Fractionated radiotherapy adjuvant to surgery of WHO-2 meningioma with and without gross total resection: a multicenter, retrospective cohort study of 1,452 patients

Mirian, Christian; Jensen, Lasse Rehne; Hoffmann, Adam Gorm; Juratli, Tareq A.; Maier, Andrea Daniela; Lindner, Pernilla; Broechner, Anders; Torp, Sverre H.; Shih, Helen A.; Morshed, Ramin A.; Young, Jacob S.; Magill, Stephen T.; Stummer, Walter; Spille, Dorothee Cacilia; Brokinkel, Benjamin; Proescholdt, Martin; Kuroi, Yasuhiro; Gousias, Konstantinos; Simon, Matthias; Prat-Acin, Ricardo; Goutagny, Stephane; Wach, Johannes; Guresir, Erdem; Yamamoto, Junkoh; Kim, Young Zoon; Lee, Joo Ho; Kim, Daniel W.; Koshy, Matthew; Cannon, Donald M.; Shrieve, Dennis C.; Suh, Chang-Ok; Chang, Jong Hee; Kamenova, Maria; Straumann, Sven; Soleman, Jehuda; Eyupoglu, Ilker Y.; Catalan, Tony; Lui, Austin; Theodosopoulos, Philip V.; Mcdermott, Michael W.; Goes, Pedro; Wang, Fang; Souhami, Luis; Guiot, Marie-Christine; Csonka, Tamas; Endo, Toshiki; Gupta, Tejpal; Patel, Akash J.; Klisch, Tiemo J.; Kim, Jun Won; Maiuri, Francesco; Barresi, Valeria; Tabernero, Maria Dolores; Skyrman, Simon; Krause, Mechthild; Law, Ian; Kristensen, Bjarne Winther; Munch, Tina Norgaard; Meling, Torstein; Fugleholm, Kare; Blanche, Paul; Mathiesen, Tiit

doi:10.1007/s11060-025-05349-7

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Fractionated radiotherapy adjuvant to surgery of WHO-2 meningioma with and without gross total resection: a multicenter, retrospective cohort study of 1,452 patients

Authors: Mirian, Christian ; Jensen, Lasse Rehne ; Hoffmann, Adam Gorm ; Juratli, Tareq A. ; Maier, Andrea Daniela ; Lindner, Pernilla ; Broechner, Anders ; Torp, Sverre H. ; Shih, Helen A. ; Morshed, Ramin A. ; Young, Jacob S. ; Magill, Stephen T. ; Stummer, Walter ; Spille, Dorothee Cacilia ; Brokinkel, Benjamin ; Proescholdt, Martin ; Kuroi, Yasuhiro ; Gousias, Konstantinos ; Simon, Matthias ; Prat-Acin, Ricardo ; Goutagny, Stephane ; Wach, Johannes ; Guresir, Erdem ; Yamamoto, Junkoh ; Kim, Young Zoon ; Lee, Joo Ho ; Kim, Daniel W. ; Koshy, Matthew ; Cannon, Donald M. ; Shrieve, Dennis C. ; Suh, Chang-Ok ; Chang, Jong Hee ; Kamenova, Maria ; Straumann, Sven ; Soleman, Jehuda ; Eyupoglu, Ilker Y. ; Catalan, Tony ; Lui, Austin ; Theodosopoulos, Philip V. ; Mcdermott, Michael W. ; Goes, Pedro ; Wang, Fang ; Souhami, Luis ; Guiot, Marie-Christine ; Csonka, Tamas ; Endo, Toshiki ; Gupta, Tejpal ; Patel, Akash J. ; Klisch, Tiemo J. ; Kim, Jun Won ; Maiuri, Francesco ; Barresi, Valeria ; Tabernero, Maria Dolores ; Skyrman, Simon ; Krause, Mechthild ; Law, Ian ; Kristensen, Bjarne Winther ; Munch, Tina Norgaard ; Meling, Torstein ; Fugleholm, Kare ; Blanche, Paul ; Mathiesen, Tiit

Citation: JOURNAL OF NEURO-ONCOLOGY, Vol.176(3), 2026-02

Article Number: 201

Journal Title: JOURNAL OF NEURO-ONCOLOGY

ISSN: 0167-594X

Issue Date: 2026-02

Keywords: Meningioma ; Radiotherapy ; Recurrence ; Progression ; Atypical meningioma ; Resection

Abstract: Purpose The role of adjuvant fractionated radiotherapy (aFRT) after gross total resection (GTR) of WHO-2 meningiomas remains unclear. We aimed to estimate the effect of aFRT on recurrence risk and survival following GTR and subtotal resection (STR). Methods We analyzed 1452 patients with WHO-2 from our international, multicenter database (followed between 1989 and 2019). Outcomes were recurrence (10-year follow-up) and death (5-year follow-up). Risk estimates were obtained using competing risks and survival analysis. Average treatment effects were estimated by G-computation, adjusted for potential confounding by age, sex, Simpson grade, Ki-67 proliferation index, location, country group (universal healthcare or not), and year of treatment initiation. The robustness of findings was examined through sensitivity analyses. Results Overall, 276 of 1452 patients (19.0%) received aFRT. Among GTR patients, unadjusted analysis showed comparable recurrence proportions between irradiated and non-irradiated patients (25.5% vs. 22.8% within 5 years). Adjusted analyses provided no evidence that aFRT reduced the risk of recurrence (largest difference: -2.7%, 95% CI -5.6 to 0.2); although, the CIs include the possibility of small beneficial effects. In STR patients, aFRT was associated with reduced recurrence risk in both unadjusted and adjusted analyses. Unexpectedly, a higher mortality was observed among irradiated GTR patients, largely driven by older patients with low Ki-67 PI receiving aFRT. Sensitivity analyses showed similar results for patients with STR but discrepancy in estimates for those with GTR. Conclusion Adjuvant FRT showed a consistent reduction in recurrence risk after STR while inconsistent recurrence risk estimates were observed for patients with GTR. The findings reflect efficacy of aFRT using real-world data without standardized guidelines.