MR relaxation times of agar-based tissue-mimicking phantoms.

Agar gels were previously proven capable of accurately replicating the acoustical and thermal properties of real tissue and widely used for the construction of tissue-mimicking phantoms (TMPs) for focused ultrasound (FUS) applications. Given the current popularity of magnetic resonance-guided FUS (MRgFUS), we have investigated the MR relaxation times T1 and T2 of different mixtures of agar-based phantoms. Nine TMPs were constructed containing agar as the gelling agent and various concentrations of silicon dioxide and evaporated milk. An agar-based phantom doped with wood powder was also evaluated. A series of MR images were acquired in a 1.5 T scanner for T1 and T2 mapping. T2 was predominantly affected by varying agar concentrations. A trend toward decreasing T1 with an increasing concentration of evaporated milk was observed. The addition of silicon dioxide decreased both relaxation times of pure agar gels. The proposed phantoms have great potential for use with the continuously emerging MRgFUS technology. The MR relaxation times of several body tissues can be mimicked by adjusting the concentration of ingredients, thus enabling more accurate and realistic MRgFUS studies.

Narrative Review of High-Dose-Rate Interstitial Brachytherapy in Primary or Secondary Liver Tumors.

The optimal management of intrahepatic malignancies involves a multidisciplinary approach. Although surgical resection has been considered the only curative approach, the use of several minimally invasive ablative techniques has dramatically increased the last two decades, mainly due to the fact that they provide similar oncological results with significantly decreased morbidity. Among these modalities, interstitial liver brachytherapy, probably the most flexible liver ablative method, with excellent clinical data on its safety and effectiveness, is frequently not even mentioned as an option in the current peer reviewed literature and guidelines. Brachytherapy is a type of radiotherapy utilizing radionuclides that are directly inserted into the tumor. Compared to external beam radiation therapy, brachytherapy has the potential to deliver an ablative radiation dose over a short period of time, with the advantage of a rapid dose fall-off, that allows for sparing of adjacent healthy tissue. For numerous malignancies such as skin, gynecological, breast, prostate, head and neck, bladder, liver and soft-tissue tumors, brachytherapy as a monotherapy or combined with external beam radiation therapy, has become a standard treatment for many decades. This review article aims to describe the high-dose-rate liver brachytherapy technique, its selection criteria, present its advantages and disadvantages, as well as the available clinical data, in order to help physicians to explore and hopefully introduce liver brachytherapy into their clinical routine.

High-dose-rate brachytherapy for prostate cancer: Rationale, current applications, and clinical outcome.

BACKGROUND: High-dose-rate brachytherapy (HDR BRT) has been enjoying rapid acceptance as a treatment modality offered to selected prostate cancer patients devoid of risk group, employed either in monotherapy setting or combined with external beam radiation therapy (EBRT) and is currently one of the most active clinical research areas. RECENT FINDINGS: This review encompasses all the current evidence to support the use of HDR BRT in various clinical scenario and shines light to the HDR BRT rationale, as an ultimately conformal dose delivery method enabling safe dose escalation to the prostate. CONCLUSION: Valid long-term data, both in regard to the oncologic outcomes and toxicity profile, support the current clinical indication spectrum of HDR BRT. At the same time, this serves as solid, rigid ground for emerging therapeutic applications, allowing the technique to remain in the spotlight alongside stereotactic radiosurgery.

High-Dose-Rate Brachytherapy as Monotherapy for Low- and Intermediate-Risk Prostate Cancer. Oncological Outcomes After a Median 15-Year Follow-Up.

