A Case-based Guide for World Health Organization (WHO) Grade 2 Meningioma Radiosurgery and Radiation Therapy from The Radiosurgery Society.

Meningiomas represent the most common primary tumor of the central nervous system. Current treatment options include surgical resection with or without adjuvant radiation therapy (RT), definitive RT, and observation. However, the radiation dose, fractionation, and margins used to treat patients with WHO grade 2 meningiomas, which account for approximately 20% of all meningiomas, are not clearly defined, and deciding on the optimal treatment modality can be challenging owing to the lack of randomized data. In this manuscript, 3 cases of patients with WHO grade 2 meningiomas are presented with descriptions of treatment options after gross total resection, subtotal resection, and recurrent tumors within a prior irradiated field. Treatment recommendations were compiled from 9 central nervous system radiation oncology and neurosurgery experts from The Radiosurgery Society, and the majority consensus of treatment guidelines are reported. Both conventional and stereotactic RT are treatment options for WHO grade 2 meningiomas. The majority of prospective data in the setting of WHO grade 2 meningiomas involve larger margins. Stereotactic radiosurgery/hypofractionated stereotactic RT are less appropriate in this setting. Conventionally fractionated RT to at least 59.4 Gy is considered standard of care with utilization of preoperative and postoperative imaging to evaluate the extent of disease and possible osseous involvement. After careful discussion, stereotactic radiosurgery/hypofractionated stereotactic RT may play a role for the subset of patients who are unable to tolerate the standard lengthy conventionally fractionated treatment course, for those with prior RT, or for small residual tumors. However, more studies are needed to determine the optimal approach. This case-based evaluation of the current literature seeks to provide examples for the management of grade 2 meningiomas and give examples of both conventional and stereotactic RT.

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Copyright © 2024 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

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Disclosures A.S. has grants/contracts from Elekta AB and Seagen through his institution, as well as consulting fees from Varian, Elekta, and BrainLAB. He also has honoraria from AstraZeneca, Elekta AB, Varian, BrainLAB, and Seagen. He has leadership roles in the International Stereotactic Radiosurgery Society as well as the SO Spine Knowledge Forum Tumor. He is a member of the Elekta MR Linac Research Consortium, the Elekta Oligometastases Group, and the Elekta Gamma Knife Icon Group. I.G. has a leadership role on the ASTRO and Radiosurgery Society BOD. He receives honoraria for lectures and from Accuray, Inc. E.C. has travel support for travel to ICOTEC meetings. F.E. has honoraria and travel support from ZAP Surgical Systems, Inc. G.G.K. has consulting fees from Varian Medical Systems. J.P. has grants/contracts from Genentech, NIH R702, NIH R01CA269948. He also has honoraria from Varian Medical Systems, Novocure, ICOTEC, and Carbofix. He is on the Novocure advisory board. He has a leadership role in the Spine Therapy Society as a Steering Committee Member. J.K. has consulting fees from Reflexion, ICOTEC, CarboFix, Accuray, Varian, Elekta, ViewRay, and Brainlab. He has honoraria from Varian, ICOTEC, Carbofix, Acurray, BrainLab, ViewRay. He has a leadership role in ASTRO, RSS, and the Accuray Exchange Community. K.R. has grants/contracts from Accuray, Canon, and ICOTEC. She receives an honoraria from Accuray.. She receives support for attending meetings from Elekta AB, Accuray, Brainlab, RSS, and AAPM. She has a radiogenomics patent shared with Canon under development. She participates on the BioMimetix Board. She is a CNS track chair leader for the ASTRO education committee. M.S. has consulting fees from Hyperfine, Inc. He receives support for attending meetings from the World Society for Stereotactic and Functional Neurosurgery. He participates on the board for Alpheus, Inc. He is the president of the Brain Tumor Foundation. He is a stock holder for Hyperfine, Inc. S.C. receives payments from GE Health care, Varian Medical Systems, and Blue Earth Diagnostics. S.L. has research funding from Kuni Foundation and Hutchinson Center as Lead Academic Participating Site. He receives support for attending the Japanese Society for Radiation Oncology (JASTRO). He has a leadership role in the Radiosurgery Society and American College of Radiology. All other authors have no disclosures.