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Opposed evolution of bone and soft parts of osteomeningioma associated with progesterone after stopping progesterone taking

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Opposed evolution of bone and soft parts of osteomeningioma associated with progesterone after stopping progesterone taking

https://pubmed.ncbi.nlm.nih.gov/36883659/

(translation made by the association, for good understanding by all)

 Simona M. Florea, MD, 1 Thibault Passeri, MD, 1 Rosaria Abbritti, MD, 1 Anne L. Bernat, MD, 1 , Sylvie Fontanel, MD, 2 Isabelle Yoldjian, MD , 3 Thomas Funck-Brentano, MD, PHD, 4 Alain Weill, MD, 5 , Emmanuel Mandonnet , Sébastien Froelich, MD 1

Departments of 1 neurosurgery and 4 rheumatology, Lariboisière hospital, AP-HP, University of Paris; 2 Grand Est regional health agency, Nancy; 3 National Agency for Medicines and Health Products (ANSM), Saint-Denis; And 5 scientific interest group Epi-Phare, Saint-Denis, France.

ACP: Cyproterone acetate

Objective of numerous studies have confirmed the existence of a close link between progestins and meningiomas, as well as the regression and/or stabilization of meningiomas after stopping treatment. Osteomeningiomas represent a small meningioma subgroups which seem to be more frequent among the meningomes linked to the progestins. However, the specificity of the behavior of this meningioma subgroups after the progestogy has not yet been evaluated.

methods (average age 49.5 years) with at least osteomeningioma linked to a progestogen (48 tumors in total) were identified from a prospective patient database which had been sent to our service for meningioma and whose use of cyproterone acetate, nomegestrol acetate and Chlormadinone had been documented. The hormonal treatment was stopped at the time of diagnosis for all patients, and the clinical and radiological evolution of this subgroup of tumors was evaluated.

Results for half of the 36 patients, the treatment was prescribed for signs of hyperandrogenism, such as hirsutism, alopecia or acne. Most lesions were spheno-orbital (35.4 %) or frontal (31.2 %) . Although the tissue part of meningioma decreased in 77.1 % of cases, the bone part presented a discordant behavior with 81.3 % increase in volume. The combination of estrogen, as well as the prolonged duration of progestin treatment, seem to increase the risk of progression of the bone part after stopping treatment (p = 0.02 and p = 0.028, respectively). No patient required surgical treatment at the time of diagnosis or during the study.

Conclusions These results show that if the soft intracranial part of osteomeningioma linked to progesterone is most likely to regress after stopping treatment, the bone part is more likely to increase in volume. These results suggest the need for careful monitoring of these patients, especially those whose tumors are located near the optical apparatus.

keywords ; progestogen; Cyproterone acetate; Nomestrol acetate; Chlormadinone acetate; Primary intra-dosseous meningioma; Oncology; tumor

 

Meningiomas are benign SNC tumors which represent approximately 39 % of primary brain tumors in the adult population. 1 Over time, the relationship between meningiomas and sex hormones has been well established and the arguments in favor of such an association are numerous: female predominance with a women/man ratio of 2.3: 1, 1 acceleration of growth during pregnancy and tendency to narrowing after childbirth, association reported between mammary carcinoma and meningioma Starting from the arachnoid cells, which naturally express progesterone receptors, as well as high levels of expression of progesterone receptors and androgens in meningiomas. 6.7 Antiprogesterone agents such as mifepristone were also used on non -rescinable meningiomas, with a rather limited effect. 8.9 However, the underlying mechanisms explaining relations between sex hormones and meningiomas are still misunderstood.

The intra-dosy osteomeningiomas or meningiomas represent a small subset of meningiomas, or about 1 to 2 % of meningiomas. 10.11 Osteomeningiomas are either calvarial tumors (mainly frontal or parietal), or tumors of the skull base (mainly in the sphenoid bone) and most often arise painless; Sphenoid lesions are located at the origin of the cranial nerve and generally cause visual deficits.

