To provide cost benefit analysis on LiTT and BEV for cranial radiation necrosis by reviewing studies to assess efficacy, safety, steroid independence, retreatment, QALY and outline evidence-based pathways.

Radiation necrosis (RN) is a complication of radiotherapy for both primary and metastatic brain tumors and can lead to progressive neurological deterioration. In patients who do not respond adequately to corticosteroids or develop intolerable side effects, alternative therapies such as bevacizumab (BEV) and laser interstitial thermal therapy (LiTT) may be considered. We performed a cost-benefit analysis to provide detailed guidance on their comparative clinical value and economic impact.

We performed a review including adult patients with brain tumors who developed RN. Outcomes included clinical and radiographic response, steroid weaning, retreatment and hospitalization, adverse events, quality-adjusted life years (QALYs), and cost-effectiveness from payer’s perspectives.

BEV results in rapid symptomatic and radiographic improvement for most patients within 3–6 weeks and significantly facilitates steroid tapering. However, recurrence of RN is common after discontinuation, often requiring retreatment. Adverse events with BEV include hypertension and proteinuria. LiTT provides minimally invasive, ablation with durable local control of RN. LiTT has higher rates of steroid independence over time, and low retreatment rates at one year. The risk of LiTT is primarily peri-procedural such as transient neurologic deficits and edema flaring. The cost-effectiveness analyses suggest BEV is typically cost-effective for short courses but less favorable with prolonged or repeated use. LiTT poses to be cost-effective over longer period of time by reducing recurrences and risk of hospitalizations.

BEV offers short term non-surgical management suited for multifocal or deep RN. LiTT is a durable solution when lesions are accessible and diagnosis is needed. Healthcare institutions should ensure access to both, using patient- and lesion-specific recommendations to maximize neurologic outcomes and QALYs while being cost-effective to the patients.