CNS Radiation Toxicity: Management and Drug Doses

BBD, non-progressive, in an uncritical location: Observation, with MRI about every 12 weeks.

BBD in a critical location, or asymptomatic RN (any location): MRI at 8–12 weeks; short-course dexamethasone can be considered depending on edema and location.

Dexamethasone 20–40 mg IV, or 8 mg once up to three times daily (1-0-0 up to 1-1-1); 3 to 5 days, then a gradual reduction to a maintenance dose of 1.5–2 mg until the first follow-up MRI (6–8 weeks after diagnosis), to prevent a rebound effect. For immediate relief, a trial of high-dose dexamethasone (for example 20 mg IV) can be reasonable. Use the lowest possible dose for the shortest possible duration. DEGRO notes that there are no studies on dose.

Xu RCT steroid arm: Methylprednisolone 500 mg/day IV for 3 days; then tapered, then prednisone 10 mg/day orally; 2 months in total. 2-month response 31.5% (nasopharyngeal carcinoma, temporal-lobe RN).

EANO 2026: Corticosteroids may be tried for symptomatic RN; no dose in the abstract.

Levin RCT: Bevacizumab 7.5 mg/kg IV every 3 weeks; 2 doses, MRI 3 weeks after the 2nd dose (week 6); responders received 2 more doses, 4 doses over 12 weeks. Response 5/5 randomized and 7/7 crossover vs 0/7 placebo; all treated patients improved neurologically. 2 patients had MRI recurrence at median 10 months after the last dose (needed 1–2 more doses).

Xu RCT: Bevacizumab 5 mg/kg IV every 2 weeks; 4 cycles. 2-month response 65.5% vs 31.5% with corticosteroids (P<.001); mean T1-Gd volume decrease 25.5% vs 5.0%; clinical improvement 62.1% vs 42.6% (P=.039).

Trial populations: Levin: progressive symptoms required, and only 5/13 evaluable patients were on dexamethasone at entry. Xu: bevacizumab vs corticosteroids as initial therapy (nasopharyngeal carcinoma). The steroid-refractory indication comes from ISRS 2024 and EANO 2026 (next row).

Safety: Levin: aspiration pneumonia, PE/DVT, superior sagittal sinus thrombosis and 3 more ischemic changes (6/11 treated patients had AEs). Xu: hypertension 20.6% was the most frequent AE.

Label (context): Recurrent glioblastoma dose 10 mg/kg every 2 weeks; RN is off-label. Withhold at least 28 days before elective surgery and at least 28 days after major surgery. Monitor blood pressure.

DEGRO: Typically 5–10 mg/kg every 2–4 weeks, at least two doses (a single application is not recommended); lower doses of 5.0–7.5 mg/kg every 2 weeks seem sufficient. MRI after 4 cycles. At least a 28-day washout before elective surgery.

ISRS 2024: Strong recommendation: corticosteroid-refractory RN that does not need urgent surgery, with non-invasive testing that favors RN, can be treated with bevacizumab in carefully selected patients. Pooled symptom improvement or stability 86% (95% CI 77–92%). Low dose (≤7.5 mg/kg every 3 weeks, the median) was better than high dose for symptoms (P=.02), not for T1/T2 imaging. Overall evidence of low quality.

EANO 2026: Recommended for corticosteroid-refractory RN, with evidence suggesting efficacy even at low doses.

Systematic review: 12 studies, 236 patients: radiographic response 84.7%; clinical improvement in 91% of responders; recurrence in 34% of responders.

3 mg/kg every 2 weeks for 2 cycles after Gamma Knife (n=22): mean T1-Gd change −45%, T2 −74%; all stopped steroids (Weng).

Under 5 mg/kg (median 3 mg/kg, median 3 cycles) vs ≥5 mg/kg (n=75, brain metastases): no difference in FLAIR or T1CE reduction at 3 and 6 months; grade ≥3 AEs 0 vs 9.8% (Gao).

2.5 vs 5 mg/kg (n=195, nasopharyngeal carcinoma): 8-week response 84.8% vs 73.6% (adjusted P=.077); AEs 21.2% vs 55.8% (Li H).

7.5 vs 10 mg/kg every 3 weeks (n=104): similar radiographic outcomes; clinical response 65.2% vs 37.8% (P=.013); cohorts differed by tumor type, so differences may be confounded (Schultz).

Single intra-arterial 2.5 mg/kg after blood-brain barrier disruption (n=10, steroid-refractory): RN volume decrease of more than 25% in 80% at 3 months (Dashti).

