title: Cerebral radiation necrosis: incidence, outcomes, and risk factors with emphasis on radiation parameters and chemotherapy.
abstract: OBJECTIVE
  To investigate radiation necrosis in patients treated for glioma in terms of incidence, outcomes, predictive and prognostic factors.
  
  
  METHODS
  Records were reviewed for 426 patients followed up until death or for at least 3 years. Logistic regression analysis was performed to identify predictive and prognostic factors. Multivariate survival analysis was conducted using Cox proportional hazards regression. Separate analyses were performed for the subset of 352 patients who received a biologically effective dose (BED) > or =85.5 Gy2 (> or =45 Gy/25 fractions) who were at highest risk for radionecrosis.
  
  
  RESULTS
  Twenty-one patients developed radionecrosis (4.9%). Actuarial incidence plateaued at 13.3% after 3 years. In the high-risk subset, radiation parameters confirmed as risk factors included total dose (p < 0.001), BED (p < 0.005), neuret (p < 0.001), fraction size (p = 0.028), and the product of total dose and fraction size (p = 0.001). No patient receiving a BED <96 Gy2 developed radionecrosis. Subsequent chemotherapy significantly increased the risk of cerebral necrosis (p = 0.001) even when adjusted for BED (odds ratio [OR], 5.8; 95% confidence interval [CI], 1.6-20.3) or length of follow-up (OR, 5.4; 95% CI, 1.5-19.3). Concurrent use of valproate appeared to delay the onset of necrosis (p = 0.013). The development of radionecrosis did not affect survival (p = 0.09).
  
  
  CONCLUSIONS
  Cerebral necrosis is unlikely at doses below 50 Gy in 25 fractions. The risk increases significantly with increasing radiation dose, fraction size, and the subsequent administration of chemotherapy.
authors.affiliation: William Buckland Radiotherapy Centre, Melbourne, Australia.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Ruben
authors.forename: Michael
authors.initials: M
authors.lastname: Dally
authors.forename: Michael
authors.initials: M
authors.lastname: Bailey
authors.forename: Robin
authors.initials: R
authors.lastname: Smith
authors.forename: Catriona A
authors.initials: CA
authors.lastname: McLean
authors.forename: Pasqual
authors.initials: P
authors.lastname: Fedele
mesh_terms: D000328:Adult; D001921:Brain / Q000473:pathology* / Q000528:radiation effects; D001932:Brain Neoplasms / Q000532:radiotherapy*; D016371:Cranial Irradiation / Q000009:adverse effects*; D005260:Female; D005910:Glioma / Q000532:radiotherapy*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009336:Necrosis; D011832:Radiation Injuries / Q000453:epidemiology / Q000209:etiology / Q000473:pathology*; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D013223:Statistics as Topic; D013997:Time Factors