Abstract
<title>Abstract</title> <p>Background Pediatric intracranial ependymoma remains a therapeutically challenging central nervous system tumor in which long-term outcomes depend primarily on maximal safe resection and postoperative focal radiotherapy (RT). Thus, the survival benefit of adjuvant chemotherapy remains uncertain. However, no meta-analysis has directly pooled survival outcomes comparing adjuvant chemotherapy vs. radiotherapy alone in pediatric intracranial ependymoma after maximal safe resection. To compare overall survival, disease control, and recurrence between chemotherapy plus radiotherapy and RT alone in pediatric intracranial ependymoma. Methods A systematic search, according to PRISMA guidelines, across PubMed, Scopus, Web of Science, and EBSCO was conducted from inception to April 2026. Included criteria were children with newly diagnosed intracranial ependymoma treated after maximal safe resection with postoperative adjuvant chemotherapy with or without radiotherapy compared with postoperative radiotherapy alone. The primary outcome was overall survival (OS). Secondary outcomes included disease-control survival and recurrence. Approximate Kaplan–Meier reconstructions were generated from extracted survival probabilities. Results From 495 records identified, 10 studies were included, representing 654 patients. Compared with RT alone, chemotherapy-containing postoperative strategies were associated with poorer overall survival (HR 1.99, 95% CI 1.21–3.28). Exploratory recurrence analysis showed no statistically significant difference between groups (RR 1.18, 95% CI 0.86–1.60). Better disease-control survival was associated with radiotherapy alone (median disease-control survival: 78.0 months vs. 36.0 months for chemotherapy-containing strategies). Conclusions These findings support postoperative focal radiotherapy as the therapeutic backbone for pediatric intracranial ependymoma and underscore the need for biomarker-driven prospective studies to identify the limited scenarios in which systemic therapy may provide meaningful benefit.</p>