Acta Neurochir (2010) 152:1955–1956 DOI 10.1007/s00701-010-0787-2 LETTER TO THE EDITOR Regression of meningiomas after discontinuation of cyproterone acetate in a transsexual patient Helene Cebula & Trang Q. Pham & Patrick Boyer & Sébastien Froelich Received: 12 April 2010 / Accepted: 24 August 2010 / Published online: 3 September 2010 # Springer-Verlag 2010 Dear editor, MRI scans showed a relative stability of the meningioma The relationship between sex hormones and meningiomas (Fig. 1d). is well known but the effect of exogenous hormones on The relationship between meningiomas and sex hormones meningiomas remains controversial. We are presenting an has been well established and is supported by the higher unusual case of tumor regression after cyproterone acetate incidence of meningiomas among women, reports of tumor discontinuation. growth during pregnancy and the higher expression of sex A 48-year-old male to female transsexual patient hormones receptors in meningiomas compared to normal presented with headaches for 2 years. A CT and magnetic meningeal tissue [1, 2]. However, the role of sex hormones resonance imaging (MRI) scan revealed a small (4.2 cm3) in meningiomas is largely unknown and the effect of sex left temporal convexity meningioma (Fig. 1a). The patient hormones antagonist and agonist has been disappointing. had been taking a feminizing endocrine regimen of Because of its potential therapeutic implications, considerable estradiol and cyproterone acetate (100 mg/day), a strong attention has been given to the progesterone and estrogene progestative agent with antiandrogenic activity, for 10 years. receptor status. The results have been conflicting with no real Because of the nonspecific nature of his headaches and the value other than prognostic [2]. small size of the lesion, a conservative treatment was Nevertheless, the relationship between sex hormones and decided. The patient was then lost for the follow-up. The meningiomas raise the crucial question of whether women patient presented 39 months later with a worsening of his known to harbor a meningioma should continue using headaches and a significant enlargement of his lesion exogenous hormones. Epidemiologic studies have shown (25.7 cm3; Fig. 1b) and a new small left temporal polar either an absence or a weak relationship between meningio- meningioma. He refused surgical treatment. Because of the mas and hormone replacement therapy or oral contraception common knowledge that progestative treatment may play a [3]. However, hormonal treatments for other indications have role in meningioma growth, cyproterone acetate was not been included in those studies. discontinued and replaced with flutamide, a nonsteroidal A recently published report described a 28-year-old antiandrogen drug, 500 mg daily. Estradiol treatment was transsexual patient treated with ethinyl estradiol (100 μg/ continued. After 10 month, the MRI scan revealed a day orally) and cyproterone acetate (100 mg/day orally) significant decrease in size of the left temporal convexity who developed a gigantic olfactory groove meningioma meningioma (15.8 cm3; Fig. 1c) and the left temporal polar within 3 years [4]. In 2010, a regression of a meningioma meningioma could not be identified anymore. The subsequent was reported in a 46-year-old woman after discontinuation of cyproterone acetate that had been taken for 10 years. However, the patient was only followed for 6 months [5]. H. Cebula : T. Q. Pham : P. Boyer : S. Froelich (*) In our patient, the meningioma progressed in size (six Department of Neurosurgery, Strasbourg University Hospital, times) within 4 years; meanwhile, he developed a new Service de Neurochirurgie, CHU de Hautepierre, small lesion. After cyproterone acetate discontinuation, the 1 avenue Molière, 67200 Strasbourg, France larger lesion rapidly decreased for the first 6 months. Then, e-mail: sebastien.froelich@chru-strasbourg.fr the size of the tumor remained relatively stable. One could 1956 Acta Neurochir (2010) 152:1955–1956 Fig. 1 a Coronal T1-weighted MR image at the time of diagnosis showing a left temporal convexity meningioma (4.2 cm3). b Enlargement of the lesion 4 years later (25,7 cm3). c Decrease in size of the lesion after 6 months (15,8 cm3). d Graphic showing the rapid progression of the meningioma, the rapid decrease in size after cyproterone acetate discontinua- tion followed by a relative stability expect that with a longer follow-up, the tumor would regain References a classic slow growth rate. The important regression in our case confirms a strong 1. Ebner FH, Bornemann A, Wilhelm H, Ernemann U, Honegger J influence of cyproterone acetate on meningiomas growth. (2008) Tuberculum sellae meningioma symptomatic during pregnancy: pathophysiological considerations. Acta Neurochir (Wien) 150:189– In case of meningioma in a patient treated with cyproterone 193 acetate and without significant symptoms, a conservative 2. Pravdenkova S, Al-Mefty O, Sawyer J, Husain M (2006) strategy, including discontinuation of cyproterone acetate, Progesterone and estrogen receptors: opposing prognostic indicators should be considered. Furthermore, because higher dose of in meningiomas. J Neurosurg 105:163–173 3. Claus EB, Black PM, Bondy ML, Calvocoressi L, Schildkraut JM, cyproterone acetate are commonly used for the male-to- Wiemels JL, Wrensch M (2007) Exogenous hormone use and female transsexual patient, clinician caring for those patient meningioma risk: what do we tell our patients? Cancer 110:471–476 should be aware of such event that could be more frequent 4. Gazzeri R, Galarza M, Gazzeri G (2007) Growth of a meningioma in the transsexual population. in a transsexual patient after estrogen–progestin therapy. N Engl J Med 357:2411–2412 5. Gonçalves AM, Page P, Domigo V, Méder JF, Oppenheim C (2010) Abrupt regression of a meningioma after discontinuation of cyproterone treatment. AJNR Am J Neuroradiol. doi:10.3174/ajnr. Conflict of interest None A1978