Salvage Repeat Gross Total Resection Followed by VMAT-Based Focal Reirradiation for Locally Recurrent Pediatric Supratentorial Ependymoma: A Case Report

Introduction/Background: Pediatric intracranial ependymomas are associated with a high risk of local recurrence despite maximal safe resection and postoperative radiotherapy. The role of reirradiation remains debated because of concerns regarding cumulative toxicity; however, modern conformal techniques allow focal retreatment in selected patients. Case Presentation: We report the case of a previously healthy girl diagnosed at 3 years and 7 months with a left frontoparietal supratentorial ependymoma. She underwent gross total resection (GTR) followed by adjuvant focal radiotherapy (59.4 Gy in 33 fractions). After nearly four years of disease control, she developed headaches and transient loss of consciousness. MRI showed an isolated local recurrence measuring 45 × 53 × 54 mm within the previous irradiation field, without neuraxial dissemination. A second GTR was achieved. Histopathological examination confirmed recurrent supratentorial ependymoma, not otherwise specified (NOS), with high-grade features including increased cellularity, focal necrosis, and elevated proliferative activity. Immunohistochemistry showed diffuse GFAP, S100, and vimentin expression with focal dot-like EMA positivity. Molecular classification was unavailable. Considering the localized recurrence, complete resection, prolonged disease-free interval, absence of dissemination, and preserved functional status, focal reirradiation was delivered using volumetric modulated arc therapy (VMAT) to 54 Gy in 30 fractions. Treatment was completed without interruption and was well tolerated, with no significant acute or late toxicity. At 19 months after reirradiation, the patient remained neurologically intact with sustained local control. Conclusions: Repeat GTR followed by VMAT-based focal reirradiation may represent an effective salvage approach for carefully selected children with recurrent supratentorial ependymoma.