BACKGROUND AND PURPOSE: Radiotherapy (RT) may be a safe alternative to surgery for selected intracranial meningiomas, particularly in eloquent or high-risk surgical locations. Reported studies of stereotactic RT have utilized stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (hFSRT), or conventional radiotherapy. This retrospective study aimed to compare toxicity in a large international cohort. MATERIALS AND METHODS: A total of 473 consecutive patients were treated for intracranial meningioma at two radiation oncology clinics. The patients underwent various treatment modalities, including stereotactic radiosurgery (SRS), hypofractionated stereotactic radiotherapy (hFSRT, 2-5 fractions), or normofractionated stereotactic radiotherapy (nFSRT, 28-30 fractions) using CT-linac or Cyberknife radiation techniques. The evaluation of potential brain edema and radiation necrosis (RN) was conducted using magnetic resonance imaging (MRI). RESULTS: Radiation-induced brain edema occurred in 11.0% of patients, including 4.9% with symptomatic edema requiring corticosteroid therapy, and 4.0% of patients developed radiation necrosis. Despite a smaller irradiated tumor volume, the risk of radiation-related toxicity was higher with SRS compared to hFSRT and nFSRT, for both brain edema (hazard ratio [HR] = 4.10, 95% confidence interval (CI; 2.02; 8.26), p < 0.001) and RN (HR = 11.07, 95% CI (2.65; 46.24), p < 0.001). Cox regression showed a 33 and 28% increased risk of brain edema and RN per 1 cm3 of tumor volume (HR = 1.33, 95% CI (1.21; 1.46), p < 0.001 and HR = 1.28, 95% CI (1.13; 1.46), p < 0.001). For tumor volumes above the median (2.05 cm3), the risk of toxicity following SRS was significantly higher for edema (HR = 9.70, 95% CI (2.90; 32.40), p < 0.001) and RN (HR = 13.34, 95% CI (1.73; 102.80), p = 0.013). CONCLUSION: Stereotactic radiotherapy and radiosurgery are safe treatment options for intracranial meningiomas. However, our data indicate a significantly increased risk of radiation necrosis and edema after SRS for tumors larger than 2 cm3 (diameter > 1.55 cm). This study also highlights the safety of both nFSRT and hFSRT in the treatment of larger tumors, supporting treatment selection based on tumor volume.

Czech Technical University Prague Czech Republic

Department of Oncology University Hospital and Faculty of Medicine Ostrava Czech Republic

Department of Radiation Oncology Amsterdam UMC Amsterdam The Netherlands

Department of Radiation Oncology UMC Utrecht Utrecht The Netherlands

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