Progestatives are synthetic hormones that act similarly to the endogenous progesterone hormone, with specific effects based on structural variations, and are used in various gynecological situations such as amenorrhea, abnormal uterine bleeding, contraception or substitute hormonal treatment in menopausal women; Some progestins have a significant antiandrogenic effect and can also be prescribed for hormonal suppression in transgender or women with clinical signs of hyperandrogenism.12

In 2008, Froelich et al. suggested for the first time an association between cyproterone acetate (ACP) and meningioma, with stabilization or regression of the tumor after stopping the ACP . 13 Since then, numerous studies have confirmed the regression and/or stabilization of meningiomas after stopping treatment. 14-17 A recent cohort study based on a large series of patients from the French national database SNDS (national health data system) has proven this association between ACP and Meningioma with a strong dose effect. 18 Other exogenous progestins such as nomestrol (nomac) acetate or chlormadinone acetate (CMA) seem to have similar effects on meningiomas. 19-21

The aim of this study was to assess the specific behaviors of osteomeningiomas linked to progestogen after stopping treatment. This study analyzed the clinical and radiological evolution of 36 patients with at least osteomeningioma after stopping progestins.

 

Methods

Ethical approval

This study was approved by the local ethics committee of the Lariboisière hospital, Paris, France.

 

Inclusion and exclusion criteria

Patients who have had at least osteomeningioma with concomitant progestin treatment between April 2010 and December 2020 were retrospectively identified from a prospective database of 249 patients addressed to our neurosurgery service for meningiom with documented use of ACP, Nomac and/or CMA at the time of diagnosis. The following inclusion criteria were taken into account: imaging assessment at the time of diagnosis before stopping treatment, including at least sequences of gadolinium weighted in 3D T1; And at least an MRI examination of the brain, including sequences of gadolinium weighted in 3D T1 after stopping treatment. Patients with history of radiotherapy or type 2 neurofibromatosis have not been taken into account in the analysis, because tumor etiology is not entirely associated with the taking of progestins.

For all patients, hormonal treatment was interrupted at the time of diagnosis. Clinical and radiological monitoring with MRI series exams was offered to each patient, the average (interval) between the diagnosis and the first clinical examination with MRI being 3.8 (1-6) months. The follow -up period after stopping treatment ranged from 5 to 104 months (average monitoring of 23 months).

 

Measures

The tumor volume was measured by MRI at the time of diagnosis and during the last follow -up assessment. The PACS Viewer software (Carestream version 12.1.6.0116, Carestream Health Inc.) was used to manually trace the contours of each meningioma, slice by edge, on 3D axial sequences with gadolinium weighted in T1. The repulsion tool was used to optimize the outline and select the region of interest. The volume was then calculated automatically using the segmentation function. The measures were obtained by two certified neurosurgeons, and the value considered for statistical analysis was the average of two measures. A change in volume of at least 10 % was considered significant.

 

Statistical methods

Data management and analysis have been evaluated with IBM SPSS Statistics version 23 (IBM Corp.). Fisher's exact test or the Square Chi test and Fisher correlation coefficient were used to compare the data. In this study, p <0.05 was considered significant.

 

Results

Participants

In total, 44 patients were identified with at least osteomeningioma and the concomitant use of ACP, Nomac or CMA, 36 of which met the inclusion criteria. A patient has been excluded due to an urgent need for surgical decompression of spheno-orbital meningioma with visual impairment, while 7 patients were excluded due to incomplete imaging data. Finally, a total of 36 patients with 48 osteomeningiomas were included in this study.

 

Basic characteristics

The average age (fork) at the time of diagnostic MRI was 49.5 (33-71) years. Twenty-four patients took ACP, 5 nomac patients and 4 AMC patients; For 3 patients, the treatment was initiated with nomac and was finally replaced by ACP (2 patients) or AMC (1 patient). The average duration of progestin treatment was 17.6 (6-33) years. For half of these patients, treatment has been prescribed for signs of hyperandrogenism, such as hirsutism, alopecia or acne. Nine patients (25 %) also took an estrogen derivative in combination with progestins. The clinical characteristics of our study group and treatment indications are presented in Table 1.

Most patients (19 [52.8 %]) were diagnosed during the recommended MRI screening exam after prolonged progestin treatment and were asymptomatic at the time of diagnosis. The 17 symptomatic patients most often presented headache (6 patients) or local signs such as exophthalmos or bone mass of the skull (7 patients).

