51
|
Chung LK, Ung N, Sheppard JP, Nguyen T, Lagman C, Choy W, Tenn S, Pouratian N, Lee P, Kaprealian T, Selch M, De Salles A, Gopen Q, Yang I. Impact of Cochlear Dose on Hearing Preservation following Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy for the Treatment of Vestibular Schwannoma. J Neurol Surg B Skull Base 2017; 79:335-342. [PMID: 30009113 DOI: 10.1055/s-0037-1607968] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/19/2017] [Indexed: 10/18/2022] Open
Abstract
Objective The objective of this study was to examine the effect of cochlear dose on hearing preservation in stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (fSRT) for vestibular schwannoma (VS). Design This is a retrospective case-control study. Setting This study was completed at the Ronald Reagan UCLA Medical Center, a university-affiliated tertiary care center. Participants Patients who underwent SRS (marginal dose of 12 Gy) or fSRT (marginal dose of 50.4 Gy) procedures for VS were included in the study. Main Outcome Measures The main outcome measure was hearing preservation. Audiometric data, when available, were used to determine the level of hearing according to the Gardner Robertson scale. Results A total of 38 patients (14 SRS and 24 fSRT) were analyzed. SRS patients with decreased hearing received a significantly higher minimum cochlear dose (7.41 vs. 4.24 Gy, p = 0.02) as compared with those with stable hearing. In fSRT patients, there were no significant differences in cochlear dose for patients with decreased hearing as compared with those with stable hearing. For SRS patients, who received a minimum cochlear dose above 6 Gy, there was a significant risk of decreased hearing preservation (odds ratio: 32, p = 0.02). Conclusion Higher minimum cochlear dose was predictive of decreased hearing preservation following SRS. Though the study is low powered, the radiation dose to the cochlea should be a parameter that is considered when planning SRS or fSRT therapies for patients with VS.
Collapse
Affiliation(s)
- Lawrance K Chung
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Nolan Ung
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - John P Sheppard
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Thien Nguyen
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Carlito Lagman
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Winward Choy
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Stephen Tenn
- Department of Radiation Oncology, University of California, California, United States
| | - Nader Pouratian
- Department of Neurosurgery, University of California, Los Angeles, California, United States.,Department of Radiation Oncology, University of California, California, United States
| | - Percy Lee
- Department of Radiation Oncology, University of California, California, United States
| | - Tania Kaprealian
- Department of Neurosurgery, University of California, Los Angeles, California, United States.,Department of Radiation Oncology, University of California, California, United States.,UCLA Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, United States
| | - Michael Selch
- Department of Radiation Oncology, University of California, California, United States
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, California, United States
| | - Quinton Gopen
- Department of Head and Neck Surgery, University of California, Los Angeles, California, United States
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, California, United States.,Department of Radiation Oncology, University of California, California, United States.,UCLA Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, United States.,Department of Head and Neck Surgery, University of California, Los Angeles, California, United States.,Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, California, United States.,Los Angeles Biomedical Research Institute, Torrance, California, United States
| |
Collapse
|
52
|
Lin RH, Wang TC, Lin CD, Lin HL, Chung HK, Wang CY, Tsou YA, Tsai MH. Predictors of hearing outcomes following low-dose stereotactic radiosurgery in patients with vestibular schwannomas: A retrospective cohort review. Clin Neurol Neurosurg 2017; 162:16-21. [PMID: 28892717 DOI: 10.1016/j.clineuro.2017.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/25/2017] [Accepted: 09/03/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Hearing deterioration is a major concern for hearing-preserved patients with vestibular schwannomas who are treated with stereotactic radiosurgery (SRS). Thus, determining which patients are more likely to have worse hearing outcomes following SRS may facilitate clinicians in deciding whether conservative policy should be applied in the interest of hearing preservation. This study aimed to define the predictors of hearing outcomes following SRS. PATIENTS AND METHODS This retrospective study included 100 patients who underwent low-dose SRS (12- to 13-Gy marginal dose) for vestibular schwannomas between January 2004 and January 2014. Clinical factors and hearing outcomes following radiosurgery were reviewed. RESULTS All patients had serviceable hearing at diagnosis and prior to SRS. The median follow-up period was 6.5years (range, 3-10years). The hearing preservation rate in the first, third, and fifth year after radiosurgery was 89%, 68%, and 63%, respectively. A mean cochlear dose lower than 4Gy was a favorable predictor of hearing outcome. Maximal cochlear dose, patient age, pre-treatment pure-tone average, and imaging characteristics were not associated with post-treatment hearing preservation. Our study showed an accelerated rate of deterioration of serial pure-tone average in the first 3years, followed by a more gradual decline after radiosurgery. CONCLUSION Our results suggest that cochlear dose constraint is the most crucial factor for hearing preservation. This study provides insight into the rate of hearing preservation and the pattern of hearing deterioration following radiosurgery and can help clinicians advise patients of hearing outcomes following SRS.
Collapse
Affiliation(s)
- Ryh-Hsin Lin
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan
| | - Tang-Chuan Wang
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan; Department of Otolaryngology, University of Iowa Hospital, Iowa City, IA, USA
| | - Chia-Der Lin
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.