Ultra-low 1 mg/kg every 3 weeks, at least 3 doses (prospective phase II, n=21, RN after stereotactic RT): enhancement reduced in 20/21, symptoms improved in 18/20 (Zhuang 2019, cited by DEGRO).

SRS-induced RN, brain metastases (n=26): most common schedule 7.5 mg/kg every 3 weeks, median 3 cycles; radiological improvement 88%; 71% of steroid users stopped steroids; recurrent symptomatic RN 19%; grade ≥2 toxicity 24% (VTE 12%, hypertension 8%, intratumoral hemorrhage 4%) (Jung).

5 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks given for tumor: 8/8 RN patients improved; mean dexamethasone reduction 8.6 mg/day (Gonzalez).

No RCT has compared doses.

Boswellia serrata extract target 4050–4500 mg daily; for at least 2 months (inclusion criterion) Brain metastases after SRS (n=94 evaluable): ORR 59.6% (95% CI 48.9–69.6%); by RN grade 1/2/3, 62/63/33%; median duration of response 13.9 months. GI toxicity grade 1 in 14%, grade 2 in 2%. The authors call for placebo-controlled trials.

AKBA-enriched extract: 5-Loxin (30% AKBA by weight) 150 mg twice daily with a fatty snack; until symptoms and edema resolved. 3 patients after failure of pentoxifylline + vitamin E; steroids stopped; edema resolved.

Case report (bilateral Gamma Knife capsulotomy for OCD, 80 Gy): Boswellia serrata 4800 mg/day in 2 divided doses. Started after a 3-month course of low-dose dexamethasone that did not help. Near-complete resolution at 8 months and complete response at last follow-up, 21 months after initial treatment; no side effects.

Review: Reported trials used 3600–4500 mg/day in divided doses; the review suggests a lecithin-based formulation with a high relative weight of AKBA, taken with a fatty snack. A high-fat meal raised boswellic acid exposure several-fold.

Safety and products: Acute kidney injury after 8 days in one case, resolved after stopping. Over-the-counter supplement, not a regulated drug; preparations differ in boswellic acid content. Interaction data are in vitro only: P-glycoprotein inhibition (Weber), OATP1B3 and MRP2 modulation (Krüger), platelet aggregation inhibition (cited in Dejonckheere).

Guideline or consensus recommendation: No published recommendation found

Pentoxifylline 400 mg twice daily; with vitamin E 1000 IU daily. Emory, n=48: improved 43.8%, no change 18.8%, worse 25%; median time to response assessment 3.17 months; 3 stopped for side effects; dexamethasone use did not change response.

Label: Contraindicated with recent cerebral or retinal hemorrhage. Bleeding reported; monitor anticoagulation with vitamin K antagonists (more frequent PT monitoring on warfarin); exposure to pentoxifylline and/or active metabolites increases in hepatic or renal impairment.

Case series regimen: Pentoxifylline 400 mg three times daily + vitamin E 400 IU twice daily, with dexamethasone 4 mg four times daily (before a switch to Boswellia).

Pittsburgh pilot: 11 patients with suspected ARE: mean edema change −72.3 mL; 2 stopped pentoxifylline for nausea or abdominal discomfort. Dose not stated in the abstract. Not verified against the original

Guideline recommendation: No published recommendation found

LAASR (n=42; 19 biopsy-proven RN, 20 recurrent tumor, 3 without diagnosis): 26-week PFS 74% and OS 72% for the whole cohort; 30% stopped or reduced steroids by 12 weeks. The RN subgroup had better 12-week PFS and OS.

ISRS: Pooled T1 post-contrast improvement or stability 88% (95% CI 82–93%); its role is evolving.

EANO: LITT can be considered an additional treatment option for symptomatic RN.

LITT vs bevacizumab: Retrospective, n=25 vs 13: median OS 24.8 vs 15.2 months; 1-year lesion volume change −64.7% vs more than +100%; possible selection bias.

ASCO-SNO-ASTRO 2022: LITT for RN was not a topic considered in the guideline.

Surgical removal, depending on location, is considered standard of care (DEGRO); symptoms improved after resection in 55%.

ISRS: Pooled symptom improvement or stability 89% (95% CI 81–96%).

EANO: Effective for rapid symptom relief and definitive diagnosis in accessible lesions.

No standard protocol in a guideline. DEGRO cites about 90% improved and 60% clinical response after a median of 30 treatments, often given with dexamethasone or bevacizumab; available evidence is low.