INTRODUCTION: To evaluate the oncological outcome of high dose rate (HDR) brachytherapy (BRT) as monotherapy for clinically localised prostate cancer (PCA). MATERIAL AND METHODS: Between January 2002 and February 2004, 141 consecutive patients with clinically localised PCA were treated with HDR-BRT monotherapy. The cohort comprised 103 (73%) low-, 32 (22.7%) intermediate- and 6 (4.3%) high risk patients according to D'Amico classification or 104 (73.8%) low-, 24 (17.0%) intermediate favourable-, 12 (8.5%) intermediate unfavourable- and one (0.7%) very high risk patient according to National Comprehensive Cancer Network (NCCN) one. Patients received four fractions of 9.5 Gy delivered within a single implant up to a total physical dose of 38 Gy. Catheter-implantation was transrectal ultrasound-based whereas treatment planning CT-based. Thirty-three patients (23.4%) received ADT neoadjuvantly and continued concurrently with BRT. Biochemical relapse-free survival (BRFS) was defined according to the Phoenix Consensus Criteria and genitourinary (GU)/gastrointestinal (GI) toxicity evaluated using the Common Toxicity Criteria for Adverse Events version 5.0. RESULTS: Median age at treatment and median follow-up time was 67.2 and 15.2 years, respectively. Twenty-three (16.3%) patients experienced a biochemical relapse and 5 (3.5%) developed distant metastases, with only one patient dying of PCA. The BRFS was 85.1% at 15 years and 78.7% at 18 years. The corresponding overall survival, metastases-free survival, and prostate cancer specific mortality at 15- and 18-years was 73.9%/59.1%, 98.3%/90.6%, and 100%/98.5% respectively. Late grade 3 GI and GU toxicity was 4.2% and 5.6% respectively. Erectile dysfunction grade 3 was reported by 27 (19%) patients. From the prognostic factors evaluated, tumor stage (≤T2b compared to ≥T2c) along with the risk group (low-intermediate vs. high) when using the D'Amico classification but not when the NCCN one was taken into account, correlated significantly with BRFS. CONCLUSION: Our long-term results confirm HDR-BRT to be a safe and effective monotherapeutic treatment modality for low- and intermediate risk PCA.

Computed tomography guided interstitial percutaneous high-dose-rate brachytherapy in the management of lung malignancies. A review of the literature.

A growing number of patients with lung cancer are not amenable to surgery due to their age or comorbidities. For this reason, local ablative techniques have gained increasing interest recently in the management of inoperable lung tumors. High-dose-rate percutaneous interstitial brachytherapy, performed under CT-guidance, is a newer form of brachytherapy and is a highly conformal radiotherapy technique. The aim of this study was to describe this method and review the existing literature. Eight articles comprising 234 patients reported toxicity and clinical outcome. The follow-up ranged from 6 to 28 months. Diverse fractionation schemes were reported, with 20 Gy in a single fraction being the most frequently utilized. Toxicity was limited; major pneumothoraces occurred after only 8% of the interventions. Local control rates at one year ranged between 37% and 91%. In conclusion, high-dose-rate percutaneous interstitial brachytherapy is a safe, fast, and efficient treatment option for inoperable lung tumors.

Simple methods to test the accuracy of MRgFUS robotic systems.

BACKGROUND: Robotic-assisted diagnostic and therapeutic modalities require a highly accurate performance to be certified for clinical application. In this paper, three simple methods for assessing the accuracy of motion of magnetic resonance-guided focused ultrasound (MRgFUS) robotic systems are presented. METHODS: The accuracy of motion of a 4 degrees of freedom robotic system intended for preclinical use of MRgFUS was evaluated by calliper-based and magnetic resonance imaging (MRI) methods, as well as visually by performing multiple ablations on a plastic film. RESULTS: The benchtop results confirmed a highly accurate motion in all axes of operation. The spatial positioning errors estimated by MRI evaluation were defined by the size of the imaging pixels. Lesions arrangement in discrete and overlapping patterns confirmed satisfactory alignment of motion trajectories. CONCLUSIONS: We believe the methods presented here should serve as a standard for evaluating the accuracy of motion of MRgFUS robotic systems.

PET/CT imaging of prostate cancer in the era of small molecule prostate specific membrane antigen targeted tracers.

Staging and restaging of prostate cancer is crucial for treatment planning and prognosis. Accurate localization is of high relevance for a tailor-made therapy and an early detection of unknown metastatic spread can lead to a survival benefit. Evidence based guidelines that are currently in use were established using data from conventional imaging (such as magnetic resonance imaging (MRI), computed tomography (CT) and bone scintigraphy). Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is rapidly evolving with promising results. However, up to now there is little consensus about the usefulness of this method, especially since different guidelines are "biased" depending on the association that shapes them. Firstly, little data exists on the staging of low risk tumors and probably PSMA PET/CT should be avoided in this setup for most patients. On the other hand, it has been recently proven that PSMA PET/CT can replace CT and bone scintigraphy (combined) in staging of advanced prostate cancer. Furthermore, the examination gained general acceptance through its excellent performance in biochemical recurrence, both for castration naïve and castration resistant tumors, and should be implemented where available. It is undisputed that PSMA PET/CT provides a more accurate picture of prostate cancer patients and can lead to both upstaging and downstaging, thus affecting therapeutic management. Though it is not clear yet if the more accurate staging will lead to better therapeutic decisions and improve patient outcomes, PSMA PET/CT appears as the next imaging standard for prostate cancer for the years to come.

