Question:

Which of the following statements is true?
1. There is strong evidence to support the use of hyperbaric oxygen therapy in radiation necrosis.
2. Long-term follow-up has shown long-lasting effects of bevacizumab therapy years after treatment for radiation necrosis.
3. Primary CNS lymphoma incidence does not depend on immune status.
4. Radiation necrosis in the CNS often shows the asymmetric target sign on MRI.
5. MRS can play an important role in distinguishing radiation necrosis from neoplastic lesions.





Answer:

The correct answer for the question "Which of the following statements is true?" is:

5. MRS can play an important role in distinguishing radiation necrosis from neoplastic lesions.



Explanation
1. There is little evidence to support the use of hyperbaric oxygen therapy in radiation necrosis. [Other therapies including anticoagulation and hyperbaric oxygen have been reported in some cases to offer benefit, but there is little evidence to support their use]

2. Studies of bevacizumab therapy in radiation necrosis are limited by short duration of follow-up. [While these studies are encouraging, they are limited by small sample size and a follow-up time of no more than 10 months]

3. Primary CNS lymphoma occurs almost exclusively in immunocompromised patients. [It is typically associated with immunosuppression as in HIV/AIDS, iatrogenic immunosuppression or congenital immunodeficiency. It is extremely rare in the immunocompetent patient.]

4. The asymmetric target sign is the hallmark of cerebral toxoplasmosis. [Toxoplasmosis lesions are usually multiple, may cause mass effect, and their hallmark sign is the asymmetric target sign seen on MRI or computed tomography (CT) where a ring-enhancing abscess contains smaller similarly-enhancing abscesses and eccentric nodules]

5. MRS typically shows elevated lactate and lipids in radiation necrosis with absence of neuro-glial markers, whereas some of these markers are typically increased in neoplasia. [MRS, as in this case, shows a dominant lactate peak, with increased lipids, while other neuro-glial markers (choline, n-acetylaspartate (NAA), creatine) are typically reduced (in radiation necrosis). MRS will show increased lactate if necrosis is present, with decreased NAA and increased choline (in brainstem gliomas and CNS lymphomas).]



From the manuscript:
Radiation necrosis of the pons after radiotherapy for nasopharyngeal carcinoma: Diagnosis and treatment
Radiology Case. 2012 Jul; 6(7):9-16


This article belongs to the Neuro section.




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From the manuscript

Radiation necrosis of the pons after radiotherapy for nasopharyngeal carcinoma: Diagnosis and treatment

Free full text article: Radiation necrosis of the pons after radiotherapy for nasopharyngeal carcinoma: Diagnosis and treatment

Abstract
We report a case of radiation necrosis in an unusual location, the pons, in a patient who had received chemoradiation for nasopharyngeal carcinoma (NPC) over one year prior to presentation. This patient presented with subacute onset of ataxic hemiparesis and slurred speech. Initial magnetic resonance imaging (MRI) studies showed two 1-2cm peripherally contrast-enhancing lesions in the pons with extensive surrounding edema. Proton magnetic resonance spectroscopy (MRS) played a key role in narrowing the differential diagnosis to radiation necrosis. The patient underwent biweekly bevacizumab therapy and has remained clinically stable with radiologic improvement of his lesion. In addition to this case, we present an overview of the use of advanced neuroimaging in distinguishing radiation necrosis of the central nervous system (CNS) from other entities as well as the role of bevacizumab in treatment.






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