| | - Hung-Lin Lin
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Hsiung-Kwang Chung
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan
| | - Ching-Yuang Wang
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan
| | - Yung-An Tsou
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Ming-Hsui Tsai
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan; Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| |
Collapse
|
53
|
Pan SY, Liu SA, Sun MH, Tsou HK, Lee SD, Chen YJ, Sheehan J, Sheu ML, Pan HC. Outcome of hearing preservation related to tumor morphologic analysis in acoustic neuromas treated by gamma knife radiosurgery. Radiat Oncol 2017; 12:134. [PMID: 28810890 PMCID: PMC5558744 DOI: 10.1186/s13014-017-0875-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 08/11/2017] [Indexed: 11/18/2022] Open
Abstract
Background Gamma Knife radiosurgery (GKRS) is an important part of the neurosurgical armamentarium in the treatment of acoustic neuromas. However, the treatment outcome related to the morphology of the tumor has not been rigorously studied. In this cohort, we evaluated the morphological features of the tumor in the tumor response and neurological outcomes after GKRS. Material and methods From July 2003 to December 2008, there were 93 cases of acoustic neuromas treated upfront with GKRS with 64 cases with serviceable hearing and 29 cases without serviceable hearing to fulfill the margin dose of 12Gy with at least follow up 5 years. Results The duration of symptom before GKRS in serviceable /no serviceable hearing was 7.9 ± 1.2 and 15.3 ± 3.1 months (p < 0.001) and associated no-hearing symptom was 70% and 35%, respectively (p < 0.001). There was 81.2% of hearing preservation after GKRS in serviceable hearing group including 27 cases of pear type (84%), 14 of linear type (70%), and 9 cases of sphere type (90%) (p < 0.01); however, there was no case of hearing improvement in the no-serviceable hearing group (0 of 29). There were 85% of patients with decreased tinnitus in serviceable hearing groups as compared to 61.5% of patients in no serviceable hearing group (p < 0.05). In multivariate analysis, the tumor morphology was highly correlated to hearing preservation rate (p < 0.01). Conclusion In the limited case of this cohort, we found that the tumor morphology and timing of treatment was highly correlated to the rate of hearing preservation. The sphere type of tumor morphology was associated with the best chance of hearing preservation.
Collapse
Affiliation(s)
- Szu-Yen Pan
- Department of Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan
| | - Shih-An Liu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ming-Hsi Sun
- Department of Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan
| | - Hsi-Kai Tsou
- Department of Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan
| | - Shinh-Dung Lee
- Department of Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan
| | - Yen-Ju Chen
- Department of Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Meei-Ling Sheu
- Institute of Biomedical Science, National Chung-Hsin University, Taichung, Taiwan
| | - Hung-Chuan Pan
- Department of Neurosurgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sec.4, 40705, Taichung, Taiwan. .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| |
Collapse
|
54
|
Régis J, Delsanti C, Roche PH. Editorial: Vestibular schwannoma radiosurgery: progression or pseudoprogression? J Neurosurg 2017; 127:374-379. [DOI: 10.3171/2016.7.jns161236] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jean Régis
- 1Department of Functional Neurosurgery, and
| | | | - Pierre-Hugues Roche
- 2Skull Base Surgery, CHU Marseille Nord, Aix Marseille University, Marseille, France
| |
Collapse
|
55
|
Effects of Intratympanic Dexamethasone on High-Dose Radiation Ototoxicity In Vivo. Otol Neurotol 2017; 38:180-186. [DOI: 10.1097/mao.0000000000001289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
56
|
Stereotactic radiotherapy of vestibular schwannoma. Strahlenther Onkol 2016; 193:200-212. [DOI: 10.1007/s00066-016-1086-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 11/14/2016] [Indexed: 01/24/2023]
|
57
|
Watanabe S, Yamamoto M, Kawabe T, Koiso T, Yamamoto T, Matsumura A, Kasuya H. Stereotactic radiosurgery for vestibular schwannomas: average 10-year follow-up results focusing on long-term hearing preservation. J Neurosurg 2016; 125:64-72. [DOI: 10.3171/2016.7.gks161494] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe aim of this study was to reappraise long-term treatment outcomes of stereotactic radiosurgery (SRS) for vestibular schwannomas (VSs). The authors used a database that included patients who underwent SRS with a unique dose-planning technique, i.e., partial tumor coverage designed to avoid excess irradiation of the facial and cochlear nerves, focusing on tumor control and hearing preservation. Clinical factors associated with post-SRS tumor control and long-term hearing preservation were also analyzed.METHODSThis institutional review board–approved, retrospective cohort study used the authors' prospectively accumulated database. Among 207 patients who underwent Gamma Knife SRS for VSs between 1990 and 2005, 183 (who were followed up for at least 36 post-SRS months) were studied. The median tumor volume was 2.0 cm3 (range 0.05–26.2 cm3). The median prescribed dose at the tumor periphery was 12.0 Gy (range 8.8–15.0 Gy; 12.0 Gy was used in 171 patients [93%]), whereas tumor portions facing the facial and cochlear nerves were irradiated with 10.0 Gy. As a result, 72%–99% of each tumor was irradiated with the prescribed dose. The mean cochlear doses ranged from 2.3 to 5.7 Gy (median 4.1 Gy).RESULTSThe median durations of imaging and audiometric follow-up were 114 months (interquartile range 73–144 months) and 59 months (interquartile range 33–109 months), respectively. Tumor shrinkage was documented in 110 (61%), no change in 48 (27%), and enlargement in the other 22 (12%) patients. A further procedure (FP) was required in 15 (8%) patients. Thus, the tumor growth control rate was 88% and the clinical control rate (i.e., no need for an FP) was 92%. The cumulative FP-free rates were 96%, 93%, and 87% at the 60th, 120th, and 180th post-SRS month, respectively. Six (3%) patients experienced facial pain, and 2 developed transient facial palsy. Serviceable hearing was defined as a pure tone audiogram result better than 50 dB. Among the 66 patients with serviceable hearing before SRS who were followed up, hearing acuity was preserved in 23 (35%). Actuarial serviceable hearing preservation rates were 49%, 24%, and 12% at the 60th, 120th, and 180th post-SRS month, respectively. On univariable analysis, only cystic-type tumor (HR 3.36, 95% CI 1.18–9.36; p = 0.02) was shown to have a significantly unfavorable association with FP. Multivariable analysis followed by univariable analysis revealed that higher age (≥ 65 years: HR 2.66, 95% CI 1.16–5.92; p = 0.02), larger tumor volume (≥ 8 cm3: HR 5.36, 95% CI 1.20–17.4; p = 0.03), and higher cochlear dose (mean cochlear dose > 4.2 Gy: HR 2.22, 95% CI 1.07–4.77; p = 0.03) were unfavorable factors for hearing preservation.CONCLUSIONSStereotactic radiosurgery achieved good long-term results in this series. Tumor control was acceptable, and there were few serious complications in patients with small- to medium-sized VSs. Unfortunately, hearing preservation was not satisfactory. However, the longer the observation period, the more important it becomes to compare post-SRS hearing decreases with the natural decline in untreated cases.
