being discovered only by chance.

00:03:18: What is known about meningiomas, is that they affect women more than men at a ratio of two to three-to one.

00:03:25: This is likely due to hormonal inferences presumably explained by hormone factors.

00:03:32: Meningiomas are more commonly found in individuals between fifty and seventy years old but can also occur less often then younger patients.

00:03:40: however It is also the case that when they appear earlier, meningomas can be associated with a rare syndrome.

00:03:48: This for example is neurofibromatosis type two where there's significantly higher risk of developing meningomas as part this syndrome.

00:03:58: Why do meningomas actually come into being?

00:04:01: There are known factors which contribute to development of meningomas.

00:04:05: These include genetic partly hormonal and environmental factors.

00:04:10: The precise course however is not yet fully clear.

00:04:13: Regarding genetic factors, for instance it's known that specific gene mutations or genetic alterations can lead to the development of sporadic meningomas.

00:04:24: For example its know that a fifty-to sixty percent of all meningomas show so called NF II mutation and the NFII gene encodes a specific protein which crucial role in regulating cell growth and defects in this gene can subsequently lead to uncontrolled cell proliferation.

00:04:47: There are other additional mutations that have become known in recent years, they've such complicated abbreviations I probably don't need list them all individually now.

00:04:58: however among the things it's important for example a so-called TERT Promotor mutation which is SPLTERT.

00:05:07: This is more frequently observed in more aggressive forms of meningiomas.

00:05:14: So it's known that this mutation plays a significant role... ...in the ultimate development and growth of tumors, And collectively it is the case.

00:05:24: these mutations impact signaling pathways which regulates cell growth & tumor suppression.

00:05:33: Then there are also hormonal factors that have certainly been considered and it is also known, these can play a role.

00:05:40: For example many germans have progesterone receptors Also fewer estrogen and androgen receptors but these Progesterones can indeed play the roles.

00:05:53: This is particularly relevant now because there are certain preparation, especially hormonal preparations that design to target these progesterone receptors.

00:06:04: It's also known through these receptors for example during pregnancy a slight homogrove in meningiomas can sometimes be observed and patients who then receive high-dose albite hormone therapy also show a slightly high risk for certain types of meningiomas.

00:06:23: Furthermore, what is definitely known as that ionizing radiation can trigger meningiomers.

00:06:29: these are X-rays ultimately radioactive radiation.

00:06:34: one had radiation exposure, however.

00:06:38: And we're talking about events that we don't typically experience in daily life like atomic bomb fallouts or reacted disasters and similar situations.

00:06:47: it's known that in such doses multiple menjomas can be triggered if for example someone received high dose ionizing radiation during childhood.

00:06:58: I always use, as an example a specific treatment that was carried out in Israel in the nineteen sixties on young people with tinea capitis which is a scalp fungal infection.

00:07:10: They were actually irradiated at that time.

00:07:14: It's known that children are actually developing angiomas later but we're talking about very high doses Which we don't typically encounter in medical therapy or diagnostics especially not now.

00:07:32: How do you actually notice a meningioma?

00:07:35: Yes, meningiomas are usually only subjectively noticed when they start to cause symptoms.

00:07:42: That means that first need to reach certain size.

00:07:45: otherwise they remain very quiet initially and don't notice anything at all.

00:07:50: They're then often only discovered by pure chance because someone let's say due relatively diffuse other generalized complaints might have had a head scan.

00:08:01: But beyond the certain size and also depending on its localization, meaning the meningioma's position symptoms can then occur.

00:08:10: The specific symptoms that appear depend very much where the meningoma develops.

00:08:16: If for example a meningoma develop in relatively sensitive areas Where let us just say important brain functions are localized or nerves are immediate proximity Then the meningomal press is there on those structures.

00:08:31: Then impairments can occur.

00:08:33: For example, let's consider the optic nerve that is under pressure.

00:08:37: then you will eventually notice it through poorer vision or visual feed defects and similar issues.

00:08:43: So its very much dependent on precisely where the meningioma has developed which specific structures are actually put down at pressure And ultimately cannot give a general size indication as to at what specific number of centimeters a meningioma truly causes symptoms.

00:09:02: This can also result in headaches, potentially also...

00:09:06: This can lead to headaches?

00:09:09: yes exactly.

00:09:09: Meningiomas can cause headaches.

00:09:12: however the difficulty here is that headache is relatively general symptom which can also arise from many other and much more frequent courses.

00:09:20: This is something we encounter quite frequently, also in my consultation hours that we then have patients who come to us with an incident of meningioma diagnosis.

00:09:29: Have a relatively small meningiomer but also receive the scan because of headaches.

00:09:34: and The question then is are the headaches caused by the meningiom itself?

