NIMG-67. DISAPPEARING DOTS – TRANSIENT LATE ENHANCING LESIONS YEARS AFTER BRAIN RADIOTHERAPY

Abstract BACKGROUND Late-delayed radiation effects appear 6 months to years following radiotherapy. We characterize a species of small enhancing lesions in the late-delayed phase of post-radiotherapy that are distinct from the classic descriptions of radiation necrosis or pseudoprogression associated with mass effect and edema. These “disappearing dots” are small, do not exert mass effect nor edema, and spontaneously resolve. METHOD We retrospectively describe a series of cases with “disappearing dots” following brain radiotherapy. RESULTS There were 10 cases (4 men), median age 42 years (range 29-63). Diagnoses were glioblastoma (3); low grade astrocytoma, anaplastic astrocytoma, and anaplastic oligodendroglioma (2 each); and solitary fibrous tumor (1). All patients received 54-60 Gy (Gray) of external beam radiotherapy, except one (proton beam therapy to 60 cobalt Gray equivalent). Disappearing dots appeared at a median of 27 months (range 5-197) post-radiotherapy. Lesions were relatively small (~< 1 cm3), peri-ventricular, and within the radiotherapy field. Most enlarged before resolving. Advanced MR imaging and fluorodeoxyglucose (FGD)-PET results were inconsistent. Lesions persisted a median of 8.5 months (range 1-49) before spontaneous resolution. All were asymptomatic. Biopsy in one case revealed treatment effects rather than recurrent tumor. CONCLUSIONS Asymptomatic small periventricular enhancing lesions can develop and remit spontaneously, years following brain radiotherapy. Such disappearing dots should be part of the differential diagnosis along with tumor recurrence. of new enhancing lesions in the late-delayed phase post-radiotherapy.

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Radiation necrosis after a combination of external beam radiotherapy and iodine-125 brachytherapy in gliomas

Radiation Oncology ◽

10.1186/s13014-021-01762-0 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Indrawati Hadi ◽

Daniel Reitz ◽

Raphael Bodensohn ◽

Olarn Roengvoraphoj ◽

Stefanie Lietke ◽

...

Keyword(s):

Risk Factors ◽

Radiation Necrosis ◽

Irradiation Time ◽

External Beam Radiotherapy ◽

High Grade Glioma ◽

Metabolic Imaging ◽

Time Interval ◽

Low Grade ◽

External Beam ◽

Iodine 125

Abstract Purpose Frequency and risk profile of radiation necrosis (RN) in patients with glioma undergoing either upfront stereotactic brachytherapy (SBT) and additional salvage external beam radiotherapy (EBRT) after tumor recurrence or vice versa remains unknown. Methods Patients with glioma treated with low-activity temporary iodine-125 SBT at the University of Munich between 1999 and 2016 who had either additional upfront or salvage EBRT were included. Biologically effective doses (BED) were calculated. RN was diagnosed using stereotactic biopsy and/or metabolic imaging. The rate of RN was estimated with the Kaplan Meier method. Risk factors were obtained from logistic regression models. Results Eighty-six patients (49 male, 37 female, median age 47 years) were included. 38 patients suffered from low-grade and 48 from high-grade glioma. Median follow-up was 15 months after second treatment. Fifty-eight patients received upfront EBRT (median total dose: 60 Gy), and 28 upfront SBT (median reference dose: 54 Gy, median dose rate: 10.0 cGy/h). Median time interval between treatments was 19 months. RN was diagnosed in 8/75 patients. The 1- and 2-year risk of RN was 5.1% and 11.7%, respectively. Tumor volume and irradiation time of SBT, number of implanted seeds, and salvage EBRT were risk factors for RN. Neither of the BED values nor the time interval between both treatments gained prognostic influence. Conclusion The combination of upfront EBRT and salvage SBT or vice versa is feasible for glioma patients. The risk of RN is mainly determined by the treatment volume but not by the interval between therapies.

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Radiosurgery alone or in combination with whole-brain radiotherapy for brain metastases.

Journal of Clinical Oncology ◽

10.1200/jco.1998.16.11.3563 ◽

1998 ◽

Vol 16 (11) ◽

pp. 3563-3569 ◽

Cited By ~ 257

Author(s):

A Pirzkall ◽

J Debus ◽

F Lohr ◽

M Fuss ◽

B Rhein ◽

...

