Laser Interstitial Thermal Therapy for Focal Cerebral Radiation Necrosis: A Case Report and Literature Review

Rahmathulla, Gazanfar; Recinos, Pablo F.; Valerio, Jose E.; Chao, Samuel T.; Barnett, Gene H.

doi:10.1159/000338251

Cited by 146 publications

(96 citation statements)

References 103 publications

(56 reference statements)

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Section: Discussionsupporting

confidence: 67%

“…In a small series of patients with histologically-proven radiation necrosis treated with LITT [15], Torres-Reveron et al [15] described all patients as tolerating the procedure well enough to be discharged within 48 hours; four had durable improvement of neurological symptoms, and all were weaned off steroids within two months. Other authors have published similar results [24,37,38].Importantly, we and others have concluded that short-term follow-up MRI must be interpreted carefully when assessing treatment effect. For two weeks to two months following LITT, lesions tend to increase in size, but develop a thinner "eggshell" rim of enhancement.…”

supporting

confidence: 76%

“…In contrast, the LITT approach offered the same diagnostic and therapeutic potential, with a considerably favorable risk profile and the ability to bring treatment lines to easily distinguished lesion borders on imaging. The first report of LITT for AIRS occurred under similar circumstances, with Rahmathulla et al [37] describing a 74-year-old with steroid-refractory edema following SRS for intracranial non-small cell lung cancer metastasis. The lesion's deep location within the centrum semiovale precluded surgery; following biopsy and LITT, the patient was discharged within 48 hours, was weaned off steroids, and demonstrated radiographic improvement at seven-week follow-up.…”

Section: Discussionmentioning

confidence: 92%

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Laser Interstitial Thermal Therapy for Radiation Necrosis/Adverse Inflammatory Responses to SRS - Case Report and Literature Review

Tsvankin¹,

Howell²,

Fecci³

2017

JNSK

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Brain metastases are the most common type of intracranial tumor, and confer a dismal prognosis. Morbidity in these patients arises not only from tumor burden but from treatment-related toxicities. Among the most significant of these is radiation necrosis, a common sequelae of stereotactic radiosurgery that may cause neurologic impairment through mass effect or steroid-refractory edema. Truly, "radiation necrosis" is a misnomer, as the process is more accurately an adverse inflammatory response post-stereotactic radiotherapy (AIRS). Because it is impossible to reliably distinguish AIRS from tumor recurrence without a biopsy, and because high-dose steroids are poorly tolerated, management of AIRS poses a significant therapeutic challenge. Laser interstitial thermal therapy (LITT) is an emerging minimally-invasive treatment modality which uses hyperthermia to ablate intracranial pathologic tissues. Here, we describe the use of LITT in a patient with steroid-refractory AIRS following radiosurgery for a right supplementary motor area metastatic focus, and provide a brief review of the utility of LITT in patients with AIRS. direct heat application across the lesion volume, resulting in controlled cell death [30]. In contrast to open surgery, LITT can be performed through the same basic operating platform as a biopsy, allowing the neurosurgeon to avoid the risk of performing a craniotomy. The incision is less than 1cm long; at our institution, patients do not require ICU admission postoperatively, and most are discharged either the same day or the following morning. The result is a minimally-morbid diagnostic and treatment option for patients with previously-treated intracranial tumors. Here, we offer an illustrative case and brief review of LITT application in the setting of AIRS. Citation Case ReportThe patient is a 66 year old right-handed female with a history of lung adenocarcinoma, initially diagnosed in January of 2014 when she presented with cough and hemoptysis. Surveillance imaging demonstrated a solitary 1cm metastasis of the right frontal lobe, and the patient was treated with Cyber Knife on 3/5/2014. She underwent concurrent chemoradiation with carboplatin/paclitaxel and 60Gy radiation to the right upper lung, mediastinum and SCV region (completed 4/16/2014), followed by an additional two cycles of chemotherapy (completed 5/20/2014). She was subsequently placed on erlotinib due to EGFR mutation, then switched to afatenib in September 2014.In July 2015 the patient noted a sense of imbalance and left hand weakness; an MRI demonstrated enlargement of the previously-treated brain metastasis at the posterior margin of the right superior frontal gyrus, with significant associated edema (Figure 1). She was started on dexamethasone, with some symptomatic improvement. Given her continued weakness, however, a plan was made for the patient to undergo stereotactic biopsy with possible subsequent LITT.On 10/12/2015 the patient was electively taken to the operating room. Using frameless stereotaxy, a biopsy was...

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Section: Discussionsupporting

confidence: 67%

supporting

confidence: 76%

Section: Discussionmentioning

confidence: 92%

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Laser Interstitial Thermal Therapy for Radiation Necrosis/Adverse Inflammatory Responses to SRS - Case Report and Literature Review

Tsvankin¹,

Howell²,

Fecci³

2017

JNSK

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“…13,14 Radiation therapy has been an integral part of treating certain cancers like highgrade gliomas, and a risk was the development of radiation necrosis. 18 Potential therapies include medicine (e.g., high doses of cortical steroids or monoclonal antibodies 16 ) and resection; for patients who are not strong candidates for surgery and who have medically refractory radiation necrosis, LITT is potentially an alternative.…”

Section: Fig 1 A: Preoperative Axial Mr Image Showing Infratentoriamentioning

confidence: 99%

“…18 Potential therapies include medicine (e.g., high doses of cortical steroids or monoclonal antibodies 16 ) and resection; for patients who are not strong candidates for surgery and who have medically refractory radiation necrosis, LITT is potentially an alternative. 7,13 For instance, Torres-Reveron et al used LITT to successfully treat two cases of cerebellar lesions in which one patient tested positive for tumor recurrence and the other for radiation necrosis. 19 Our report provides further evidence that LITT is a viable treatment option when more conventional therapies are contraindicated.…”

