Radiation Necrosis from Stereotactic Radiosurgery—How Do We Mitigate?

Balamurugan A. Vellayappan, Tresa McGranahan, Jerome Graber, Lynne Taylor, Vyshak Venur, Richard Ellenbogen, Andrew E. Sloan, Kristin J. Redmond, Matthew Foote, Samuel T. Chao, John H. Suh, Eric L. Chang, Arjun Sahgal, Simon S. Lo

Research output: Contribution to journalReview articlepeer-review

Abstract

Intracranial stereotactic radiosurgery (SRS) is an effective and convenient treatment for many brain conditions. Data regarding safety come mostly from retrospective single institutional studies and a small number of prospective studies. Variations in target delineation, treatment delivery, imaging follow-up protocols and dose prescription limit the interpretation of this data. There has been much clinical focus on radiation necrosis (RN) in particular, as it is being increasingly recognized on follow-up imaging. Symptomatic RN may be treated with medical therapy (such as corticosteroids and bevacizumab) with surgical resection being reserved for refractory patients. Nevertheless, RN remains a challenging condition to manage, and therefore upfront patient selection for SRS remains critical to provide complication-free control. Mitigation strategies need to be considered in situations where the baseline risk of RN is expected to be high—such as large target volume or re-irradiation. These may involve reduction in the prescribed dose or hypofractionated stereotactic radiation therapy (HSRT). Recently published guidelines and international meta-analysis report the benefit of HSRT in larger lesions, without compromising control rates. However, careful attention to planning parameters and SRS techniques still need to be adhered, even with HSRT. In cases where the risk is deemed to be high despite mitigation, a combination approach of surgery with or without post-operative radiation should be considered.

Original languageEnglish (US)
Article number57
JournalCurrent treatment options in oncology
Volume22
Issue number7
DOIs
StatePublished - Jul 2021

Keywords

  • Brain metastases
  • Hypofractionated stereotactic radiotherapy
  • Mitigation strategies
  • Radiation necrosis
  • Stereotactic radiosurgery

ASJC Scopus subject areas

  • Oncology
  • Pharmacology (medical)

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