UNIVERSA MEDICINA
pISSN: 1907-3062 / eISSN: 2407-2230 Univ Med 2025.
44:318-327
DOI: https://doi.
org/10.
18051/UnivMed.
ORIGINAL ARTICLE
The survival benefits of adjuvant radiotherapy for malignant meningioma: a retrospective cohort study Yuriz Bakhtiar1* .
Fariz Eka Setiawan1 .
Rafi Ilmansyah1* .
Krisna Tsaniadi Prihastomo1 .
Dody Priambada1 .
Faiza Rizky Aryani Septarina2.
Muhamad Thohar Arifin1 , and Zainal Muttaqin1 Department of Neurosurgery.
Faculty of Medicine.
Universitas Diponegoro.
Dr.
Kariadi Hospital.
Semarang.
Indonesia Department of Anatomical Pathology.
Universitas Diponegoro.
Dr.
Kariadi Hospital.
Semarang.
Indonesia * Correspondence Author:
yuriz_b@fk.
Date of first submission.
June 2, 2025 Date of acceptance.
November 7, 2025 Date of publised.
November 27, 2025 Cite this article as: Bakhtiar Y.
Setiawan FE.
Ilmansyah R.
Prihastomo KT.
Priambada D.
Setarina FRA.
Arifin MT.
Muttaqin The survival benefits of adjuvant radiotherapy for malignant meningioma: a retrospective cohort study.
Univ Med
44:318-327
ABSTRACT
BACKGROUND
Malignant meningiomas (MM) are rare aggressive tumors associated with poor survival outcomes.
Due to their rarity, there is limited data on the outcomes and prognostic factors of MM patients, particularly on adjuvant radiotherapy roles in this tumor population.
This study aims to investigate the clinical characteristics, prognostic factors, and survival outcomes of MM with focus on survival benefits of adjuvant radiotherapy.
METHODS
This retrospective cohort study analyzed 19 MM patients, who were initially subjected to postoperative radiotherapy, at Dr.
Kariadi General Hospital.
Semarang, from 2013 to 2023.
Kaplan-Meier analysis was used to estimate survival rates at 1, 2, and 5 years.
Univariate and multivariate Cox regression analyses were performed to identify factors associated with overall survival (OS).
Variables with a p-value O0.
25 in univariate analysis were included in the multivariate models.
RESULTS
The median OS was 16 months .
% CI 0.
0Ae40.
, with estimated 1-year, 2-year, and 5-year survival rates of 6%, 42.
1%, and 15.
8%, respectively.
Adjuvant radiotherapy (RDT) was associated with a significantly improved OS .
<0.
However, sex, age, tumor location, and extent of resection did not show a significant association with OS.
Cox regression showed that RDT had no statistically significant effect on OS in the multivariate model (HR=0, 95% CI 0Ae1.
8, p=0.
CONCLUSION
Adjuvant radiotherapy is critical for improving OS in MM patients, and gross-total resection (GTR) alone does not guarantee better long-term outcomes.
Further studies with larger cohorts and molecular analysis are necessary to refine treatment strategies for MM.
Keyword: Adjuvant radiotherapy, malignant meningioma, prognostic factor, survival outcome Copyright@Author.
- https://univmed.
org/ejurnal/index.
php/medicina/article/view/1761 Malignant meningioma in Indonesia
INTRODUCTION
Meningiomas commonly arise from mesodermal arachnoid cells of the dura.
Meningiomas are more frequently found in the central nervous system (CNS) compared to other malignancies, and constitute 36% of all CNS meningiomas (MM) are considered uncommon and aggressive tumors.
Malignant meningiomas represent only 1Ae3% of all meningiomas and are correlated with poor survival outcomes.
It is mentioned that 80% of MM recur 5 years after complete resection.
Men are more commonly afflicted by MM rather than woman.
In addition, the 5Aeyear survival rates of MM are reported to be around 28Ae61%.
In contrast, low-grade meningiomas are more frequently found in women and have more favorable survival outcomes.