Keyword(s):

Brain Metastases ◽

Median Survival ◽

Local Control ◽

Radiation Necrosis ◽

Whole Brain Radiotherapy ◽

Low Grade ◽

Median Dose ◽

Whole Brain ◽

Brain Radiotherapy ◽

Extracranial Disease

PURPOSE Evaluation of the treatment outcome after radiosurgery (RS) alone or in combination with whole-brain radiotherapy (WBRT) with special attention to prescribed dose and its influence on local control and survival. PATIENTS AND METHODS Between September 1984 and January 1997, 236 patients with 311 brain metastases treated with radiosurgery met the following inclusion criteria: one to three brain metastases per patient; no previous WBRT; and Kamofsky performance status (KPS) > or = 50%. One hundred fifty-eight patients treated only with RS received a median dose of 20 Gy prescribed to the 80% isodose line; 78 patients received RS with a median dose of 15 Gy/80% and an additional course of WBRT. RESULTS For the entire series, overall median survival was 5.5 months, with control of CNS disease achieved in 92% of the treated brain metastases; the results were not significantly different between patients treated by RS with or without WBRT. However, in patients without evidence of extracranial disease, median survival was increased for patients who received WBRT (15.4 vs 8.3 months; P=.08). Additionally, there was a suggestion that increased doses for patients treated with RS only resulted in improved outcome. Four lesions were suspicious for radiation necrosis by magnetic resonance imaging (MRI); in one of the four lesions, radiation necrosis was confirmed histologically. The incidence of transient low-grade toxicity was 18%; symptoms could be treated by the temporary administration of steroids. CONCLUSION RS is an effective, noninvasive means of controlling brain metastases when used alone or in combination with WBRT. There is a trend for superior local control and especially in patients without extracranial disease for superior survival when RS is used in conjunction with WBRT. Randomized trials would seem to be warranted, comparing the benefit of RS with or without additional WBRT.

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Benign Intracranial Lesions - Radiotherapy: An Overview of Treatment Options, Indications and Therapeutic Results

Reviews on Recent Clinical Trials ◽

10.2174/1574887114666191111100635 ◽

2020 ◽

Vol 15 (2) ◽

pp. 93-121

Author(s):

Vasileios Tzikoulis ◽

Areti Gkantaifi ◽

Filippo Alongi ◽

Nikolaos Tsoukalas ◽

Haytham Hamed Saraireh ◽

...

Keyword(s):

Effective Treatment ◽

Treatment Modality ◽

Radiation Effects ◽

Treatment Options ◽

Proton Beam Therapy ◽

Tumor Control ◽

Control Growth ◽

Effective Treatment Modality ◽

Intracranial Lesions

Background: Radiation Therapy (RT) is an established treatment option for benign intracranial lesions. The aim of this study is to display an update on the role of RT concerning the most frequent benign brain lesions and tumors. Methods: Published articles about RT and meningiomas, Vestibular Schwannomas (VSs), Pituitary Adenomas (PAs), Arteriovenous Malformations (AVMs) and craniopharyngiomas were reviewed and extracted data were used. Results: In meningiomas RT is applied as an adjuvant therapy, in case of patientrefusing surgery or in unresectable tumors. The available techniques are External Beam RT (EBRT) and stereotactic ones such as Stereotactic Radiosurgery (SRS), Fractionated Stereotactic RT (FSRT), Intensity Modulated RT (IMRT) and proton-beam therapy. The same indications are considered in PAs, in which SRS and FSRT achieve excellent tumor control rate (92-100%), acceptable hormone remission rates (>50%) and decreased Adverse Radiation Effects (AREs). Upon tumor growth or neurological deterioration, RT emerges as alone or adjuvant treatment against VSs, with SRS, FSRT, EBRT or protonbeam therapy presenting excellent tumor control growth (>90%), facial nerve (84-100%), trigeminal nerve (74-99%) and hearing (>50%) preservation. SRS poses an effective treatment modality of certain AVMs, demonstrating a 3-year obliteration rate of 80%. Lastly, a combination of microsurgery and RT presents equal local control and 5-year survival rate (>90%) but improved toxicity profile compared to total resection in case of craniopharyngiomas. Conclusion: RT comprises an effective treatment modality of benign brain and intracranial lesions. By minimizing its AREs with optimal use, RT projects as a potent tool against such diseases.

