Ependymomas are the most common intramedullary
tumors in adults. While gross total resection is the aim of surgery,
tumor infiltration might limit resection. In cases of subtotal removal, the necessary adjuvant management remains unclear. The aim of our study was to assess the need for
adjuvant radiotherapy after an incomplete resection of grade II intramedullary
ependymomas (IME-II). We retrospectively reviewed all cases of IME-II operated upon at a single tertiary neurosurgical center from 2009 to 2018. Patients with anaplastic or
myxopapillary ependymomas, and patients with a follow-up of less than three years, were excluded. We included 46 patients: 19 (41.3%) had a gross total resection; 21 (45.7%) had a subtotal resection; and 6 (13%) had a partial resection. None of the patients underwent
adjuvant radiotherapy. Over a median follow-up of 79 months (range = 36-186), seven patients presented a radiological
tumor progression with a mean delay of 50.9 months (range = 18-85), of which two were symptomatic (4.3%). Progression-free survival (PFS) was 90.1% at 5 years and 76.8%
at 10 years. The extent of the resection was the only significant risk factor for secondary
tumor progression (p = 0.012). Four of the seven patients with recurring IME-II were treated: three patients had a second surgery, leading to two GTR and one STR, followed by
radiotherapy in one case, and one patient underwent
radiotherapy alone. In this study, the rate of symptomatic progression and
retreatment after incomplete resection of IME-II without
adjuvant radiotherapy was low, suggesting a conservative approach in such cases.