Side effects: Ear barotrauma, dyspnea, ear pain requiring myringotomy, sinusitis.

Reviews: The ISRS review found 1 HBO report. A review of 11 studies (46 patients, tumors and AVMs) reported improvement in most.

Heparin and warfarin are listed among past approaches; none has proven effective in controlled clinical trials.

Dexamethasone 4–8 mg/day; starting dose. Level 3.

Dexamethasone is the drug of choice (Level 3).

Asymptomatic, no mass effect: Insufficient evidence to recommend steroids.

Dexamethasone 16 mg/day or more. Level 3.

Vecht RCT: Trial 1: 8 vs 16 mg/day for 7 days; trial 2: 4 vs 16 mg/day for 28 days; each then tapered. 4 mg/day gave the same improvement in KPS as 16 mg/day at 1 week in patients without impending herniation; toxicity was more frequent with 16 mg (P<0.03).

Taper as rapidly as possible but no faster than clinically tolerated (CNS 2019, Level 3).

CNS 2010: Taper slowly over a 2-week period, or longer in symptomatic patients (Level 3).

EFNS (as cited in CNS 2010): Start tapering within 1 week of starting and stop within 2 weeks if possible (Good Practice Point); twice-daily dosing is sufficient.

Exact taper steps: No published recommendation found

Hyperglycemia 47%, peripheral edema 11%, psychiatric disorder 10%, candidiasis 7%, Cushing syndrome 4%, weakness 4%, PE 2%.

12/13 asymptomatic patients given RT without dexamethasone did not worsen.

Brain-tumor or RT guideline: No published recommendation found

Meta-analysis: Corticosteroids raised the risk of GI bleeding or perforation (OR 1.43, 95% CI 1.22–1.66). The risk was significant in hospitalized patients (OR 1.42) and not in ambulatory care (0.13% events; OR 1.63, CI 0.42–6.34).

ASCO/IDSA: Prophylaxis for regimens with more than 3.5% PJP risk, for example ≥20 mg prednisone equivalent daily for ≥1 month. Not specific to brain tumors.

Conversion (not a guideline statement): 20 mg prednisone is about 3 mg/day dexamethasone by standard steroid equivalence.

ASCO/IDSA drug and dose: Not verified against the original

ECIL-5: Indications include more than 4 weeks of corticosteroids.

Brain-tumor case series: All 10 PJP episodes were on dexamethasone (median 69 days; dose at onset 1–16 mg, median 9); all had lymphopenia; 3 deaths. The authors suggest considering prophylaxis with lymphopenia or dexamethasone for more than 5 weeks. A second series: 4 cases during taper.

Temozolomide label: Newly diagnosed glioblastoma: PCP prophylaxis for all patients during the concomitant phase; continue with lymphopenia until grade ≤1. Agent not specified.

ECIL-5 (A-II): TMP-SMX 2–3 times weekly; for the whole period at risk. Drug of choice for primary prophylaxis in adults. Tablet strength and dose per administration are not in the abstract.

Label: TMP-SMX 1 double-strength tablet (800 mg sulfamethoxazole / 160 mg trimethoprim) daily. For adults who are immunosuppressed and at increased risk; differs in frequency from ECIL-5.

Second line (ECIL-5): Pentamidine, atovaquone, dapsone.

Dose in mg: Of these sources, only the label gives a dose in mg (1 double-strength tablet daily); the ECIL-5 abstract gives a frequency without a dose.

Inpatients: Glucocorticoid-associated hyperglycemia: NPH-based or basal-bolus insulin (Rec 2.1, conditional, low certainty), with ongoing glucose monitoring. Hyperglycemia is defined as BG >140 mg/dL (Rec 10.1).

Monitoring frequency in patients without diabetes: No brain-specific guideline. No published recommendation found

Kirste pilot RCT: Boswellia serrata (H15 preparation, per the review) 4200 mg/day vs placebo; during RT. Fractionated RT to ≥60% of brain volume. Edema reduction of more than 75% at the end of RT in 60% vs 26% (P=.023); no difference 4 weeks after RT. No severe AEs; 6 patients had minor GI discomfort. Quality of life, cognition and dexamethasone dose did not differ.

Daily schedule (number of doses or tablets) and tablet strength: Not verified against the original

Single-arm series: H15 1200 mg three times daily (dose per the Dejonckheere review; n=12): edema reduced in 3/5 with treatment-related leukoencephalopathy; all 5 improved clinically.

