CHAPTER 1 Meningioma
History of the Tumor and Its Management
Meningioma/s has attracted the attention of surgeons, anatomists, pathologists, and physicians for many centuries. Given the tendency of these neoplasms to cause thickening of the overlying calvarium, meningiomas have left an unmistakable mark on human skulls dated as far back as prehistoric times.1–4 Most of this evidence has come from the well-preserved skulls of the Incas in the Peruvian Andes that show classic hyperostosis indicating the presence of an underlying meningioma (Fig. 1-1).
FIGURE 1-1 Prehistoric Peruvian skull, showing hyperostosis from an underlying meningioma.
(From al-Rodhan NR, Laws ER Jr. Meningiomas: a historical study of the tumor and its surgical management. Neurosurgery 1990:26(5):832–46; discussion 846–7.)
Felix Plater (Fig. 1–2) was probably the first to describe a meningioma in more recent times. Born in 1536 in Sion, Switzerland, he was educated at Montpellier, where he received his doctorate in 1557. Caspar Bonecurtius, a nobleman, was Plater’s patient with a meningioma who presented with gradual physical and mental deterioration. On autopsy, Plater described a round fleshy tumor, like an acorn.5,6 It was as large as a medium-sized apple, hard and full of holes. It was covered with a membrane and entwined with veins. Plater described it as having no connections with the matter of the brain, so much so that when it was removed by hand, it left behind a remarkable cavity. This first clear description of a meningioma is most consistent with an encapsulated meningioma.7,8 Felix Plater continued to practice as a distinguished Professor of Medicine at the University of Basel and died in Basel at the age of 78.
FIGURE 1-2 Felix Plater (1536–1614) of Switzerland, the first to describe a meningioma.
(From al-Rodhan NR, Laws ER Jr. Meningiomas: a historical study of the tumor and its surgical management. Neurosurgery 1990:26(5):832–46; discussion 846–7.)
NOMENCLATURE
Harvey Cushing coined the term meningioma in 1922 to describe a benign neoplasm of the meninges of the brain. However, many other surgeons and pathologists described and named this neoplasm as well. In fact, naming of the tumor likely represents one of the most frequently changed nomenclatures in the history of medicine. Antoine Louis, born in Metz, France, in 1723 into a family of surgeons, developed an interest in surgery of dural tumors, which he named tumeurs fongueuses de la dure-mere or fungoid tumors of the dura mater.9 He included their description in Memoire de l’Académie Royale de Chirurgie in 1774. In 1854, Sir James Paget named the neoplasm myeloid tumor (marrow like), based on its gross appearance and less malignant behavior. In 1863, Virchow was the first to describe the granules in these tumors and named it psammoma (sand-like). As Virchow was uncertain of the origin of these bodies, he gave the neoplasm a descriptive name. Subsequently, he changed the nomenclature from psammoma to Sarkoma der dura mater to describe these tumors.2,10
In the mid-1800s, Meyer, Bouchard, and Robin popularized the term epithelioma which was replaced later by the term endothelioma.2,10 Golgi believed that because the tumor was of mesenchymal origin, endothelioma was a more suitable term. Despite the myriad terminology, Virchow’s “sarcoma” and “psammoma” and Golgi’s “endothelioma” came into general use in the late 1800s and early 1900s.
Harvey Cushing was troubled by the confusion that resulted from the different nomenclatures and thought that it would be desirable to place this tumor under a single unified designation. Cushing knew that since the cellular composition of the tumor was in dispute, a histogenic name would not be universally accepted. Further, because these tumors arose from many areas of the brain, a location-based tumor name was not possible. Therefore, Cushing decided on a simple, suitable “tissue name,” meningioma, that was “noncommittal and all-embracing.” In his Cavendish lecture in 1922, Harvey Cushing used this designation to discuss 85 patients with these tumors.10
CLASSIFICATION
In 1863, Virchow was the first to attempt a classification of meningiomas.2 This was followed by classification schemas by Engert (1900), Cushing (1920), Oberling (1922), Globus (1935), Russell and Rubinstein (1971), and others.2,11 The World Health Organization (WHO) classification is widely used today and has been revised regularly.12 It includes the recent concept of the “atypical meningioma” as an aggressive variant. Table 1-1 lists the various classifications described.
| Year | Author | Classification |
|---|---|---|
| 1900 | Engert | Four types: (1) fibromatous; (2) cellular; (3) sarcomatous; (4) angiomatous |
| 1920 | Cushing | Five types: (1) frontal; (2) paracentral; (3) parietal; (4) occipital; (5) temporal |
| 1922 | Oberling; later endorsed by Roussy | Three types: (1) type neuroepithelial; (2) type glial fusiforme; (3) type conjunctif |
| 1928 | Cushing and Bailey | Four types: (1) meningothelial; (2) fibroblastic; (3) angioblastic; (4) osteoblastic |
| 1930 | Bailey and Bucy | Nine types: (1) mesenchymatous; (2) angioblastic; (3) meningotheliomatous; (4) psammomatous; (5) osteoblastic; (6) fibroblastic; (7) melanoblastic; (8) lipomatous; (9) generalized sarcomatosis of the meninges. |
| 1935 | Globus | Five types: (with emphasis on the tumor content of pial vessels: (1) leptomeningioma; (2) pachymeningioma; (3) meningioma omniforme; (4) meningioma indifferentiale; (5) meningioma piale |
| 1938 | Cushing and Eisenhardt | Nine types with subvariants: (1) non-reticulin or collagen-forming meningothelial tumor; (2) meningothelial tumor pattern with tendency to form reticulin or collagen; (3) reticulin- or collagen-forming fibroblastic tumors of benign type; (4) reticulin-forming angioblastic tumors; (5) non–reticulin- or collagen forming epithelioid tumors; (6) reticulin- or collagen-forming fibroblastic tumors of malignant type; (7) osteoblastic meningiomas; (8) chondroblastic meningiomas; (9) lipoblastic |
| 1971 | Russell and Rubinstein | Five types: (1) syncytial; (2) transitional; (3) fibroblastic; (4) angioblastic; (5) mixed type |
| 2007 | WHO (World Health Organization) | (1) meningothelial: (2) fibrous (fibroblastic); (3) transitional (mixed); (4) psammomatous; (5) angiomatous; (6) microcystic; (7) secretory; (8) lymphoplasmacyte-rich; (9) metaplastic; (10) chordoid; (11) clear cell; (12) atypical; (13) papillary; (14) rhabdoid; (15) anaplastic (malignant) |
Adapted from Al-Rodhan and Laws2 (1990).
PATHOGENESIS
Antonius Pacchioni described arachnoidal granulations in 1705 as analogous to lymph glands.13 It was not until 1846, however, that Rainey suggested that these granulations were leptomeningeal in origin.14 Luschka, Ludwig Meyer, and Key and Retzius supported this view but the association between the granulations and meningeal tumors went unrecognized. In 1864, John Cleland, a Professor of Anatomy at Glasgow, described two dural tumors.15 One was an olfactory groove tumor and the other was right frontal in origin. In the dissecting suite, Cleland was able to separate the tumors from the dura, and hence appropriately described them as villous tumors of the arachnoid (Fig. 1-3
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