Cerebral radionecrosis: Incidence and risk in relation to dose, time, fractionation and volume

The authors irradiated 152 patients with primary brain and pituitary tumors from 1974 to 1976. Seven of 139 patients (5%) who received 4500 rad or greater using 180 to 200 rad fractions, developed pathologically documented cerebral radionecrosis within a median time of 14 months after completion of irradiation. The necrosis was documented by autopsy in four patients, at reoperation in two and after needle biopsy in one. It was located in the brain, distant from the original tumor in three patients, adjacent to tumor in two, and within the tumor bed in two. The latter two were classified as radionecrosis because one patient died with only minimal tumor remaining and the other patient deteriorated neurologically and stabilized after removal of the necrotic mass. On clinical grounds, we suspect that two additional patients had radiation damage to the brain, because they deteriorated neurologically without neuroradiologic evidence of tumor. Study of computerized tomography (CT) scans and superimposed dose distributions showed that necrosis was mot always within the zone of highest dose (3 patients). Risk of radionecrosis was greatest in the upper regions of dose but could not be associated with shorter time, larger fractions, or larger field size. Pathologically documented radionecrosis of brain did not develop below doses that were biologically equivalent to 5400 rad in 30 fractions over 42 days.