Glioblastoma pilot: Lecithin-based extract 4500 mg/day from the first week of RT through temozolomide maintenance, up to 34 weeks (n=20).

Children (palliative): H15 up to 126 mg/kg/day in progressive brain tumors (n=19); no side effects over a median of 9 months.

Clinicians should not prescribe antiepileptic drugs (AEDs) to reduce the risk of seizures (Level A).

Brain metastases (CNS 2019, ASCO/SNO-endorsed): Prophylactic AEDs are not recommended for routine use.

Insufficient evidence to recommend AEDs in the peri- or postoperative period (Level C).

Background: The retired AAN statement that tapering after the first postoperative week is appropriate appears as background only.

Levetiracetam may be chosen over older AEDs to reduce side effects (Level C; prophylaxis or after a seizure).

Label dose, adults ≥16 years, partial-onset: Levetiracetam 500 mg twice daily; increase by 500 mg twice daily every 2 weeks to 1500 mg twice daily (maximum 3000 mg/day)

Renal adjustment (label, adults; CrCl in mL/min/1.73 m²): Above 80: 500–1500 mg every 12 hours; 50–80: 500–1000 mg every 12 hours; 30–50: 250–750 mg every 12 hours; below 30: 250–500 mg every 12 hours; ESRD on dialysis: 500–1000 mg every 24 hours, with a 250–500 mg supplemental dose after dialysis.

Tumor-specific AED dosing after seizures: No published recommendation found

Memantine 20 mg/day for 24 weeks; week 1, 5 mg once daily; week 2, 5 mg twice daily; week 3, 10 mg morning and 5 mg evening; weeks 4–24, 10 mg twice daily. Started within 3 days of starting WBRT (RTOG 0614); in NRG CC001, the same day as RT and at the latest before the 4th fraction. The titration is identical in both trials.

RTOG 0614 (WBRT 37.5 Gy in 15 fractions): Time to cognitive decline HR 0.78 (95% CI 0.62–0.99), P=.01; cognitive failure at 24 weeks 53.8% vs 64.9%. Delayed recall at 24 weeks P=.059 (only 149 analyzable, 35% power). Toxicity similar to placebo.

Extended release (CC001): 7, 14, 21 and 28 mg daily in weeks 1 to 4, then 28 mg to week 24.

Renal (CC001 protocol): Eligibility CrCl ≥30 mL/min (Cockcroft-Gault). If CrCl falls to 5–29 mL/min: 5 mg twice daily (ER 14 mg daily), recheck weekly, and continue the reduced dose if not above 29 after 3 weeks. CrCl under 5: hold, and stop if not above 5 after 3 weeks.

Label: Start 5 mg daily and step up by 5 mg at least 1 week apart to 20 mg/day; severe renal impairment (CrCl 5–29 mL/min), target 5 mg twice daily.

HA-WBRT 30 Gy in 10 fractions (hippocampus + 5 mm excluded from the PTV) with memantine. Metastases more than 5 mm from either hippocampus; KPS ≥70.

NRG CC001 (n=518): Cognitive failure adjusted HR 0.74 (95% CI 0.58–0.95), P=.02. Less executive-function decline at 4 months (23.3% vs 40.4%) and less learning and memory decline at 6 months. No difference in OS, intracranial PFS or toxicity.

ASCO-SNO-ASTRO 2022, Rec 3.5: Memantine and hippocampal avoidance should be offered to patients who will receive WBRT, have no hippocampal lesions and have 4 months or more expected survival (evidence high; strong).

ASTRO 2022: For patients with favorable prognosis receiving WBRT, hippocampal avoidance and memantine are strongly recommended.

Hippocampi: D100% ≤9 Gy (9–10 Gy acceptable variation); D0.03cc ≤16 Gy (16–17 Gy acceptable).

PTV_3000: D2% ≤37.5 Gy (37.5–40 Gy acceptable); D98% ≥25 Gy (22.5–25 Gy); V30Gy ≥95% (90–95%).

Optic nerves and chiasm: Dmax ≤30 Gy (30–37.5 Gy acceptable).

Values beyond the acceptable-variation limits are an unacceptable deviation.

Donepezil 5 mg daily for 6 weeks, then 10 mg daily for 18 weeks; 24 weeks; 10 mg only if 5 mg was tolerated. Adults ≥6 months after ≥30 Gy partial- or whole-brain RT.

Results: Primary composite cognitive score no different (P=.48). Better memory recognition (P=.027), discrimination (P=.007) and motor speed and dexterity (P=.016).