Image-guided interstitial high-dose-rate brachytherapy for dose escalation in the radiotherapy treatment of locally advanced lung cancer: A single-institute experience.

PURPOSE: To evaluate the clinical outcome after CT-guided interstitial high-dose-rate (HDR) brachytherapy for dose escalation in the radiotherapy treatment of inoperable locally advanced non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS: From 2005 to 2015, 16 patients with unresectable NSCLC were treated. Median age was 65.7 years (range, 52-86). The median tumor volume was 95.3 cm3 (range, 20.0-2000.0). The median prescribed HDR was 15.0 Gy (range, 7.0-32.0) delivered in twice-daily fractions of 6.0-8.0 Gy in 4 patients and in once-daily fractions of 7.0-15.0 Gy in 12 patients, respectively. RESULTS: After a median followup of 12.5 months, median overall survival and local control was 12.9 and 24.9 months, respectively. The corresponding median overall survival and local control rates at 1, 2, and 3 years were 56.2%, 37.5%, and 12.5% as well as 68.9%, 57.4%, and 43%, respectively. Apart from one Grade 1 cough episode persisting for 1 week and one patient developing a minor hemopneumothorax requiring no postprocedural drainage, no other adverse events were recorded. CONCLUSIONS: CT-guided interstitial HDR brachytherapy is a safe modality for radiation dose escalation which may play a role in the definitive radiotherapy treatment of locally advanced NSCLC.

Interstitial high-dose-rate brachytherapy in the primary treatment of inoperable glioblastoma multiforme.

PURPOSE: To report our results of image-guided interstitial (IRT) high-dose-rate (HDR) brachytherapy (BRT) in the primary treatment of patients with inoperable glioblastoma multiforme (GBM) in the pre-temozolomide period. MATERIAL AND METHODS: Between 1994 and 2004, 17 patients were treated with HDR BRT for inoperable GBM. Of those, only 11 patients were treated with IRT BRT, and the remaining six patients received combined IRT BRT and external beam radiotherapy (EBRT). Patient's median age was 59.3 years (range, 29-83 years) and median tumor volume was 39.3 cm3 (range, 2-162 cm3). The prescribed HDR dose was median 40 Gy (range, 30-40 Gy), delivered twice daily in 5.0 Gy fractions over four consecutive days. Survival from BRT, toxicity as well as the impact of several prognostic factors was evaluated. RESULTS: At a median follow-up of 9.3 months, the median overall survival for the whole population, after BRT alone, and combined BRT with EBRT was 9.3, 7.3, and 10.1 months, respectively. Of the prognostic variables evaluated in univariate analysis, i.e., age, Karnofsky performance score, BRT dose, and tumor volume, only the latter one reached statistical significance. Two patients (11.7%) developed treatment-associated adverse events, with one (5.8%) symptomatic radionecrosis and one (5.8%) severe convulsion episode, respectively. CONCLUSIONS: For patients with inoperable GBM, IRT HDR BRT alone or in combination with EBRT is a safe and effective irradiation method providing palliation without excessive toxicity.

CT-guided interstitial HDR-brachytherapy for recurrent glioblastoma multiforme: a 20-year single-institute experience.

