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Radiation and Chemotherapy
Miral D. Jhaveri, MD, MBA
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Synonyms

                • Radiation changes, chemotherapy effects, treatment-related changes
              • Definitions

                • Radiation-induced brain injury (RIBI): Variety of imaging findings that result from radiation therapy
                  • Acute (during or shortly after radiation), early delayed (typically 1-6 months after radiation), and late delayed (6 months to years after completion of radiation)
                  • Radiation-induced vascular injury
                    • Radiation-induced vasculopathy, radiation-induced vascular malformations (RIVMs), and mineralizing microangiopathy
                  • Radiation-induced parenchymal injury 
                    • Radiation necrosis, combination of vascular & parenchymal injury with necrosis of tumor &/or normal brain parenchyma
                    • Radiation-induced leukoencephalopathy denotes white matter (WM) injury, necrotizing leukoencephalopathy (NLE)
                  • Radiation-induced neoplasms
                  • Stroke-like migraine attacks after radiation therapy (SMART) syndrome
                • Chemotherapeutic agents related toxicity to CNS: Drug-related toxic leukoencephalopathy, posterior reversible encephalopathy syndrome (PRES)

              IMAGING

              • General Features

                • CT Findings

                  • MR Findings

                    • Angiographic Findings

                      • Nuclear Medicine Findings

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • General Features

                              • Staging, Grading, & Classification

                                • Gross Pathologic & Surgical Features

                                  • Microscopic Features

                                    CLINICAL ISSUES

                                    • Presentation

                                      • Demographics

                                        • Natural History & Prognosis

                                          • Treatment

                                            DIAGNOSTIC CHECKLIST

                                            • Consider

                                              • Image Interpretation Pearls

                                                Selected References

                                                1. Ali FS et al: Cerebral radiation necrosis: incidence, pathogenesis, diagnostic challenges, and future opportunities. Curr Oncol Rep. 21(8):66, 2019
                                                2. Furuse M et al: Radiological diagnosis of brain radiation necrosis after cranial irradiation for brain tumor: a systematic review. Radiat Oncol. 14(1):28, 2019
                                                3. Kanda T et al: Imaging findings in radiation therapy complications of the central nervous system. Jpn J Radiol. 36(9):519-27, 2018
                                                4. Kessler AT et al: Brain tumour post-treatment imaging and treatment-related complications. Insights Imaging. 9(6):1057-75, 2018
                                                5. Nolan CP et al: Neurologic complications of chemotherapy and radiation therapy. Continuum (Minneap Minn). 21(2 Neuro-oncology):429-51, 2015
                                                6. Diaz AZ et al: Radiation-associated toxicities in the treatment of high-grade gliomas. Semin Oncol. 41(4):532-40, 2014
                                                7. O'Brien BJ et al: Post-treatment imaging changes in primary brain tumors. Curr Oncol Rep. 16(8):397, 2014
                                                8. Zhang H et al: Role of magnetic resonance spectroscopy for the differentiation of recurrent glioma from radiation necrosis: a systematic review and meta-analysis. Eur J Radiol. 83(12):2181-9, 2014
                                                9. Reddy K et al: MRI patterns of T1 enhancing radiation necrosis versus tumour recurrence in high-grade gliomas. J Med Imaging Radiat Oncol. 57(3):349-55, 2013
                                                10. Shah R et al: Radiation necrosis in the brain: imaging features and differentiation from tumor recurrence. Radiographics. 32(5):1343-59, 2012
                                                11. Chan KC et al: MRI of late microstructural and metabolic alterations in radiation-induced brain injuries. J Magn Reson Imaging. 29(5):1013-20, 2009
                                                12. Hackney DB: Forget the diffusion--do we need T2-weighted MR images to detect early central nervous system injury? Radiology. 250(2):303-4, 2009
                                                13. Pružincová L et al: MR imaging of late radiation therapy- and chemotherapy-induced injury: a pictorial essay. Eur Radiol. 19(11):2716-27, 2009
                                                14. Sundgren PC et al: Metabolic alterations: a biomarker for radiation-induced normal brain injury-an MR spectroscopy study. J Magn Reson Imaging. 29(2):291-7, 2009
                                                15. Sundgren PC: MR spectroscopy in radiation injury. AJNR Am J Neuroradiol. 30(8):1469-76, 2009
                                                16. Kang TW et al: Morphological and functional MRI, MRS, perfusion and diffusion changes after radiosurgery of brain metastasis. Eur J Radiol. 72(3):370-80, 2008
                                                17. Welzel T et al: Diffusion tensor imaging screening of radiation-induced changes in the white matter after prophylactic cranial irradiation of patients with small cell lung cancer: first results of a prospective study. AJNR Am J Neuroradiol. 29(2):379-83, 2008
                                                18. Burn S et al: Incidence of cavernoma development in children after radiotherapy for brain tumors. J Neurosurg. 106(5 Suppl):379-83, 2007
                                                19. Zeng QS et al: Multivoxel 3D proton MR spectroscopy in the distinction of recurrent glioma from radiation injury. J Neurooncol. 84(1):63-9, 2007
                                                20. Chan MS et al: MR imaging of the brain in patients cured of acute lymphoblastic leukemia--the value of gradient echo imaging. AJNR Am J Neuroradiol. 27(3):548-52, 2006
                                                21. Chan YL et al: Dynamic susceptibility contrast-enhanced perfusion MR imaging in late radiation-induced injury of the brain. Acta Neurochir Suppl. 95:173-5, 2005
                                                22. Weybright P et al: Differentiation between brain tumor recurrence and radiation injury using MR spectroscopy. AJR Am J Roentgenol. 185(6):1471-6, 2005
                                                23. Vázquez E et al: Neuroimaging in pediatric leukemia and lymphoma: differential diagnosis. Radiographics. 22(6):1411-28, 2002
                                                24. Chong VF et al: Temporal lobe changes following radiation therapy: imaging and proton MR spectroscopic findings. Eur Radiol. 11(2):317-24, 2001
                                                25. Kamiryo T et al: Radiosurgery-induced microvascular alterations precede necrosis of the brain neuropil. Neurosurgery. 49(2):409-14; discussion 414-5, 2001
                                                26. Kumar AJ et al: Malignant gliomas: MR imaging spectrum of radiation therapy- and chemotherapy-induced necrosis of the brain after treatment. Radiology. 217(2):377-84, 2000
                                                27. Keime-Guibert F et al: Neurological complications of radiotherapy and chemotherapy. J Neurol. 245(11):695-708, 1998
                                                Related Anatomy
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                                                Related Differential Diagnoses
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                                                References
                                                Tables

