BACKGROUND: A variety of agents have been investigated with modest results in recurrent grade II and III ependymomas failing surgery and/or radiotherapy. Few data are available on the role of temozolomide (TMZ). We investigated patterns of response, outcome and correlations with MGMT promoter methylation in a cohort of patients with recurrent ependymomas of the adult receiving temozolomide as salvage therapy. METHODS: We retrospectively studied all patients aged ≥18 years with recurrent intracranial ependymoma, who received as part of their treatment standard temozolomide between 1999 and 2011. Clinical information were retrieved from the database and follow-up visits, while MRI images were reviewd by an investigator blind to patients' outcome. Response to TMZ on MRI was evaluated according to Macdonald Criteria. An analysis of MGMT gene promoter methylation by PCR was performed. RESULTS: We found 18 evaluable patients of whom 12 were males and 6 females, and 10 (56%) were of grade III and 8 (44%) of grade II. Tumor location at initial surgery was supratentorial in 11 (61%) patients and infratentorial in 7 (39%), and type of progression before TMZ was local in 10 (56%), local and spinal in 6 (33%) and spinal alone in 2 (11%). Median age was 42 years (18-61) and median KPS 70 (60-90). Previous treatments consisted of radiotherapy (either adjuvant or at relapse) in 17/18 (94%) patients, and chemotherapy (cisplatin + VP16, PCV, BCNU) in 6/18 (33%). A median of 8 cycles of TMZ (1-24) were administered. Best response to TMZ was as follows: CR 1/18 (5%) and PR 3/18 (17%), with an overall RR of 22%; SD 7/18 (39%) and PD 7/18 (39%). Maximum reponse in 3 out of 4 patients was observed after 10, 14 and 15 cycles, respectively. All 4 responding patients were chemotherapy-naive. Responses occurred in both anaplastic (2) and low grade (2) tumors. Median PFS was 9 months (1 month-13 years), while PFS 6 and 12 were 72% and 39%, respectively. Median OS was 31 months (3 months-14 years), and 4/18 (22%) patients are alive. MGMT analysis was available in 10 patients, of whom 6 were unmethylated and 4 methylated. There were no correlations between MGMT methylation and response to TMZ or survival. CONCLUSIONS: Temozolomide has activity in recurrent ependymomas, regardless of tumor grade. Responses are often delayed and prevail in chemo-naive patients. MGMT promoter methylation does not influence neither response nor survival. SECONDARY CATEGORY: n/a.