Yusuf Kavuzlu, Serdar Solak, Zafer Koçak
Balkan Medical Journal - 2026;43(5):288-290
A 57-year-old man presented with a one-week history of visual impairment in the right eye and headaches. His medical history included heavy smoking (approximately 300 pack-years) and liver hemangiomas. Ophthalmological examination revealed no abnormalities, and a brain magnetic resonance imaging (MRI) was recommended. The initial contrast-enhanced brain MRI revealed two mass lesions in the left cerebral hemisphere: a prominent lesion in the left occipital lobe (30 mm) and a smaller lesion in the frontal lobe (15 mm). Thoracic computed tomography (CT) showed a 20-mm mass in the apicoposterior segment of the upper lobe of the left lung and a subcentimetric hilar lymph node. Given a possible diagnosis of metastatic lung cancer, fractionated stereotactic radiation therapy (FSRT) using volumetric-modulated arc therapy was planned for the brain lesions. The planned target volume included a 2-mm margin around the gross tumor volume. A single-isocenter treatment plan was generated using Varian Eclipse (Varian Medical Systems, Palo Alto, CA). The patient received a total dose of 30 Gy (6 Gy per fraction) with Varian TrueBeam 6 MV photons, ensuring that at least 99% of the planning target volume received the full prescription dose. Normal tissue dose constraints were applied as follows: normal brain tissue volume V28 < 7 cc, maximum brainstem dose < 31 Gy, maximum optic nerve/chiasm dose < 25 Gy, and maximum lens dose < 7 Gy. Positron emission tomography/CT revealed only a mass in the lung, with no additional lesions. Given the patient's good performance status, surgical resection of the lung mass was undertaken. A wedge resection of the left lung with lymph node sampling was performed. Postoperative pathology confirmed acinar adenocarcinoma without lymph node involvement (pT2N0). Molecular analysis showed no expression of PD-L1, EGFR, ALK, or ROS1. The patient subsequently received three cycles of adjuvant carboplatin and paclitaxel.One year after the diagnosis of brain metastases, new lesions developed in the left frontal gyrus, cingulate gyrus, and temporal lobe. These lesions were treated with FSRT using volumetric-modulated arc therapy, delivering a total dose of 25 Gy in five fractions. The same normal tissue dose constraints described previously were applied. Follow-up MRI showed complete regression of all left cerebral lesions. Six months later, a new left temporooccipital lesion (Figures 1a, b) was treated again with volumetric-modulated arc therapy, 25 Gy in five fractions. Three months after this treatment, the patient presented with headaches. MRI revealed significant loss of contrast enhancement on axial post-contrast T1-weighted images, while vasogenic edema had slightly progressed on axial fluid-attenuated inversion recovery images (Figures 1c, d). The increase in edema and symptoms was attributed to radiation therapy and classified as grade 2 toxicity according to Common Terminology Criteria for Adverse Events version 5.0. Dexamethasone was initiated at 12 mg/day. Follow-up imaging demonstrated persistent vasogenic edema despite steroid therapy, while contrast enhancement had resolved (Figures 1e, f). The patient remained steroid-dependent due to recurrent headaches and fatigue upon tapering. Bevacizumab was avoided because of a history of pulmonary embolism. After reviewing the literature, Boswellia serrata was considered. Warnick1 reported a case series of three patients with refractory radiation-induced cerebral edema or necrosis who responded to 300 mg/day of Boswellia extract. Boswellia extract [5-Loxin- acetyl-11-keto-beta-boswellic acid (AKBA)] at 400 mg/day was initiated alongside low-dose steroids. Two months later, MRI demonstrated substantial resolution of vasogenic edema (Figures 1g, h), and the patient's headaches improved. Steroids were subsequently discontinued, and Boswellia therapy was continued for an additional two months.
