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Radiation Necrosis from Stereotactic Radiosurgery—How Do We Mitigate?

  • Neuro-oncology (GJ Lesser, Section Editor)
  • Published:
Current Treatment Options in Oncology Aims and scope Submit manuscript

Opinion statement

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.

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Authors and Affiliations

  1. Department of Radiation oncology, National University Cancer Institute, 1E Kent Ridge Road, Level 7 Tower block, Singapore, 119228, Singapore

    Balamurugan A. Vellayappan

  2. Department of Neurology, Alvord Brain Tumor Center, University of Washington, Seattle, WA, USA

    Tresa McGranahan, Jerome Graber, Lynne Taylor, Vyshak Venur & Richard Ellenbogen

  3. Department of Neurological Surgery, University of Washington, Seattle, WA, USA

    Tresa McGranahan, Jerome Graber, Lynne Taylor, Vyshak Venur & Richard Ellenbogen

  4. Department of Neurological Surgery, Seidman Cancer Center and University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH, USA

    Andrew E. Sloan

  5. Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University, Baltimore, MD, USA

    Kristin J. Redmond

  6. Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia

    Matthew Foote

  7. Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA

    Samuel T. Chao & John H. Suh

  8. Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA

    Eric L. Chang

  9. Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

    Arjun Sahgal

  10. Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA, USA

    Simon S. Lo

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  1. Balamurugan A. Vellayappan
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Matthew Foote has received travel and honoraria from Elekta, consulting fee from Varian. Kristin Redmond has received research funding and travel expenses from Accuray, has received research funding from Elekta, has received honorarium from AstraZeneca and acts as a consultant for Medtronic. Simon Lo has received research support from Elekta AB for Gamma Knife ICON Expert Group. Balamurugan A. Vellayappan declares that there is no conflict of interest. Tresa McGranahan declares that there is no conflict of interest. Jerome Graber declares that there is no conflict of interest. Lynne Taylor declares that there is no conflict of interest. Vyshak Venur declares that there is no conflict of interest. Richard Ellenbogen declares that there is no conflict of interest. Andrew E. Sloan declares that there is no conflict of interest. Samuel T. Chao declares that there is no conflict of interest. John H. Suh declares that there is no conflict of interest. Eric L. Chang declares that there is no conflict of interest. Arjun Sahgal declares that there is no conflict of interest.

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Vellayappan, B.A., McGranahan, T., Graber, J. et al. Radiation Necrosis from Stereotactic Radiosurgery—How Do We Mitigate?. Curr. Treat. Options in Oncol. 22, 57 (2021). https://doi.org/10.1007/s11864-021-00854-z

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