Evolving treatment strategies in meningioma: from traditional approaches to emerging therapies

Meningiomas are the second most prevalent adult central nervous system neoplasm, developing from arachnoid cap cells. While most are benign (WHO Grade I), atypical (Grade II), and anaplastic (Grade III), meningiomas portray aggressive behavior, higher relapse rates, and resistance to standard treatments.

To study the progression of treatment strategies for meningiomas, underscoring emerging treatments and challenges, especially in recurrent and high-grade subtypes.

A narrative review was conducted, identifying studies from the PubMed, Scopus, and Google Scholar databases (2000-2025). Keywords included "meningioma," "surgery," "radiotherapy," "targeted therapy," "immunotherapy," and "PRRT." Included studies addressed conventional or novel treatments for meningiomas.

Surgical resection continues as the gold standard, with the extent of removal impacting recurrence. Radiotherapy, comprising fractionated and stereotactic techniques, plays a vital role when surgery is incomplete or not possible. Chemotherapy demonstrates limited benefit. Advances in molecular profiling have shown genetic drivers (e.g., NF2, TRAF7, AKT1) and hormonal receptors as clinical targets. Emerging options include mTOR inhibitors (everolimus), anti-angiogenic agents (bevacizumab), PD-1/PD-L1 inhibitors (pembrolizumab), and peptide receptor radionuclide therapy (PRRT). Drug delivery treatments like convection-improved delivery show promise in improving CNS penetration. Nonetheless, resistance mechanisms, the absence of validated biomarkers, and insufficient trial data pose significant challenges.

Management of severe aggressive meningiomas is evolving with novel molecular and immunotherapeutic strategies. A multidisciplinary treatment strategy combining surgery, radiation, and targeted therapies, facilitated by further clinical trials and biomarker research, is necessary to enhance patient outcomes.