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Cappabianca et al. Mini-invasive Surg 2020;4:83 I http://dx.doi.org/10.20517/2574-1225.2020.67 Page 7 of 11

changed irradiation of these tumors and fractionated radiotherapy and radiosurgery have entered the
armamentarium of modern neurosurgery. Advances in the molecular characterization of meningioma have
enabled the identification of genetic alterations and methylation profiling subclasses that correlate with the
likelihood of tumor recurrence and represent promising medical therapy targets [97,98] . Thus, genomics has
altered the understanding of the molecular underpinnings of meningiomas, and ongoing clinical trials have
the potential to alter how meningiomas are treated.

The high local control rates with low morbidity achieved by radiation modalities and the surgical
philosophy of maximal safe resection for meningiomas associated at higher risk of morbidity should guide
the best treatment options in a patient-based and lesion-specific approach. Radiotherapy is currently
adopted as first-line treatment for cavernous sinus meningiomas, due to increased complication and
mortality rates associated to surgical resection [16,29] . For adjuvant radiotherapy, the goal of treatment is
preventing progression to higher-grade malignancy and decreasing recurrence rate. In cases of grade
II (atypical) and grade III (anaplastic/malignant) meningiomas, there is a substantially greater risk
of recurrence and a clearer role for adjuvant radiotherapy, even following a gross total resection. It is
important to note that recommendations for radiotherapy in different meningioma scenarios, coming from
the European Association of Neuro-Oncology (EANO) and the Current National Comprehensive Cancer
Network (NCCN), do not take into account tumor location or any molecular pathological markers, and
both were published prior to the revised 2016 WHO classification, whose criteria may result in more WHO
grade II meningiomas that would have been classified as grade I under the older criteria [16,99] .

CONCLUSION
The continuous evolution of the surgical techniques and, above all, the magnification of the surgical
view provided by the endoscope have brought terrific contributions to the effectiveness of meningioma
surgery. The most challenging task confronting modern meningioma surgery remains the selection of
the most appropriate surgical approach: multiple factors including tumor size consistency and location,
extent of dural attachment, and relation with neurovascular structures, along with surgeon’s preference
and experience, should be taken in account. With the amount of support and guidance that current
technologies and advances have provided, modern criteria for meningioma treatment should further
consider the careful balance between the desired goal of meningioma surgical cure, and the patient’s
neurological function preservation should guide the surgery. Improvements in radiation therapy modalities
and advances in the molecular characterization of these tumors will further refine the criteria for the
surgical approach to meningiomas.

DECLARATIONS
Authors’ contributions
Made substantial contribution to conception of the study: Cappabianca P, Solari D
Prepared the manuscript draft: d’Avella E
Critically revised the final version of the manuscript: Cappabianca P, Cavallo LM

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.