Radiation necrosis mimicking tumor recurrence after chemoradiation for vaginal squamous cell carcinoma

Radiation necrosis is a rare but serious complication of pelvic chemoradiotherapy that may closely mimic tumor recurrence on both imaging and clinical examination. We describe the case of a 43-year-old woman with FIGO stage II vaginal squamous cell carcinoma and synchronous CIN3 who developed profuse vaginal discharge and necrotic cervical lesions five months after completing chemoradiation and brachytherapy. MRI revealed a necrotic cervical mass with suspicious features, while biopsies initially yielded inconclusive results. A multidisciplinary approach was adopted: the patient received empirical antibiotics, underwent necrotic tissue debridement, and repeat biopsies. Final histology showed no viable malignancy, confirming radiation necrosis. The patient was managed conservatively with symptomatic improvement. This case highlights the diagnostic challenge of distinguishing necrosis from recurrence, where early imaging, cytology, and even initial biopsies may be misleading. Thorough evaluation and repeated sampling are essential to avoid overtreatment. We provide a literature-informed comparison of distinguishing features to guide clinical decision-making.