Collapse
Affiliation(s)
- Shinya Watanabe
- 1Katsuta Hospital Mito GammaHouse, Hitachi-naka
- 2Department of Neurosurgery, Mito Medical Center, Ibaraki-machi
| | - Masaaki Yamamoto
- 1Katsuta Hospital Mito GammaHouse, Hitachi-naka
- 3Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo
| | - Takuya Kawabe
- 4Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Sciences, Kyoto; and
| | - Takao Koiso
- 1Katsuta Hospital Mito GammaHouse, Hitachi-naka
- 5Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Japan
| | - Tetsuya Yamamoto
- 5Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Japan
| | - Akira Matsumura
- 5Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Japan
| | - Hidetoshi Kasuya
- 3Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo
| |
Collapse
|
58
|
Golfinos JG, Hill TC, Rokosh R, Choudhry O, Shinseki M, Mansouri A, Friedmann DR, Thomas Roland J, Kondziolka D. A matched cohort comparison of clinical outcomes following microsurgical resection or stereotactic radiosurgery for patients with small- and medium-sized vestibular schwannomas. J Neurosurg 2016; 125:1472-1482. [DOI: 10.3171/2015.12.jns151857] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
A randomized trial that compares clinical outcomes following microsurgery (MS) or stereotactic radiosurgery (SRS) for patients with small- and medium-sized vestibular schwannomas (VSs) is impractical, but would have important implications for clinical decision making. A matched cohort analysis was conducted to evaluate clinical outcomes in patients treated with MS or SRS.
METHODS
The records of 399 VS patients who were cared for by 2 neurosurgeons and 1 neurotologist between 2001 and 2014 were evaluated. From this data set, 3 retrospective matched cohorts were created to compare hearing preservation (21 matched pairs), facial nerve preservation (83 matched pairs), intervention-free survival, and complication rates (85 matched pairs) between cases managed with SRS and patients managed with MS. Cases were matched for age at surgery (± 10 years) and lesion size (± 0.1 cm). To compare hearing outcomes, cases were additionally matched for preoperative Class A hearing according to the American Academy of Otolaryngology-Head and Neck Surgery guidelines. To compare facial nerve (i.e., cranial nerve [CN] VII) outcomes, cases were additionally matched for preoperative House-Brackmann (HB) score. Investigators who were not involved with patient care reviewed the clinical and imaging records. The reported outcomes were as assessed at the time of the last follow-up, unless otherwise stated.
RESULTS
The preservation of preoperative Class A hearing status was achieved in 14.3% of MS cases compared with 42.9% of SRS cases (OR 4.5; p < 0.05) after an average follow-up interval of 43.7 months and 30.3 months, respectively. Serviceable hearing was preserved in 42.8% of MS cases compared with 85.7% of SRS cases (OR 8.0; p < 0.01). The rates of postoperative CN VII dysfunction were low for both groups, although significantly higher in the MS group (HB III–IV 11% vs 0% for SRS; OR 21.3; p < 0.01) at a median follow-up interval of 35.7 and 19.0 months for MS and SRS, respectively. There was no difference in the need for subsequent intervention (2 MS patients and 2 SRS patients).
CONCLUSIONS
At this high-volume center, VS resection or radiosurgery for tumors ≤ 2.8 cm in diameter was associated with low overall morbidity. The need for subsequent intervention was the same in both groups. SRS was associated with improved hearing and facial preservation rates and reduced morbidity, but with a shorter average follow-up period. Facial function was excellent in both groups. Since patients were not randomly selected for surgery, different clinical outcomes may be of different value to individual patients. Both anticipated medical outcomes and patient goals remain the drivers of treatment decisions.
Collapse
Affiliation(s)
| | | | | | | | | | | | - David R. Friedmann
- 2Otolaryngology, NYU Langone Medical Center, New York University, New York, New York
| | - J. Thomas Roland
- 2Otolaryngology, NYU Langone Medical Center, New York University, New York, New York
| | | |
Collapse
|
59
|
Teo M, Zhang M, Li A, Thompson PA, Tayag AT, Wallach J, Gibbs IC, Soltys SG, Hancock SL, Chang SD. The Outcome of Hypofractionated Stereotactic Radiosurgery for Large Vestibular Schwannomas. World Neurosurg 2016; 93:398-409. [DOI: 10.1016/j.wneu.2016.06.080] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/19/2016] [Accepted: 06/20/2016] [Indexed: 11/30/2022]
|
60
|
Optimal outcomes for hearing preservation in the management of small vestibular schwannomas. The Journal of Laryngology & Otology 2016; 130:606-10. [DOI: 10.1017/s0022215116007969] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:To undertake a systematic review of the role of microsurgery, in relation to observation and stereotactic radiation, in the management of small vestibular schwannomas with serviceable hearing.Methods:The Medline database was searched for publications that included the terms ‘vestibular schwannoma’ and/or ‘acoustic neuroma’, occurring in conjunction with ‘hearing’. Articles were manually screened to identify those concerning vestibular schwannomas under 1.5 cm in greatest dimension. Thereafter, only publications discussing both pre-operative and post-operative hearing were considered.Results:Twenty-six papers were identified. Observation is an acceptable strategy for small tumours with slow growth where hearing preservation is not a consideration. In contrast, microsurgery, including the middle fossa approach, may provide excellent hearing outcomes, particularly when a small tumour has begun to cause hearing loss. Immediate post-operative hearing usually predicts long-term hearing. Recent data on stereotactic radiation suggest long-term deterioration of hearing following definitive therapy.Conclusion:In patients under the age of 65 years with small vestibular schwannomas, microsurgery via the middle fossa approach offers durable preservation of hearing.
