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Many publications report laser-interstitial thermal therapy (LITT) as a viable alternative treatment to craniotomy for radiation necrosis (RN) and re-growing tumor occurring after stereotactic radiosurgery (SRS) for brain metastases. No studies to-date have compared the two options. The aim of this study was to retrospectively compare outcomes after LITT versus craniotomy for regrowing lesions in patients previously treated with SRS for brain metastases. Data were collected from a single-institution chart review of patients treated with LITT or craniotomy for previously irradiated brain metastasis. Of 75 patients, 42 had recurrent tumor (56%) and 33 (44%) had RN. Of patients with tumor, 26 underwent craniotomy and 16 LITT. For RN, 15 had craniotomy and 18 LITT. There was no significant difference between LITT and craniotomy in ability to taper off steroids or neurological outcomes. Progression-free survival (PFS) and overall survival (OS) were similar for LITT versus craniotomy, respectively: %PFS-survival at 1-year = 72.2% versus 61.1%, %PFS-survival at 2-years = 60.0% versus 61.1%, p = 0.72; %OS-survival at 1-year = 69.0% versus 69.3%, %OS-survival at 2-years = 56.6% versus 49.5%, p = 0.90. This finding persisted on sub-analysis of smaller lesions under < 3cm in diameter. Craniotomy resulted in higher rates of pre-operative deficit improvement than LITT (p < 0.01). On sub-group analysis, the single factor most significantly associated with OS and PFS was pathology of the lesion. About 40% of tumor lesions needed post-operative salvage with radiation after both craniotomy and LITT. LITT was as efficacious as craniotomy in achieving local control of recurrent irradiated brain metastases and facilitating steroid taper, regardless of pathology. Craniotomy appears to be more advantageous for providing symptom relief in those with pre-operative symptoms. more...

INTRODUCTION: Both medical management with bevacizumab and surgical management via craniotomy or more recently with laser interstitial thermal ablation (LITT) have been shown to be efficacious in the management of radiation necrosis (RN) after radiosurgery for brain metastases (BM). Indications for how to choose medical versus surgical management however remains unclear. METHODS: Single-institution chart review was performed of all patients with biopsy or radiographically confirmed RN after radiosurgery for BM between 2011 and 2017. Progression-free survival (PFS) and overall survival (OS) were compared between those treated using bevacizumab versus surgical intervention. RESULTS: 15 patients underwent craniotomy, 18 patients underwent LITT, and 18 patients were treated with bevacizumab. Those treated with bevacizumab had significantly higher number of regrowing lesions (n >1) at time of intervention (50.0%) versus those treated with surgery (15.2%) (p< 0.05). Likewise, pre-treatment KPS was lower in the bevacizumab cohort (median: 60) vs the surgery cohort (median: 90) (p< 0.05). Patients treated with bevacizumab demonstrated significantly decreased PFS (%PFS at 1-year 16.7% vs 86.7% and 87.8% for craniotomy and LITT, respectively; %PFS at 2-years 0% vs 86.7% and 73.2% for craniotomy and LITT, respectively, p < 0.05). Similar results were observed for OS (%OS at 1-year for bevacizumab 33.3% vs 93.3% and 73.8% for craniotomy and LITT, respectively; %OS at 2-years for bevacizumab 11.1% vs 64.6% and 63.2% for craniotomy and LITT, respectively, p< 0.05). CONCLUSIONS: Preliminary analysis shows that bevacizumab therapy in our institution is being chosen for patients with lower KPS and multiple regrowing lesions while surgical intervention is being chosen for patients with good KPS and single, symptomatic regrowing lesions. While the comparative outcomes after bevacizumab appear to be significantly worse than surgical management, it remains unknown if the difference is more related to its true efficacy or the significant discrepancy between the comparison groups. more...