Radiation necrosis metastatic brain cancer

Introduction

Metastatic brain cancer is the most common type of brain tumor in adults, in which 30% of cancer patients will develop brain tumors. ^, This rate is expected to increase as the management of metastatic brain tumors and systemic disease improves with the use of radiation therapy, surgical resection, targeted therapy, and/or immunotherapy, among others. Because of an increase in long-term survivors, there will be an increase in the number of late toxicities, including radiation necrosis. The risk of radiation necrosis varies between 5% and 25% in most series. In this chapter, we present a case of a metastatic brain tumor that was treated with stereotactic radiosurgery (SRS) and had symptomatic growth with increased vasogenic edema concerning for local tumor recurrence versus radiation necrosis.

Example case

Chief complaint: double vision and headaches

History of present illness

A 69-year-old, right-handed woman with a history of non–small cell lung cancer status post right upper lobectomy and chemoradiation 3 years prior, and two metastatic brain tumors treated with SRS 8 months prior, who presented with worsening headaches over 3 weeks. These headaches were constant, associated with nausea, vomiting, and double vision. She was given high-dose steroids with minimal improvement. Imaging showed progression of both lesions, more so on the right than the left ( Fig. 39.1 ).

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : non–small cell lung cancer status post right upper lobectomy and chemoradiation 3 years prior, two brain metastases status post SRS 8 months prior.
Family history : No history of intracranial malignancies.
Social history : Homemaker, no smoking and no alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: intact naming and repetition; Cranial nerves II to XII intact; No drift, moves all extremities with full strength.
Computed tomography chest/abdomen/pelvis : No evidence of systemic disease. Magnetic resonance (MR) perfusion unable to distinguish between radiation necrosis versus recurrent tumor.

	Peter E. Fecci, MD, PhD, Duke University, Durham, NC, United States	Fernando Hakim, MD, Diego Gomez, MD, Hospital Universitario Fundacion Santafe de Bogota, Bogota, Colombia	Michael Lim, MD, Stanford University School of Medicine, Stanford, CA, United States	Claudio Gustavo Yampolsky, MD, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Preoperative
Additional tests requested	None	MRS PET	None	MRS Neurooncology evaluation
Surgical approach selected	LITT for steroid responder, craniotomy for nonresponders	Right and left temporal craniotomies	Right craniotomy	Right fronto-temporal and left temporal craniotomies
Anatomic corridor	Right temporal	Right and left temporal	Right temporal	Right and left temporal
Goal of surgery	Diagnosis, local and symptom control	Gross total resection of both lesions	Diagnosis and decompression	Maximal safe resection without affecting function
Perioperative
Positioning	Right supine	Right lesion: right supine with 30-degree left rotation Left lesion: left supine with 30-degree left rotation	Right supine	Right lesion: right semilateral Left lesion: right lateral
Surgical equipment	Surgical navigation Intraoperative MRI Biopsy frame LITT	Surgical navigation Ultrasonic aspirator	Surgical navigation IOM (SSEP)	Right lesion: none Left lesion: surgical navigation, surgical microscope
Medications	Steroids Antiepileptics Mannitol	Steroids Mannitol	Steroids Antiepileptics	Steroids Antiepileptics
Anatomic considerations	Vein of Labbe, temporal horn, optic radiation	Right lesion: vein of Labbe, M3 branches Left lesion: vein of Labbe	Optic radiations	Right lesion: Sylvian fissure, MCA, temporal lobe Left lesion: temporal lobe
Complications feared with approach chosen	Venous infarct, visual field cut, cerebral edema, pseudomeningocele	Right lesion: hemorrhage Left lesion: language deficit	Visual field cuts	Speech deficit, motor complications
Intraoperative
Anesthesia	General	General	General	General
Skin incision	Linear	Right lesion: reverse question mark Left lesion: preauricular curvilinear	Linear	Right lesion: curvilinear Left lesion: linear
Bone opening	Right temporal burr hole	Right lesion: right temporal Left lesion: left temporal	Right temporal	Right lesion: right fronto-temporal Left lesion: left temporal
Brain exposure	STG	Right lesion: right temporal Left lesion: left temporal	Right temporal	Right lesion: right temporal Left lesion: left temporal
Method of resection	Biopsy frame, navigation-guided biopsy, LITT bolt, insertion of laser catheter and attachment of driver, intraoperative MRI, ablation, removal of catheter and bolt	Right craniotomy first guided by navigation, U-shaped dural opening, expose STG and avoid vein of Labbe and MCA branches, corticectomy in STG, capsulotomy and internal debulking with ultrasonic aspirator, find gliotic plane to achieve gross total resection, watertight dural closure; redrape for left temporal craniotomy with navigation, U-shaped dural openings, corticectomy in MTG, same resection strategy as right lesion, watertight dural closure	Navigation-guided craniotomy, cruciate dural opening, intraoperative excisional biopsy, if biopsy consistent with treatment effect then resect lesion, if active tumor place radiation seeds	Right craniotomy first, fronto-temporal Penfield incision, temporal craniotomy, expose Sylvian fissure, have Sylvian fissure be top boundary and ITS inferior boundary, corticectomy in STG and dissect to reach tumor, en bloc removal. After 2 weeks of healing, left temporal incision, left temporal 4 x 4 cm craniotomy, cruciate dural opening, corticectomy in MTG based on navigation, supramarginal en bloc tumor removal
Complication avoidance	LITT with intraoperative MRI	Identify vasculature and avoid, internal debulking, address larger tumor first	Intraoperative biopsy, resection of lesion if radiation necrosis and tumor seeds if active tumor	Surgeries separated by 2 weeks, en bloc resection
Postoperative
Admission	Floor	ICU	ICU	ICU
Postoperative complications feared	Field cut, venous infarct, pseudomeningocele	Cerebral edema	Field cut	Seizures, visual field deficit
Follow-up testing	MRI within 24 hours after surgery	MRI within 72 hours after surgery	MRI within 48 hours after surgery	MRI within 48 hours after surgery
Follow-up visits	14 days after surgery	7 days after surgery	14 days after surgery	7 days after surgery
Adjuvant therapies recommended	Observation	Observation, chemotherapy per oncology	Observation	Chemotherapy per oncology