The study by Seo et al.
showed that in the US the five-year survival rate of anaplastic meningioma patients was 41.
In Asia.
Seo et .
reported a similar five-year survival rate of Advanced age, high comorbidity scores, subtotal resection (STR), and lack of adjuvant therapy are factors linked to increased morbidity in patients.
There have been a number of inconsistent results regarding prognostic variables for patients with MM.
Grade I and II meningiomas have shown promising outcomes with surgical However.
MM have shown suboptimal results with surgical intervention alone.
Previous studies found a significant correlation between complete resection after surgery and improved patient survival outcomes.
However.
Sughrue et al.
mentioned that there are no improved survival outcomes for anaplastic meningioma patients who underwent gross total resection (GTR).
Previous literature has agreed that radiotherapy is a substantial positive predictive factor of overall survival (OS) in patients with MM, independent of previous resection treatment results.
Due to the rarity of MM, there is a paucity of research in its prognostic Most of the available data on MM place the emphasis more on the treatment implication of surgery in patients with MM.
,6,.
A retrospective study involving 102 patients with atypical or malignant meningiomas who underwent microsurgical resection found that total resection of atypical and malignant meningiomas provided better outcomes and local control.
Adjuvant radiation therapy is indicated for patients with MM with incompletely excised or with tumors in the parasagittal or posterior fossa area.
Another study involving 275 adult patients with histologically confirmed MM showed that surgical resection is recommended for elderly patients with MM in the absence of surgical contraindications, but gross total resection (GTR) does not present survival benefit in the elderly patients compared with subtotal resection (STR).
Currently, there is a lack of data on the outcomes of various treatment strategies for MM Further information regarding patient characteristics and outcomes is necessary to better guide management decisions for these patients.
this study, we aimed to investigate the prognostics factors related to the survival of MM patients, with particular focus on the use of adjuvant radiotherapy in treatment, accompanied by longterm follow-up.
METHODS
Research design This was a retrospective cohort study of MM patients located in Dr.
Kariadi General Hospital.
Semarang from 2013 to 2023.
Research subjects A total of 23 patients were diagnosed with MM based on histopathological findings after surgical resection.
The data were retrieved from a prospectively maintained local brain tumor Included patients were selected based on several criteria: .
patients diagnosed with WHO grade i MM based on histopathological .
surgery performed in Kariadi Hospital.
complete pre- and postoperative radiological data.
Patients who died before the 30day follow-up period and patients with intracranial metastases that originated from spinal meningioma were excluded from the study.
Data collection Baseline characteristics of patients were recorded such as age at diagnosis, sex, weight, height, clinical manifestations, previous history of chemotherapy, previous history of neurosurgical radio-intervention, chemotherapy, post-operative post-operative histopathology diagnosis and post-surgery treatment or follow-up.
Bakhtiar Y.
Setiawan FE.
Ilmansyah R, et al Radiologic data of those diagnosed with primary MM were evaluated based on the following criteria: tumor location .
eep vs superficia.
, peritumoral edema .
ild vs sever.
, and shape .
ounded vs AumushroomAy-shape.
Tumors located in convexity or parasagittal locations were considered AusuperficialAy.
Opposite to that, falcine, intraventricular, and skull baseAe located tumors were considered AudeepAy.
Tumor size was defined as the greatest tumor diameter measured by radiological examination.
Edema index (EI) was defined as greatest area of tumor edema in comparison to tumor size.
Patients were grouped into two subgroups based on an EI cutoff EI < 0.
5 was considered Auno edema to mild edemaAy and EI Ou 0.
5 was considered Aumoderate to severe edema.
Ay.
Tumor shape was assessed by CT scan or MRI, and AumushroomAy-shaped tumors were defined if there was prominent pannus from globoid portions of the tumor spreading over the cerebral surface.
Postoperative computed tomography (CT) or magnetic resonance imaging (MRI), along with the surgical record, were used to determine the extent of resection, which was defined by the Simpson grading system.
Grades 1 and 2 were considered as gross-total resection (GTR) and grades 3Ae5 as subtotal resection (STR).