Collapse
|
61
|
Clinical outcome of neurofibromatosis type 2-related vestibular schwannoma: treatment strategies and challenges. Neurosurg Rev 2016; 39:643-53. [DOI: 10.1007/s10143-016-0728-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 03/06/2016] [Accepted: 03/07/2016] [Indexed: 11/26/2022]
|
62
|
Wise SC, Carlson ML, Tveiten ØV, Driscoll CL, Myrseth E, Lund-Johansen M, Link MJ. Surgical salvage of recurrent vestibular schwannoma following prior stereotactic radiosurgery. Laryngoscope 2016; 126:2580-2586. [DOI: 10.1002/lary.25943] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/25/2016] [Accepted: 02/02/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Stephanie C. Wise
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
| | - Matthew L. Carlson
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurologic Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
| | - Øystein Vesterli Tveiten
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Colin L. Driscoll
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurologic Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
| | - Erling Myrseth
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
| | - Morten Lund-Johansen
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - Michael J. Link
- Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurologic Surgery; Mayo Clinic School of Medicine; Rochester Minnesota U.S.A
- Department of Neurosurgery; Haukeland University Hospital; Bergen Norway
| |
Collapse
|
63
|
Horiba A, Hayashi M, Chernov M, Kawamata T, Okada Y. Hearing Preservation after Low-dose Gamma Knife Radiosurgery of Vestibular Schwannomas. Neurol Med Chir (Tokyo) 2016; 56:186-92. [PMID: 26876903 PMCID: PMC4831944 DOI: 10.2176/nmc.oa.2015-0212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The objective of the retrospective study was to evaluate the factors associated with hearing preservation after low-dose Gamma Knife radiosurgery (GKS) of vestibular schwannomas performed according to the modern standards. From January 2005 to September 2010, 141 consecutive patients underwent such treatment in Tokyo Women’s Medical University. Mean marginal dose was 11.9 Gy (range, 11–12 Gy). The doses for the brain stem, cranial nerves (V, VII, and VIII), and cochlea were kept below 14 Gy, 12 Gy, and 4 Gy, respectively. Out of the total cohort, 102 cases with at least 24 months follow-up were analyzed. Within the median follow-up of 56 months (range, 24–99 months) the crude tumor growth control was 92% (94 cases), whereas its actuarial rate at 5 years was 93%. Out of 49 patients with serviceable hearing on the side of the tumor before GKS, 28 (57%) demonstrated its preservation at the time of the last follow-up. No one evaluated factor, namely Gardner-Robertson hearing class before irradiation, Koos tumor stage, extension of the intrameatal part of the neoplasm up to fundus, nerve of tumor origin, presence of cystic changes in the neoplasm, and cochlea dose demonstrated statistically significant association with preservation of the serviceable hearing after radiosurgery. In conclusion, GKS of vestibular schwannomas performed according to the modern standards of treatment permits to preserve serviceable hearing on the side of the tumor in more than half of the patients. The actual causes of hearing deterioration after radiosurgery remain unclear.
Collapse
Affiliation(s)
- Ayako Horiba
- Department of Neurosurgery, Tokyo Women's Medical University
| | | | | | | | | |
Collapse
|
64
|
Hasegawa T, Kato T, Kida Y, Hayashi M, Tsugawa T, Iwai Y, Sato M, Okamoto H, Kano T, Osano S, Nagano O, Nakazaki K. Gamma Knife surgery for patients with facial nerve schwannomas: a multiinstitutional retrospective study in Japan. J Neurosurg 2016; 124:403-10. [DOI: 10.3171/2015.3.jns142677] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The aim of this study was to explore the efficacy and safety of stereotactic radiosurgery for patients with facial nerve schwannomas (FNSs).
METHODS
This study was a multiinstitutional retrospective analysis of 42 patients with FNSs treated with Gamma Knife surgery (GKS) at 1 of 10 medical centers of the Japan Leksell Gamma Knife Society (JLGK1301). The median age of the patients was 50 years. Twenty-nine patients underwent GKS as the initial treatment, and 13 patients had previously undergone surgery. At the time of the GKS, 33 (79%) patients had some degree of facial palsy, and 21 (50%) did not retain serviceable hearing. Thirty-five (83%) tumors were solid, and 7 (17%) had cystic components. The median tumor volume was 2.5 cm3, and the median prescription dose to the tumor margin was 12 Gy.
RESULTS
The median follow-up period was 48 months. The last follow-up images showed partial remission in 23 patients and stable tumors in 19 patients. Only 1 patient experienced tumor progression at 60 months, but repeat GKS led to tumor shrinkage. The actuarial 3- and 5-year progression-free survival rates were 100% and 92%, respectively. During the follow-up period, 8 patients presented with newly developed or worsened preexisting facial palsy. The condition was transient in 3 of these patients. At the last clinical follow-up, facial nerve function improved in 8 (19%) patients, remained stable in 29 (69%), and worsened in 5 (12%; House-Brackmann Grade III in 4 patients, Grade IV in 1 patient). With respect to hearing function, 18 (90%) of 20 evaluated patients with a pure tone average of ≤ 50 dB before treatment retained serviceable hearing.
CONCLUSIONS
GKS is a safe and effective treatment option for patients with either primary or residual FNSs. All patients, including 1 patient who required repeat GKS, achieved good tumor control at the last follow-up. The incidence of newly developed or worsened preexisting facial palsy was 12% at the last clinical follow-up. In addition, the risk of hearing deterioration as an adverse effect of radiation was low. These results suggest that GKS is a safe alternative to resection.