 

Clinical development after stopping treatment

After stopping treatment, none of the asymptomatic patients has become symptomatic. Among the 17 symptomatic patients, 10 improved, 5 remained stable and 2 aggravated. The two patients whose state worsened presented local clinical signs and had been processed with an associated estrogen derivative. The first patient was diagnosed with a spheno-orbital meningiom of discreet exophthalmia, which has increased slightly during the 12 months of follow-up, without any associated visual sign. The second patient had a cranial bone mass which increased during the 41 months of surveillance, without associated mass effect on the brain because it developed mainly at the extracranial level. No patient needed surgery or irradiation during follow -up.

Table 1: Clinical characteristics of patients

See link

 

Characteristics of meningioma

Twelve patients (33.3 %) had a single tumor, while the other 24 patients (66.7 %) had multiple meningiomas, including one or more osteomeningiomas associated with multiple tumors without bone component.

Twenty-seven osteomeningiomas were located on convexity (56.25%), and the 21 remaining tumors were located on the skull (1 tumor of the previous cranial pit and 20 tumors of the average cranial pit, which were mainly spheno-orbital). Twenty-seven bone meningiomas (56.25 %) were located in areas of intersection of 3 or more cranial bones, as was the case for spheno-orbital meningiomas (17 lesions), pterional meningiomas (3 lesions) and meningiomas located in the asterion (7 lesions). A meningioma was located on the coronal suture, while the other 20 meningiomas were located on a single bone and most (15 meningiomas [31.25 %]) were frontal (Table 2).

Image 1 shows an example of bone meningioma at the time of diagnosis and its evolution after stopping hormones.

 

Volumetric study

Volumetric analysis of the tissue component of osteomeningiomas has shown a behavior similar to that described in previous reports, the majority with a significant reduction in volume (37 meningiomas [77.1 %]) or stability (8 [16.7 %]) during monitoring. Only 3 meningiomas increased in volume (6.2%), and the progression was also objectified for the bone component of these 3 lesions.

However, the bone part of meningiomas has shown a rather discordant evolution compared to the tissue part, with only 1 tumor showing a volume reduction, 8 remaining stable lesions (16.6%), and 39 meningiomas (81.25%) showing a significant increase in the volume of the bone component. Among the 39 meningiomas with a clear bone increase, 7 were considered stable for the tissue part, while 32 (66.66% of all the meningiomas studied) showed a significant decrease in the volume indicating an opposite volumetric evolution. Volumetric data is detailed in Table 2 and represented graphically in image 2. The evaluation of the total volume of lesions, including tissue and bone parts, showed 27 evolutionary osteomeningiomas, 13 stable tumors and 8 tumors that have decreased in size during follow -up. No significant difference in terms of tumor evolution was observed between the different locations.

Estrogens have been prescribed in combination with progestins in 9 patients (15 meningiomas). By analyzing the evolution of the tumor volume in these patients, we observed a rate of increase in the bone part of the higher tumor than in the progestogen group alone, with a relative risk of 1.94 (p = 0.02). Even if these patients also seem to have a less favorable clinical evolution because the only 2 patients whose state has worsened were processed by the progestogen-esrogenic hormonal association, the results are not statistically significant (p = 0.2). No difference was observed between the two groups for the tissue component.

The duration of hormonal treatment has been associated with a relative risk of bone progression of 1.6 in women taking progestins for at least 10 years (p = 0.028). No significant statistical difference was observed in tumor progression between patients who took progestins for signs related to hyperandrogenia and those treated for gynecological disease (p = 0.7).

Table 2: Location of the tumor and volumetric evolution

See link

 

Discussion

The influence of sex hormones on the evolution of meningiomas is a well -established phenomenon , various studies showing a favorable clinical and radiological evolution in patients who have used long -term progestins after stopping treatment. 14.20-23 A first series of cases by Froelich et al. suggested a link between taking ACP and the appearance of multiple meningomes. 13 In addition, this fundamental study reported stabilization or even the regression of tumors after stopping treatment with ACP. Many cases of cases and small series of patients have since been published, strengthening the initial presumption. 14,16,17,19-28 recently, Voormolen et al. 29 reported the results of the largest cohort of meningiomas linked to the use of ACP, in which 72 % of meningiomas regressed after the interruption of the ACP and 20 % of tumors remained stable. A vast cohort study based on the French national data, recently published by Weill et al. 18 , has proven the strong association and dose-dependent between the APC and the meningiomas requiring treatment in women. Regarding the location of meningiomas linked to progesterone, several studies have shown a clear predisposition for the anterior and average skull base , 13,14,18,29,30 as was the case for patients included in our analysis.