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Mid-Treatment Magnetic Resonance Imaging in Pediatric Intracranial Low-Grade Gliomas Treated With Proton Beam Therapy

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/j.ijrobp.2014.05.2115 ◽

2014 ◽

Vol 90 (1) ◽

pp. S725

Author(s):

R. Sreeraman ◽

T. Vern-Gross ◽

D.J. Indelicato ◽

J. Bradley ◽

S. Huh ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Proton Beam ◽

Proton Beam Therapy ◽

Low Grade ◽

Resonance Imaging ◽

Low Grade Gliomas

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Current treatment of patients with multiple brain metastases

Neurosurgical FOCUS ◽

10.3171/foc.2000.9.2.6 ◽

2000 ◽

Vol 9 (2) ◽

pp. 1-5 ◽

Cited By ~ 3

Author(s):

Steven D. Chang ◽

John R. Adler

Keyword(s):

Brain Metastases ◽

Treatment Options ◽

Whole Brain Radiotherapy ◽

Mass Effect ◽

Current Treatment ◽

Rapid Reduction ◽

Multiple Brain Metastases ◽

Brain Radiotherapy ◽

Multiple Metastases ◽

Difficult Challenge

The management of patients with multiple brain metastases remains a difficult challenge for neurosurgeons. This patient population has a poor prognosis when compared with those harboring a solitary brain metastasis, and historically treatment has generally consisted of administering whole-brain radiotherapy once the diagnosis of multiple brain metastases is made. Resection can be useful in a subset of patients with multiple metastases in whom one or two of the lesions are symptomatic, as this may provide rapid reduction of mass effect and edema. Furthermore, the authors of recent studies have shown that stereotactic radiosurgery can be used in certain patients with multiple brain metastases as part of the treatment regimen. In this review the authors outline the treatment options and indications as well as a management strategy for the treatment of patients with multiple brain metastases.

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Radiation necrosis or glioma recurrence: is computer-assisted stereotactic biopsy useful?

Journal of Neurosurgery ◽

10.3171/jns.1995.82.3.0436 ◽

1995 ◽

Vol 82 (3) ◽

pp. 436-444 ◽

Cited By ~ 94

Author(s):

Peter A. Forsyth ◽

Patrick J. Kelly ◽

Terrence L. Cascino ◽

Bernd W. Scheithauer ◽

Edward G. Shaw ◽

...

Keyword(s):

Disease Progression ◽

Tumor Recurrence ◽

Stereotactic Biopsy ◽

Radiation Necrosis ◽

Low Grade ◽

Tumor Type ◽

Content Type ◽

Radiation Induced ◽

Chondroblastic Osteosarcoma ◽

Fine Print

✓ Fifty-one patients with supratentorial glioma treated with external beam radiotherapy (median dose 59.5 Gy) who then demonstrated clinical or radiographic evidence of disease progression underwent stereotactic biopsy to differentiate tumor recurrence from radiation necrosis. The original tumor histological type was diffuse or fibrillary astrocytoma in 21 patients (41%), oligodendroglioma in 13 (26%), and oligoastrocytoma in 17 (33%); 40 tumors (78%) were low-grade (Kernohan Grade 1 or 2). The median time to suspected disease progression was 28 months. Stereotactic biopsy showed tumor recurrence in 30 patients (59%), radiation necrosis in three (6%), and a mixture of both in 17 (33%); one patient (2%) had a parenchymal radiation-induced chondroblastic osteosarcoma. The tumor type at stereotactic biopsy was similar to the original tumor type and was astrocytoma in 24 patients (47%), oligodendroglioma in eight (16%), oligoastrocytoma in 16 (31%), unclassifiable in two (4%), and chondroblastic osteosarcoma in one patient (2%). At biopsy, however, only 19 tumors (37%) were low grade (Kernohan Grade 1 or 2). Subsequent surgery confirmed the stereotactic biopsy histological findings in eight patients. Follow-up examination showed 14 patients alive with a median survival of 1 year for the entire group. Median survival times after biopsy were 0.83 year for patients with tumor recurrence and 1.86 years for patients with both tumor recurrence and radionecrosis; these findings were significantly different (p = 0.008, log-rank test). No patient with radiation necrosis alone died. Other factors associated with reduced survival were a high proportion of residual tumor (p = 0.024), a low proportion of radionecrosis (p < 0.001), and a Kernohan Grade of × or 4 (p = 0.005). In conclusion, in patients with previously irradiated supratentorial gliomas in whom radionecrosis or tumor recurrence was clinically or radiographically suspected, results of stereotactic biopsy could be used to differentiate tumor recurrence, radiation necrosis, a mixture of both lesions, or radiation-induced neoplasm. In addition, biopsy results could predict survival rates.

