DEGRO practical guideline for central nervous system radiation necrosis part 1: classification and a multistep approach for diagnosis

Abstract

Purpose The Working Group for Neuro-Oncology of the German Society for Radiation Oncology in cooperation with members of the Neuro-Oncology Working Group of the German Cancer Society aimed to define a practical guideline for the diagnosis and treatment of radiation-induced necrosis (RN) of the central nervous system (CNS). Methods Panel members of the DEGRO working group invited experts, participated in a series of conferences, supplemented their clinical experience, performed a literature review, and formulated recommendations for medical treatment of RN including bevacizumab in clinical routine. Conclusion Diagnosis and treatment of RN requires multidisciplinary structures of care and defined processes. Diagnosis has to be made on an interdisciplinary level with the joint knowledge of a neuroradiologist, radiation oncologist, neurosurgeon, neuropathologist, and neuro-oncologist. A multistep approach as an opportunity to review as many characteristics as possible to improve diagnostic confidence is recommended. Additional information about radiotherapy (RT) techniques is crucial for the diagnosis of RN. Misdiagnosis of untreated and progressive RN can lead to severe neurological deficits. In this practice guideline, we propose a detailed nomenclature of treatment-related changes and a multistep approach for their diagnosis.

Management of initial and recurrent radiation-induced contrast enhancements following radiotherapy for brain metastases: Clinical and radiological impact of bevacizumab and corticosteroids

“…This makes an interdisciplinary approach for diagnostic review and a treatment in specialized centers to avoid devastating complications of RN all the more important. [13] , [28] .…”

“…Overall, radiation brain injury can have devastating and life-threatening complications, especially in cases of RICE recurrences that can suggest RN, and prompt therapy initiation was supported by our analysis. International guidelines provide treatment strategies for initial treatment, but data for recurrences after RICE-improvement are lacking and prior studies report wide ranges of 5.9% to 76.9% in small patient cohorts with undefined treatment recommendations [13] , [20] , [28] , [34] . Our study suggests that bevacizumab is also superior for the treatment of flare-ups compared to corticosteroids.…”

“…Moreover, surgical samples may contain insufficient quantities of tissue, which may or may not represent the plurality of the lesion. Thus, guidelines advocate for an interdisciplinary multistep approach in managing these complex cases with respect not only to criteria of radiological courses and (ir)reversibility of RICE lesions, but also RT techniques and dose ranges, treated volumes, time intervals after RT, progression patterns and occurring symptoms [13] . Even though magnetic resonance (MR)-based imaging combined with advanced diffusion or perfusion sequences has the potential to add clarity to a nebulous spectrum of diagnoses, the treatment remains challenging [14] , [15] .…”

Analysis of safety and efficacy of proton radiotherapy for IDH-mutated glioma WHO grade 2 and 3

“…If symptoms were severe, bevacizumab was started immediately. This approach was chosen according to the DEGRO practical guideline for Central Nervous System Radiation Necrosis Part I: Classification and a multi-step approach for Diagnosis [ 35 ] and DEGRO practical guideline for Central Nervous System Radiation Necrosis Part II: Treatment of the German Society for Radiation Oncology [ 36 ].…”

Verlängerung des Gesamtüberlebens durch die Impfung von autologen tumorlysatbeladenen dendritischen Zellen (DCVax-L) bei Patienten mit neu diagnostiziertem und rezidivierendem Glioblastom

“…Zudem wurden die Bewertungskriterien zur Definition eines realen Progresses beim Glioblastom nach Immuntherapie mehrfach aktualisiert: von den MacDonalds-Kriterien, wie sie initial in der vorliegenden Studie angewendet wurden, über die Response-Assessment-in-Neuro-Oncology-Kriterien (RANO) und „immunotherapy RANO“ (iRANO) bis hin zu den Modified-RANO-Kriterien [ 5 – 7 ]. Die Tatsache, dass es zu solch einer hohen Abweichung bei der Response-Beurteilung kam, adressiert ebenfalls eine gewisse Unsicherheit sowohl bei aktuell laufenden Studien als auch bei bereits publizierten Studien, die das PFS als Endpunkt gewählt haben [ 8 – 10 ].…”