Rescue with dexamethasone (IV/B). The 2023 update moved low emetic risk from prophylaxis to rescue.

ASCO 2017, Rec 15: Brain: rescue dexamethasone therapy (low quality; weak; informal consensus).

Prophylaxis with a 5-HT3 receptor antagonist (RA) ± dexamethasone (II/A; for adding dexamethasone II/C).

ASCO 2017, Rec 14: Moderate risk (craniospinal irradiation is classed as moderate): 5-HT3 RA before each fraction, with or without dexamethasone before the first 5 fractions (high quality; moderate strength).

Rescue with dexamethasone, a dopamine RA or a 5-HT3 RA (IV/B).

ASCO 2017, Recs 15 and 16: Head and neck, thorax or pelvis (low) and minimal-risk sites: rescue 5-HT3 RA, dexamethasone or dopamine RA (low quality; weak; informal consensus).

Prophylaxis with a 5-HT3 RA + dexamethasone (II/B; dexamethasone III/C).

ASCO 2017, Rec 13: High risk: 5-HT3 RA + dexamethasone before each fraction and on the day after each fraction if there is no RT that day (high quality; strong).

Antiemetics follow the chemotherapy risk category unless the RT risk is higher (IV/D).

RT-specific antiemetic doses: ASCO 2017 radiotherapy dosing table not retrieved. Not verified against the original

MASCC/ESMO 2023 gives no RT-specific doses in the accessible text. Doses for 5-HT3 RAs and dexamethasone are in the chemotherapy tables of the full guidelines.

7/44 linac-SRS patients had nausea or vomiting within 6 hours. Median area-postrema dose in those patients 618 cGy (range 275–1257); no emesis at doses from under 5 to 184 cGy. The authors recommend premedication when the area postrema receives large single-fraction doses.

Spine-SBRT-specific antiemetic recommendation: No published recommendation found

MASCC/ESMO categories are by irradiated region (for example, upper abdomen is moderate risk).

Steroid-naive: 68.3% (28/41), most often on day 1 after SBRT; predictors were higher KPS and cervical or lumbar location.

MD Anderson phase I/II secondary analysis: 23% (44/195); median day 5; fewer fractions predicted flare (OR 0.66).

ESTRO 2024, KQ 4 Rec 7: Routine prophylactic steroids not recommended (conditional; moderate).

Khan 2015: Dexamethasone 4 mg or 8 mg orally; 1 hour before SBRT and daily for 4 days after. Observational; see the comparison above.

SBRT-specific RCT: None found.

NCIC SC.23: Dexamethasone 8 mg orally; at least 1 hour before RT and daily on days 1–4. Flare 26% vs 35% (difference 8.9%, one-sided P=.05). Grade 3 (2 patients) and grade 4 (1 patient) hyperglycemia with dexamethasone.

Dutch DEXA: 8 mg before RT + 3 daily doses vs 8 mg once vs placebo: flare 38% / 27% / 39% (P=.07); dexamethasone delayed flare.

Meta-analysis: 4 RCTs, 765 patients: RR 0.59 (95% CI 0.35–0.98).

14% of segments (57/410); 65% within the first 4 months; cumulative 12.35% at 1 year and 13.49% at 2 years. Predictors: dose per fraction (≥24 Gy > 20–23 Gy > ≤19 Gy), baseline VCF, lytic tumor, spinal deformity. Caution at ≥20 Gy per fraction.

ESTRO: Most frequent AE after spine SBRT, 6–14%. Further risk factors: pain at baseline, thoracic location, SINS >8, Bilsky >0, age >55, female sex, lung primary (prostate lower). Follow-up MRI, for example every 3 months in year 1.

SINS: 6 components: location, pain, bone lesion quality, alignment, vertebral body collapse, posterolateral involvement.

CAFE RCT (n=134, not SBRT-specific): Balloon kyphoplasty vs non-surgical care for painful cancer VCF: RDQ change −8.3 vs 0.1 points at 1 month; treatment effect −8.4 points (P<0.0001).

Prophylactic cement augmentation before SBRT: No published recommendation found

ESTRO KQ 4 Rec 5 (strong; high): Accurate cord imaging, PRV, accepted constraints, cord priority over coverage, high-precision delivery.

HyTEC thecal sac Dmax for under 5% risk: 12.4–14.0 Gy in 1 fraction; 17.0–19.3 Gy in 2; 20.3–23.1 Gy in 3; 23.0–26.2 Gy in 4; 25.3–28.8 Gy in 5.

