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Curious if ROAM will impact anyone's practice here? G2 meningioma with GTR do you routinely offer adjuvant RT. If so, 54Gy/30# or 60Gy/30#? Thanks
Radiotherapy versus observation following surgical resection of WHO grade 2 atypical meningioma (ROAM/EORTC-1308)
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Honestly, I find the design of the trial flawed.
Showing that adjuvant RT will increase disease free survival by lowering recurrence rates of atypical meningioma was a no-brainer (haha, see what I did there?}.
The interesting part would have been, if adjuvant RT increases OS (apparently it doesn‘t) or prevent neurologic deterioration due to progression down the road, which salvage therapies cannot fix (not as well).
Regardless of that, it was a very ambitious project and very hard to accrue patients, from what I‘ve heard from colleagues who put patients on trial.
Based on the trial results, I think the majority of patients with GTR will opt to skip adjuvant RT.
Showing that adjuvant RT will increase disease free survival by lowering recurrence rates of atypical meningioma was a no-brainer (haha, see what I did there?}.
The interesting part would have been, if adjuvant RT increases OS (apparently it doesn‘t) or prevent neurologic deterioration due to progression down the road, which salvage therapies cannot fix (not as well).
Regardless of that, it was a very ambitious project and very hard to accrue patients, from what I‘ve heard from colleagues who put patients on trial.
Based on the trial results, I think the majority of patients with GTR will opt to skip adjuvant RT.
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The magnitude of local control benefit is smaller than I expected.
It’s still very positive at 15%/5 year, but you have to balance that out against RT toxicities. I think the significant toxicities are likely overestimated by seizures occuring in patients who already had seizure issues, but grade 2/3 unexpected toxicity is given at 8%. Of course you also have all the usual fatigue and alopecia.
I’ll be curious if the magnitude of benefit increases on long term follow-up, either from more local control gain or more toxicity from salvage therapies and recurrent disease.
Ultimately, it probably skews me more away from radiating after surgery. Many of these patients don’t make it to rad onc at my institution anyway, either due to lack of referral from neurosurgery or getting basically intercepted by neuro-oncology which I find strange since neuro-oncology has little to offer that works for meningioma.
It’s still very positive at 15%/5 year, but you have to balance that out against RT toxicities. I think the significant toxicities are likely overestimated by seizures occuring in patients who already had seizure issues, but grade 2/3 unexpected toxicity is given at 8%. Of course you also have all the usual fatigue and alopecia.
I’ll be curious if the magnitude of benefit increases on long term follow-up, either from more local control gain or more toxicity from salvage therapies and recurrent disease.
Ultimately, it probably skews me more away from radiating after surgery. Many of these patients don’t make it to rad onc at my institution anyway, either due to lack of referral from neurosurgery or getting basically intercepted by neuro-oncology which I find strange since neuro-oncology has little to offer that works for meningioma.
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Tell me about it. I have had neurooncologists argue with me about giving salvage Y90-DOTATOC treatment in patients who have not yet received EBRT.
I had to show them the data (or better said, the lack of data), in order to persuade them to go for EBRT first.
A 15% chance of reducing recurrence without an overall survival advantage is an important data point in terms of shared decision making with patients as to whether it's necessary or not.
This should not, on its own, determine whether a patient be offered RT or not in this scenario - the patient should be the one to make this decision.
F/U question for the forum - if a G2 meningioma after GTR and observation, will the NSGs re-resect? Or just send for 'definitive' RT?
This should not, on its own, determine whether a patient be offered RT or not in this scenario - the patient should be the one to make this decision.
F/U question for the forum - if a G2 meningioma after GTR and observation, will the NSGs re-resect? Or just send for 'definitive' RT?
Upfront meningioma diagnosis (NOT recurrence) that is G2 and GTR gets 54/30 as per RTOG. I understand this trial did 60/30 but that is unnecessary IMO and would likely not improve oncologic outcomes, and likely worsen toxicities.
The ones I see get re-resection then adjuvant RT
BN003 was 59.4 Gy/33 fractions, and I say was because it closed I believe yesterday since ROAM was published. It's mostly accrued, so I imagine we'll get those trial results eventually.
60/30 vs. 59.4/33 seems more or less equivalent. If ROAM had done 54/30, the criticism would probably have been that the control could have been better with a few more fractions.
Depends on resectibality and size. I've seen it go both ways. I advocate for re-resection given the better outcomes s/p GTR vs. STR for atypical meningioma, but I'm often in the position where I'm considering stereo or dose escalation for something unresected in that situation.
The two trends are
1. Using a molecular assay to determine risk and need for RT. There several competing ones.
2. Using dotatate PET to guide. I do use this. My problem is that I have seen too many equivocal or false positive scans, so it’s hard for me to use this as a hard cutoff. Sometimes it helps me make the decision about something equivocal on MRI, and sometimes it helps me find other meningioma s I may have missed. I always run it full body and it occasionally picks up something else intracranial or in the spine.
Thank you for bringing this up. Allow me to pick you brain.
I listened to a nice talk by Dr. Zadeh in last (?) year's ESMO, where she described this particular group of tumors with NF-2 mutations and high-aneuploidy, who seem to benefit very little from adjuvant RT.
Do you actually withhold RT in these groups, although they have a high recurrence risk, simply because (based on retrospective data) RT won't decrease risk of recurrence?
My 2 cents from community practice.
I have been offering adjuvant XRT to these patients with the caveat that we do not have a definitive answer. I have been using ~60 Gy in 30 Fx as these studies use a higher dose. I have seen a lot of radio necrosis in this patient population, sometimes quite severe. It has made me very hesitant to offer adjuvant XRT moving forward. I think the data will be good to have to guide these discussions and look forward to the BN003 study reporting results.
I have been offering adjuvant XRT to these patients with the caveat that we do not have a definitive answer. I have been using ~60 Gy in 30 Fx as these studies use a higher dose. I have seen a lot of radio necrosis in this patient population, sometimes quite severe. It has made me very hesitant to offer adjuvant XRT moving forward. I think the data will be good to have to guide these discussions and look forward to the BN003 study reporting results.
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Molecular classification to refine surgical and radiotherapeutic decision-making in meningioma - Nature Medicine
In a large, partially prospective cohort of patients with molecularly profiled and clinically annotated meningioma, the extent of surgical resection and radiotherapy (RT) response correlate with molecular classification, which can be used in a molecular model to predict clinical outcomes in...
www.nature.com
I have also found in practice (and heard from attendings in residency) that these meningioma patients have particularly bad problems with edema and necrosis after RT. Substantially worse tolerance than partial brain radiation to similar doses and much larger volumes. Is anyone aware of a hypothesis why this is?
i have no idea. I agree. It is worse than what i see in GBM patients...at similar time points. I am also pretty tight with my expansions/margins for meningioma cases
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