Cancer Res Treat.  2007 Mar;39(1):16-21.

Radiation-induced Necrosis Deteriorating Neurological Symptoms and Mimicking Progression of Brain Metastasis after Stereotactic-guided Radiotherapy

• Kim YZ
• Kim DY
• Yoo H
• Yang HS
• Shin SH
• Hong EK
• Cho KH
• Lee SH

Abstract

PURPOSE: Although radiation-induced necrosis (RIN) is not a tumor in itself, the lesion progressively enlarges with mass effects and diffuse peritumoral edema in a way that resembles neoplasm. To identify the RIN that mimics progression of brain metastasis, we performed surgical resections of symptomatic RIN lesions. Meterials and Methods: From June 2003 to December 2005, 7 patients received stereotactic-guided radiotherapy (SRT) for metastatic brain tumor, and they later underwent craniotomy and tumor resection due to the progressive mass effects and the peritumoral edema that caused focal neurological deficit. On MR imaging, a ring-like enhanced single lesion with massive peritumoral edema could not be distinguished from progression of brain metastasis.
RESULTS
Four patients had non-small cell lung cancer, 2 patients had colorectal cancer and 1 patient had renal cell carcinoma. The mean tumor volume was 8.7 ml (range: 3.0~20.7 ml). The prescribed dose of SRT was 30 Gy with 4 fractions for one patient, 18 Gy for two patients and 20 Gy for the other four patients. The four patients who received SRT with a dose of 20 Gy had RIN with or without microscopic residual tumor cells.
CONCLUSIONS
Early detection of recurrent disease after radiotherapy and identifying radiation-induced tissue damage are important for delivering adequate treatment. Therefore, specific diagnostic tools that can distinguish RIN from progression of metastatic brain tumor need to be developed.

Keyword

Radiation-induced necrosis; Stereotactic guided radiotherapy; Brain metastasis

MeSH Terms

Brain Neoplasms
Brain*
Carcinoma, Non-Small-Cell Lung
Carcinoma, Renal Cell
Colorectal Neoplasms
Craniotomy
Edema
Humans
Magnetic Resonance Imaging
Necrosis*
Neoplasm Metastasis*
Neoplasm, Residual
Radiotherapy*
Tumor Burden

Figure

• 

  Fig. 1 MR imaging findings. At diagnosis, MRI shows a ring-like enhanced mass in the right precentral gyrus in T1-weighted image with Gadolinium enhancement and combined peritumoral edema in T2-weighted image (A). One month after SRS, increased central necrosis and still remained peritumoral edema were shown (B). Eight months after SRS, progressive increased extent of peritumoral edema without significant change in ring-like enhancing lesion (C). After surgical resection of brain lesion, surgical defect was found at the previous tumor site and decreased signal intensity of peritumoral edema (D).

• 

  Fig. 2 Histopathological findings in tissue from the zone of Gd-enhancement on MRI shows characteristics of radiation necrosis. There is coagulative type necrosis of the normal brain. The blood vessels show fibrinoid necrosis and hyalinization of the vascular walls. In the left lower of this figure, minimal cytologic atypia or reactive glial cells is noted (H&E staining, ×100).

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