00:09:38: And if it's just very one centimeter meningiome It's rather unlikely That they can truly be linked.

00:09:46: If you Otherwise, a five or six centimeter meningioma that doesn't cause specific neurological deficits in that sense but generalized headache then it's more likely to be considered.

00:09:58: Is It Possible To Prevent Meningeomas In Any Shape Or Form?

00:10:02: Well, to put it briefly a targeted prevention of specific prophylaxis against meningomas is unfortunately not feasible at this moment because you see the most crucial underlying causes are actually not directly influenceable or subject to modification.

00:10:18: These factors include genetic changes various mutations age gender and host other such things.

00:10:25: Ultimately, these are things that cannot be changed and they also can not be influenced.

00:10:31: Nonetheless there indeed a few factors that one could certainly take into account.

00:10:37: One of those is radiation exposure.

00:10:41: So in our daily lives, as I just mentioned we wouldn't voluntarily enter a reactor or engage in similar activities.

00:10:48: If such events occur there are things that happen due to an accident and then they're also not truly influenceable.

00:10:57: but you can certainly make sure avoid for example unnecessary city examinations of the head.

00:11:07: But what I want to make it very clear again at this point is that medical CT scans in everyday practice today are so low on radiation, there's no need for worry about actually developing many geomorphous just one or two more CT scans.

00:11:25: So i really wanted to emphasize once here.

00:11:29: I just mentioned that certain times of meningiomas react to progesterone and increased risk for their growth, development was also identified.

00:11:38: So one should be careful with high dose progesteron preparations or long-term hormone therapy and pay a little attention.

00:11:44: especially must also be mentioned that, for example regarding standard hormone birth control methods there's currently no clear established evidence or a known risk connection to the development of meningiomas.

00:11:59: Are there any other factors that need to be considered?

00:12:03: As another factor we can mention obesity.

00:12:07: they are now studies that indeed show correlation between obesity and that is BMI over thirty with a moderately increased risk of development in certain types of tumors.

00:12:18: Main germers also mind them, the exact reasons for this are not yet known.

00:12:23: whether they're hormonal or other inflammatory processes Of course that's something one can pay attention to.

00:12:30: but I must say achieving healthy weight is naturally and it isn't an easy thing But you definitely work on.

00:12:42: And then the other things like genetics, age gender all these factors you ultimately can't influence them.

00:12:49: How is a meningioma reliably diagnosed?

00:12:52: It's not a malignant tumor but rather a benign one.

00:12:55: isn't that right?

00:12:57: so how do you diagnose it

00:13:00: Exactly.

00:13:01: Most men and Germans are classified as B-nine, a WHO grade one to two tumors.

00:13:07: unfortunately malignant ones also exist.

00:13:11: that's the WHO grade three and luckily they're very rare.

00:13:15: And how are they diagnosed?

00:13:17: Well most often there actually diagnose because patients get an MRI for unspecific symptoms and then they have a meningoma as an incidental finding.

00:13:29: On the other hand there's group of patients whose meningoma causes symptoms very specific to its location, these can be visual disturbance, hemiparesis speech disorders sometimes seizures etc... And that leads to imaging!

00:13:44: Some patients are referred directly to MRI.

00:13:47: in the MRI after contrast agent administration These tumors are clearly visible because they accumulate against the agent very strongly and homogenously.

00:13:57: Some were sent to CT first, in a CT scan.

00:14:00: bones seem better than soft tissue so calcified hard meningiomas can certainly be clearly identified on CT scans as large meningioms.

00:14:10: however computer tomography scan or CT meningiomers also easily missed if there is small and not very radiopack.

00:14:20: where it becomes truly difficult is when you only perform a simple x-ray of the head.

00:14:28: There, you see practically nothing at all... ...only very large significantly classified menajomas that then create visible shadow and those would be recognizable on these types of images.

00:14:40: How will you be proceeding from this point?

00:14:43: how Will You Be Handling This Situation?

00:14:46: Yes, essentially one must consider and decide if the meningioma even needs a treatment at all.

00:14:52: or is it enough to simply continue monitoring the meningoma with an MRI?

00:14:56: So that's very first thing.

00:14:58: That one really need to decide.

00:15:00: for patients who present with very clear symptoms And are quite obviously experiencing issues due to the meningomal It's actually straightforward decision as well than opts for therapy.

00:15:10: However, with small meningiomas which perhaps have hardly grown at all and where it's also quite questionable whether the primary symptoms are truly connected to the meningoma.

00:15:20: One really needs to think is there even an indication to become active?

00:15:24: There That's the third thing And that needs to be decided individually based on size of a meningoma its location etc.

00:15:34: as we've just discussed.

