Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Radiation Necrosis Treatment & Management

  • Author: Michael J Schneck, MD, MBA; more...
 
Updated: Nov 18, 2015
 

Medical Care

Probably the most important factor in providing good care is the clinician's confidence of diagnosis. Exposing a patient with radiation necrosis to unwarranted antineoplastic treatment is not desirable.

A conservative option in treating a patient with radiation necrosis is observation. This may be appropriate for a patient found to have an asymptomatic necrotic mass on follow-up MRI. If the patient is asymptomatic and definitive diagnosis of radiation necrosis or recurrent glioma does not make a difference in clinical management, the patient should be monitored clinically and with serial MRI scans.

For patients with signs and symptoms of mass effect, increased intracranial pressure, or neurologic disability, consider other treatment options. Consider surgical evaluation, steroids, anticoagulation, or hyperbaric oxygen therapy separately or in combination.[20, 21]

A study of 14 patients with radiographic or biopsy proof of central nervous system radiation necrosis and progressive neurologic symptoms or signs responded to bevacizumab with decreases in T(2)-weighted fluid-attenuated inversion recovery and T(1)-weighted gadolinium-enhanced volumes and a decrease in endothelial transfer constant. This trial provided class I evidence of the efficacy of bevacizumab as a treatment for CNS radiation necrosis.[22]

In another study of the efficacy of bevacizumab, researchers reviewed 14 lesions in 11 patients treated with bevacizumab for brain RN secondary to SRS for their brain metastases. The mean percentage decrease in RN volume seen on T1 post-Gadolinium and fluid-attenuated inversion recovery (FLAIR) MRI at first follow-up, at a mean of 26 days (range, 15-43 days), was 64.4% and 64.3%, respectively.[23]

Hyperbaric oxygen promotes perfusion and angiogenesis.

  • Oxygen is delivered at 20-24 atm for 20-30 sessions. Each session lasts approximately 90-120 minutes.
  • Hyperbaric oxygen therapy is expensive, time-consuming, and not readily available at most medical centers.
  • Efficacy is not well documented.
  • Small case studies exist, but many of these patients also were receiving concomitant steroid therapy. These clinical series showed resolution of a lesion on MRI. [20]
  • Hyperbaric oxygen can be provided in conjunction with anticoagulation.
Next

Surgical Care

In addition to providing potential histologic diagnosis, surgery has other therapeutic benefits. Surgical debulking of the lesion can relieve increased intracranial pressure and improve disability. Patients with obstructive hydrocephalus may require a shunting procedure. Surgery, however, is associated with a high risk of complications or neurologic deficit and should be reserved for symptomatic patients in whom medical therapy fails.

Previous
 
 
Contributor Information and Disclosures
Author

Michael J Schneck, MD, MBA Vice Chair and Professor, Departments of Neurology and Neurosurgery, Loyola University, Chicago Stritch School of Medicine; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center

Michael J Schneck, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, Stroke Council of the American Heart Association, Neurocritical Care Society

Disclosure: Received honoraria from Boehringer-Ingelheim for speaking and teaching; Received honoraria from Sanofi/BMS for speaking and teaching; Received honoraria from Pfizer for speaking and teaching; Received honoraria from UCB Pharma for speaking and teaching; Received consulting fee from Talecris for other; Received grant/research funds from NMT Medical for independent contractor; Received grant/research funds from NIH for independent contractor; Received grant/research funds from Sanofi for independe.

Coauthor(s)

Anna Janss, MD, PhD Associate Professor of Pediatric Neuro-oncology, Emory University School of Medicine; Consulting Neuro-oncologist, Children's Healthcare of Atlanta

Anna Janss, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Association for Cancer Research, American Medical Association, International Association for the Study of Pain, Pennsylvania Medical Society, Society for Neuroscience, Children's Oncology Group, Society for Neuro-Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Frederick M Vincent, Sr, MD Clinical Professor, Department of Neurology and Ophthalmology, Michigan State University Colleges of Human and Osteopathic Medicine

Frederick M Vincent, Sr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners Institute, American College of Legal Medicine, American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Robert Wilson, MD to the development and writing of this article.