PURPOSE: To report our results of computed tomography-guided interstitial high-dose-rate (HDR) brachytherapy (BRT) in the treatment of patients with recurrent inoperable glioblastoma multiforme (GBM). PATIENTS AND METHODS: Between 1995 and 2014, 135 patients were treated with interstitial HDR BRT for inoperable recurrent GBM located within previously irradiated volumes. Patient's median age was 57.1 years (14-82 years). All patients were pretreated with surgery, postoperative external beam radiation therapy (EBRT) and systemic chemotherapy (ChT). The median recurrent tumor volume was 42 cm3 (2-207 cm3). The prescribed HDR dose was median 40 Gy (30-50 Gy) delivered in twice-daily fractions of 5.0 Gy over consecutive days. No repeat surgery or ChT was administered in conjunction with BRT. Survival from BRT, progression-free survival (PFS), toxicity as well as the impact of several prognostic factors were evaluated. RESULTS: At a median follow-up of 9.2 months, the median overall survival following BRT and the median PFS were 9.2 and 4.6 months, respectively. Of the prognostic variables evaluated in univariate analysis, extent of surgery at initial diagnosis, tumor volume at recurrence, as well as time from EBRT to BRT reached statistical significance, retained also in multivariate analysis. Eight patients (5.9%) developed treatment-associated complications including intracerebral bleeding in 4 patients (2.9%), symptomatic focal radionecrosis in 3 patients (2.2%), and severe convulsion in 1 patient (0.7%). CONCLUSIONS: For patients with recurrent GBM, interstitial HDR BRT is an effective re-irradiation method for even larger tumors providing palliation without excessive toxicity.

Inverse planning and inverse implanting for breast interstitial brachytherapy. Introducing a new anatomy specific breast interstitial template (ASBIT).

An innovative template, based on thoracic cage surface reconstructions for breast interstitial brachytherapy was developed. Hybrid-inverse-planning-optimisation-based implantations and brachytherapy plans, using three custom anthropomorphic breast phantoms, were utilised for its validation. A user independent, inverse planning and inverse implanting technique is proposed.

Combined high dose rate brachytherapy and external beam radiotherapy for clinically localised prostate cancer.

PURPOSE: To report the clinical outcomes and treatment-related toxicities after combined high-dose-rate (HDR) brachytherapy (BRT) with external beam radiotherapy (EBRT) for patients with clinically localised high-risk prostate cancer. MATERIAL AND METHODS: Between 2008 and 2012, three hundred and three consecutive patients with organ-confined high-risk prostate cancer were treated with definitive radiotherapy consisting of HDR-BRT followed by supplemental EBRT. The transrectal 3D-ultrasound-based HDR-BRT boost consisted of two single-fraction implants of 10.5 Gy, prescribed to the 90% of the gland (D90), for a total physical dose of 21.0 Gy delivered to the prostatic gland. EBRT was delivered with conventional fractionation, prescribing 45.0 Gy to the prostatic gland and seminal vesicles. Biochemical failure was defined according to the Phoenix Consensus Criteria, genitourinary (GU)/gastrointestinal (GI) toxicity was evaluated using the Common Toxicity Criteria for Adverse Events (version 3.0). RESULTS: The median follow-up was 71.6 months. The 7-year overall survival, biochemical control and metastasis-free-survival rates for the entire cohort were 85.7%, 88.3% and 93.8%, respectively. Androgen deprivation therapy was initiated prior to treatment for 92.7% of patients with a median duration of 12 months. Toxicity was scored per event with late Grade 2, 3 and 4 GU adverse events and was found to be 15.3%, 2.2% and 0.3%, respectively. Late Grade 2 GI toxicity accounted for 0.3% with no instances of Grade 3 or higher late adverse events. CONCLUSION: HDR-BRT with supplemental EBRT results in low biochemical relapse-free survival rates associated with a very low incidence of higher-grade late adverse events.

High dose rate brachytherapy as monotherapy for localised prostate cancer.

BACKGROUND AND PURPOSE: To evaluate the oncological outcome of a three-implant high dose rate (HDR) brachytherapy (BRT) protocol as monotherapy for clinically localised prostate cancer. MATERIAL AND METHODS: Between February 2008 and December 2012, 450 consecutive patients with clinically localised prostate cancer were treated with HDR monotherapy. The cohort comprised of 198 low-, 135 intermediate- and 117 high risk patients being treated with three single-fraction implants of 11.5Gy delivered to an intraoperative real-time, transrectal ultrasound defined planning treatment volume up to a total physical dose of 34.5Gy with an interfractional interval of 21days. Fifty-eight patients (12.8%) received ADT, 32 of whom were high- and 26 intermediate-risk. Biochemical failure was defined according to the Phoenix Consensus Criteria and genitourinary/gastrointestinal toxicity evaluated using the Common Toxicity Criteria for Adverse Events version 3.0. RESULTS: The median follow-up time was 56.3months. The 60-month overall survival, biochemical control and metastasis-free-survival rates were 96.2%, 95.0% and 99.0%, respectively. Toxicity was scored per event with late Grade 2 and 3 genitourinary adverse events of 14.2% and 0.8%, respectively. Late Grade 2 gastrointestinal toxicity amounted 0.4% with no instances of Grade 3 or greater late adverse events to be reported. CONCLUSIONS: Our results confirm HDR BRT to be a safe and effective monotherapeutic treatment modality for clinically localised prostate cancer.

