Management of patients with a persistently elevated PSA after radical prostatectomy: a narrative review.

INTRODUCTION: The management of the postoperative biological relapse of prostate cancer is most often based on salvage radiotherapy (SRT) with or without the addition of a variable duration of hormone therapy (HT). The indications for SRT +/- HT are established in the setting of a rising PSA level after a period where an undetectable PSA was achieved. However, in case of detectable PSA immediately after radical prostatectomy, the treatment options and prognosis are still unclear. MATERIALS AND METHODS: We conducted a narrative review based on an analysis of the literature focusing on articles targeting the population of patients with postoperative persistently detectable PSA level. Case reports, original articles, clinical trials, and published reviews were studied for this purpose. CONCLUSION: This article will describe current management of patients with detectable PSA immediately after radical prostatectomy, notably the contribution of modern imaging and new treatment options involving the combination of RT and HT.

Predicting response to radiotherapy of head and neck squamous cell carcinoma using radiomics from cone-beam CT images.

INTRODUCTION: Radiotherapy (RT) for head and neck cancer is now guided by cone-beam computed tomography (CBCT). We aim to identify a CBCT radiomic signature predictive of progression to RT. MATERIAL AND METHODS: A cohort of 93 patients was split into training (n = 60) and testing (n = 33) sets. A total of 88 features were extracted from the gross tumor volume (GTV) on each CBCT. Receiver operating characteristic (ROC) curves were used to determine the power of each feature at each week of treatment to predict progression to radio(chemo)therapy. Only features with AUC > 0.65 at each week were pre-selected. Absolute differences were calculated between features from each weekly CBCT and baseline CBCT1 images. The smallest detectable change (C = 1.96 × SD, SD being the standard deviation of differences between feature values calculated on CBCT1 and CBCTn) with its confidence interval (95% confidence interval [CI]) was determined for each feature. The features for which the change was larger than C for at least 5% of patients were then selected. A radiomics-based model was built at the time-point that showed the highest AUC and compared with models relying on clinical variables. RESULTS: Seven features had an AUC > 0.65 at each week, and six exhibited a change larger than the predefined CI 95%. After exclusion of inter-correlated features, only one parameter remains, Coarseness. Among clinical variable, only hemoglobin value was significant. AUC for predicting the treatment response were 0.78 (p = .006), 0.85 (p < .001), and 0.99 (p < .001) for clinical, CBCT4-radiomics (Coarseness) and clinical + radiomics based models respectively. The mean AUC of this last model on a 5-fold cross-validation was 0.80 (±0.09). On the testing cohort, the best prediction was given by the combined model (balanced accuracy [BAcc] 0.67 , p < .001). CONCLUSIONS: We described a feature selection methodology for delta-radiomics that is able to select reproducible features which are informative due to their change during treatment. A selected delta radiomics feature may improve clinical-based prediction models.

A density assignment method for dose monitoring in head-and-neck radiotherapy.

BACKGROUND AND PURPOSE: During head-and-neck (H&N) radiotherapy, the parotid glands (PGs) may be overdosed; thus, a tool is required to monitor the delivered dose. This study aimed to assess the dose accuracy of a patient-specific density assignment method (DAM) for dose calculation to monitor the dose to PGs during treatment. PATIENTS AND METHODS: Forty patients with H&N cancer received an intensity modulated radiation therapy (IMRT), among whom 15 had weekly CTs. Dose distributions were calculated either on the CTs (CTref), on one-class CTs (1C-CT, water), or on three-class CTs (3C-CT, water-air-bone). The inter- and intra-patient DAM uncertainties were evaluated by the difference between doses calculated on CTref and 1C-CTs or 3C-CTs. PG mean dose (Dmean) and spinal cord maximum dose (D2%) were considered. The cumulated dose to the PGs was estimated by the mean Dmean of the weekly CTs. RESULTS: The mean (maximum) inter-patient DAM dose uncertainties for the PGs (in cGy) were 23 (75) using 1C-CTs and 12 (50) using 3C-CTs (p ≤ 0.001). For the spinal cord, these uncertainties were 118 (245) and 15 (67; p ≤ 0.001). The mean (maximum) DAM dose uncertainty between cumulated doses calculated on CTs and 3C-CTs was 7 cGy (45 cGy) for the PGs. Considering the difference between the planned and cumulated doses, 53% of the ipsilateral and 80% of the contralateral PGs were overdosed by +3.6 Gy (up to 8.2 Gy) and +1.9 Gy (up to 5.2 Gy), respectively. CONCLUSION: The uncertainty of the three-class DAM appears to be clinically non-significant (<0.5 Gy) compared with the PG overdose (up to 8.2 Gy). This DAM could therefore be used to monitor PG doses and trigger replanning.