00:15:36: Then next you primarily look If it needs to be treated, is whether it's surgically accessible and if the tumor can't be surgically removed well.

00:15:48: And that depends very much on the meningioma location.

00:15:52: How accessible a meningiomah?

00:15:54: A meningiomer located in the brain surface or head surfaces are easier to remove than meningiomas for example developed at the skull base which is the bony base located beneath beneath or below the brain, where just for gaining access to that area it's very difficult.

00:16:17: One has to account for and also needs determine how he takes excess and expose this particular region with least possible risk in order then be able carry out tumor section at all.

00:16:30: That is something which need determined beforehand.

00:16:32: so primarily surgical removal.

00:16:36: Then there's also the option to treat a meningioma differently by using radiation therapy.

00:16:41: And when does radiation therapy become an option as an alternative or in addition to surgery?

00:16:49: Yes, radiation therapy is considered as an option whenever meningiomas can only be surgically approached and operated on with extremely high risk If a meningioma, if an operation is no longer feasible at all because patients are very old also have many comorbidities and surgery under generalized seizure then it's also risky.

00:17:08: Then one would explore other options And that where radiation therapy or single session radio-surgery which has highly concentrated radiation of the tumour area in one treatment sessions becomes an option.

00:17:20: Are there any risks side effects with surgery or radiation therapy?

00:17:26: Yes, there are always risks involved.

00:17:29: Actually as soon you begin any therapy with operative therapy There's a risk that complications can arise due to the surgical approach itself.

00:17:38: Furthermore tumor resection also carries risks because one operates in close proximity To truly vital structures such as cranial nerves As well as brain spying vessels and critical brain areas.

00:17:50: And all these things can become irritated or perhaps even inflamed and sensitive due to the surgery, or even for quite a long period of time being permanently disrupted.

00:18:04: Ultimately all this must be considered.

00:18:07: risk inherent in operation itself... ...and specific risk profile meaning how probable it is that one might actually experience neurological deficits following such surgical procedures must ultimately be analyzed in each individual case and thoroughly discussed with the patient.

00:18:25: Because that is very much dependent on how you choose the axis of your head, where do you make the skull opening?

00:18:33: Do you operate on a skull cap or do also operate through the nose to remove meningioma which are possible.

00:18:39: so ultimately we will discuss mobility.

00:18:41: due to access then risk associated with operations deep within our brain And this applies equally to radiation treatment as well.

00:18:54: Radiation therapy might sound a little bit more harmless at first glance, but the radiation itself must also achieve something.

00:19:02: This means ultimately they must destroy tumor cells or at least modify them so that can no longer continue to grow.

00:19:09: This mean it has local effect.

00:19:12: in radiation therapy The surrounding tissue is automatically radiated along with even if the dosage is quite different.

00:19:22: Modern radiation therapy's truly so precise that dose distribution can then be concentrated solely on tumor, nevertheless surrounding tissue effected to some extent more or less depending upon method and side effects also occur.

00:19:39: These are relatively similar what one would describe as surgical side-effects.

00:19:44: These are rotations of the surrounding region, which means nerve rotations but also ultimately indirect injuries resulting from radiation therapy and also the vital areas of brain.

00:19:55: This effect can also manifest with a certain latency meaning not immediately after radiation therapy is carried out... ...but also within time delay.

00:20:05: What does care in support look like?

00:20:09: And what's the aftercare for patients?

00:20:12: Yes, following a minijoma operation it's typically the case that patients are usually monitored for at least one night in your observation ward and then they're transferred to regular warden or discharged from inpatient treatment after approximately five days.

00:20:26: Its variable we must say because it also depends on how well one has recovered with what is long operation very difficult one at the skull base or relatively simple ones on brain surface.

00:20:40: once you've discharged You usually still have skin sutures from the incision, and these are then typically removed at our clinic after eight days on an outpatient basis.

00:20:51: Then relatively soon after discharge there's another follow-up appointment scheduled to discuss the histology that is go over the tissue results.

00:21:00: even though we as surgeons can state with relative certainty it a meningioma.

00:21:05: now their various gradings of meningiomas ranging from grade one up to grade three.

00:21:11: In most cases it's grade one, less frequently grade two.

00:21:14: But with the new tumor classification Grade Two meningiomers are becoming somewhat more frequent in assessment and grade three is very rare.

00:21:23: And these other things that one then has to discuss specifically regarding any necessary further treatment

00:21:30: or not How good are chances of a cure for a meningioma?

00:21:36: Perhaps you could now elaborate on different grades.

00:21:41: The chances of success are very good if the main jaw can be removed without significant irritation to the surrounding brain tissue, including cranial nerves and it is completely removed.

