Radiomic Analysis of Treatment Effect for Patients with Radiation Necrosis Treated with Pentoxifylline and Vitamin E.

Simple Summary: Patients who undergo stereotactic radiosurgery (SRS) are at risk of developing radiation necrosis (RN), which may lead to permanent neurological injury. While corticosteroids are common in first-line treatment, they carry their own side effect profile. Prior studies have shown that the combination of pentoxifylline (Ptx) and vitamin E (VitE) may be a possible alternative management route for RN. In this study, we provide our institutional experience on the use of Ptx + VitE in patients who developed RN after SRS. We found that nearly half of our patients showed some evidence of improvement on MRI with Ptx + VitE, with very few side effects. Furthermore, deeper analyses of post-contrast MRIs show that derivable radiomic features may predict how patients will respond to this treatment. Our results suggest that Ptx + VitE for RN and radiomic analysis of treatment response be evaluated in a larger-scale study. Background: The combination of oral pentoxifylline (Ptx) and vitamin E (VitE) has been used to treat radiation-induced fibrosis and soft tissue injury. Here, we review outcomes and perform a radiomic analysis of treatment effects in patients prescribed Ptx + VitE at our institution for the treatment of radiation necrosis (RN). Methods: A total of 48 patients treated with stereotactic radiosurgery (SRS) had evidence of RN and had MRI before and after starting Ptx + VitE. The radiation oncologist's impression of the imaging in the electronic medical record was used to score response to treatment. Support Vector Machine (SVM) was used to train a model of radiomics features derived from radiation necrosis on pre- and 1st post-treatment T1 post-contrast MRIs that can classify the ultimate response to treatment with Ptx + VitE. Results: A total of 43.8% of patients showed evidence of improvement, 18.8% showed no change, and 25% showed worsening RN upon imaging after starting Ptx + VitE. The median time-to-response assessment was 3.17 months. Nine patients progressed significantly and required Bevacizumab, hyperbaric oxygen therapy, or surgery. Patients who had multiple lesions treated with SRS were less likely to show improvement (p = 0.037). A total of 34 patients were also prescribed dexamethasone, either before (7), with (16), or after starting (11) treatment. The use of dexamethasone was not associated with an improved response to Ptx + VitE (p = 0.471). Three patients stopped treatment due to side effects. Finally, we were able to develop a machine learning (SVM) model of radiomic features derived from pre- and 1st post-treatment MRIs that was able to predict the ultimate treatment response to Ptx + VitE with receiver operating characteristic (ROC) area under curve (AUC) of 0.69. Conclusions: Ptx + VitE appears safe for the treatment of RN, but randomized data are needed to assess efficacy and validate radiomic models, which may assist with prognostication. [ABSTRACT FROM AUTHOR]