High-dose-rate brachytherapy as salvage modality for locally recurrent prostate cancer after definitive radiotherapy : A systematic review.

PURPOSE: To review the current status of interstitial high-dose-rate brachytherapy as a salvage modality (sHDR BRT) for locally recurrent prostate cancer after definitive radiotherapy (RT). MATERIALS AND METHODS: A literature search was performed in PubMed using "high-dose-rate, brachytherapy, prostate cancer, salvage" as search terms. In all, 51 search results published between 2000 and 2016 were identified. Data tables were generated and summary descriptions created. The main outcome parameters used were biochemical control (BC) and toxicity scores. RESULTS: Eleven publications reported clinical outcome and toxicity with follow-up ranging from 4-191 months. A variety of dose and fractionation schedules were described, including 19.0 Gy in 2 fractions up to 42.0 Gy in 6 fractions. The 5­year BC ranged from 18-77%. Late grade 3 genitourinary and gastrointestinal toxicity was 0-32% and 0-5.1%, respectively. CONCLUSIONS: sHDR BRT appears as safe and effective salvage modality for the reirradiation of locally recurrent prostate cancer after definitive RT.

Iridium-Knife: Another knife in radiation oncology.

PURPOSE: Intratarget dose escalation with superior conformity is a defining feature of three-dimensional (3D) iridium-192 (192Ir) high-dose-rate (HDR) brachytherapy (BRT). In this study, we analyzed the dosimetric characteristics of interstitial 192Ir HDR BRT for intrathoracic and cerebral malignancies. We examined the dose gradient sharpness of HDR BRT compared with that of linear accelerator-based stereotactic radiosurgery and stereotactic body radiation therapy, usually called X-Knife, to demonstrate that it may as well be called a Knife. METHODS AND MATERIALS: Treatment plans for 10 patients with recurrent glioblastoma multiforme or intrathoracic malignancies, five of each entity, treated with X-Knife (stereotactic radiosurgery for glioblastoma multiforme and stereotactic body radiation therapy for intrathoracic malignancies) were replanned for simulated HDR BRT. For 3D BRT planning, we used identical structure sets and dose prescription as for the X-Knife planning. The indices for qualitative treatment plan analysis encompassed planning target volume coverage, conformity, dose falloff gradient, and the maximum dose-volume limits to different organs at risk. RESULTS: Volume coverage in HDR plans was comparable to that calculated for X-Knife plans with no statistically significant difference in terms of conformity. The dose falloff gradient-sharpness-of the HDR plans was considerably steeper compared with the X-Knife plans. CONCLUSIONS: Both 3D 192Ir HDR BRT and X-Knife are effective means for intratarget dose escalation with HDR BRT achieving at least equal conformity and a steeper dose falloff at the target volume margin. In this sense, it can reasonably be argued that 3D 192Ir HDR BRT deserves also to be called a Knife, namely Iridium-Knife.

Photobiomodulation therapy for the management of radiation-induced dermatitis : A single-institution experience of adjuvant radiotherapy in breast cancer patients after breast conserving surgery.