References
  1. Lai R, Abrey LE, Rosenblum MK, DeAngelis LM. Treatment-induced leukoencephalopathy in primary CNS lymphoma: a clinical and autopsy study. Neurology. 2004 Feb 10. 62(3):451-6. [Medline].

  2. Liu AK, Macy ME, Foreman NK. Bevacizumab as therapy for radiation necrosis in four children with pontine gliomas. Int J Radiat Oncol Biol Phys. 2009 Nov 15. 75(4):1148-54. [Medline].

  3. Barajas RF Jr, Chang JS, Segal MR, Parsa AT, McDermott MW, Berger MS, et al. Differentiation of recurrent glioblastoma multiforme from radiation necrosis after external beam radiation therapy with dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging. Radiology. 2009 Nov. 253(2):486-96. [Medline]. [Full Text].

  4. Levin VA, Bidaut L, Hou P, et al. Randomized double-blind placebo-controlled trial of bevacizumab therapy for radiation necrosis of the central nervous system. Int J Radiat Oncol Biol Phys. 2011 Apr 1. 79(5):1487-95. [Medline]. [Full Text].

  5. Plimpton SR, Stence N, Hemenway M, Hankinson TC, Foreman N, Liu AK. Cerebral Radiation Necrosis in Pediatric Patients. Pediatr Hematol Oncol. 2013 May 7. [Medline].

  6. Kureshi SA, Hofman FM, Schneider JH, Chin LS, Apuzzo ML, Hinton DR. Cytokine expression in radiation-induced delayed cerebral injury. Neurosurgery. 1994 Nov. 35(5):822-9; discussion 829-30. [Medline].

  7. Langleben DD, Segall GM. PET in differentiation of recurrent brain tumor from radiation injury. J Nucl Med. 2000 Nov. 41(11):1861-7. [Medline].

  8. Cheng KM, Chan CM, Fu YT, Ho LC, Cheung FC, Law CK. Acute hemorrhage in late radiation necrosis of the temporal lobe: report of five cases and review of the literature. J Neurooncol. 2001 Jan. 51(2):143-50. [Medline].

  9. Ruben JD, Dally M, Bailey M, Smith R, McLean CA, Fedele P. Cerebral radiation necrosis: incidence, outcomes, and risk factors with emphasis on radiation parameters and chemotherapy. Int J Radiat Oncol Biol Phys. 2006 Jun 1. 65(2):499-508. [Medline].

  10. Shah R, Vattoth S, Jacob R, Manzil FF, O'Malley JP, Borghei P, et al. Radiation necrosis in the brain: imaging features and differentiation from tumor recurrence. Radiographics. 2012 Sep-Oct. 32(5):1343-59. [Medline].

  11. Asao C, Korogi Y, Kitajima M, et al. Diffusion-weighted imaging of radiation-induced brain injury for differentiation from tumor recurrence. AJNR Am J Neuroradiol. 2005 Jun-Jul. 26(6):1455-60. [Medline].

  12. Dequesada IM, Quisling RG, Yachnis A, Friedman WA. Can standard magnetic resonance imaging reliably distinguish recurrent tumor from radiation necrosis after radiosurgery for brain metastases? A radiographic-pathological study. Neurosurgery. 2008 Nov. 63(5):898-903; discussion 904. [Medline].

  13. Reddy K, Westerly D, Chen C. MRI patterns of T1 enhancing radiation necrosis versus tumour recurrence in high-grade gliomas. J Med Imaging Radiat Oncol. 2013 Jun. 57(3):349-55. [Medline].

  14. Miyashita M, Miyatake S, Imahori Y, Yokoyama K, Kawabata S, Kajimoto Y, et al. Evaluation of fluoride-labeled boronophenylalanine-PET imaging for the study of radiation effects in patients with glioblastomas. J Neurooncol. 2008 Sep. 89(2):239-46. [Medline].

  15. Xiangsong Z, Weian C. Differentiation of recurrent astrocytoma from radiation necrosis: a pilot study with 13N-NH3 PET. J Neurooncol. 2007 May. 82(3):305-11. [Medline].