Rare, low frequency and common coding variants in CHRNA5 and their contribution to nicotine dependence in European and African Americans.

The common nonsynonymous variant rs16969968 in the α5 nicotinic receptor subunit gene (CHRNA5) is the strongest genetic risk factor for nicotine dependence in European Americans and contributes to risk in African Americans. To comprehensively examine whether other CHRNA5 coding variation influences nicotine dependence risk, we performed targeted sequencing on 1582 nicotine-dependent cases (Fagerström Test for Nicotine Dependence score⩾4) and 1238 non-dependent controls, with independent replication of common and low frequency variants using 12 studies with exome chip data. Nicotine dependence was examined using logistic regression with individual common variants (minor allele frequency (MAF)⩾0.05), aggregate low frequency variants (0.05>MAF⩾0.005) and aggregate rare variants (MAF<0.005). Meta-analysis of primary results was performed with replication studies containing 12 174 heavy and 11 290 light smokers. Next-generation sequencing with 180 × coverage identified 24 nonsynonymous variants and 2 frameshift deletions in CHRNA5, including 9 novel variants in the 2820 subjects. Meta-analysis confirmed the risk effect of the only common variant (rs16969968, European ancestry: odds ratio (OR)=1.3, P=3.5 × 10(-11); African ancestry: OR=1.3, P=0.01) and demonstrated that three low frequency variants contributed an independent risk (aggregate term, European ancestry: OR=1.3, P=0.005; African ancestry: OR=1.4, P=0.0006). The remaining 22 rare coding variants were associated with increased risk of nicotine dependence in the European American primary sample (OR=12.9, P=0.01) and in the same risk direction in African Americans (OR=1.5, P=0.37). Our results indicate that common, low frequency and rare CHRNA5 coding variants are independently associated with nicotine dependence risk. These newly identified variants likely influence the risk for smoking-related diseases such as lung cancer.

A phase II trial of induction chemotherapy and chemo-IMRT for head and neck squamous cell cancers at risk of bilateral nodal spread: the application of a bilateral superficial lobe parotid-sparing IMRT technique and treatment outcomes.

PURPOSE: To determine the feasibility of induction chemotherapy and chemo-IMRT in head and neck squamous cell cancers at risk of bilateral nodal spread (midline tumours) and to evaluate whether bilateral superficial lobe parotid-sparing IMRT can reduce the incidence of ⩾G2 subjective xerostomia. METHODS: Patients with midline tumours were enrolled to a phase II trial to receive induction platinum/5-fluorouracil and concomitant platinum with combined superficial lobe parotid-sparing IMRT. The primary site and involved nodal levels received 65 Gy in 30 fractions (f) and at risk nodal levels, 54 Gy/30f. Incidence of ⩾G2 subjective xerostomia was defined as the primary endpoint. Secondary endpoints included incidences of acute and late toxicities and survival outcomes dependent on human papilloma virus (HPV) status. RESULTS: One hundred and twenty patients with midline cancers completed treatment between December 2005 and May 2010 with median follow-up of 50 months. Incidences of ⩾G2 acute toxicities were: dysphagia 75%; xerostomia 65%; mucositis 86%; pain 83%; and fatigue 64%. At 12 months, ⩾G2 subjective xerostomia was observed in 21% (17% in HPV +ve). Two-year loco-regional progression-free survival (PFS) was 90.7% (95% CI: 85.2-96.2). According to HPV status, there was a significant difference for 2-year loco-regional PFS, 76.8% (HPV-negative) vs 98.6% (HPV-positive), P=0.001. 2-year overall survival was 93% for HPV-positive compared with 52% for HPV-negative cases, P<0.001. CONCLUSIONS: Sequential chemotherapy/chemo-IMRT for midline tumours is feasible, with excellent survival outcomes. At 1 year, 21% experience ⩾G2 subjective xerostomia. Two-year survival outcomes differ significantly between HPV-positive and HPV-negative disease, suggesting development of different treatment schedules for the different disease entities.