In our study, only one patient received preoperative chemotherapy with doxorubicin The chemotherapy was done in the previous hospital, before the patient was referred to our institution (Dr.
Kariadi General Hospita.
for further treatment.
In Dr.
Kariadi General Hospital, all patients were subjected to postoperative adjuvant radiotherapy to ensure that the tumors diminished All patients were subjected equally, unless the patients refused the treatment or had major adverse events that prevented treatment Ethical clearance The Dr.
Kariadi General Hospital Institutional Review Board (IRB) has approved this study under number 167/EC/KEPKRSDK/2024.
Statistical analysis The primary outcome of this study was overall survival (OS), which we defined as the interval from the surgical procedure to the time of We categorized continuous variables, such as age and tumor size, into two groups using the median as a cutoff point.
Differences in baseline data were evaluated using either independent ttests or Mann-Whitney U tests for continuous variables, and chi-square tests or Fisher's exact tests for categorical variables.
Both univariate and multivariate Cox regression analyses were Variables that showed a statistically significant relationship with OS .
=0.
in the univariate analysis were included in the multivariate Cox regression model.
Kaplan-Meier analysis was used to generate survival curves, and the log-rank test was applied to compare these curves between different groups.
For patients who were still living at the last follow-up, their data were censored.
Statistical Package for the Social Sciences (SPSS) version 26 (IBM.
USA) and R software .
ncluding the survival, survminer, readxl, and ggsurvplot package.
[R Foundation for Statistical Computing.
Vienna.
Austri.
were used to perform all data analysis throughout the Statistical significance was determined at a p-value of <0.
RESULTS
Participant baseline data The baseline characteristics of the study subjects indicate several trends between the surgery and surgery radiotherapy groups.
Both groups had similar ages .
6 years for the surgery group and 39.
5 years for the surgery radiotherapy group.
p=1.
The surgery radiotherapy group had a higher but statistically non-significant proportion of males .
% vs.
25%) .
=0.
and a greater incidence of superficial tumors .
7% vs.
p=0.
Notably, this group also exhibited more moderate to severe edema .
% vs.
p=0.
In terms of tumor shape, the surgery group had more round tumors .
% vs.
p = 0.
Diagnosis types were similar, with the surgery radiotherapy group having a slightly higher percentage of primary diagnoses .
6% vs.
p=1.
Simpson grades and subtype pathology showed no significant differences, with the surgery group having a higher proportion of WHO grade i, anaplastic meningiomas .
3% vs.
p=0.
From 23 successfully extracted patientsAo medical records, 19 patients were included in this study.
One patient was excluded for not meeting the 2016 WHO criteria for MM, one for missing clinical and radiological data, and two patients for having a follow-up period of less than 1 month (Table .
Malignant meningioma in Indonesia Table 1.
Baseline characteristics of study subjects .
Variables Age .
Sex Male Female Tumor location Superficial Deep Tumor size .
< 55 mm Ou 55 mm Edema index No edemaAemild ModerateAesevere Tumor shape Round Mushroom Diagnosis type Primary Secondary Preoperative chemotherapy Yes Simpson grade 1Ae2 3Ae5 Subtype of pathology Grade i papillary Grade i rhabdoid Grade i anaplastic Surgery .
= .
63 A 19.
Surgery Radiotherapy .
= .
45 A 13.
88 A 16.
18 A 16.
p-value Note : Data presented as n (%), except age and tumor size as mean A SD.
AIndependent T-test.
AFisher-Exact test PatientsAo treatment outcomes Postoperatively.
GTR was achieved in 16 patients .
2%).
Simpson grade 1Ae2 was achieved in 16 patients .
2%), while 3 patients .
8%) achieved Simpson grade 3Ae4.
There were no patients with Simpson grade 5 in this cohort.
After tumor removal of confirmed WHO grade 3 meningioma, 12 patients .
2%) underwent adjuvant external beam radiotherapy, and only one patient received adjuvant chemotherapy using doxorubicin regimen (Supplementary Material.