Collapse
Affiliation(s)
| | - Takenori Kato
- 1Department of Neurosurgery, Komaki City Hospital, Komaki
| | - Yoshihisa Kida
- 2Department of Neurosurgery, Kamiiida Daiichi General Hospital, Nagoya
| | - Motohiro Hayashi
- 3Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo
| | | | - Yoshiyasu Iwai
- 5Department of Neurosurgery, Osaka City General Hospital, Osaka
| | - Mitsuya Sato
- 6Department of Neurosurgery, Kitanihon Neurosurgical Hospital, Gosen
| | | | - Tadashige Kano
- 8Department of Neurosurgery, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki
| | - Seiki Osano
- 9Department of Neurosurgery, Shonan Fujisawa Tokushukai Hospital, Fujisawa
| | - Osamu Nagano
- 10Department of Neurosurgery, Chiba Cerebral and Cardiovascular Center, Ichihara; and
| | - Kiyoshi Nakazaki
- 11Department of Neurosurgery, Brain Attack Center, Ota Memorial Hospital, Fukuyama, Japan
| |
Collapse
|
65
|
Han JH, Kim DG, Chung HT, Paek SH, Jung HW. Hearing Outcomes After Stereotactic Radiosurgery for Vestibular Schwannomas : Mechanism of Hearing Loss and How to Preserve Hearing. Adv Tech Stand Neurosurg 2016:3-36. [PMID: 26508404 DOI: 10.1007/978-3-319-21359-0_1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The use of stereotactic radiosurgery (SRS) expanded to include the treatment of vestibular schwannomas (VSs) in 1969; since then, efforts to increase tumour control and to reduce cranial neuropathy have continued. Using the currently recommended marginal dose of 12-13 Gy, long-term reported outcomes after SRS include not only excellent tumour control rates of 92-100 % but also outstanding functional preservation of the trigeminal and facial nerves, with values of 92-100 % and 94-100 %, respectively. Nonetheless, hearing preservation remains in the range of 32-81 %. Previous studies have suggested possible prognostic factors of hearing preservation such as the Gardner-Robertson grade, radiation dose to the cochlea, transient volume expansion (TVE) after SRS, length of irradiated cochlear nerve, marginal dose to the tumour, and age. However, we still do not clearly understand why patients lose their hearing after SRS for VS.Relevant to these considerations, one study recently reported that the auditory brainstem response (ABR) wave V latency and waves I and V interval (IL_I-V) correlated well with intracanalicular pressure values and even with hearing level. The demonstration that ABR values, especially wave V latency and IL_I-V, correlate well with intracanalicular pressure suggests that patients with previously elevated intracanalicular pressure might have an increased chance of hearing loss on development of TVE, which has been recognised as a common phenomenon after SRS or stereotactic radiotherapy (SRT) for intracranial schwannomas.In our experience, the ABR IL_I-V increased during the first 12 months after SRS for VSs in patients who lost their serviceable hearing. The effect of increased ABR IL_I-V on hearing outcome also became significant over time, especially at 12 months after SRS, and was more prominent in patients with poor initial pure-tone average (PTA) and/or ABR values. We hypothesise that patients with considerable intracanalicular pressure at the time of SRS are prone to lose their serviceable hearing due to the added intracanalicular pressure induced by TVE, which usually occurs within the first 12 months after SRS for VSs. Using these findings, we suggested a classification system for the prediction of hearing outcomes after SRS for VSs. This classification system could be useful in the proper selection of management modalities for hearing preservation, especially in patients with only hearing ear schwannoma or neurofibromatosis type 2.Advances in diagnostic tools, treatment modalities, and optimisation of radiosurgical dose have improved clinical outcomes, including tumour control and cranial neuropathies, in patients with VSs. However, the preservation of hearing function still falls short of our expectation. A prediction model for hearing preservation after each treatment modality will guide the proper selection of treatment modalities and permit the appropriate timing of active treatment, which will lead to the preservation of hearing function in patients with VSs.
Collapse
Affiliation(s)
- Jung Ho Han
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Hee-Won Jung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
66
|
Iorio-Morin C, AlSubaie F, Mathieu D. Safety and Efficacy of Gamma Knife Radiosurgery for the Management of Koos Grade 4 Vestibular Schwannomas. Neurosurgery 2015; 78:521-30. [DOI: 10.1227/neu.0000000000001154] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Gamma Knife radiosurgery (GKRS) is commonly used in treating small vestibular schwannomas; however, its use for larger vestibular schwannomas is still controversial.
OBJECTIVE:
To assess the long-term safety and efficacy of treating eligible Koos grade 4 vestibular schwannomas with GKRS.
METHODS:
We conducted a single-center, retrospective evaluation of patient undergoing GKRS for Koos grade 4 vestibular schwannomas. We evaluated clinical, imaging, and treatment characteristics and assessed treatment outcome. Inclusion criteria were tumor size of ≥4 cm3 and follow-up of at least 6 months. Patients with neurofibromatosis type 2 were excluded. Primary outcomes measured were tumor control rate, hearing and facial function preservation rate, and complications. All possible factors were analyzed to assess clinical significance.
RESULTS:
Sixty-eight patients met inclusion criteria. Median follow-up was 47 months (range, 6-125 months). Baseline hearing was serviceable in 60%. Median tumor volume at radiosurgery was 7.4 cm3 (range, 4-19 cm3). The median marginal dose used was 12 Gy at the 50% isodose line. Actuarial tumor control rates were 95% and 92% at 2 and 10 years, respectively. Actuarial serviceable hearing preservation rates were 89% and 49% at 2 and 5 years, respectively. Facial nerve preservation was 100%. Clinical complications included balance disturbance (11%), facial pain (10%), facial numbness (5%), and tinnitus (10%). Most complications were mild and transient. Hydrocephalus occurred in 3 patients, requiring ventriculoperitoneal shunt insertion. Larger tumor size was significantly associated with persisting symptoms post-treatment.
CONCLUSION:
Patients with Koos grade 4 vestibular schwannomas and minimal symptoms can be treated safely and effectively with GKRS.
Collapse
Affiliation(s)
- Christian Iorio-Morin
- Neurosurgery Division, Université de Sherbrooke, Centre Hospitalier Universitaire de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Fahd AlSubaie
- Neurosurgery Division, Université de Sherbrooke, Centre Hospitalier Universitaire de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
- Saudi National Neuroscience Institute, Riyadh, Saudi Arabia
| | - David Mathieu
- Neurosurgery Division, Université de Sherbrooke, Centre Hospitalier Universitaire de Sherbrooke, Centre de Recherche du CHUS, Sherbrooke, Quebec, Canada
| |
Collapse
|
67
|
Ikonomidis C, Pica A, Bloch J, Maire R. Vestibular Schwannoma: The Evolution of Hearing and Tumor Size in Natural Course and after Treatment by LINAC Stereotactic Radiosurgery. Audiol Neurootol 2015; 20:406-15. [PMID: 26571111 DOI: 10.1159/000441119] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To review the natural course of tumor size and hearing during conservative management of 151 patients with unilateral vestibular schwannoma (VS), and to evaluate the same parameters for the part of the group (n = 84) who were treated by LINAC stereotactic radiosurgery (SRS). METHODS In prospectively collected data, patients underwent MRI and complete audiovestibular tests at inclusion, during the conservative management period and after SRS. Hearing was graded according to the Gardner-Robertson (GR) scale and tumor size according to Koos. Statistics were performed using Kaplan-Meier survival analysis and multivariate analyses including linear and logistic regression. Specific insight was given to patients with serviceable hearing. RESULTS During the conservative management period (mean follow-up time: 24 months, range: 6-96), the annual risk of GR class degradation was 6% for GRI and 15% for GR II patients. Hearing loss as an initial symptom was highly predictive of further hearing loss (p = 0.003). Tumor growth reached 25%. For SRS patients, functional hearing preservation was 51% at 1 year and 36% at 3 years. Tumor control was 94 and 91%, respectively. CONCLUSION In VS patients, hearing loss at the time of diagnosis is a predictor of poorer hearing outcome. LINAC SRS is efficient for tumor control. Patients who preserved their pretreatment hearing presented less hearing loss per year after SRS than before treatment, suggesting a protective effect of SRS when cochlear function can be preserved.
