Role of Boswellia Serrata in Management of CNS Radiation Necrosis After Radiosurgery for Brain Metastases

no other distant metastases. She underwent video-assisted thoracoscopic surgery (VATS) biopsy of parietal pleural nodules, which confirmed metastatic renal cell carcinoma. Baseline contrast-enhanced MRI of brain was negative for intracranial metastases. She was started on first-line systemic therapy with pembrolizumab and axitinib. Restaging scans revealed good response with improvement in small pulmonary nodules with minimal residual pleural thickening in the right lung base. About 6 months after initial diagnosis, the patient presented with headaches and left-sided neck pain. A brain MRI with and without contrast revealed interval development of a 1.5 × 1.4-cm enhancing nodule in the left frontal lobe with mild to moderate surrounding vasogenic edema and mass effect. She also had an MRI of the cervical spine, which demonstrated multilevel degenerative changes but no metastatic disease. She was started on a short course of tapering Abstract Radiation necrosis (RN) is a concerning late toxicity after radiation therapy for brain metastases. The management of RN primarily depends on the extent of edema on imaging and presence of symptoms. Oral corticosteroids are the mainstay of management; however, they are not optimal for long-term management because of multiple side effects and drug interactions. Boswellia serrata is an extract derived from Indian frankincense, which is available as an over-the-counter supplement, and has been traditionally used in the treatment of asthma, arthritis and colitis due to its anti-inflammatory properties. Recent data have reported the benefits of Boswellia on reducing cerebral edema. We discuss a case report involving a patient with brain metastases treated with stereotactic radiosurgery who developed early RN and had a good response with resolution of postradiation edema with the use of Boswellia.