Trastuzumab emtansine increases the risk of stereotactic radiosurgery-induced radionecrosis in HER2 + breast cancer

Introduction In this study, we investigate factors associated with radionecrosis (RN) in HER2 + (human epidermal growth factor receptor 2) patients with brain metastases (BrM) treated with stereotactic radiosurgery (SRS). Methods Patients with HER2 + breast cancer BrM treated with SRS (2010–2020) were identified from an institutional database. The incidence of RN was determined per treated BrM according to serial imaging and/or histology. Factors associated with RN such as age, RT dose, BrM volume, and initiation of Trastuzumab Emtansine (T-DM1) were investigated with univariate and multivariable analyses (MVA). Results 67 HER2 + patients with 223 BrM were identified. 21 patients (31.3%) were treated with T-DM1 post-SRS, including 14 patients (20.9%) who received T-DM1 within 12 months of SRS. The median follow-up was 15.6 (interquartile range (IQR) 5.4–35.3) months. The overall probability of RN post-SRS was 21.6% (95% confidence interval (CI) 2.7–10.7), and the 1 and 2 year risk was 6.7% (95% CI 2.7–10.7) and 15.2% (95% CI 9.2–21.3). MVA identified T-DM1 treatment post-SRS (hazard ratio (HR) 2.5, 95% CI 1.2–5.3, p = 0.02) and equivalent dose in 2 Gy fractions (EQD2) > 90 Gy 2 (HR 2.4, 95% CI 1.1–5.1, p = 0.02) as predictors of RN. Patients treated with T-DM1 and SRS had a 29.9% (95% CI 15.3–44.6%) probability of RN, with a 25.2% (95% CI 12.8–37.6%) risk at 1- and 2 years post-T-DM1. The majority of RN were symptomatic (71%), with a median time to RN of 4.8 months. Conclusion T-DM1 exposure post-SRS was associated with a higher risk of RN among patients with HER2 + BrM.