Assessment of Local and Regional Control in High-Risk Atypical (WHO Grade 2) Meningiomas Receiving Stereotactic Fractionated Radiosurgery

Purpose Adjuvant radiation therapy for atypical meningiomas (AMs) aids in local control following surgery and salvage after recurrence. The role of fractionated stereotactic radiosurgery (FSRT) in this population remains an area of active study with many unanswered clinical questions. This single-institution retrospective study evaluates the local control, marginal control, and toxicity of FSRT in treating AM. Methods Between 2009 and 2022, 39 patients with WHO grade 2 AM underwent FSRT via marginless, frameless volumetric-modulated arc therapy (VMAT) at doses of 27.5-30 Gy in five fractions. Local recurrence was defined as an increase of 20% in the greatest cross-sectional diameter on MRI or CT, following RECIST criteria. Cavity and marginal recurrences were defined as any new lesion outside the prescription volume but within the resection cavity or within 2 cm of the resection cavity, respectively. High-grade toxicity was defined per Common Terminology Criteria for Adverse Events (CTCAE) v5. Resection for radionecrosis with viable residual tumor was considered a local failure. Results Twenty-six AMs were treated post-subtotal resection (STR), 16 post-gross total resection (GTR) with recurrence, and five treated definitively. Patient characteristics included a mean age of 54 years, 20 (51%) male patients, and 31 (79%) patients with ECOG 0-1. The three-year local control rate was 84.0%. Larger tumors were more likely to fail locally (p > 0.001). Two (5%) patients experienced high-grade toxicity necessitating resection. The three-year marginal control rate was 92.3%, and recurrent tumors post-GTR failed marginally more often compared to those treated after STR (p = 0.009). One (4%) tumor treated after STR failed marginally, while four (33%) tumors treated after GTR recurrence failed marginally. The three-year control rate of the unirradiated cavity was 88%. Conclusion The rate of high-grade toxicity in AM patients receiving FSRT was low. Local control appeared comparable to historical rates, which may suggest the potential need for dose escalation with longer-term follow-up. Recurrent tumors were more prone to marginal failures. Further investigation is needed to determine which patients may benefit from whole-cavity treatment, additional CTV margin, or prolonged fractionated dose schedules. Newer imaging studies, including DOTATATE PET, should be explored to assess whether improvements in targeting accuracy can enhance outcomes.