Background: Radiation necrosis (RN) is a delayed and potentially debilitating complication of radiotherapy for central nervous system (CNS) tumors. It presents significant diagnostic and therapeutic challenges due to the variable clinical manifestations and overlap with tumor recurrence. Although advances in radiotherapy have improved tumor control, RN remains incompletely understood and inadequately addressed. This narrative review synthesizes current evidence on RN pathophysiology, risk factors, diagnostic strategies, and management approaches. Methods: A literature search was conducted for English-language literature published between January 1990 and December 2024. Studies were included if they addressed RN incidence, diagnosis, treatment, or novel preventive strategies in CNS tumor populations. Relevant findings were synthesized to produce a narrative review summarizing pathophysiology, diagnostic challenges, and treatment strategies. Results: RN results from radiation-induced neurovascular injury, inflammation, and vessel permeability, with incidence ranging from 3 to 26% depending on tumor type, location, and treatment parameters. Risk is influenced by dose, fractionation, cumulative exposure, re-irradiation, and adjuvant therapies. Advanced modalities such as SRS, HFSRT, brachytherapy, proton therapy, and IORT reduce but do not eliminate RN risk. Diagnosis remains challenging despite advanced MRI and PET techniques, with histopathology as the gold standard. Management includes corticosteroids, bevacizumab, surgery, LITT, and experimental therapies. Connectomics-based planning shows promise in minimizing RN by sparing critical brain networks. Conclusions: RN is a clinically significant and multifactorial complication of CNS radiotherapy. Precision treatment modalities and advanced imaging have improved prevention and detection, but diagnostic uncertainty and recurrence risk persist. Integration of connectomics into treatment planning may offer future promise of a reduction in RN-related morbidity by preserving structural and functional network integrity.
背景：放射性坏死（RN）是中枢神经系统（CNS）肿瘤放疗后一种延迟发生且可能致残的并发症。由于其临床表现多变且与肿瘤复发存在重叠，RN的诊断和治疗面临重大挑战。尽管放疗技术的进步提高了肿瘤控制率，但RN的机制尚未完全阐明，临床应对仍不充分。本文通过叙述性综述整合了当前关于RN病理生理学、危险因素、诊断策略及治疗方法的证据。 方法：检索了1990年1月至2024年12月期间发表的英文文献。纳入标准为涉及CNS肿瘤患者RN发生率、诊断、治疗或新型预防策略的研究。综合相关研究结果，形成一篇总结病理生理机制、诊断挑战及治疗策略的叙述性综述。 结果：RN由辐射诱导的神经血管损伤、炎症反应及血管通透性改变引起，发生率介于3%至26%之间，具体取决于肿瘤类型、位置及治疗参数。其风险受剂量、分割方式、累积照射、再程放疗及辅助治疗等因素影响。立体定向放射外科（SRS）、大分割立体定向放疗（HFSRT）、近距离放疗、质子治疗及术中放疗等先进技术可降低但无法完全消除RN风险。尽管高级MRI与PET技术不断发展，诊断仍具挑战性，组织病理学仍是金标准。治疗手段包括皮质类固醇、贝伐珠单抗、手术、激光间质热疗（LITT）及实验性疗法。基于连接组学的放疗计划设计通过保护关键脑网络，展现出减少RN发生的潜力。 结论：RN是CNS放疗中具有重要临床意义且受多因素影响的并发症。精准放疗技术与先进影像学手段提升了预防与检测水平，但诊断不确定性与复发风险依然存在。将连接组学整合至治疗计划中，有望通过保护结构和功能网络完整性，未来进一步降低RN相关发病率。
Radiation Necrosis in Neuro-Oncology: Diagnostic Complexity and Precision Radiotherapy Strategies
肿瘤(癌症)患者之家