Collapse
Affiliation(s)
- Christos Ikonomidis
- Departments of Otolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | | | | |
Collapse
|
68
|
Gasser Rutledge KL, Prasad KG, Emery KR, Mikulec AA, Varvares M, Gratton MA. Short-term Peripheral Auditory Effects of Cranial Irradiation: A Mouse Model. Ann Otol Rhinol Laryngol 2015; 124:903-10. [PMID: 26085370 PMCID: PMC4605863 DOI: 10.1177/0003489415591205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Assess postcranial irradiation: (1) short-term threshold shift, (2) short-term peripheral auditory histopathology, and (3) the mouse as an experimental model. METHODS Adult mice were exposed to single-dose radiation of 10 to 60 Gy. Pre- and post-irradiation (baseline, 2-8 days) audiometric brainstem response data were recorded with analysis of cochlear ultrastructure. RESULTS Significant threshold shift occurred at all test frequencies in mice exposed to ≥20 Gy at 4 to 6 days post-irradiation. Ultrastructurally in Rosenthal's canal and the spiral lamina, neuronal density and extracellular matrix decreased dramatically. There was overall preservation of hair cells, stria vascularis, and vasculature. No difference within Gy group was noted in the frequency or severity of pathology along the length of the cochlea. CONCLUSIONS The initial impact of radiation in the first week post-exposure focuses on spiral ganglion cell bodies and peripheral projections, resulting in significant threshold shift for irradiation dosages≥20 Gy. This study demonstrates that the mouse is a viable model for study of short-term peripheral auditory effects using single-dose cranial irradiation. Additionally, with access to a precise animal irradiator, the mouse may be used as an experimental model for a fractionated irradiation dosage of 10 Gy, simulating stereotactic therapeutic cranial irradiation.
Collapse
Affiliation(s)
- Krysta L Gasser Rutledge
- Department of Otolaryngology Head-Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Kumar G Prasad
- Department of Otolaryngology Head-Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Kara R Emery
- Department of Otolaryngology Head-Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Anthony A Mikulec
- Department of Otolaryngology Head-Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Mark Varvares
- Department of Otolaryngology Head-Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| | - Michael Anne Gratton
- Department of Otolaryngology Head-Neck Surgery, Saint Louis University, St. Louis, Missouri, USA
| |
Collapse
|
69
|
Upadhyay U, Almefty RO, Dunn IF, Al-Mefty O. Letter to the Editor: Save the nerve. J Neurosurg 2015; 123:821-2. [DOI: 10.3171/2014.12.jns142826] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
70
|
Iwai Y, Ishibashi K, Watanabe Y, Uemura G, Yamanaka K. Functional Preservation After Planned Partial Resection Followed by Gamma Knife Radiosurgery for Large Vestibular Schwannomas. World Neurosurg 2015; 84:292-300. [DOI: 10.1016/j.wneu.2015.03.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/09/2015] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
|
71
|
Abstract
Vestibular schwannomas (VS) comprise 8% of all intracranial tumors and 90% of cerebellopontine angle and internal auditory canal neoplasms. Secondary to the widespread adoption of screening protocols for asymmetrical hearing loss and the increasing use of advanced imaging, the number of VS diagnosed each year continues to rise, while the average size has declined. Microsurgery remains the treatment of choice for large tumors, however the management of small- to medium-sized VS remains highly controversial with options including observation, radiotherapy, or microsurgery. Within this chapter, the authors provide an overview of the contemporary management of VS, reviewing important considerations and common controversies.
Collapse
|
72
|
Jacob JT, Pollock BE, Carlson ML, Driscoll CLW, Link MJ. Stereotactic radiosurgery in the management of vestibular schwannoma and glomus jugulare: indications, techniques, and results. Otolaryngol Clin North Am 2015; 48:515-26. [PMID: 25873444 DOI: 10.1016/j.otc.2015.02.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Gamma Knife stereotactic radiosurgery (GKS) has become an important management strategy for an increasing number of patients with skull base tumors. For select patients with lateral skull base disorders, given the proximity to sensitive critical structures such as the brainstem, cranial nerves, and cochlea, this technology has emerged as a first-line treatment to achieve the paramount goals of long-term tumor control and maintenance of existing neurologic function. This article reviews the indications, technique, and results of GKS for the treatment of vestibular schwannoma and glomus jugulare tumors, and highlights our experience in treating these tumors at the Mayo Clinic.
