Radiation Necrosis in Neuro-Oncology: Diagnostic Complexity and Precision Radiotherapy Strategies.

Area of Science:

• Neuro-oncology
• Radiation Oncology
• Neuropathology

Background:

• Radiation necrosis (RN) is a significant complication following radiotherapy for central nervous system (CNS) tumors.
• It poses diagnostic and therapeutic challenges due to overlapping symptoms with tumor recurrence.
• Current understanding and management of RN require further advancement.

Purpose of the Study:

• To synthesize current evidence on the pathophysiology, risk factors, diagnostic strategies, and management of RN.
• To provide a comprehensive overview of RN in CNS tumor patients.
• To highlight emerging strategies for RN prevention and treatment.

Main Methods:

• A narrative review of English-language literature published between 1990 and 2024.
• Inclusion criteria focused on studies addressing RN incidence, diagnosis, treatment, or prevention in CNS tumor populations.
• Synthesis of relevant findings on RN pathophysiology, diagnosis, and treatment.

Main Results:

• RN stems from radiation-induced neurovascular injury, with incidence varying by tumor type, location, and treatment parameters (3-26%).
• Risk factors include radiation dose, fractionation, cumulative exposure, re-irradiation, and adjuvant therapies.
• Advanced treatment modalities reduce but do not eliminate RN risk; diagnosis remains challenging despite advanced imaging, and management involves corticosteroids, bevacizumab, surgery, and experimental therapies. Connectomics-based planning shows promise.

Conclusions:

• RN is a clinically significant complication of CNS radiotherapy with multifactorial origins.
• Precision treatments and advanced imaging have improved prevention and detection, yet diagnostic uncertainty and recurrence risk persist.
• Integrating connectomics into treatment planning may reduce RN-related morbidity by preserving neural network integrity.