CT respiratory motion synthesis using joint supervised and adversarial learning.

Objective.Four-dimensional computed tomography (4DCT) imaging consists in reconstructing a CT acquisition into multiple phases to track internal organ and tumor motion. It is commonly used in radiotherapy treatment planning to establish planning target volumes. However, 4DCT increases protocol complexity, may not align with patient breathing during treatment, and lead to higher radiation delivery.Approach.In this study, we propose a deep synthesis method to generate pseudo respiratory CT phases from static images for motion-aware treatment planning. The model produces patient-specific deformation vector fields (DVFs) by conditioning synthesis on external patient surface-based estimation, mimicking respiratory monitoring devices. A key methodological contribution is to encourage DVF realism through supervised DVF training while using an adversarial term jointly not only on the warped image but also on the magnitude of the DVF itself. This way, we avoid excessive smoothness typically obtained through deep unsupervised learning, and encourage correlations with the respiratory amplitude.Main results.Performance is evaluated using real 4DCT acquisitions with smaller tumor volumes than previously reported. Results demonstrate for the first time that the generated pseudo-respiratory CT phases can capture organ and tumor motion with similar accuracy to repeated 4DCT scans of the same patient. Mean inter-scans tumor center-of-mass distances and Dice similarity coefficients were 1.97 mm and 0.63, respectively, for real 4DCT phases and 2.35 mm and 0.71 for synthetic phases, and compares favorably to a state-of-the-art technique (RMSim).Significance.This study presents a deep image synthesis method that addresses the limitations of conventional 4DCT by generating pseudo-respiratory CT phases from static images. Although further studies are needed to assess the dosimetric impact of the proposed method, this approach has the potential to reduce radiation exposure in radiotherapy treatment planning while maintaining accurate motion representation. Our training and testing code can be found athttps://github.com/cyiheng/Dynagan.

A study of the decision outcomes and financial costs of multidisciplinary team meetings (MDMs) in oncology.