Section: Fig 1 A: Preoperative Axial Mr Image Showing Infratentoriamentioning

confidence: 99%

Stereotactic robot-assisted MRI-guided laser thermal ablation of radiation necrosis in the posterior cranial fossa: technical note

Chan

Tran

Gill

et al. 2016

FOC

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Laser interstitial thermal therapy (LITT) is a minimally invasive procedure used to treat a variety of intracranial lesions. Utilization of robotic assistance with stereotactic procedures has gained attention due to potential for advantages over conventional techniques. The authors report the first case in which robot-assisted MRI-guided LITT was used to treat radiation necrosis in the posterior fossa, specifically within the cerebellar peduncle. The use of a stereotactic robot allowed the surgeon to perform LITT using a trajectory that would be extremely difficult with conventional arc-based techniques. A 60-year-old man presented with facial weakness and brainstem symptoms consistent with radiation necrosis. He had a history of anaplastic astrocytoma that was treated with CyberKnife radiosurgery 1 year prior to presentation, and he did well for 11 months until his symptoms recurred. The location and form of the lesion precluded excision but made the patient a suitable candidate for LITT. The location and configuration of the lesion required a trajectory for LITT that was too low for arc-based stereotactic navigation, and thus the ROSA robot (Medtech) was used. Using preoperative MRI acquisitions, the lesion in the posterior fossa was targeted. Bone fiducials were used to improve accuracy in registration, and the authors obtained an intraoperative CT image that was then fused with the MR image by the ROSA robot. They placed the laser applicator and then ablated the lesion under real-time MR thermometry. There were no complications, and the patient tolerated the procedure well. Postoperative 2-month MRI showed complete resolution of the lesion, and the patient had some improvement in symptoms.

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Liquid Biopsy Strategies to Distinguish Progression from Pseudoprogression and Radiation Necrosis in Glioblastomas

et al. 2020

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despite aggressive treatment. [1] Currently, maximal resection followed by radiation therapy with concurrent temozolomide (TMZ) and adjuvant TMZ treatment is the standard of care. Post-treatment surveillance involves serial MRI. A challenge faced by clinicians is the diagnosis and management of a gadolinium enhancing lesion on a follow-up MRI post-treatment. This suspicious lesion could be progressive disease (PD) or a mere post-treatment radiation effects such as pseudoprogression or radiation necrosis (RN). Pseudoprogression and RN are distinct clinical entities, which when identified and managed appropriately result in better outcomes, while PD of the tumor is often dismal. Patients with PD have a median survival of 3-6 months, [2] and there is no standard of care. Systemic options include TMZ rechallenge, lomustine, and antiangiogenic therapy such as bevacizumab, but their effectiveness is limited. Reradiation and reresection can be considered depending on the location of the tumor and the condition of the patient. [3] Conversely, antiangiogenic drugs like bevacizumab or cediranib decrease contrast enhancement by altering permeability of tumor vasculature without actual reduction in tumor burden, referred to as pseudoresponse. Distinguishing these clinical entities from PD is crucial to avoid unnecessary reoperations, premature discontinuation of adjuvant TMZ or its substitution with second line agents. MR imaging based monitoring is the current standard of care for post-surgical monitoring. Contrast enhancement on imaging is indicative of disrupted blood brain barrier (BBB), but not tumor presence. [4] Currently, MRI-based Response Assessment in Neuro-Oncology (RANO) criteria is used to monitor treatment response in GBM patients. The criteria included T1 gadolinium enhancing disease, T2/FLAIR changes, new lesions, corticosteroid use, and clinical status. [5] Adoption of RANO criteria for monitoring response is not without limitations. There is ambiguity in identifying radiation effects, enrolling patients into clinical trials and monitoring immunotherapy response. [6] Advanced imaging modalities including diffusion-tensor imaging, perfusion imaging, MR spectroscopy (MRS), and positron emission tomography (PET) imaging Liquid biopsy for the detection and monitoring of central nervous system tumors is of significant clinical interest. At initial diagnosis, the majority of patients with central nervous system tumors undergo magnetic resonance imaging (MRI), followed by invasive brain biopsy to determine the molecular diagnosis of the WHO 2016 classification paradigm. Despite the importance of MRI for long-term treatment monitoring, in the majority of patients who receive chemoradiation therapy for glioblastoma, it can be challenging to distinguish between radiation treatment effects including pseudoprogression, radiation necrosis, and recurrent/progressive disease based on imaging alone. Tissue biopsy-based monitoring is high risk and not always feasible. However, distinguishing these entities is of critical im...

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Laser Interstitial Thermal Therapy for Focal Cerebral Radiation Necrosis: A Case Report and Literature Review

Cited by 146 publications

References 103 publications

Laser Interstitial Thermal Therapy for Radiation Necrosis/Adverse Inflammatory Responses to SRS - Case Report and Literature Review

Laser Interstitial Thermal Therapy for Radiation Necrosis/Adverse Inflammatory Responses to SRS - Case Report and Literature Review

Stereotactic robot-assisted MRI-guided laser thermal ablation of radiation necrosis in the posterior cranial fossa: technical note

Liquid Biopsy Strategies to Distinguish Progression from Pseudoprogression and Radiation Necrosis in Glioblastomas

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