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OC-0514: radiation necrosis after proton beam therapy - when and where does it happen?

Radiotherapy and Oncology ◽

10.1016/s0167-8140(17)30954-4 ◽

2017 ◽

Vol 123 ◽

pp. S271 ◽

Cited By ~ 2

Author(s):

S. Harrabi ◽

C. Gudden ◽

S. Adeberg ◽

N. Bougatf ◽

T. Haberer ◽

...

Keyword(s):

Proton Beam ◽

Radiation Necrosis ◽

Proton Beam Therapy

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Bevacizumab for pediatric radiation necrosis

Neuro-Oncology Practice ◽

10.1093/nop/npz072 ◽

2020 ◽

Vol 7 (4) ◽

pp. 409-414 ◽

Cited By ~ 1

Author(s):

Lorena V Baroni ◽

Daniel Alderete ◽

Palma Solano-Paez ◽

Carlos Rugilo ◽

Candela Freytes ◽

...

Keyword(s):

Monoclonal Antibody ◽

Clinical Trials ◽

Radiation Necrosis ◽

Treatment Options ◽

Mass Effect ◽

Pediatric Brain Tumors ◽

Controlled Clinical Trials ◽

Wide Range ◽

Fluid Attenuated Inversion Recovery ◽

Pediatric Brain

Abstract Background Radiation necrosis is a frequent complication occurring after the treatment of pediatric brain tumors; however, treatment options remain a challenge. Bevacizumab is an anti-VEGF monoclonal antibody that has been shown in small adult cohorts to confer a benefit, specifically a reduction in steroid usage, but its use in children has not been well described. Methods We describe our experience with bevacizumab use for symptomatic radiation necrosis at 5 institutions including patients treated after both initial irradiation and reirradiation. Results We identified 26 patients treated with bevacizumab for symptomatic radiation necrosis, with a wide range of underlying diagnoses. The average age at diagnosis of radiation necrosis was 10.7 years, with a median time between the last dose of radiation and the presentation of radiation necrosis of 3.8 months (range, 0.6-110 months). Overall, we observed that 13 of 26 patients (50%) had an objective clinical improvement, with only 1 patient suffering from significant hypertension. Radiological improvement, defined as reduced T2/fluid-attenuated inversion recovery signal and mass effect, was observed in 50% of patients; however, this did not completely overlap with clinical response. Both early and late radiation necrosis responded equally well to bevacizumab therapy. Overall, bevacizumab was very well tolerated, permitting a reduction of corticosteroid dose and/or duration in the majority of patients. Conclusions Bevacizumab appears to be effective and well-tolerated in children as treatment for symptomatic radiation necrosis and warrants more robust study in the context of controlled clinical trials.

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C.03 Deformation-based morphometry analysis of longitudinal low-grade glioma growth

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

10.1017/cjn.2019.98 ◽

2019 ◽

Vol 46 (s1) ◽

pp. S12

Author(s):

C Gui ◽

JC Lau ◽

J Kai ◽

AR Khan ◽

JF Megyesi

Keyword(s):

Tissue Expansion ◽

Mass Effect ◽

Low Grade ◽

Normal Brain ◽

Primary Brain Tumours ◽

Morphometry Analysis ◽

Glioma Growth ◽

Deformation Based Morphometry ◽

Over Time ◽

Nonlinear Registration

Background: Diffuse low-grade gliomas (LGGs) are primary brain tumours with infiltrative, anisotropic growth related to surrounding white and grey matter structures. Deformation-based morphometry (DBM) is a simple and objective image analysis method that can identify areas of local volume change over time. In this study, we illustrate the use of DBM to study the local expansion patterns of LGGs monitored by serial magnetic resonance imaging (MRI). Methods: We developed an image processing pipeline optimized for the study of LGG growth involving the fusion of follow-up MRIs for a given patient into an average template space using nonlinear registration. The displacement maps derived from nonlinear registration were converted to Jacobian maps, which estimate local tissue expansion and contraction over time. Results: Our results demonstrate that neoplastic growth occurs primarily around the edges of the tumour while the lesion core and areas adjacent to obstacles, such as the skull, show no significant expansion. Regions of normal brain tissue surrounding the lesion show slight contraction over time, representing compression due to mass effect of the tumour. Conclusions: DBM is a useful tool to understand the long-term clinical course of individual tumours and identify areas of rapid growth, which may explain the current presentation and/or predict future symptoms.

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