BACKGROUND: The benefits of multidisciplinary working in oncology are now accepted as the norm and widely accepted as being pivotal to the delivery of optimal cancer care. Central to this are the multidisciplinary meetings (MDMs) and we have evaluated decision outcomes and financial costs of these. METHODS: We reviewed the electronic patient records of 551 newly referred patients, discussed at 14 tumour site-specific MDMs for adult solid tumours and lymphoma (paediatric oncology and acute leukaemia were excluded) over a 1-month period, a total of 52 MDMs were studied. In addition, the records of a further 81 patients from 10 different MDMs were reviewed where the treating consultant had clearly recorded their opinion of how the patient should be managed and this was compared with the final MDM's consensus view. We also costed the MDMs utilising two different methodologies. RESULTS: The mean age of the 551 patients in the study was 62 years. In all, 536 (97.3%) patients were treatment naive before MDM discussion and 15 (2.7%) had prior treatment. Median time to treatment after the MDM was 16 days. In 535 (97.1%) cases, the MDM discussions were clearly documented, 16 (2.9%) were not clearly documented. In total, 319 (57.9%) patients were discussed once, and 232 (42.1%) were re-discussed (one to six occasions). In 62 (12.7%) patients, there were delays in MDM discussion, 30 (48.4%) were related to radiology, 26 (41.9%) to histopathology and 6 (9.7%) a combination of both. Adherence to the MDM management plan decision occurred 503 times (91.3%) with 48 (8.7%) deviations. In the smaller cohort of 81 patients, the consultant management plan and MDM consensus was compatible 71 (87.6%) times. On four occasions, there were major alterations in management while six were minor. The cost per month of our MDMs ranged from £2192 to £10 050 (median £5136) with total cost of £80 850 per month and the cost per new patient discussed was £415. CONCLUSION: Adherence to MDM decisions by health-care professionals occurs in the majority of patients. MDMs are costly, which may have relevance in the currently challenged health-care financial environment. There is a need to improve MDM efficiency without losing the considerable benefits associated with regular MDMs.

Radiotherapy modification based on artificial intelligence and radiomics applied to (18F)-fluorodeoxyglucose positron emission tomography/computed tomography.

Over the last decades, the refinement of radiation therapy techniques has been associated with an increasing interest for individualized radiation therapy with the aim of increasing or maintaining tumor control and reducing radiation toxicity. Developments in artificial intelligence (AI), particularly machine learning and deep learning, in imaging sciences, including nuclear medecine, have led to significant enthusiasm for the concept of "rapid learning health system". AI combined with radiomics applied to (18F)-fluorodeoxyglucose positron emission tomography/computed tomography ([18F]-FDG PET/CT) offers a unique opportunity for the development of predictive models that can help stratify each patient's risk and guide treatment decisions for optimal outcomes and quality of life of patients treated with radiation therapy. Here we present an overview of the current contribution of AI and radiomics-based machine learning models applied to (18F)-FDG PET/CT in the management of cancer treated by radiation therapy.

Impact of age on the Quadrella index assessing oncological and functional results after prostate brachytherapy: A 6-year analysis.

Purpose: As the oncological results of prostate brachytherapy (BT) are excellent for low-risk (LR) or favorable intermediate-risk (FIR) prostate cancer (PCa), evaluating the side effects has become a major issue, especially for young men. The objective of the study was to compare the oncologic and functional results of BT using Quadrella index for patients aged 60 or less compared with older patients. Material and methods: From June, 2007 to June, 2017, 222 patients, including 70 ≤ 60 years old and 152 > 60 years old, underwent BT for LR-FIR PCa, with good erectile function at baseline according to International Index of Erectile Function-5 (IIEF-5) > 16. Quadrella index was achieved under the following circumstances: 1) Absence of biological recurrence (Phoenix criteria); 2) Absence of erectile dysfunction (ED) (IIEF-5 > 16); 3) No urinary toxicity (international prostate score symptom) IPSS < 15 or IPSS > 15, and ΔIPSS < 5; 4) No rectal toxicity (RT) (Radiation Therapy Oncology Group, RTOG = 0). Patients were treated on demand with phosphodiesterase inhibitors (PDE5i) post-operatively. Results: The Quadrella index was satisfied for about 40-80% of patients ≤ 60 years vs. 33-46% for older patients during 6-year follow-up (significant difference from the second year). At year 5, 100% of evaluable patients aged ≤ 60 and 91.8% > 60 (p = 0.29) reached Phoenix criteria. The criterion of ED (IIEF-5 < 16) largely explained the validity rate of Quadrella alone. There was no ED for 67.2-81.4% of patients ≤ 60 years compared with 40.0-56.1% for patients > 60 (significant difference since year 4 in favor of young men). After two years of follow-up, more than 90% of patients in both the groups showed neither urinary nor rectal toxicities. Conclusions: For young men displaying LR-FIR PCa, BT appears to be a first-class therapeutic option, as the oncological results were at least equivalent to those of older patients with good long-term tolerance.