De novo incidence 0.4% (pooled, more than 1000 patients).

Corticosteroids, hyperbaric oxygen and bevacizumab have been used; none is supported by high-quality evidence.

Dose: No published recommendation found

Median PTV dose 24 Gy (n=182): acute 15%, late 12%, grade ≥3 6.8%. Predictors (median splits): V12Gy 3.78 cc, V15Gy 1.87 cc, V20Gy 0.11 cc, V22Gy 0 cc, D2.5cc 14.02 Gy. All grade ≥4 events were linked to radiation recall (doxorubicin, gemcitabine) or manipulation of the irradiated esophagus.

Management drugs (spine-specific): No published recommendation found

14 events in 13 of 447 patients (single fraction 18–26 Gy), median 10 months (Stubblefield, as cited by ESTRO).

At 1 week: scalp numbness 24%; pin-site pain 13% (median 2/10); pin-site infection 4%. At 1 month: pin pain 3%, new local hair loss 10%. New or worse fatigue 23% (1 week), 16% (1 month), 15% (2 months). New tinnitus 1–6%. Nausea worse at 1 month (P=.0114). No change in headache, vomiting or seizures vs baseline. 84% returned to work at a median of 4 days.

Periprocedural steroid, analgesic or antiemetic protocol: Searched for steroid prophylaxis, pin-site care and headache protocols. No published recommendation found

See Part V (7/44 patients; median area-postrema dose 618 cGy in those with symptoms).

Pittsburgh: 80 Gy maximum, 4-mm isocenter, n=503: new or worse paresthesia or numbness 10.5% (53 patients), resolved in 17; 1 deafferentation pain. Patients with sensory loss had better pain control (78% at 5 years).

Marseille: Median 85 Gy, retrogasserian, n=497: actuarial hypesthesia 20.4% at 5 years and 21.1% at 7 years, stable to 14 years; median onset 12 months; very bothersome in 0.6% (3 patients).

Management of numbness: No published recommendation found

Pooled radiologic RIC 35.5%; symptomatic 9.2%; permanent 3.8%. Radiologic RIC linked to no prior rupture (OR 0.57) and repeat SRS (OR 6.19); symptomatic RIC linked to deep location.

Steroid regimen specific to AVM RIC: No published recommendation found

Bevacizumab: 11 of 12 studies (pilot trials, case series, case reports) addressed post-SRS necrosis or steroid-resistant edema and were consistently associated with clinical and radiological improvement; 1 used bevacizumab as standalone AVM treatment (no nidus reduction). Small samples, no controls, doses varied.

HBO: Included among the 46 patients in the HBO review (tumors and AVMs).

General RN management is in Part I.

After treatment (survivors): Recommend exercise, CBT and mindfulness-based programs; yoga, acupressure and moxibustion may be recommended.

During treatment: Exercise, CBT, mindfulness, tai chi or qigong; psychoeducation and American ginseng may be recommended.

Not recommended: L-carnitine, antidepressants, wakefulness agents; psychostimulants not routinely. At end of life, CBT and corticosteroids may be offered.

Local hair loss 10% at 1 month after Gamma Knife.

Prevention or treatment after cranial RT: No published recommendation found

MASCC 2023 Delphi: Prevention with photobiomodulation and Mepitel film (in breast cancer), Hydrofilm, mometasone, betamethasone, olive oil; management with Mepilex Lite dressings. Most other agents not recommended.

Scalp-specific recommendation: The evidence is mostly from breast and head-and-neck cancer. No published recommendation found

No published recommendation found

Point prevalence after cranial RT for non-pituitary tumors: any deficiency 0.66; GH 0.45; LH/FSH 0.30; TSH 0.25; ACTH 0.22. The authors advise structured periodic assessment for all patients.

GH: lifelong periodic clinical assessment if hypothalamic-pituitary RT ≥18 Gy (height every 6–12 months). LH/FSH: screen if ≥30 Gy (no frequency given). TSH: lifelong annual screening if ≥30 Gy. ACTH: lifelong annual if ≥30 Gy, and suggested if 24–30 Gy and more than 10 years after RT (weak). Tests are the same as in patients without cancer.

Adults: Applying this schedule to adults is extrapolation; no adult equivalent was found.

Adult cranial RT: The pediatric COG long-term follow-up guidelines were not read. No published recommendation found

Adult cranial RT: The pediatric COG long-term follow-up guidelines were not read. No published recommendation found