Radiotherapy for Meningiomas: Molecular, Imaging, and Therapeutic Advances

Purpose of review: Treatment of meningioma is rapidly evolving, as molecular classification, functional imaging, and radiotherapeutic techniques have undergone recent advances. The purpose of this review is to integrate these developments with clinical trial data to guide modern radiotherapy approaches. We specifically sought to address how new biological and imaging insights inform radiation planning, dose, and outcomes. Recent findings: Molecular classification provides prognostic insights beyond the classic WHO grading system. DOTATATE-PET has proven valuable for accurate delineation of tumor extent and biologically active regions, directly impacting radiotherapy planning. Recent clinical studies highlight the potential for improved local control with dose escalation and PET-guided planning. Ongoing clinical trials in the intact and salvage settings will provide further insight into the integration of imaging, biology, and radiotherapy. Summary: Radiotherapy for meningiomas is transitioning into a precision discipline, leveraging molecular and imaging biomarkers for individualized care. Integration of DOTATATE-PET, advanced radiation delivery techniques, and biologically guided dose escalation are redefining standards. Future research will test whether personalized, biomarker-driven radiotherapy can significantly improve outcomes in aggressive and recurrent meningiomas.