Reassessing the Management of Treatment-Induced Brain Necrosis in Metastatic Patients: Advancing Surgical Alternatives to Steroid Therapy
The emergence of modern adjuvant therapies has significantly improved outcomes for patients with brain metastases. However, treatment-related side effects present an ongoing challenge, particularly, treatment-induced necrosis characterized by perilesional edema and inflammation. Standard management with steroids compromises the efficacy of otherwise efficacious immunotherapeutic approaches. This position paper critiques traditional management strategies that rely heavily on systemic corticosteroid therapy-often ineffective in providing lasting relief and associated with serious side effects-and proposes a paradigm shift that prioritizes surgical resection. Resection facilitates prompt edema reduction with a low recurrence rate of symptoms and mitigates the adverse effects of prolonged corticosteroid use. We propose increased consideration for resecting symptomatic radiation necrosis to facilitate improved efficacy of immunotherapies in patients with brain metastases.
Authors
- Joshua D. Bernstock (ORCID: https://orcid.org/0000-0002-7814-3867)
- Nicholas B. Dadario (ORCID: https://orcid.org/0000-0002-8657-187X)
- Pierpaolo Peruzzi (ORCID: https://orcid.org/0000-0001-5034-2963)
- Jakob V. E. Gerstl (ORCID: https://orcid.org/0000-0002-8100-0517)
- Timothy R. Smith (ORCID: https://orcid.org/0000-0001-9607-8985)
- Pablo A. Valdés (ORCID: https://orcid.org/0000-0002-6788-8003)
- Omar Arnaout (ORCID: https://orcid.org/0000-0003-3890-8615)
- Wenya Linda Bi (ORCID: https://orcid.org/0000-0002-4635-0247)
- Ayal A. Aizer (ORCID: https://orcid.org/0000-0002-8941-188X)
- Lennard Spanehl (ORCID: https://orcid.org/0009-0009-9419-7302)
- E. Antonio Chiocca
- Florian Geßler (ORCID: https://orcid.org/0000-0002-3471-0575)
- Benjamin R. Johnston (ORCID: https://orcid.org/0000-0001-5622-1257)
- Gregory K. Friedman (ORCID: https://orcid.org/0000-0002-6653-7420)
Institutions
- Brigham and Women's Hospital (US)
- Boston Children's Hospital (US)
- The University of Texas MD Anderson Cancer Center (US)
- Harvard University (US)
- Dana-Farber Cancer Institute (US)
- Dana-Farber Brigham Cancer Center (US)
- University of Rostock (DE)
- Massachusetts Institute of Technology (US)
- Webster University (US)
Publication Details
- Journal
- Neurosurgery Open
- Published
- 2025-10-28
- DOI
- https://doi.org/10.1227/neuprac.0000000000000185
- Primary Topic
- Brain Metastases and Treatment
- Type
- article
- Field-Weighted Citation Impact
- 0.00