Collapse
Affiliation(s)
- Jeffrey T Jacob
- Department of Neurologic Surgery, Mayo Clinic School of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic School of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Radiation Oncology, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Colin L W Driscoll
- Department of Neurologic Surgery, Mayo Clinic School of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic School of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
73
|
Combs SE, Engelhard C, Kopp C, Wiedenmann N, Schramm O, Prokic V, Debus J, Molls M, Grosu AL. Long-term outcome after highly advanced single-dose or fractionated radiotherapy in patients with vestibular schwannomas – Pooled results from 3 large German centers. Radiother Oncol 2015; 114:378-83. [DOI: 10.1016/j.radonc.2015.01.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 01/18/2015] [Accepted: 01/20/2015] [Indexed: 10/24/2022]
|
74
|
Basura GJ, Budenz C, Arts HA. Vestibular Schwannomas: Surgical and Nonsurgical Management. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0082-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
75
|
Modern Gamma Knife radiosurgery of vestibular schwannomas: treatment concept, volumetric tumor response, and functional results. Neurosurg Rev 2014; 38:309-18; discussion 318. [DOI: 10.1007/s10143-014-0601-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 05/19/2014] [Accepted: 08/04/2014] [Indexed: 10/24/2022]
|
76
|
Boari N, Bailo M, Gagliardi F, Franzin A, Gemma M, Vecchio AD, Bolognesi A, Picozzi P, Mortini P. Gamma Knife radiosurgery for vestibular schwannoma: clinical results at long-term follow-up in a series of 379 patients. J Neurosurg 2014; 121 Suppl:123-42. [DOI: 10.3171/2014.8.gks141506] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectSince the 1990s, Gamma Knife radiosurgery (GKRS) has become the first-line treatment option for small- to medium-size vestibular schwannomas (VSs), especially in patients without mass effect–related symptoms and with functional hearing. The aim of this study was to assess the safety and efficacy of GKRS, in terms of tumor control, hearing preservation, and complications, in a series of 379 consecutive patients treated for VS.MethodsOf 523 patients treated at the authors' institution for VS between 2001 and 2010, the authors included 379 who underwent GKRS as the primary treatment. These patients were not affected by Type 2 neurofibromatosis and had clinical follow-up of at least 36 months. Clinical follow-up (mean and median 75.7 and 69.5 months, respectively) was performed for all patients, whereas audiometric and quantitative radiological follow-up examinations were obtained for only 153 and 219 patients, respectively. The patients' ages ranged from 23 to 85 years (mean 59 years). The mean tumor volume was 1.94 ± 2.2 cm3 (median 1.2 cm3, range 0.013–14.3 cm3), and the median margin dose was 13 Gy (range 11–15 Gy). Parameters considered as determinants of the clinical outcome were long-term tumor control, hearing preservation, and complications. A statistical analysis was performed to correlate clinical outcomes with the radiological features of the tumor, dose-planning parameters, and patient characteristics.ResultsControl of the tumor with GKRS was achieved in 97.1% of the patients. In 82.7% of the patients, the tumor volume had decreased at the last follow-up, with a mean relative reduction of 34.1%. The rate of complications was very low, with most consisting of a transient worsening of preexisting symptoms. Patients who had vertigo, balance disorders, or facial or trigeminal impairment usually experienced a complete or at least significant symptom relief after treatment. However, no significant improvement was observed in patients previously reporting tinnitus. The overall rate of preservation of functional hearing at the long-term follow-up was 49%; in patients with hearing classified as Gardner-Robertson (GR) Class I, this value was 71% and reached 93% among cases of GR Class I hearing in patients younger than 55 years.ConclusionsGamma Knife radiosurgery is a safe and effective treatment for VS, achieving tumor control in 97.1% of cases and resulting in a very low morbidity rate. Younger GR Class I patients had a significantly higher probability of retaining functional hearing even at the 10-year follow-up; for this reason, the time between symptom onset, diagnosis, and treatment should be shortened to achieve better outcomes in functional hearing preservation.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Angelo Bolognesi
- 4Service of Radiation Oncology, I.R.C.C.S. San Raffaele Hospital; and
| | | | - Pietro Mortini
- 1Department of Neurosurgery,
- 5Department of Neurosurgery, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
77
|
Yamakami I, Ito S, Higuchi Y. Retrosigmoid removal of small acoustic neuroma: curative tumor removal with preservation of function. J Neurosurg 2014; 121:554-63. [DOI: 10.3171/2014.6.jns132471] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Management of small acoustic neuromas (ANs) consists of 3 options: observation with imaging follow-up, radiosurgery, and/or tumor removal. The authors report the long-term outcomes and preservation of function after retrosigmoid tumor removal in 44 patients and clarify the management paradigm for small ANs.
Methods
A total of 44 consecutively enrolled patients with small ANs and preserved hearing underwent retrosigmoid tumor removal in an attempt to preserve hearing and facial function by use of intraoperative auditory monitoring of auditory brainstem responses (ABRs) and cochlear nerve compound action potentials (CNAPs). All patients were younger than 70 years of age, had a small AN (purely intracanalicular/cerebellopontine angle tumor ≤ 15 mm), and had serviceable hearing preoperatively. According to the guidelines of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology–Head and Neck Surgery Foundation, preoperative hearing levels of the 44 patients were as follows: Class A, 19 patients; Class B, 17; and Class C, 8. The surgical technique for curative tumor removal with preservation of hearing and facial function included sharp dissection and debulking of the tumor, reconstruction of the internal auditory canal, and wide removal of internal auditory canal dura.
Results
For all patients, tumors were totally removed without incidence of facial palsy, death, or other complications. Total tumor removal was confirmed by the first postoperative Gd-enhanced MRI performed 12 months after surgery. Postoperative hearing levels were Class A, 5 patients; Class B, 21; Class C, 11; and Class D, 7. Postoperatively, serviceable (Class A, B, or C) and useful (Class A or B) levels of hearing were preserved for 84% and 72% of patients, respectively. Better preoperative hearing resulted in higher rates of postoperative hearing preservation (p = 0.01); preservation rates were 95% among patients with preoperative Class A hearing, 88% among Class B, and 50% among Class C. Reliable monitoring was more frequently provided by CNAPs than by ABRs (66% vs 32%, p < 0.01), and consistently reliable auditory monitoring was significantly associated with better rates of preservation of useful hearing. Long-term follow-up by MRI with Gd administration (81 ± 43 months [range 5–181 months]; median 7 years) showed no tumor recurrence, and although the preserved hearing declined minimally over the long-term postoperative follow-up period (from 39 ± 15 dB to 45 ± 11 dB in 5.1 ± 3.1 years), 80% of useful hearing and 100% of serviceable hearing remained at the same level.
Conclusions
As a result of a surgical technique that involved sharp dissection and internal auditory canal reconstruction with intraoperative auditory monitoring, retrosigmoid removal of small ANs can lead to successful curative tumor removal without long-term recurrence and with excellent functional outcome. Thus, the authors suggest that tumor removal should be the first-line management strategy for younger patients with small ANs and preserved hearing.