BACKGROUND: Radiation therapy (RT) comprises a key component in the treatment of breast cancer. Radiation-induced skin toxicity is the major adverse event experienced by patients; however, radiodermatitis (RD) prevention and management remains trivial. It is proven that photobiomodulation (PBM) therapy using light-emitting diode (LED) increases wound healing and depicts an anti-inflammatory effect. This single-institute study evaluates the beneficial role of PBM-LED in preventing/reducing RD during breast cancer RT. PATIENTS AND METHODS: Of 70 consecutively treated patients, 25 patients were treated with PBM-LED twice a week prior to adjuvant 3D conformal RT after breast-conserving surgery. RD was reported using Common Toxicity Criteria for Adverse Events Version 4.0 and pain intensity using a visual analog scale (VAS). For comparison, a control group (n = 45) received RT without PBM-LED. In addition, a "matched" group (n = 25) was generated from the control group based on propensity for potentially confounding variables. RESULTS: In the PBM group, 22 patients (88%) presented grade 1 and 3 (12%) grade 2 RD. In the control group, 25 patients (55.6%) developed grade 1 reactions, 18 patients (40%) grade 2, and 2 (4.4%) patients grade 3 RD. Concerning pain intensity, 15 patients (60%) of the PBM treatment arm reported no pain, 5 patients (20%) VAS 2, and 5 (20%) VAS 3. In the control group, 13 patients (28.9%) reported no pain, 2 (4.4%) VAS 1, 7 (15.6%) VAS 2, 9 patients (20%) reported VAS 3, 12 (26.7%) patients VAS 4, and 2 (4.4%) patients VAS 5. CONCLUSION: PBM-LED therapy applied prior to RT might be effective in decreasing the incidence and sequelae of radiation-induced skin toxicity in breast cancer patients treated with breast-conserving surgery.

Image-guided interstitial high-dose-rate brachytherapy in the treatment of inoperable recurrent head and neck malignancies: An effective option of reirradiation.

BACKGROUND: In recurrent head and neck cancer, therapeutic options are limited and high-quality evidence is rare. The purpose of this report was to present our experience of CT-guided interstitial high-dose rate (HDR) brachytherapy in 4 challenging cases of inoperable recurrent head and neck cancer. METHODS: A 53-year-old man with mucosal melanoma of the paranasal sinuses, a 61-year-old man with myofibroblastic sarcoma of the nasal cavity, a 51-year-old woman with nasopharyngeal cancer, and a 44-year-old woman with orbital leiomyosarcoma were treated with reirradiation by HDR brachytherapy after previous comprehensive therapy, including full course external radiotherapy (RT). RESULTS: All patients showed response to brachytherapy with 1 patient experiencing locoregional failure. The mean lesion-specific disease control was 15 months. Currently, 1 patient is alive and 3 patients died after mean 20 months after treatment. CONCLUSION: In patients with inoperable recurrent head and neck cancer, CT-guided interstitial HDR brachytherapy can play a role in providing palliation and tumor control. © 2017 Wiley Periodicals, Inc. Head Neck 39: E61-E68, 2017.

Docetaxel-induced radiation recall dermatitis : A case report and literature review.

Radiation recall dermatitis (RRD) refers to an acute inflammatory skin reaction appearing on a previously irradiated area following the systemic administration of a reaction-triggering agent. Despite various hypotheses, the pathomechanism of RRD appears complex and is still not fully understood. In addition, no clinical guidelines exist concerning whether drug treatment should be continued upon manifestation of an associated radiation recall phenomenon. We present the case of a patient with docetaxel-induced RRD, which was successfully treated with topical steroids and systemic antihistamines; re-challenge to docetaxel did result in very mild remanifestation of skin reactions.

Combined salvage therapies for recurrent glioblastoma multiforme: evaluation of an interdisciplinary treatment algorithm.

Glioblastoma multiforme patients presenting with recurrence following multimodality therapy have limited palliative treatment options when the major modalities of therapy including surgery, radiochemotherapy and adjuvant chemotherapy have been exhausted. The authors introduce a clinical and radiological indication-solving algorithm and provide outcome rates of a glioblastoma recurrence cohort. Sixty six consecutive adult patients with recurrent glioblastoma who underwent a combined scheme of salvage treatments consisting of reoperation, high dose rate (HDR) brachytherapy and chemotherapy were included in this prospective study and were compared to a historical control group of 24 recurrent glioblastoma patients who have been treated with intensive temozolomide chemotherapy as the only treatment modality. Median follow-up was 32 months (range 28-36 months). Median survival was 9 months for the entire cohort after salvage treatment and can be translated into a 3-month improvement in survival compared to the control group of patients with glioblastoma recurrence treated with temozolomide alone (P = 0.043). Toxicity and adverse events of reoperation, HDR brachytherapy combined with chemotherapy were quite favourable compared to intensive temomozolomide chemotherapy as the only treatment. Our experience suggests that a combined salvage treatment plan appears to be both feasible and effective and can be considered in selected patients affected by recurrent high grade gliomas. The authors' clinical and radiological indication-solving algorithm may assist in providing the best possible salvage treatment for this difficult population.