Recent molecular studies on progesterone meningiomas have revealed that certain transferred genes are more frequent in this meningioma subset and that the genetic profile of meningiomas varies depending on location. 31 In addition, Peyre et al. have shown that hormonal factors may have the ability to produce changes in the mutational patterns of meningiomas associated with hormones, which could explain both the evolution of these tumors as a function of taking exogenous sex hormones and their variable evolution after stopping treatment. 30

Osteomeningiomas represent only a low percentage of meningiomas, 10.11 associated hyperostosis being linked to the invasion of the bone by tumor cells. 11.32 Thus, to obtain a resection of Simpson grade I, surgical treatment must remove both tissue and bone components, which is sometimes difficult, in particular for sphero-orbital meningiomas and large calvarial lesions which require extensive cranial reconstructions.

The peculiarities of sphen's meningiomas, which are the most frequent osteomeningiomas of the skull base, were discussed by Apra et al. In a recent article 33 which showed associations between female sex, the use of progesterone analogues and the expression of progesterone receptors in patients with this osteomeningioma subtype. The study being based on operated spheno-orbital meningiomas, the authors could not determine whether the spherian-orbital meningiomas regressed after stopping treatment, unlike other meningiomas linked to progesterone. However, 21% of operated patients had to undergo an ipsilateral reoperation despite stopping progestin treatment, which seems to indicate that regression or stabilization is perhaps not as frequent as in patients with other meningiomas linked to progesterone. More recently, Abijaoude et al. 34 reported the case of 3 patients with an increase in the volume of bone meningioma linked to hormones after stopping progestin treatment.

The role of the cranial sutures in the cranio-facial growth is well known, because they are responsible for bone formation by mechanical stimulation due to the development of the neurocrâne. 35 In this series, 28 (58.33 %) Méningiomes were located on the sutures and 20 (41.67 %) affected only one cranial bone; Most were in frontal calvaria (15 [31.25 %]), which is the preferred location of internal frontal hyperostosis, a bone condition observed mainly in women and which is believed to be linked to hormonal status36. In a recent study, goalsidt et al. described 4 phases of the bone reaction to the tumor invasion which begins with an initial phase of increased bone absorption followed by the growth of tumor cells, then by an increase in bone formation and mineralization, and finally by sclerosis of the calvarian bone. 11

Osteoclasts and osteoblasts, which are involved in the hyperostosis process, are influenced by sex hormones, which have a direct effect on their function. The effect of sex hormones on bones has been the subject of in -depth studies over the years, starting with the studies of Albright in the 1940s 37.38 which reported the stimulating effect of estrogens on osteoblasts and the impact of the drop in estrogen levels after menopause, responsible for osteoporosis in women; He also indicated that the loss of androgens in men had a similar effect. In the 1990s, Prior described the role of progesterone activity on bone formation and its direct actions on bone reshaping, 39 while Comston and Lindsay clearly stated the essential role of sexual steroids in the Homeostasis of the Skeleton. 40.41

Androgens were also associated with bone reshaping, either by a direct effect or by transformation into estrogens. 42 Several studies have shown that women with hirsutism, polycystic ovaries and secreting ovarian tumors also have higher bone mineral density. 43.44 This is explained by the proapoptotic effect of androgens on osteoclasts and the antipopoptotic effect on osteoblasts and osteocytes, which promote bone formation and decrease bone resorption. 45.46 In our series, the tissue part of meningioma decreased in 77.1 % of tumors after stopping progestins, while the bone part increased in volume in 81.2 % of tumors; This evolution may have been influenced by the well -known effect of androgens on the bone. One hypothesis is that the bone part is partially controlled by the antiandrogen effect during the taking of hormones, while the progression of the bone component of these meningiomas after stopping the administration of antiandrogens is explained by the hyperandrogenic state of these patients.

By analyzing the effects of the association between estrogen and progestogens on bone mineralization, the authors of most studies have concluded that progestins reinforce the beneficial effects of estrogens and thus increase bone mineralization 47-49 due to the estrogen-like effect presented by progestins. It is interesting to note that we have also observed a higher rate of increase in the bone part of osteomeningiomas after stopping treatment in patients who took estrogens in combination with progestins, with a relative risk of 1.94 (p = 0.02) compared to the group which only took progestins.

