title: Results of a questionnaire regarding practice patterns for the diagnosis and treatment of intracranial radiation necrosis after SRS.
abstract: Although stereotactic radiosurgery (SRS) is an effective treatment option for patients with brain tumors, its increased use has raised concern for increased incidence of radiation necrosis (RN). No established standard or guidelines exists regarding non-invasive techniques to diagnose or treat RN. This study was conducted to assess current patterns of evaluation and treatment of RN among physicians who treat intracranial malignancies. A questionnaire consisting of 20 questions was sent to 3,041 members of the American Society for Radiation Oncology (ASTRO) and the Society for Neurologic Oncology (SNO). Questions addressed demographics, utilization of SRS, perceptions regarding RN diagnosis treatment, approach to steroid-refractory RN, and management of two clinical scenarios using Kwiksurvey© software. The survey response rate was 8.74 % (266/3,041). Most respondents practice in an academic and/or university setting (62 %) at a facility that performs SRS (94 %) with a variety of systems. The number of annual cases performed at the participant's institution varied from <50 to >400, with a wide degree of variability. Most respondents practice at an institution that performs 50-100 cases/year (28 %). The most common range of symptomatic RN seen in clinical practice was 1-5 % (61 %). Most respondents reported that asymptomatic RN occurs in 6-10 % (33 %). Favored non-invasive diagnostic mechanisms were clinical evaluation (37 %) and MRI (19 %). In response to a clinical scenario depicting an asymptomatic patient post-SRS for brain metastasis with an enlarging lesion and edema at the treatment site, most respondents felt the image represented RN or a combination of RN and tumor progression. Most (58 %) favored short-term follow-up with repeat MRI. Ninety-three percent of the respondents initiated steroids as a first-line approach if patient was to develop symptoms. Steroids were the preferred first therapy in symptomatic patients on initial follow-up (81 %). In steroid-refractory patients, most recommend surgical intervention (63 %). Most physicians who responded to this questionnaire believe that post-SRS RN is uncommon (≤10 % of cases). The approach to establish the diagnosis of RN is variable. Steroids are the most commonly utilized first-line treatment for suspected RN. Considerable variation exists in the management of steroid-refractory RN. Additional studies are required to establish guidelines for evaluation and treatment of RN.
authors.affiliation: Radiation Oncology Department, Taussig Cancer Center, Cleveland Clinic, 9500 Euclid Avenue, Mailstop T-28, Cleveland, OH, 44195, USA.
authors.forename: Abigail L
authors.initials: AL
authors.lastname: Stockham
authors.forename: Manmeet
authors.initials: M
authors.lastname: Ahluwalia
authors.forename: Chandana A
authors.initials: CA
authors.lastname: Reddy
authors.forename: John H
authors.initials: JH
authors.lastname: Suh
authors.forename: Aryavarta
authors.initials: A
authors.lastname: Kumar
authors.forename: Michael A
authors.initials: MA
authors.lastname: Vogelbaum
authors.forename: Gene H
authors.initials: GH
authors.lastname: Barnett
authors.forename: Erin S
authors.initials: ES
authors.lastname: Murphy
authors.forename: Samuel T
authors.initials: ST
authors.lastname: Chao
mesh_terms: D001932:Brain Neoplasms / Q000150:complications / Q000601:surgery*; D006801:Humans; D009336:Necrosis; D010818:Practice Patterns, Physicians'; D011832:Radiation Injuries / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D016634:Radiosurgery / Q000009:adverse effects*; D011795:Surveys and Questionnaires
references.citation: Int J Radiat Oncol Biol Phys. 2011 Apr 1;79(5):1487-95
references.pmid: 20399573
references.citation: Int J Radiat Oncol Biol Phys. 1995 Oct 15;33(3):619-26
references.pmid: 7558951
references.citation: Radiat Oncol. 2011 May 15;6:48
references.pmid: 21575163
references.citation: JAMA. 2006 Jun 7;295(21):2483-91
references.pmid: 16757720
references.citation: Int J Radiat Oncol Biol Phys. 2010 Jul 15;77(4):996-1001
references.pmid: 19783374
references.citation: Cancer. 2012 Jun 1;118(11):2780-6
references.pmid: 22614656
references.citation: Clin Neurol Neurosurg. 2011 Nov;113(9):798-802
references.pmid: 21906869
references.citation: J Neurooncol. 2011 Sep;104(2):611
references.pmid: 21188468
references.citation: Br J Cancer. 2012 Mar 13;106(6):1021-6
references.pmid: 22374464
references.citation: Acta Neurochir (Wien). 2003 Jul;145(7):557-64; discussion 564
references.pmid: 12910398
references.citation: J Neurosurg. 2005 Jan;102 Suppl:266-71
references.pmid: 15662823
references.citation: Eur J Med Res. 2012 Aug 23;17:25
references.pmid: 22913802
references.citation: Lancet. 2004 May 22;363(9422):1665-72
references.pmid: 15158627
references.citation: J Clin Oncol. 2011 Mar 1;29(7):e159-62
references.pmid: 21149667
references.citation: Semin Radiat Oncol. 2007 Apr;17(2):99-107
references.pmid: 17395040
references.citation: Dig Dis Sci. 2010 Mar;55(3):617-25
references.pmid: 19294507
references.citation: Int J Radiat Oncol Biol Phys. 2012 Jul 1;83(3):e431-6
references.pmid: 22483739
references.citation: Clin Nucl Med. 2011 Nov;36(11):978-81
references.pmid: 21975383
references.citation: Int J Radiat Oncol Biol Phys. 2013 Jan 1;85(1):47-52
references.pmid: 22541963
references.citation: Strahlenther Onkol. 2011 Feb;187(2):135-9
references.pmid: 21336713
references.citation: Neurosurgery. 2008 Nov;63(5):898-903; discussion 904
references.pmid: 19005380
references.citation: Ann Nucl Med. 2011 Apr;25(3):213-20
references.pmid: 21188660
references.citation: World Neurosurg. 2010 Apr;73(4):361-4
references.pmid: 20849794
references.citation: Neurosurgery. 2010 Mar;66(3):486-91; discussion 491-2
references.pmid: 20173543
references.citation: Radiology. 1986 Jan;158(1):149-55
references.pmid: 3940373
references.citation: Folia Neuropathol. 2010;48(2):81-92
references.pmid: 20602289
references.citation: J Neurooncol. 2012 Aug;109(1):149-58
references.pmid: 22638727
references.citation: Eur J Radiol. 2012 Nov;81(11):3496-503
references.pmid: 22483601
references.citation: J Neurol. 2009 Jun;256(6):878-87
references.pmid: 19274425
references.citation: Stereotact Funct Neurosurg. 2008;86(6):359-66
references.pmid: 18854663
references.citation: N Engl J Med. 2010 Mar 25;362(12):1119-27
references.pmid: 20335588
references.citation: Laryngoscope. 1997 Mar;107(3):391-5
references.pmid: 9121320
references.citation: Prog Neurol Surg. 2012;25:210-20
references.pmid: 22236682