Radiation Necrosis Following the Radiosurgical Treatment of Brain Metastases

Abstract Many publications report laser-interstitial thermal therapy (LITT) as a viable alternative treatment to craniotomy for radiation necrosis (RN) and re-growing tumor occurring after stereotactic radiosurgery (SRS) for brain metastases. No studies to-date have compared the two options. The aim of this study was to retrospectively compare outcomes after LITT versus craniotomy for regrowing lesions in patients previously treated with SRS for brain metastases. Data were collected from a single-institution chart review of patients treated with LITT or craniotomy for previously irradiated brain metastasis. Of 75 patients, 42 had recurrent tumor (56%) and 33 (44%) had RN. Of patients with tumor, 26 underwent craniotomy and 16 LITT. For RN, 15 had craniotomy and 18 LITT. There was no significant difference between LITT and craniotomy in ability to taper off steroids or neurological outcomes. Progression-free survival (PFS) and overall survival (OS) were similar for LITT versus craniotomy, respectively: %PFS-survival at 1-year = 72.2% versus 61.1%, %PFS-survival at 2-years = 60.0% versus 61.1%, p = 0.72; %OS-survival at 1-year = 69.0% versus 69.3%, %OS-survival at 2-years = 56.6% versus 49.5%, p = 0.90. This finding persisted on sub-analysis of smaller lesions under < 3cm in diameter. Craniotomy resulted in higher rates of pre-operative deficit improvement than LITT (p < 0.01). On sub-group analysis, the single factor most significantly associated with OS and PFS was pathology of the lesion. About 40% of tumor lesions needed post-operative salvage with radiation after both craniotomy and LITT. LITT was as efficacious as craniotomy in achieving local control of recurrent irradiated brain metastases and facilitating steroid taper, regardless of pathology. Craniotomy appears to be more advantageous for providing symptom relief in those with pre-operative symptoms.

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MLTI-15. A CASE SERIES OF PRE-OPERATIVE GAMMA-KNIFE RADIOSURGERY FOR RESECTABLE BRAIN METASTASES

Neuro-Oncology Advances ◽

10.1093/noajnl/vdz014.074 ◽

2019 ◽

Vol 1 (Supplement_1) ◽

pp. i17-i17

Author(s):

Tatsuya Takezaki ◽

Haruaki Yamamoto ◽

Naoki Shinojima ◽

Jun-ichiro Kuroda ◽

Shigeo Yamashiro ◽

...

Keyword(s):

Brain Metastases ◽

Stereotactic Radiosurgery ◽

Gamma Knife ◽

Systemic Treatment ◽

Radiation Necrosis ◽

Gamma Knife Radiosurgery ◽

Case Series ◽

Phase 3 ◽

Optimal Sequence ◽

Median Margin

Abstract Recent advances in the systemic treatment of various cancers have resulted in longer survival and higher incidence of brain metastases. Phase 3 trials in north America and in Japan have demonstrated that stereotactic radiosurgery will be a standard adjuvant modality following surgery for resectable brain metastases. However, we don’t know the optimal sequence of this combination therapy. We hypothesized that pre-operative stereotactic radiosurgery for resectable brain metastases provides favorable rates of local control, overall survival, leptomeningeal dissemination and symptomatic radiation necrosis. We have experienced 4 cases of resected brain metastases within 1–7 days after Gamma-knife surgery (median margin dose:22Gy) and have been following their clinical course. We will show the repressive cases.

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Clinical and Dosimetric Factors Related to Radiation Necrosis After Five Fraction Radiosurgery for Resected Brain Metastases

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2017.06.749 ◽

2017 ◽

Vol 99 (2) ◽

pp. E66-E67

Author(s):

Z.S. Buchwald ◽

J. Switchenko ◽

J. Jhaveri ◽

M. Abugideiri ◽

R.J. Cassidy ◽

...

Keyword(s):

Brain Metastases ◽

Radiation Necrosis

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Impact of pemetrexed on intracranial disease control and radiation necrosis in patients with brain metastases from non-small cell lung cancer receiving stereotactic radiation

Radiotherapy and Oncology ◽

10.1016/j.radonc.2018.01.005 ◽

2018 ◽

Vol 126 (3) ◽

pp. 511-518 ◽

Cited By ~ 8

Author(s):

Daniel N. Cagney ◽

Allison M. Martin ◽

Paul J. Catalano ◽

Zachary J. Reitman ◽

Gabrielle A. Mezochow ◽

...

Keyword(s):

Lung Cancer ◽

Brain Metastases ◽

Small Cell Lung Cancer ◽

Disease Control ◽

Cell Lung Cancer ◽

Radiation Necrosis ◽

Small Cell ◽

Small Cell Lung ◽

Stereotactic Radiation ◽

Intracranial Disease

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31. RADIATION NECROSIS IN STEREOTACTIC RADIOSURGERY AND CHECKPOINTS INHIBITORS FOR BRAIN METASTASES FROM LUNG ADENOCARCINOMA

Neuro-Oncology Advances ◽

10.1093/noajnl/vdaa073.019 ◽

2020 ◽

Vol 2 (Supplement_2) ◽

pp. ii5-ii5

Author(s):

James Jurica ◽

Shraddha Dalwadi ◽

David Baskin ◽

Eric Bernicker ◽

Brian Butler ◽

...