  16. Mogard J, Kihlstrom L, Ericson K, Karlsson B, Guo WY, Stone-Elander S. Recurrent tumor vs radiation effects after gamma knife radiosurgery of intracerebral metastases: diagnosis with PET-FDG. J Comput Assist Tomogr. 1994 Mar-Apr. 18(2):177-81. [Medline].

  17. Kahn D, Follett KA, Bushnell DL, et al. Diagnosis of recurrent brain tumor: value of 201Tl SPECT vs 18F-fluorodeoxyglucose PET. AJR Am J Roentgenol. 1994 Dec. 163(6):1459-65. [Medline].

  18. Chung JK, Kim YK, Kim SK, et al. Usefulness of 11C-methionine PET in the evaluation of brain lesions that are hypo- or isometabolic on 18F-FDG PET. Eur J Nucl Med Mol Imaging. 2002 Feb. 29(2):176-82. [Medline].

  19. Rock JP, Hearshen D, Scarpace L, et al. Correlations between magnetic resonance spectroscopy and image-guided histopathology, with special attention to radiation necrosis. Neurosurgery. 2002 Oct. 51(4):912-9; discussion 919-20. [Medline].

  20. Chuba PJ, Aronin P, Bhambhani K, et al. Hyperbaric oxygen therapy for radiation-induced brain injury in children. Cancer. 1997 Nov 15. 80(10):2005-12. [Medline].

  21. Ashamalla HL, Thom SR, Goldwein JW. Hyperbaric oxygen therapy for the treatment of radiation-induced sequelae in children. The University of Pennsylvania experience. Cancer. 1996 Jun 1. 77(11):2407-12. [Medline].

  22. Levin VA, Bidaut L, Hou P, Kumar AJ, Wefel JS, Bekele BN, et al. Randomized double-blind placebo-controlled trial of bevacizumab therapy for radiation necrosis of the central nervous system. Int J Radiat Oncol Biol Phys. 2011 Apr 1. 79 (5):1487-95. [Medline].

  23. Boothe D, Young R, Yamada Y, Prager A, Chan T, Beal K. Bevacizumab as a treatment for radiation necrosis of brain metastases post stereotactic radiosurgery. Neuro Oncol. 2013 Sep. 15 (9):1257-63. [Medline].

  24. Glantz MJ, Burger PC, Friedman AH, Radtke RA, Massey EW, Schold SC Jr. Treatment of radiation-induced nervous system injury with heparin and warfarin. Neurology. 1994 Nov. 44(11):2020-7. [Medline].

  25. Wong ET, Huberman M, Lu XQ, Mahadevan A. Bevacizumab reverses cerebral radiation necrosis. J Clin Oncol. 2008 Dec 1. 26(34):5649-50. [Medline].

  26. Gonzalez J, Kumar AJ, Conrad CA, Levin VA. Effect of bevacizumab on radiation necrosis of the brain. Int J Radiat Oncol Biol Phys. 2007 Feb 1. 67(2):323-6. [Medline].

  27. Buchpiguel CA, Alavi JB, Alavi A, Kenyon LC. PET versus SPECT in distinguishing radiation necrosis from tumor recurrence in the brain. J Nucl Med. 1995 Jan. 36(1):159-64. [Medline].

  28. Cerghet M, Redman B, Junck L, Forman J, Rogers LR. Prolonged survival after multifocal brain radiation necrosis associated with whole brain radiation for brain metastases: case report. J Neurooncol. 2008 Oct. 90(1):85-8. [Medline].

  29. Chen W. Clinical applications of PET in brain tumors. J Nucl Med. 2007 Sep. 48(9):1468-81. [Medline].

  30. de Vries B, Taphoorn MJ, van Isselt JW, Terhaard CH, Jansen GH, Elsenburg PH. Bilateral temporal lobe necrosis after radiotherapy: confounding SPECT results. Neurology. 1998 Oct. 51(4):1183-4. [Medline].

  31. Deshmukh A, Scott JA, Palmer EL, Hochberg FH, Gruber M, Fischman AJ. Impact of fluorodeoxyglucose positron emission tomography on the clinical management of patients with glioma. Clin Nucl Med. 1996 Sep. 21(9):720-5. [Medline].

