Management of symptomatic radiation necrosis after stereotactic radiosurgery and clinical factors for treatment response

Abstract

Purpose: Approximately 10\% of patients who received brain stereotactic radiosurgery (SRS) develop symptomatic radiation necrosis (RN). We sought to determine the effectiveness of treatment options for symptomatic RN, based on patient-reported outcomes. Materials and Methods: We conducted a retrospective review of 217 patients with 414 brain metastases treated with SRS from 2009 to 2018 at our institution. Symptomatic RN was determined by appearance on serial magnetic resonance images (MRIs), MR spectroscopy, requirement of therapy, and development of new neurological complaints without evidence of disease progression. Therapeutic interventions for symptomatic RN included corticosteroids, bevacizumab and/or surgical resection. Patient-reported therapeutic outcomes were graded as complete response (CR), partial response (PR), and no response. Results: Twenty-six patients experienced symptomatic RN after treatment of 50 separate lesions. The mean prescription dose was 22 Gy (range, 15 to 30 Gy) in 1 to 5 fractions (median, 1 fraction). Of the 12 patients managed with corticosteroids, 6 patients (50\%) reported CR and 4 patients (33\%) PR. Of the 6 patients managed with bevacizumab, 3 patients (50\%) reported CR and 1 patient (18\%) PR. Of the 8 patients treated with surgical resection, all reported CR (100\%). Other than surgical resection, age >= 54 years (median, 54 yearsrange, 35 to 81 years) was associated with CR (odds ratio = 8.4095\% confidence interval, 1.27-15.39p = 0.027). Conclusion: Corticosteroids and bevacizumab are commonly utilized treatment modalities with excellent response rate. Our results suggest that patient's age is associated with response rate and could help guide treatment decisions for unresectable symptomatic RN.