Radiation Necrosis Treatment & Management
- Author: Michael J Schneck, MD, MBA; more...
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.
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.
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. 
Hyperbaric oxygen can be provided in conjunction with anticoagulation.
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.
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