  32. Ishikawa M, Kikuchi H, Miyatake S, Oda Y, Yonekura Y, Nishizawa S. Glucose consumption in recurrent gliomas. Neurosurgery. 1993 Jul. 33(1):28-33. [Medline].

  33. Kumar AJ, Leeds NE, Fuller GN, et al. Malignant gliomas: MR imaging spectrum of radiation therapy- and chemotherapy-induced necrosis of the brain after treatment. Radiology. 2000 Nov. 217(2):377-84. [Medline].

  34. Lee AW, Foo W, Chappell R, et al. Effect of time, dose, and fractionation on temporal lobe necrosis following radiotherapy for nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 1998 Jan 1. 40(1):35-42. [Medline].

  35. McPherson CM, Warnick RE. Results of contemporary surgical management of radiation necrosis using frameless stereotaxis and intraoperative magnetic resonance imaging. J Neurooncol. 2004 May. 68(1):41-7. [Medline].

  36. Nelson MD Jr, Soni D, Baram TZ. Necrosis in pontine gliomas: radiation induced or natural history?. Radiology. 1994 Apr. 191(1):279-82. [Medline].

  37. Nelson SJ, Huhn S, Vigneron DB, et al. Volume MRI and MRSI techniques for the quantitation of treatment response in brain tumors: presentation of a detailed case study. J Magn Reson Imaging. 1997 Nov-Dec. 7(6):1146-52. [Medline].

  38. Olivero WC, Dulebohn SC, Lister JR. The use of PET in evaluating patients with primary brain tumours: is it useful?. J Neurol Neurosurg Psychiatry. 1995 Feb. 58(2):250-2. [Medline].

  39. Omuro AM, Leite CC, Mokhtari K, Delattre JY. Pitfalls in the diagnosis of brain tumours. Lancet Neurol. 2006 Nov. 5(11):937-48. [Medline].

  40. Packer RJ, Zimmerman RA, Kaplan A, et al. Early cystic/necrotic changes after hyperfractionated radiation therapy in children with brain stem gliomas. Data from the Childrens Cancer Group. Cancer. 1993 Apr 15. 71(8):2666-74. [Medline].

  41. Peterson K, Clark HB, Hall WA, Truwit CL. Multifocal enhancing magnetic resonance imaging lesions following cranial irradiation. Ann Neurol. 1995 Aug. 38(2):237-44. [Medline].

  42. Posner JB. Side effects of radiation therapy. Neurologic Complications of Cancer. No. 54. Philadelphia, Pa: FA Davis; 1995. 311-37.

  43. Rizzoli HV, Pagnanelli DM. Treatment of delayed radiation necrosis of the brain. A clinical observation. J Neurosurg. 1984 Mar. 60(3):589-94. [Medline].

  44. Slizofski WJ, Krishna L, Katsetos CD, et al. Thallium imaging for brain tumors with results measured by a semiquantitative index and correlated with histopathology. Cancer. 1994 Dec 15. 74(12):3190-7. [Medline].

 
Previous
Next
 
MRI of a patient with symptoms of gait unsteadiness 1 year after being diagnosed with a posterior fossa primitive neuroectodermal tumor (PNET). Treatment during the 1-year interval prior to this MRI consisted of surgical resection, craniospinal radiation of 2340 cGy, boost dose given to the posterior fossa for a total of 5500 cGy, chemotherapy (vincristine, cis-platinum, and cyclohexylchloroethylnitrosurea [CCNU]), and dexamethasone therapy.
Positron emission tomography with [18F]-labeled fluorodeoxyglucose (PET-FDG) performed following the MRI of a patient with symptoms of gait unsteadiness 1 year after being diagnosed with a posterior fossa primitive neuroectodermal tumor (PNET). Treatment during the 1-year interval prior to these studies consisted of surgical resection, craniospinal radiation of 2340 cGy, boost dose given to the posterior fossa for a total of 5500 cGy, chemotherapy (vincristine, cis-platinum, and cyclohexylchloroethylnitrosurea [CCNU]), and dexamethasone therapy. PET-FDG demonstrates hypometabolism consistent with probable radiation necrosis. Four years later, the patient is stable and without evidence of tumor progression.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.