Table S.
In general, adjuvant radiotherapy is however, there were eight patients who did not receive or finish radiotherapy due to COVID-19 mobility restrictions and the considerable distance they needed to travel to reach the hospital.
All patients were irradiated in our institution (Dr.
Kariadi General Hospita.
Adjuvant radiotherapy was started 1 month after surgery.
All patients were treated with intensity-modulated radiotherapy (Varian.
California.
USA).
Patients received single doses of 1.
8Ae2 Gy up to a total dose of 54Ae60 Gy.
Three patients stopped radiotherapy because of nonrelated illnesses.
The patientsAo treatment index could not be retrieved from the medical records because these patients were treated before the electronic medical records era in our institution.
Complete information regarding individual patientsAo treatment may be found in supplementary Table S1.
Analysis of survival During the follow-up, sixteen patients .
2%) did not complete the observation period.
The median overall survival (OS) was 16 months .
% confidence interval [CI] 0.
0Ae40.
The estimated OS probabilities at 1, 2, and 5 years were 52.
6% .
% CI 40.
1Ae65.
1% .
% CI 30.
5Ae55.
, and 15.
8% .
% CI
2Ae30.
, respectively (Fig.
1A).
Patients treated with adjuvant radiotherapy (RDT) demonstrated a Bakhtiar Y.
Setiawan FE.
Ilmansyah R, et al significant increase in survival relative to nonRDT patients .
<0.
(Fig.
1B).
However, this study did not find a significantly longer OS based on sex .
azard ratio [HR] 2.
01, 95% CI 0.
74Ae5.
p=0.
, a greater extent of resection (HR 0.
95% CI 0.
26Ae3.
p=0.
, or age (HR 1.
95% CI 0.
41Ae3.
p=0.
(Figs.
1CAeE) Following univariate Cox regression analyses, we included all variables with a p-value less than 0.
2 in the multivariate models .
resented in Table .
However, the results of the multivariate Cox regression analysis indicated that none of the examined factors, including sex (HR 85, 95% CI 0.
2Ae3.
0, p=0.
, tumor location (HR 2.
7, 95% CI 0.
9Ae8.
6, p=0.
, and adjuvant radiotherapy (HR 0, 95% CI 0Ae1.
8, p=0.
, had a statistically significant impact on OS (Table .
Supplementary Table S1.
Detailed information on anaplastic meningioma patientsAo surgical and adjuvant radiotherapy intervention Sex
Age
Diagnosis Type
Location Extent of Adjuvant
Chemotherapy Status
Primary Olfactory Groove GTR
RDT
Death
Primary Convexity GTR
Death
Primary Tuberculum
Sellae GTR
RDT
Death
Primary Tentorial STR
RDT
Death
Primary Convexity GTR
RDT
Alive
Primary Parasagittal GTR
RDT
Death
Primary Convexity GTR
Death
Primary Convexity STR
RDT
Death
Primary Convexity GTR
RDT
Death
Primary Convexity GTR
Death
Primary Petro-clival STR
Death
Primary Sphenoorbital GTR
Death
Primary Primary Primary Sphenoid
Planum
Sphenoid
Not RDT
Not RDT
GTR
Death
GTR
RDT
Death
Parasagittal GTR
RDT
Alive
Primary Sphenoid
GTR
Not RDT
Death
Primary Convexity GTR
RDT
Doxorubicin
Death
Primary Parasagittal GTR
RDT
Alive Primary Parasagittal GTR Death Malignant meningioma in Indonesia Figure 1.
A: OS curve for patients diagnosed with malignant meningioma.
B: Differences in OS for patients who received adjuvant radiotherapy versus those who did not.
C: Differences in OS for males versus females.
Differences in OS for patients aged < 43 versus Ou 43 years.
E: Differences in OS between patients receiving STR versus GTR.
Shaded areas in the survival curves represent 95% confidence intervals.
RDT = adjuvant GTR = gross total resection.
STR = subtotal resection.
DISCUSSION