The value of radiotherapy in patients with recurrent atypical meningioma: an update.

Introduction: Atypical meningiomas (WHO Grade 2) comprise approximately 18% of all meningiomas and may recur, despite surgical resection. Current evidence, derived from prospective cohort studies and retrospective series, supports the use of radiotherapy in achieving local control in atypical meningiomas. Given the lack of level 1 data, the role of RT in the management of recurrent disease in radiotherapy-naïve or previously irradiated patients remains a subject of ongoing debate, and optimal strategies are yet to be established.

Areas covered: This narrative review examines recent developments in radiotherapy techniques, including dose escalation and particle therapy, alongside advances in imaging and molecular profiling relevant to meningioma management. The authors summarize the existing evidence and provide an updated perspective on the evolving role and value of radiotherapy in treating recurrent atypical meningiomas. This article also proposes a new treatment algorithm. This review is based on a literature search using PubMed to identify relevant studies on recurrent atypical meningioma (WHO grade 2) up to August 2025. Key references from recent guidelines and high-impact studies were also included.

Expert opinion: The authors believe that treatment plans for recurrent atypical meningioma should consider prior radiotherapy exposure. The integration of PET-guided radiotherapy planning and molecular-based risk stratification will allow for personalized treatment plans, setting a framework for its future clinical management.