Dose escalation by brachytherapy for gynecological cancers.

Brachytherapy (BT), a type of focal cancer radiation therapy, delivers a highly focused dose of radiation to localized tumors, sparing surrounding normal tissue. Brachytherapy has been used to treat gynecologic malignancies, particularly cervical cancer, for over 100 years. From the first gynecologic brachytherapy treatments in the early 20th century to the modern era, significant transformations have taken place, largely due to advances in technology. The development of high-dose-rate sources, remote afterloaders, new applicators, and three-dimensional image guidance has increased tumor dose and, consequently, local control and survival, reinforcing brachytherapy's role as an integral component of gynecologic cancer treatment. Current research efforts involving biomarker research, integration of new imaging modalities, radiosensitizing therapies are aimed at further personalizing the dose delivered in BT to further improve local control and reduce treatment's related toxicities.

Integration of functional imaging in brachytherapy.

Functional imaging allows the evaluation of numerous biological properties that could be considered at all steps of the therapeutic management of patients treated with brachytherapy. Indeed, it enables better initial staging of the disease, and some parameters may also be used as predictive biomarkers for treatment response, allowing better selection of patients eligible for brachytherapy. It may also improve the definition of target volumes with the aim of dose escalations by dose-painting. Finally, it could be useful during the follow-up to assess response to treatment. In this review, we report how functional imaging is integrated at the present time during the brachytherapy procedure, and what are its potential future contributions in the main tumour locations where brachytherapy is recommended. Functional imaging has great potential in the contact of brachytherapy, but still, several issues remain to be resolved before integrating it into clinical practice, especially as a biomarker or in dose painting strategies.

Radiotherapy and pregnancy.

We present the updated recommendations of the French society for radiation oncology on radiotherapy and pregnancy. The occurrence of cancer during pregnancy is a rare event (approximately 1 in 1000 pregnancies). The risks for the embryo or the foetus depend on the gestational age at the time of irradiation. The main risks are malformations with microcephaly and mental retardation. There is also a risk of radiation-induced cancer in the unborn child. In the case of only supradiaphragmatic irradiation, radiotherapy can be performed most often in pregnant women without risk to the foetus. On the other hand, in the case of an indication for subdiaphragmatic irradiation, therapeutic termination of the pregnancy should be proposed. In all cases, when radiotherapy is chosen, a phantom estimation of the dose delivered to the foetus, confirmed by in vivo measurement, is recommended. Conformational radiotherapy is the preferred technique because of the lower dose delivered to the foetus (except in tumour locations where other techniques such as IMRT are recommended).

[Practice changing clinical trials in radiation oncology in 2022]. / Les essais qui changent les pratiques : le point en 2022.

This section highlights selected specific new recommendations and/or updates that have been published during the very last years in the fields of stereotactic radiotherapy, pediatrics, lung cancer, gynecologic and breast cancer, as well as in the area of radiation oncology of urogenital cancer.

External radiotherapy for prostatic cancers.

We present the update of the recommendations of the French society of oncological radiotherapy on external radiotherapy of prostate cancer. External radiotherapy is intended for all localized prostate cancers, and more recently for oligometastatic prostate cancers. The irradiation techniques are detailed. Intensity-modulated radiotherapy combined with prostate image-guided radiotherapy is the recommended technique. A total dose of 74 to 80Gy is recommended in case of standard fractionation (2Gy per fraction). Moderate hypofractionation (total dose of 60Gy at a rate of 3Gy per fraction over 4 weeks) in the prostate has become a standard of therapy. Simultaneous integrated boost techniques can be used to treat lymph node areas. Extreme hypofractionation (35 to 40Gy in five fractions) using stereotactic body radiotherapy can be considered a therapeutic option to treat exclusively the prostate. The postoperative irradiation technique, indicated mainly in case of biological recurrence and lymph node involvement, is detailed.