Keyword(s):

Overall Survival ◽

Multivariate Analysis ◽

Brain Metastases ◽

Lung Adenocarcinoma ◽

Stereotactic Radiosurgery ◽

Median Survival ◽

Radiation Necrosis ◽

Concomitant Treatment ◽

Prognostic Assessment ◽

Graded Prognostic Assessment

Abstract PURPOSE Treatment with stereotactic radiosurgery (SRS) and immune checkpoint inhibitors (ICI) is increasingly common for brain metastases (BM) from lung adenocarcinoma. Rates of radiation necrosis (RN) with SRS in the setting of ICIs is an ongoing area of research. We investigated rates of RN in patients with BM from lung adenocarcinoma treated with SRS with or without concurrent ICIs. METHODS We identified 39 patients at a single institution who underwent SRS treatment for BM from lung adenocarcinoma. Of these, 19 (49%) received SRS without ICIs and 20 (51%) patients received ICIs within a month of SRS. The rate of RN, defined by MRI features and histology when available, was compared between each group using multivariate analysis. Kaplan Meier survival estimates were calculated based on overall survival and compared to median survival predicted by the graded prognostic assessment. RESULTS Overall survival for all patients from diagnosis of brain metastases was 16.6 months (range 3.6–45.9) and median survival predicted by the graded prognostic assessment was 13.7 months (range 6.9–26.5). In total 11 (28%) patients developed MRI and/or histologic evidence for RN during the follow-up period; 5 of 20 (25%) from the SRS with ICI group and 6 of 19 (31%) from the SRS without ICI group. In multivariate analysis, ICI treatment had no significant impact on rates of RN between groups (OR 0.72 [95% CI: 0.17–2.93]; p=0.65) while bevacizumab treatment was associated with a decreased RN risk (OR 0.88 [95% CI: 0.43–0.99]; p=0.02). CONCLUSION Retrospective analysis of patients with BM from lung adenocarcinoma treated with SRS suggested that administration of ICIs does not increase risk for development of RN. Further, concomitant treatment with bevacizumab may decrease risk of RN. These findings suggest that patients with BM from lung adenocarcinoma can be treated with combination therapy without increased risk of neurologic toxicity.

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OS3 - 187 Differentiating Radionecrosis from Tumor Progression Using IVIM perfusion Fraction in Brain Metastases Treated with Radiosurgery

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.334 ◽

2016 ◽

Vol 43 (S4) ◽

pp. S2-S2

Author(s):

J Detsky ◽

J Conklin ◽

J Keith ◽

S Symons ◽

A Sahgal ◽

...

Keyword(s):

Brain Metastases ◽

Tumor Progression ◽

Gold Standard ◽

Diffusion Weighted Imaging ◽

Radiation Necrosis ◽

The Other ◽

Recurrent Tumor ◽

Perfusion Fraction ◽

The Mean ◽

Pathology Reports

Radiation necrosis occurs in 5-25% of patients who undergo stereotactic radiosurgery (SRS) for brain metastases. Intravoxel incoherent motion (IVIM) uses MRI diffusion-weighted imaging (DWI) to assess regional perfusion. We investigated the utility of IVIM to differentiate recurrent tumor from radionecrosis after SRS. Patients who had SRS and subsequent surgical resection of what was thought to be either tumor progression or necrosis were included. ROIs were contoured on the pre-operative post-Gd T1-weighted images and transferred to DWI images using automated co-registration. The perfusion fraction (f) was calculated using asymptotic fitting and the mean f (fmean), 90th percentile for f (f90), mean ADC (ADCmean) and 10th percentile for ADC (ADC10) were calculated. Pathology reports were used to identify the predominant feature (necrosis versus tumor). Nine patients with ten lesions were included. One lesion exhibited pure necrosis while the other nine were mixed; three were predominantly (>75%) tumor, three predominantly necrosis, and three were equal parts of both. The perfusion fraction was significantly higher in cases with predominantly tumor compared to those with predominantly necrosis (fmean 0.10±0.01 vs 0.08±0.01, p=0.02 and f90 0.22±0.01 vs 0.14±0.02, p<0.001). ADC did not differentiate tumor from necrosis (ADCmean 0.97±0.23 vs 1.02±0.36, p=0.8 and ADC10 0.53±0.29 vs 0.76±0.29, p=0.33). The IVIM perfusion fraction is useful in differentiating recurrent tumor from radionecrosis in brain metastases treated with SRS. This is the first study to evaluate IVIM against the gold standard (histopathology).

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