00:21:51: That means that the tumor itself and its attachment point – this is what's known as a Simpsons Grade I Resection which means complete resection.

00:22:02: So one can always grade this differently, but the more thoroughly and completely the tumours removed, the lower likelihood that the meningioma will return at a particular site.

00:22:13: This is highly attainable for the majority of meningiomas.

00:22:17: The prospects for success are also very good.

00:22:20: But I just mentioned again That possibility over radical complete removal of meningoma naturally Very much depends on the location where the meningoma has grown.

00:22:30: There are certain areas within the brain and also at the skull base where it is already evident to the surgeon right from start that a full and complete removal cannot possibly be achieved.

00:22:40: For example, in the cavernous sinus there's special area of the skull-base.

00:22:46: one could almost say those specific locations.

00:22:49: mangiomas should actually left undisturbed if they develop up their and don't cause true truly massive symptoms, or also in the so-called petroplival region.

00:23:02: There one needs to be a bit more cautious if during their operation when it doesn't aggressively try to completely remove the tumor at all costs and then the risk profile of that operation also decreases.

00:23:15: So unless one has to operate on them two more for hours an hour is the better It is for the patient's neurological function in long run And you can actually make a compromise and say Okay, I see the tumor is very fibrous.

00:23:29: Very tough hard to remove especially in a very awkward spot at the skull base And only move what it's absolutely necessary for instance What causes the symptoms and leave the remainder?

00:23:41: At the base of the skull.

00:23:42: this is entirely legitimate because This particular area can be subsequently treated with radiation therapy and for example radio surgery.

00:23:53: How do you envision the future of therapeutic approaches for meningiomas?

00:24:00: The future and current developments in innovations, in neurosurgery?

00:24:03: there's really a lot happening.

00:24:06: When it comes to the future new angioma treatment A great deal is also happening on our field right now.

00:24:11: It all begins with the fact that we are partially and ultimately supported by machine learning And AI both imaging and subsequent image analysis.

00:24:20: That can be carried out at completely different level.

00:24:23: One hope is that with modern and also AI-supported imaging, it's ultimately possible to make a better prediction about the tumor itself.

00:24:32: And perhaps also regarding the tissue characteristics and the tumor behavior.

00:24:37: This all still very much in works essentially can not yet be widely applied but truly holds great deal of promise that through what's called radiomics, these are essentially modern AI-based methods that enable AI supported image analysis and then also allow for different predictions from large data sets.

00:24:59: What is also very interesting as the molecular genetic composition of meningiomas – they're now being analyzed in much greater detail but have found their way into a classification of meningomers.

00:25:12: Previously meningiomas were classified according to their histological appearance, meaning the tissue looked under a microscope.

00:25:18: If I may put it very simply in the WHO classification however It was then observed that there are indeed meningiomers classified as grade one That somehow don't behave as expected.

00:25:32: they grow faster and cause more problems.

00:25:35: And conversely, there are grade two meningiomas that don't grow at all like typical grade-two tumors.

00:25:42: Essentially the new or rather relatively new WHO classification has also incorporated molecular genetic markers.

00:25:51: so there's quite a bit of back and forth regarding declassification of meningiomers but we can say The classification will now be more precise and though this new classification we can ultimately better assess the risk profile for recurrence, so on.

00:26:13: And also make a better prediction.

00:26:16: What's very interesting from technical standpoint is that the operations, neurosurgical procedures of meningiomas are becoming less invasive.

00:26:26: So the trend towards minimally invasive surgery and has been for quite some years now, but it's constantly advancing.

00:26:35: This means with the refined instruments and techniques that we have available in the operation room... ...it is possible to reach even very inaccessible tumors through relatively small keyhole incisions and openings.

00:26:52: It begins with surgical procedures carried out through nose or through a small key hole trepanation which are then endoscopically guided and supported, treated or operated upon.

00:27:05: And this has become simply much more feasible because of the advanced technologies for displaying endoscopic images is superior.

00:27:15: The endoscropic technology itself has significantly improved also the specialized instruments that we ultimately use during surgical procedure.

00:27:26: These include devices such as neural navigation or other equipment that ultimately allows for comprehensive, interpretive analysis of tissues and interpretive fluorescence imaging of tumors in similar conditions.

00:27:42: So these are indeed aspects that have increasingly found their way into neurosurgery For the surgical procedure, they allow for much better feasibility and for the patient ultimately an operation with a significantly lower risk.

00:27:57: Professor Nakamura I extend my heartfelt thanks for this very detailed explanation And i wish you much continued success.

00:28:06: Oh yes!

00:28:06: A big thank to you too.

00:28:07: Thank You Very Much.

00:28:08: This

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