Peer-Review Short ReportLaser-Interstitial Thermal Therapy for Refractory Cerebral Edema from Post-Radiosurgery Metastasis
Introduction
Stereotactic radiosurgery is often the treatment of choice for brain metastases (5). Persistent or worsening cerebral edema can occur after radiosurgery and, in some instances, patients can develop radiation necrosis (1). Treatment of this edema includes observation, corticosteroid therapy, and surgical removal of the mass. Systemic side effects from corticosteroids and lesions that are difficult to access surgically can make the treatment of edema after radiosurgery for a metastasis difficult.
Laser-interstitial thermal therapy (LITT) delivers focal heat energy to coagulate tissue with a sharp ablation boundary zone (8). Intracranial LITT involves the stereotactic placement of a probe into a lesion followed by laser ablation while performing real-time magnetic resonance (MR) thermometry to monitor intracranial temperature. Recent studies have suggested the utility of LITT in the treatment of brain metastases and intracranial radiation necrosis 2, 8.
Persistent cerebral edema despite conventional therapies in patients with brain metastases remains a neurosurgical challenge. Current alternative therapies include bevacizumab and pentoxifylline combined with vitamin E 6, 10. LITT may be a useful treatment option for cerebral edema after stereotactic radiosurgery to a metastasis.
Section snippets
History and Physical Examination
A 64-year-old man with lung adenocarcinoma presented with left hemiparesis. He was diagnosed with stage IIIB lung adenocarcinoma 3 years prior, for which he underwent a pneumonectomy followed by chest radiotherapy and cisplatin–gemcitabine chemotherapy. The patient's past medical history was significant for hypertension, atrial fibrillation, and coronary artery disease status after coronary artery bypass grafting. On physical examination, the patient had a left hemiparesis with left proximal
Discussion
Multiple treatment options exist after stereotactic radiosurgery radiation necrosis. In patients who are asymptomatic, close monitoring with serial imaging is often sufficient. In those patients who become symptomatic from persistent edema or direct mass effect, treatment is warranted. Corticosteroids are the first line of treatment as a temporizing measure until the inflammatory reaction rescinds. If corticosteroids are insufficient or intolerable, craniotomy or bevacizumab is warranted. It is
Conclusions
LITT may be a viable, minimally invasive treatment option for refractory cerebral edema after stereotactic radiosurgery to a brain metastasis. This therapy may be of particular use for ablation of deep-seated lesions that have failed corticosteroid therapy.
Acknowledgments
The authors thank Paul H. Dressel, B.F.A., for preparation of the illustrations and Debra J. Zimmer for editorial assistance.
References (10)
- et al.
A multi-institutional experience with stereotactic radiosurgery for solitary brain metastasis
Int J Radiat Oncol Biol Phys
(1994) - et al.
Effect of bevacizumab on radiation necrosis of the brain
Int J Radiat Oncol Biol Phys
(2007) - et al.
Stereotactic radiosurgery for the treatment of brain metastases. Results of a single institution series
Cancer
(1997) - et al.
Real-time magnetic resonance-guided laser thermal therapy for focal metastatic brain tumors
Neurosurgery
(2008) - et al.
Long-term survival of patients with unresectable colorectal liver metastases treated by percutaneous interstitial laser thermotherapy
World J Surg
(2004)
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2020, Cancer LettersCitation Excerpt :The main limitations in this study were the short follow up and no histopathology confirmation of tumor recurrence versus radiation necrosis at the time of LITT procedure. From 2008 to 2017, several studies were published describing the use of LITT to treat BM recurrence after SRS, with median recurrence time ranging from 3 months up to 9.8 months and complications rates up to 44% [17,23–32]. Again, the major limitations of these studies was the lack of differentiation between RN and tumor recurrence, which precluded a better understanding regarding outcomes for these two different types of recurrence after radiation therapy.
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2017, Neurosurgery Clinics of North AmericaCitation Excerpt :Although the use of LITT in radiation necrosis is still in its infancy, early studies have suggested favorable results. Case reports involving LITT as a treatment of radiation necrosis after SRS for lung metastases have demonstrated favorable outcomes with resolution of radiation necrosis and no apparent adverse effects.58,59 Furthermore, the evaluation of an enhancing mass postradiation is often flawed, and the distinction between recurrence and radiation necrosis is in many cases ambiguous.
Laser neurosurgery: A systematic analysis of magnetic resonance-guided laser interstitial thermal therapies
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.