                                                Tables

                                                KEY FACTS

                                                • Terminology

                                                  • Imaging

                                                    • Top Differential Diagnoses

                                                      • Pathology

                                                        • Clinical Issues

                                                          • Diagnostic Checklist

                                                            TERMINOLOGY

                                                            • Synonyms

                                                              • Radiation changes, chemotherapy effects, treatment-related changes
                                                            • Definitions

                                                              • Radiation-induced brain injury (RIBI): Variety of imaging findings that result from radiation therapy
                                                                • Acute (during or shortly after radiation), early delayed (typically 1-6 months after radiation), and late delayed (6 months to years after completion of radiation)
                                                                • Radiation-induced vascular injury
                                                                  • Radiation-induced vasculopathy, radiation-induced vascular malformations (RIVMs), and mineralizing microangiopathy
                                                                • Radiation-induced parenchymal injury 
                                                                  • Radiation necrosis, combination of vascular & parenchymal injury with necrosis of tumor &/or normal brain parenchyma
                                                                  • Radiation-induced leukoencephalopathy denotes white matter (WM) injury, necrotizing leukoencephalopathy (NLE)
                                                                • Radiation-induced neoplasms
                                                                • Stroke-like migraine attacks after radiation therapy (SMART) syndrome
                                                              • Chemotherapeutic agents related toxicity to CNS: Drug-related toxic leukoencephalopathy, posterior reversible encephalopathy syndrome (PRES)

