Multidisciplinary Management of HER2+ Breast Cancer - Episode 14

HER2+ MBC: Radiation Necrosis Vs Disease Progression

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Improvements regarding the identification and management of radiation necrosis in patients with HER2-positive metastatic breast cancer.

Sara A. Hurvitz, MD: Kamran, I want to ask you 1 question before we round up because we struggle with this in patients who’ve received radiation for brain metastases, and that’s the issue of radiation necrosis. If you could give us a picture of what this is, how we treat it, and approaches being developed to help us distinguish necrosis from progression in the brain.

Kamran Ahmed, MD: Radiation necrosis is 1 of the most worrisome adverse effects that radiation oncologists follow patients for and counsel patients on, in terms of the risks of that happening post-stereotactic treatment. The rates vary in series, but it can occur in up to 15% of patients who receive stereotactic radiation treatment. There’s the potential that if we don’t sequence therapies correctly, there might be a synergistic effect with certain systemic therapies. There are some data showing that immunotherapies might potentially increase the risks of radiation necrosis when combined with stereotactic radiation treatment. This is something that we have to watch for and counsel patients for.

In terms of our diagnosis, the gold standard for a long time has been surgical pathology. For patients who develop radiation necrosis, what’s often needed is surgical resection of that metastasis because it’s difficult to tell whether it’s local progression vs radiation necrosis. There are newer imaging techniques available to us, like MRI perfusion and PET [positron emission tomography]–CT imaging, that can be used to help differentiate. Steroids are commonly given for helping manage the adverse effects of radiation necrosis too, and then sometimes bevacizumab as well. There are improvements that we’re making in terms of the diagnosis and potential management of radiation necrosis.

Sara A. Hurvitz, MD: Thank you. It’s a really important thing for clinicians to be aware of. Sometimes the assumption is its progression. It takes a multidisciplinary team to sort out if it’s progression or necrosis. Thank you for that update.

Transcript edited for clarity.