Radiation Therapy for Meningiomas - Where Do We Stand and What's on the Horizon?

Radiation therapy, including conventionally fractionated external beam radiation therapy, stereotactic radiosurgery, and fractionated stereotactic radiation therapy, is a cornerstone in the interdisciplinary management of meningiomas. Recent advances in radiation oncology and also in other fields, such as neuropathology and imaging, have various implications for meningioma radiation therapy. This review aims to summarize current and anticipated developments, as well as active clinical trials related to the use of radiation therapy for meningiomas. In imaging, positron emission tomography has proven valuable for assessing the spatial extension of meningiomas and may enhance target delineation, treatment response monitoring, and recurrence assessment after radiation therapy. Particle therapy, including protons and carbon ions, as well as stereotactic radiosurgery and fractionated stereotactic radiation therapy, allow for conformal treatments that permit dose escalation in selected patients with high-grade meningiomas. Additionally, emerging integrated molecular and genetic classifications offer superior risk stratification and may refine patient selection for radiation therapy. However, there is a paucity of active meningioma trials directly investigating or refining the use of radiation therapy. In summary, significant advances in functional imaging, molecular and genetic diagnostics, and radiation treatment techniques hold the potential to improve patient outcomes and to avoid over- and undertreatment. Collaborative efforts and further clinical trials are essential to optimize meningioma radiation therapy.