OPTIMISST protocol

• a faster recovery of our patients
• a shorter hospital stay
• a higher degree of patient autonomy
• a higher level of treatment safety
• an improved quality of life
• a positive effect on tumor control
• improved life expectancy

Our OPTIMISST protocol comprises 3 stages and optimizes treatment before, during and after surgery. After examination of the individual criteria, each patient receives an optimization of all influencing factors relevant to him, i.e. a personalized resection and monitoring concept.

Depending on the patient's individual risk factors and the location and size of the tumor, a personal treatment plan is drawn up for the patient. The individual steps of inpatient treatment and their timing are discussed in detail with the patient and his or her relatives. This includes

• preparation, beginning, duration of the operation
• exact operation procedure
• expected peculiarities when waking up from anesthesia
• stay in the intensive care unit
• return to the room
• full mobilization
• planning of discharge
• organization of rehabilitation
• expected duration of tissue examination
• scheduling of the discussion of findings
• presentation in the neuro-oncological tumor board

The waiting time until surgery is kept short. The patient's diet is checked, possibly switched to an immune diet (immunonutrition) for optimal preparation for surgery.

• early involvement and education of the patient
• admission on the day of surgery
• special shampoo for infection prophylaxis
• minimal fasting, possible dietary changes before surgery and carboloading
• special diet in case of more than 10% weight loss, BMI above 18.5, NRS > 3 or serum albumin < 30 g/L
• nutritional counseling according to the guidelines of the German Society of Nutritional Medicine (DGEM)

The body's immune response is increasingly becoming the focus of new therapies. We are currently conducting a Resdex study to demonstrate that routine treatment rarely requires the administration of dexamethasone (cortisone). Dexamethasone is an anti-inflammatory, immunosuppressive agent from the steroid group. The administration of dexamethasone before surgery is widely used, but in our view it is not always necessary. Dexamethasone inhibits the immune response and also has other side effects. If possible, administration of dexamethasone before surgery should be avoided. Data show that patients live longer who are treated without or with minimal and short-term doses of dexamethasone *

We advise our patients on participation in ongoing clinical trials - depending on the tumor and individual requirements. It has been scientifically proven that patients who participate in clinical trials show the best results in terms of quality of life and treatment success.
On the international database ClinicalTrials.gov you will find all brain tumor studies registered there

glioblastoma trials

astrozytoma and oligodendroglioma trials

Hair shaving is kept to a minimum. We also strive for minimal invasiveness with the smallest possible wound. Depending on the tumor location, we perform awake surgery with local anesthesia at the patient's request.

Modern surgical principles also include optimization of preparations and induction of anesthesia and other procedures to shorten surgical times, as well as our neurosurgery-specific time-out checklist.

Depending on the tumor location, size and functional risk due to the tumor location, different technological procedures are used during surgery:

• image-based GPS navigation
• intraoperative magnetic resonance imaging
• 4 x 12-channel neuromonitoring
• motor mapping and monitoring
• awake surgery
• intraoperative laser
• surgery with augmented reality
• Kinevo with 3 fluorescence modes (5-ALA fluorescence, ICG infrared angiography, sodium fluorescein)
• specialized neuro intensive care unit
• ultrasound
• other technologies

We combine intraoperative fluorescence and/or MRI monitoring during surgery with innovative monitoring of brain functions to prevent deficits and maximize resection.

High-end neurophysiological monitoring is a focus of our clinic, where we are among the world's leading centers and continuously co-develop new procedures. At Inselspital we have developed a special "Bern Concept" of neuromonitoring with continuous dynamic mapping to prevent paralysis.

In addition, we use:

• awake operations to avoid speech disorders or disorders of higher functions (reading, music, orientation, etc.).
• augmented reality (tracts, cortex, tumor, etc.)
• intraoperative imaging as GPS-like navigation to the surgical target.
• navigated transcranial magnetic stimulation (nTMS) before surgery
• other techniques

We use a resection technique strictly below the pia mater with minimal obliteration of vessels in the surgical area. In this way, we want to avoid even very small circulatory disturbances. These become visible on MRI as lesions with reduced DWI sequence. Normally, recurrences occur more frequently in the immediate vicinity of a tumor. DWI lesions also favor more distant recurrences.

Here, efforts are made to address all factors that reduce patient distress and promote recovery and return to (near) normal life activity.

• Postoperative:
  • early mobilization on the day of surgery
  • early drinking, early eating
  • personalized pain concept
  • standardized thrombosis prophylaxis
  • close monitoring in the first 24 hours after surgery for immediate reaction in case of one of the rare postoperative complications (epileptic seizure, bleeding, other), which occur with a frequency of about 2%.
• return to preoperative mobility on postoperative day 1.
• early showering and hair washing on day 3 after surgery
• rapid discharge in consultation with the patient and relatives, organizing support and care if necessary
• air travel, jogging and light sports activities as of day 7 after surgery, if the patient feels well

As mentioned above, the body's immune response is increasingly becoming the focus of new therapies, especially in the context of chemotherapy. The administration of dexamethasone, an anti-inflammatory, immunosuppressive agent, is widely used after surgery and during radiation. However, for long-term success, the use of dexamethasone is often unfavorable and should be avoided.

There are numerous other factors that affect the immune system:

• negative factors include smoking, greater alcohol consumption, extreme sports, stress, and continuous fasting.
• positive factors are a healthy lifestyle, general physical and mental activity, and work and structure in the daily schedule.

Here, it is important for us to provide the patient with an already familiar, personal person as a contact and coordinator for further follow-up.

Also to be mentioned here are the adjustment of medication, diet and activities and – whenever possible – the avoidance of dexamethasone even during radiotherapy.

Other factors include:

• switching from Keppra to lamotrigine with fewer mood-impairing side effects
• counseling about keto diet at the patient's request
• information about Novo-TTF as a new form of therapy
• a complementary medicine therapy consultation at the Institute for Complementary and Integrative Medicine

A postoperative MRI for control is performed within 24–48 hours. Any residual tumor is immediately re-operated. This is followed by MRI and PET follow-up. A recurrence is removed surgically or, for example, by laser thermotherapy.

Since tissue cannot be resected in the brain with a safety margin in the centimeter range, there is a 10% chance that a minimal tumor remnant remains, which is, however, visible on MRI. We aim for immediate (<   72  h) resection of any residual tumor, as fresh surgery allows access in minutes without additional exposure. If a suspicious focus is seen during the course, surgery (open, minimally invasive, or laser-induced thermotherapy, for example) is performed without loss of time to prevent the tumor from growing exponentially and scattering cells.

To see early on what treatment options are available beyond standard therapy, a genetic analysis is performed of the tumor, as well as an additional methylation classifier. Genetic analysis and methylation analysis can help to better classify a brain tumor and find targeted chemotherapy that may be rare for certain mutation patterns.

A healthy lifestyle with a balanced diet and moderate exercise, as well as abstaining from smoking, have a positive impact on patients' quality of life and disease progression.

• 5 servings of fruits or vegetables per day
• optimization of body weight
• light to moderate exercise for 30–45 minutes on 2–5 days per week
• no high-intensity sports over 1 hour
• physical therapy
• reduction of concomitant diseases
• and others

All these measures have a beneficial effect on the patients' condition, quality of life and immune system.