                                                            IMAGING

                                                            • General Features

                                                              • CT Findings

                                                                • MR Findings

                                                                  • Angiographic Findings

                                                                    • Nuclear Medicine Findings

                                                                      • Imaging Recommendations

                                                                        DIFFERENTIAL DIAGNOSIS

                                                                          PATHOLOGY

                                                                          • General Features

                                                                            • Staging, Grading, & Classification

                                                                              • Gross Pathologic & Surgical Features

                                                                                • Microscopic Features

                                                                                  CLINICAL ISSUES

                                                                                  • Presentation

                                                                                    • Demographics

                                                                                      • Natural History & Prognosis

                                                                                        • Treatment

                                                                                          DIAGNOSTIC CHECKLIST

                                                                                          • Consider

                                                                                            • Image Interpretation Pearls

                                                                                              Selected References

                                                                                              1. Ali FS et al: Cerebral radiation necrosis: incidence, pathogenesis, diagnostic challenges, and future opportunities. Curr Oncol Rep. 21(8):66, 2019
                                                                                              2. Furuse M et al: Radiological diagnosis of brain radiation necrosis after cranial irradiation for brain tumor: a systematic review. Radiat Oncol. 14(1):28, 2019
                                                                                              3. Kanda T et al: Imaging findings in radiation therapy complications of the central nervous system. Jpn J Radiol. 36(9):519-27, 2018
                                                                                              4. Kessler AT et al: Brain tumour post-treatment imaging and treatment-related complications. Insights Imaging. 9(6):1057-75, 2018
                                                                                              5. Nolan CP et al: Neurologic complications of chemotherapy and radiation therapy. Continuum (Minneap Minn). 21(2 Neuro-oncology):429-51, 2015
                                                                                              6. Diaz AZ et al: Radiation-associated toxicities in the treatment of high-grade gliomas. Semin Oncol. 41(4):532-40, 2014
                                                                                              7. O'Brien BJ et al: Post-treatment imaging changes in primary brain tumors. Curr Oncol Rep. 16(8):397, 2014
                                                                                              8. Zhang H et al: Role of magnetic resonance spectroscopy for the differentiation of recurrent glioma from radiation necrosis: a systematic review and meta-analysis. Eur J Radiol. 83(12):2181-9, 2014
                                                                                              9. Reddy K et al: MRI patterns of T1 enhancing radiation necrosis versus tumour recurrence in high-grade gliomas. J Med Imaging Radiat Oncol. 57(3):349-55, 2013
                                                                                              10. Shah R et al: Radiation necrosis in the brain: imaging features and differentiation from tumor recurrence. Radiographics. 32(5):1343-59, 2012
                                                                                              11. Chan KC et al: MRI of late microstructural and metabolic alterations in radiation-induced brain injuries. J Magn Reson Imaging. 29(5):1013-20, 2009
                                                                                              12. Hackney DB: Forget the diffusion--do we need T2-weighted MR images to detect early central nervous system injury? Radiology. 250(2):303-4, 2009
                                                                                              13. Pružincová L et al: MR imaging of late radiation therapy- and chemotherapy-induced injury: a pictorial essay. Eur Radiol. 19(11):2716-27, 2009
                                                                                              14. Sundgren PC et al: Metabolic alterations: a biomarker for radiation-induced normal brain injury-an MR spectroscopy study. J Magn Reson Imaging. 29(2):291-7, 2009
                                                                                              15. Sundgren PC: MR spectroscopy in radiation injury. AJNR Am J Neuroradiol. 30(8):1469-76, 2009
                                                                                              16. Kang TW et al: Morphological and functional MRI, MRS, perfusion and diffusion changes after radiosurgery of brain metastasis. Eur J Radiol. 72(3):370-80, 2008
                                                                                              17. Welzel T et al: Diffusion tensor imaging screening of radiation-induced changes in the white matter after prophylactic cranial irradiation of patients with small cell lung cancer: first results of a prospective study. AJNR Am J Neuroradiol. 29(2):379-83, 2008
                                                                                              18. Burn S et al: Incidence of cavernoma development in children after radiotherapy for brain tumors. J Neurosurg. 106(5 Suppl):379-83, 2007
                                                                                              19. Zeng QS et al: Multivoxel 3D proton MR spectroscopy in the distinction of recurrent glioma from radiation injury. J Neurooncol. 84(1):63-9, 2007
                                                                                              20. Chan MS et al: MR imaging of the brain in patients cured of acute lymphoblastic leukemia--the value of gradient echo imaging. AJNR Am J Neuroradiol. 27(3):548-52, 2006
                                                                                              21. Chan YL et al: Dynamic susceptibility contrast-enhanced perfusion MR imaging in late radiation-induced injury of the brain. Acta Neurochir Suppl. 95:173-5, 2005
                                                                                              22. Weybright P et al: Differentiation between brain tumor recurrence and radiation injury using MR spectroscopy. AJR Am J Roentgenol. 185(6):1471-6, 2005
                                                                                              23. Vázquez E et al: Neuroimaging in pediatric leukemia and lymphoma: differential diagnosis. Radiographics. 22(6):1411-28, 2002
                                                                                              24. Chong VF et al: Temporal lobe changes following radiation therapy: imaging and proton MR spectroscopic findings. Eur Radiol. 11(2):317-24, 2001
                                                                                              25. Kamiryo T et al: Radiosurgery-induced microvascular alterations precede necrosis of the brain neuropil. Neurosurgery. 49(2):409-14; discussion 414-5, 2001
                                                                                              26. Kumar AJ et al: Malignant gliomas: MR imaging spectrum of radiation therapy- and chemotherapy-induced necrosis of the brain after treatment. Radiology. 217(2):377-84, 2000
                                                                                              27. Keime-Guibert F et al: Neurological complications of radiotherapy and chemotherapy. J Neurol. 245(11):695-708, 1998