title: Targeted intraarterial anti-VEGF therapy for medically refractory radiation necrosis in the brain.
abstract: Radiation necrosis (RN) is a serious complication that can occur in up to 10% of brain radiotherapy cases, with the incidence dependent on both dose and brain location. Available medical treatment for RN includes steroids, vitamin E, pentoxifylline, and hyperbaric oxygen. In a significant number of patients, however, RN is medically refractory and the patients experience progressive neurological decline, disabling headaches, and decreased quality of life. Vascular endothelial growth factor (VEGF) is a known mediator of cerebral edema in RN. Recent reports have shown successful treatment of RN with intravenous bevacizumab, a monoclonal antibody for VEGF. Bevacizumab, however, is associated with significant systemic complications including sinus thrombosis, pulmonary embolus, gastrointestinal tract perforation, wound dehiscence, and severe hypertension. Using lower drug doses may decrease systemic exposure and reduce complication rates. By using an intraarterial route for drug administration following blood-brain barrier disruption (BBBD), the authors aim to lower the bevacizumab dose while increasing target delivery. In the present report, the authors present the cases of 2 pediatric patients with cerebral arteriovenous malformations, who presented with medically intractable RN following stereotactic radiosurgery. They received a single intraarterial infusion of 2.5 mg/kg bevacizumab after hyperosmotic BBBD. At mean follow-up duration of 8.5 months, the patients had significant and durable clinical and radiographic response. Both patients experienced resolution of their previously intractable headaches and reversal of cushingoid features as they were successfully weaned off steroids. One of the patients regained significant motor strength. There was an associated greater than 70% reduction in cerebral edema. Intraarterial administration of a single low dose of bevacizumab after BBBD was safe and resulted in durable clinical and radiographic improvements at concentrations well below those required for the typical systemic intravenous route. Advantages over the intravenous route may include higher concentration of drug delivery to the affected brain, decreased systemic toxicity, and a significantly lower cost.
authors.affiliation: Norton Neuroscience Institute and.
authors.forename: Shervin R
authors.initials: SR
authors.lastname: Dashti
authors.forename: Aaron
authors.initials: A
authors.lastname: Spalding
authors.forename: Rob J
authors.initials: RJ
authors.lastname: Kadner
authors.forename: Tom
authors.initials: T
authors.lastname: Yao
authors.forename: Arooshi
authors.initials: A
authors.lastname: Kumar
authors.forename: David A
authors.initials: DA
authors.lastname: Sun
authors.forename: Renato
authors.initials: R
authors.lastname: LaRocca
mesh_terms: D020533:Angiogenesis Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage / Q000627:therapeutic use*; D000068258:Bevacizumab; D001921:Brain / Q000473:pathology* / Q000528:radiation effects; D001929:Brain Edema / Q000209:etiology; D002648:Child; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D007261:Infusions, Intra-Arterial; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D009336:Necrosis / Q000209:etiology; D011832:Radiation Injuries / Q000150:complications* / Q000209:etiology; D016634:Radiosurgery / Q000009:adverse effects*; D016896:Treatment Outcome; D042461:Vascular Endothelial Growth Factor A / Q000037:antagonists & inhibitors*
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; C467484:VEGFA protein, human; D042461:Vascular Endothelial Growth Factor A; D000068258:Bevacizumab
keywords: AVM = arteriovenous malformation; BBB = blood-brain barrier; BBBD = BBB disruption; RN = radiation necrosis; SRS = stereotactic radiosurgery; VEGF = vascular endothelial growth factor; arteriovenous malformation; bevacizumab; blood-brain barrier disruption; intraarterial chemotherapy; oncology; radiation adverse effect; radiation necrosis; stereotactic radiosurgery