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The role of adjuvant radiotherapy (RT) following gross total resection (GTR) in atypical meningioma (AM) is not well established and its benefit remains unclear. We aim to evaluate the survival benefit of adjuvant RT in AM following GTR. We searched biomedical databases for studies published between January 1964-February 2021 and included studies reporting primary outcomes of 5-year PFS, 5-year OS and had survival curves for restricted mean survival time (RMST) calculations. Data extracted from survival curves were pooled and analyzed using a random-effects model. Hazard ratio (HR) was calculated for sensitivity analysis. We included 12 non-randomized studies comprising 1,078 patients. 803 (74.5%) patients were treated with GTR alone and 275 (25.5%) patients received adjuvant RT. In 9 studies, RT included 3 D conformal RT, intensity modulated RT, or fractionated stereotactic radiotherapy); in 3 studies, stereotactic radiosurgery was also used. Median dose of RT was 59.4 Gy. Adjuvant RT resulted in an increase of 3.9 months for restricted mean PFS truncated at 5 years (95% CI 0.23–7.72;  p  = 0.037) and a 22% reduction in the hazard of disease progression or death (hazards ratio 0.78; 95% CI 0.46–1.33;  p  = 0.370). Restricted mean OS, truncated at 5 years, was improved with adjuvant RT by 1.1 months (95% CI 0.37–1.81;  p  = 0.003) and a 21% reduction in the hazard of death from any cause (HR 0.79; 95% CI 0.51–1.24;  p  = 0.310). Meta-regression analysis of the RMST of EBRT dose did not reveal any significant difference in PFS or OS between studies reporting median dose of &lt;59.4 Gy  vs . ≥ 59.4 Gy. Adjuvant RT following GTR in patients with AM improved restricted mean PFS and OS. While we await the results from ongoing randomized controlled trials, adjuvant RT should be recommended.

Should adjuvant radiotherapy be used in atypical meningioma (WHO grade 2) following gross total resection? A systematic review and Meta-analysis