Impact of radiotherapy on survival in resected or unresectable anaplastic thyroid carcinomas, a Rare Cancer Network study.

PURPOSE: Anaplastic thyroid carcinomas (ATC) are a heterogenous group of tumors of overall dismal prognosis. We designed models to identify relevant prognostic factors of survival of irradiated ATC patients including radiotherapy modalities (field size, dose). MATERIAL AND METHODS: Between 2000 and 2017, 166 ATC patients' treatments were divided into surgery and postoperative radiotherapy (poRT) or definitive radiotherapy (RT). Multiple imputation approach was used for missing data. Prognostic factors were identified using Lasso-penalized Cox modelling and predicted risk scores were built. RESULTS: Patients undergoing RT (n=70) had more adverse patient and disease characteristics than those undergoing poRT (n=96). Corresponding median survival rates were 5.4 and 12.1 months, respectively. PoRT patients undergoing poRT more likely received extended-field radiotherapy with prophylactic nodal irradiation, but rather received platinum- vs. adriamycin-based chemoradiotherapy. Radiotherapy was conventionally fractionated, delivered >60Gy in 51.9% and 61.7% and used extended fields in 88.5% and 71.2% of patients with poRT or RT. Radiotherapy interruption rates for toxicity were similar in the two groups. The best poRT-group model identified age>45yo, PS≥1, pathologic tumor stage≥pT4b,>N1 and R2 resection as poor prognostic factors. The best RT-group model (C-index of 0.72) identified PS≥3,>N1 and extended-field radiotherapy with prophylactic nodal irradiation (as opposed to tumour-bed irradiation only) as poor prognostic factors. CONCLUSION: In patients undergoing poRT, radiotherapy parameters had little influence over their survival irrespective of patient, disease characteristics, and quality of resection. In patients undergoing RT, extended-field radiotherapy improved survival in addition to PS and nodal stage.

Recommendations for stereotactic body radiation therapy for spine and non-spine bone metastases. A GETUG (French society of urological radiation oncolgists) consensus using a national two-round modified Delphi survey.

Background and purpose: The relevance of metastasis-directed stereotactic body radiation therapy (SBRT) remains to be demonstrated through phase III trials. Multiple SBRT procedures have been published potentially resulting in a disparity of practices. Therefore, the french society of urological radiation oncolgists (GETUG) recognized the need for joint expert consensus guidelines for metastasis-directed SBRT in order to standardize practice in trials carried out by the group. Materials and methods: After a comprehensive literature review, 97 recommendation statements were created regarding planning and delivery of spine bone (SBM) and non-spine bone metastases (NSBM) SBRT. These statements were then submitted to a national online two-round modified Delphi survey among main GETUG investigators. Consensus was achieved if a statement received ≥ 75 % agreements, a trend to consensus being defined as 65-74 % agreements. Any statement without consensus at round one was re-submitted in round two. Results: Twenty-one out of 29 (72.4%) surveyed experts responded to both rounds. Seventy-five statements achieved consensus at round one leaving 22 statements needing a revote of which 16 achieved consensus and 5 a trend to consensus. The final rate of consensus was 91/97 (93.8%). Statements with no consensus concerned patient selection (3/19), dose and fractionation (1/11), prescription and dose objectives (1/9) and organs at risk delineation (1/15). The voting resulted in the writing of step-by-step consensus guidelines. Conclusion: Consensus guidelines for SBM and NSBM SBRT were agreed upon using a validated modified Delphi approach. These guidelines will be used as per-protocole recommendations in ongoing and further GETUG clinical trials.

Histosurgical mapping of endoscopic endonasal surgery of sinonasal tumours to improve radiotherapy guidance.

