Recurrent radionecrosis

[Palex80]

An elderly patient has been suffering from a radionecrosis, following an SRS to a NSCLC brain metastasis in 2017.

He received steroids first, then underwent 4 cycles of Bevacizumab in 2019 after showing radiologic signs of necrosis without symptoms. There was radiologic response on imaging to the Bevacizumab and he remained symptom-free.

In 2022 he developed symptoms and the radionecrosis seemed to grow again, so he had another 4 cycles of Bevacizumab, this time with no response (neither clinical, nor radiologic).

He has started developing seizures now, with only minimal growth of the necrosis on the MRI.

Do you have any good ideas?

a) another round of Bevacizumab will likely not help.
b) hyperbaric oxygen treatment is not possible due to the seizures and pulmonary issues
c) has anyone tried out a TNF-a blocker for radionecrosis?

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[madchemist89]

Can the focus of necrosis be resected?

 

[TheWallnerus]

Surgery and/or Trental/Vit E and/or Decadron 2mg q8h for a month. I would also presume anti seizure meds have started. Without dramatic radiographic changes, and if the seizures are controlled, then crisis averted?

 

[BobbyHeenan]

I've had some of these cases over the years and i'm often shocked at how well bevacizumab does ...but when it doesn't work I think these other suggestions are the best option(s) you have - resect if feasible, try trental/vit e/steroids and hyperbaric. The recurrent seizures can be VERY hard to manage.

Boswellia Serrata (can be purchased via amazon) has some modest avastin-like effects and anecdotally i've seen it kind of work...but if bev isn't working i doubt it would.

I bet Neuronix will have good input.

There is some literature out there for laser interstitial thermal therapy, but very few places are doing this as far as I understand it. I sent one patient for an eval of this but she ended up stabilizing after round two of bev.

Efficacy of laser interstitial thermal therapy for biopsy-proven radiation necrosis in radiographically recurrent brain metastases

AbstractBackground. Laser interstitial thermal therapy (LITT) in the setting of post-SRS radiation necrosis (RN) for patients with brain metastases has gro

academic.oup.com

 

[Palex80]

Can the focus of necrosis be resected?

Sorry, I forgot to state the obvious. Unfortunately not. The patient is elderly and the it's a no-go for the surgeons due to the location as well.

Appreciate all the other input!

 

[Neuronix]

@BobbyHeenan said it all. Thanks for mentioning me.

Keep in mind that the boswellia has to be at high doses (1500 mg PO TID) compared to what comes in most over the counter formulations.

How did you confirm that this is RT necrosis? Is it possible that it is recurrent disease? This should be entertained since it did not respond to another course of Avastin.

We do a lot of LITT here for RT necrosis. Not just for those who I treated, but we're a big referral center for it. That is also a reasonable option.

 

[Palex80]

How did you confirm that this is RT necrosis? Is it possible that it is recurrent disease? This should be entertained since it did not respond to another course of Avastin.

True, this is a good point. The neuroradiologists are pretty confindent it is one, based on specteoscopy and DWI.

We do a lot of LITT here for RT necrosis. Not just for those who I treated, but we're a big referral center for it. That is also a reasonable option.

Interesing, never heard of that!

 

[Barcelona PSG]

An elderly patient has been suffering from a radionecrosis, following an SRS to a NSCLC brain metastasis in 2017.

He received steroids first, then underwent 4 cycles of Bevacizumab in 2019 after showing radiologic signs of necrosis without symptoms. There was radiologic response on imaging to the Bevacizumab and he remained symptom-free.

In 2022 he developed symptoms and the radionecrosis seemed to grow again, so he had another 4 cycles of Bevacizumab, this time with no response (neither clinical, nor radiologic).

He has started developing seizures now, with only minimal growth of the necrosis on the MRI.

Do you have any good ideas?

a) another round of Bevacizumab will likely not help.
b) hyperbaric oxygen treatment is not possible due to the seizures and pulmonary issues
c) has anyone tried out a TNF-a blocker for radionecrosis?

I would try Boswellia, LITT and if resectable-resect the necrosis in the order of preference

 

[temujim]

An elderly patient has been suffering from a radionecrosis, following an SRS to a NSCLC brain metastasis in 2017.

He received steroids first, then underwent 4 cycles of Bevacizumab in 2019 after showing radiologic signs of necrosis without symptoms. There was radiologic response on imaging to the Bevacizumab and he remained symptom-free.

In 2022 he developed symptoms and the radionecrosis seemed to grow again, so he had another 4 cycles of Bevacizumab, this time with no response (neither clinical, nor radiologic).

He has started developing seizures now, with only minimal growth of the necrosis on the MRI.

Do you have any good ideas?

a) another round of Bevacizumab will likely not help.
b) hyperbaric oxygen treatment is not possible due to the seizures and pulmonary issues
c) has anyone tried out a TNF-a blocker for radionecrosis?

Can try thalidomide. Almost half responded by imaging and clinically in a bev/steroid refractory cohort.

https://www.science.org/doi/10.1126/scitranslmed.abm6543

 

[RickyScott]

I have tried boswelli twice to no avail. Low dose avastin much better

 

[gmsquid]

HBO? Never done it for brain but do it frequently for HN and all sorts of soft tissue necrosis

 

[gmsquid]

But agree with concern for recurrence

 

[medgator]

HBO? Never done it for brain but do it frequently for HN and all sorts of soft tissue necrosis

Have seen it done in the pelvis as well

 

[evilbooyaa]

if only symptom is seizures then get patient started on anti-epileptics. If seizures get controlled and no radiographic changes then consider maintaining on just that. Certainly concern for recurrence at 7 years but without radiographic changes unlikely.

LITT is a reasonable option as well if you can get patient into a facility. Haven't used HBO for radionecrosis in the brain and I see that resection is not an option.