Contemporary Management of Radiation Necrosis: Insights and Avenues

Radiation necrosis (RN) remains a challenging complication of upfront radiation therapy for both brain metastases and primary tumors. Despite development of an array of advanced imaging modalities to differentiate RN and true tumor progression, tissue diagnosis remains the gold standard. Synergizing artificial intelligence to assist with imaging and intraoperative pathologic diagnosis may represent a fruitful future direction. Similarly, laser interstitial thermal therapy (LITT) is an attractive alternative for RN management when the costs and complications of chronic steroid or bevacizumab are considered. Current evidence suggests an angio-inflammatory cascade is responsible for RN development; tissue-based studies and preclinical modeling are needed to reveal targetable causal mechanisms that may support clinical risk stratification and treatment.