PURPOSE: Endoscopic endonasal surgery (EES) is becoming a standard for most malignant sinonasal tumours. Margin analysis after piecemeal resection is complex and optimally relies on accurate histosurgical mapping. Postoperative radiotherapy may be adapted based on margin assessment mapping to reduce the dose to some sinonasal subvolumes. We assessed the use of histosurgical mapping by radiation oncologists (RO). MATERIAL AND METHODS: A French practice survey was performed across 29 ENT expert RO (2 did not answer) regarding integration of information on EES, as well as quality of operative and pathology reportsto refine radiotherapy planning after EES. This was assessed through an electronic questionnaire. RESULTS: EES was ubiquitously performed in France. Operative and pathology reports yielded accurate description of EES samples according to 66.7% of interviewed RO. Accuracy of margin assessment was however insufficient according to more than 40.0% of RO. Additional margins/biopsies of the operative bed were available in 55.2% (16/29) of the centres. In the absence of additional margins, quality of resection after EES was considered as microscopically incomplete in 48.3% or dubious in 48.3% of RO. As performed, histosurgical mapping allowed radiotherapy dose and volumes adaptation according to 26.3% of RO only. CONCLUSIONS: Standardized histosurgical mapping with margin and additional margin analysis could be more systematic. Advantages of accurate EES reporting could be dose painting radiotherapy to further decrease morbidity in sinonasal tumours.

Hemangiopericytomas grade II are not benign tumors.

BACKGROUND: Hemangiopericytomas (HPs) of the central nervous system are rare tumors and afflicted with a high propensity of recurrences and metastases. Histopathologically, HPs correspond to differentiated (WHO grade II) and anaplastic (WHO grade III) tumors. With respect to the available literature and our own experiences, the aggressiveness, especially of differentiated grade II HPs, seems to be underestimated. METHODS: Thus, in this retrospective study, we describe tumor behavior and examined the effect of radio- and chemotherapy on tumor control with respect to the WHO classification of grade II and III neoplasms. This study consists of 15 patients with cerebral (n = 10) and spinal (n = 5) HPs. RESULTS: Seven HPs were histopathologically classified as grade II and eight as anaplastic grade III tumors. Complete surgical resection could be achieved in 60% of cerebral and in 25% of spinal HPs. In total, local recurrences occurred in 20% of patients within 17.3 months after the primary operation. Recurrences occurred both from differentiated (n = 1) and anaplastic (n = 2) neoplasms. Treatment comprised re-operation followed by radio- and chemotherapy. Pointing out the importance of the extent of surgical resection, in this study, we could not detect a single patient showing any recurrences or systemic metastases after complete surgical resection of grade II HPs. During primary diagnostics, four patients showed systemic metastases. Although these tumors could be controlled via surgery, systemic metastases appeared in further four patients within 60.4 months. Interestingly, two of them were classified as differentiated tumors (WHO grade II). To control tumor progress, radiotherapy seemed to be partially effective. On the other hand, however, chemotherapy did not show any effect on tumor control. With respect to these results, screening investigations seem to be indispensable and are highly recommended during primary diagnostics and after the appearance of recurrences or metastases, independent of the histopathological staging of the tumor. CONCLUSION: With respect to our results, radical surgical resection offers the best treatment option to control tumor progress. In case of subtotal resection or histopathologically diagnosed anaplasia (WHO III), radiotherapy seems to be indicated; however, chemotherapy did not show effectiveness to control tumor progress.

[Acoustic neuroma (vestibular schwannoma). Treatment from a neurosurgical perspective]. / Akustikusneurinome (Vestibularisschwannome). Behandlung aus neurochirurgischer Sicht.

During the last century microsurgical approaches laid emphasis in descending order on preservation of life, total tumor excision and function. Today, the priority of microsurgery has changed to functional preservation. The management of vestibular schwannomas consists of observation, surgical resection, or radiation therapy. In recent years, there has been an increase in observation-only management for small tumors, or radiotherapy in the case of tumor progression. The number of surgical procedures is in decline, with surgery being reserved mainly for large tumors.