The results of our study have shown that most of the initially symptomatic patients have become asymptomatic or have seen their symptoms improve during follow -up, which agrees with the results of previous studies 14,15, 18, 20, 24.25 and suggests that most symptoms of osteomeningioma linked to the progestins are mainly caused by the intracranial tissue tumor. Only two patients saw their state worsen during follow-up, one with a discreet evolution of its exophthalmia and the other an enlargement of the subcutaneous bone mass which led to the initial diagnosis.

None of the patients in this series had to be made due to the progression of the symptoms linked to the increase in hyperostosis after stopping progesterone. However, like osteomeningiomas such as sphen-orbital meningiomas often appear with exophthalmos or visual impairment, most often due to a narrowing of the optical channel, it is likely that certain patients need surgical intervention for decompression of the optic nerve or orbit. In patients with documented regression of the tissue part of meningiomas, the objective of surgery would be functional rather than COLOGIC, the only goal being to decompress the neural structures.

 

Picture. 1 . Brain MRI and computed tomography obtained in a 39-year-old woman to whom sphen-orbital osteomeningioma was diagnosed, revealed by exophthalmia on the left side. The patient took nomac for 16 years as oral contraceptive. The images on the left side (A and C) come from the diagnostic examination, while the images on the right side (B and D) were obtained 20 months after the initial diagnosis and the stopping of the taking of Nomac. These images illustrate a decrease in the soft intracranial part of the tumor (visible on the MRI sequences weighted in T1 and enhanced with gadolinium in the upper row) and an increase in the volume of the bone part, as shown by computed tomography (lower row).

See image here.

 

Boundaries

The results reported here must however be interpreted in the light of certain limitations. First of all, this study is based on a subgroup of patients selected retrospectively in our database on meningiomas under progestin, for which radiological monitoring consisted of a brain MRI. Some patients have not undergone computed tomography at the time of diagnosis and during follow -up; These studies would have made it possible to increase the accuracy of the bone volume measurement. In addition, no surgical treatment has been indicated for patients included in the study, whether at the time of diagnosis or during the study; Therefore, pathological data concerning the WHO grade or specific molecular markers remain unknown. Second, the study focused on a small number of patients, making certain statistical tests inapplicable.

 

Picture. 2 . Graphic illustration of the evolution of the volume (in cubic millimeters) of soft tumors (A) compared to bone tumors (B). While the soft part has shown a clear tendency to decrease, the bone part of the meningiomas has had a rather opposite evolution. The median (central line), the interquartile interval (box), the extent (green lines), the data outside the average values ​​(open circles) and the aberrant values ​​(red squares) are indicated.

See image here

 

Conclusions

Our results suggest that if the tissue part of meningiomas linked to progesterone has a benign behavior with regression or stabilization in most cases, the bone part tends to continue to grow even after stopping the progesterone administration .

Due to the volumetric regression of the tissue part of the tumor, which is mainly responsible for neurological symptoms, the initial consideration during the diagnosis should be whether patients who do not require immediate surgical treatment should stop the progestins.

However, closer clinical surveillance is indicated for osteomeningiomas, in particular tumors linked to the optical apparatus.

 

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Information

The authors do not report any conflict of interest regarding the equipment or methods used in this study or the results specified in this document.

 

Contributions from authors

Design and realization: Florea, Passeri, Mandonnet, Froelich.

Acquisition of data: Florea, Passeri, Mandonnet. Analysis and interpretation

The interpretation of the data: Florea, Passeri, Funck-Bretano, Weill.

Drafting of the article: Florea, Funck-Bretano. Critical revision of the article

The article: Abbritti, Fontanel, Funck-Bretano, Mandonnet, Froelich.

Revision of the submissive version of the manuscript: Florea, Yoldjian,

FUNCK-Bretano, Weill, Mandonnet, Froelich. Approved the

Approved the final version of the manuscript on behalf of all the authors: Florea.

Statistical analysis: Florea. Administrative/Technical/Material support

Material: Florea, Froelich. Study supervision: Bernat, Froelich.

 

Correspondence

Simona M. Florea: Lariboisière hospital, AP-HP, University of Paris, France. sm.floreamd@gmail.com.

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