Collapse
Affiliation(s)
- Iwao Yamakami
- 1Neurosurgery, Chiba Central Medical Center, Chiba, Japan
| | - Seiro Ito
- 2Neurosurgery, Chiba Rosai Hospital, Ichihara, Japan; and
| | - Yoshinori Higuchi
- 3Neurosurgery, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
78
|
Champ CE, Shen X, Shi W, Mayekar SU, Chapman K, Werner-Wasik M, Farrell CJ, Gunn V, Downes MB, Liu H, Evans JJ, Andrews DW. Reduced-dose fractionated stereotactic radiotherapy for acoustic neuromas: maintenance of tumor control with improved hearing preservation. Neurosurgery 2014; 73:489-96. [PMID: 23756743 DOI: 10.1227/neu.0000000000000019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fractionated stereotactic radiotherapy (FSRT) is a noninvasive treatment for acoustic neuromas (ANs). Initial reports from our institution demonstrated that the reduction of treatment dose to 46.8 Gy resulted in improved preservation of functional hearing status. OBJECTIVE We now report the tumor control (TC), symptomatic outcome, and hearing preservation (HP) rate in patients treated with reduced-dose FSRT. METHODS We analyzed all patients with AN treated from 2002 to 2011. All patients received 46.8 Gy in 1.8-Gy fractions. Follow-up audiogram and magnetic resonance imaging were performed in ≤ 1-year intervals. TC and HP were calculated by the Kaplan-Meier method. Analysis of HP, defined as Gardner-Robertson value ≤ 2, was determined by audiometric data. Non-hearing-related symptoms were defined by Common Terminology Criteria for Adverse Events version 4. RESULTS In total, 154 patients were analyzed. At a median follow-up of 35 months (range, 4-108), TC was achieved in 96% of patients (n = 148/154) and at 3 and 5 years was 99% and 93%. Eighty-seven patients had serviceable hearing at the time of FSRT and evaluable audiometric follow-up. Overall HP was 67% and at 3 and 5 years was 66% and 54%. Pure tone average decreased by a median of 13 dB in all patients. Nineteen percent (n = 31) of patients experienced symptom improvement, and 8% (n = 13) had worsening of symptoms. Cranial nerve dysfunction occurred in 3.8% of patients (n = 6). CONCLUSION Reduced-dose FSRT to 46.8 Gy for AN achieves excellent functional HP rates and limited toxicity without compromising long-term TC. Based on these promising outcomes, further attempts at dose deescalation may be warranted.
Collapse
Affiliation(s)
- Colin E Champ
- Department of Radiation Oncology, Kimmel Cancer Center and Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
79
|
Kranzinger M, Zehentmayr F, Fastner G, Oberascher G, Merz F, Nairz O, Rahim H, Sedlmayer F. Hypofractionated stereotactic radiotherapy of acoustic neuroma: volume changes and hearing results after 89-month median follow-up. Strahlenther Onkol 2014; 190:798-805. [PMID: 24638268 DOI: 10.1007/s00066-014-0630-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The goal of this work was to evaluate toxicity and local control following hypofractionated stereotactic radiation treatment with special focus on changes in tumor volume and hearing capacity. PATIENTS AND METHODS In all, 29 patients with unilateral acoustic neuroma were treated between 2001 and 2007 within a prospective radiation protocol (7 × 4 Gy ICRU dose). Median tumor volume was 0.9 ml. Follow-up started at 6 months and was repeated annually with MRI volumetry and audiometry. Hearing preservation was defined as preservation of Class A/B hearing according to the guidelines of the American Academy of Otolaryngology (1995). RESULTS No patient had any intervention after a median imaging follow-up of 89.5 months, one patient showed radiological progression. Transient increase of tumor volume developed in 17/29 patients, whereas 22/29 patients (75.9%) presented with a volume reduction at last follow-up. A total of 21 patients were eligible for hearing evaluation. Mean pure tone average (PTA) deteriorated from 39.3 to 65.9 dB and mean speech discrimination score (SDS) dropped from 74.3 to 38.1%. The 5-year actuarial Class A/B hearing preservation rate was 50.0 ± 14.4%. CONCLUSION Radiation increases only minimally, if at all, the hearing deterioration which emerges by observation alone. Presbyacusis is not responsible for this deterioration. Transient tumor enlargement is common. Today radiation of small- and medium-sized acoustic neuroma can be performed with different highly conformal techniques as fractionated treatment or single low-dose radiosurgery with equal results regarding tumor control, hearing preservation, and side effects. Hypofractionation is more comfortable for the patient than conventional regimens and represents a serious alternative to frameless radiosurgery.
Collapse
Affiliation(s)
- Manfred Kranzinger
- University Clinic of Radiotherapy and Radio-Oncology, Salzburg County Hospital, Paracelsus Medical University Clinics (PMU), Müllner Hauptstraße 48, 5020, Salzburg, Austria,
| | | | | | | | | | | | | | | |
Collapse
|
80
|
Jacob JT, Carlson ML, Schiefer TK, Pollock BE, Driscoll CL, Link MJ. Significance of Cochlear Dose in the Radiosurgical Treatment of Vestibular Schwannoma. Neurosurgery 2014; 74:466-74; discussion 474. [DOI: 10.1227/neu.0000000000000299] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cochlear dose has been identified as a potentially modifiable contributor to hearing loss after stereotactic radiosurgery (SRS) for vestibular schwannoma (VS).
OBJECTIVE:
To evaluate the association between computed tomography-based volumetric cochlear dose and loss of serviceable hearing after SRS, to assess intraobserver and interobserver reliability when determining modiolar point dose with the use of magnetic resonance imaging and computed tomography, and to discuss the clinical significance of the cochlear dose with regard to radiosurgical planning strategy.
METHODS:
Patients with serviceable pretreatment hearing who underwent SRS for sporadic VS between the use of Gamma Knife Perfexion were studied. Univariate and multivariate associations with the primary outcome of time to nonserviceable hearing were evaluated.
RESULTS:
A total of 105 patients underwent SRS for VS during the study period, and 59 (56%) met study criteria and were analyzed. Twenty-one subjects (36%) developed nonserviceable hearing at a mean of 2.2 years after SRS (SD, 1.0 years; median, 2.1 years; range 0.6-3.8 years). On univariate analysis, pretreatment pure tone average, speech discrimination score, American Academy of Otolaryngology-Head and Neck Surgery hearing class, marginal dose, and mean dose to the cochlear volume were statistically significantly associated with time to nonserviceable hearing. However, after adjustment for baseline differences, only pretreatment pure tone average was statistically significantly associated with time to nonserviceable hearing in a multivariable model.
CONCLUSION:
Cochlear dose is one of many variables associated with hearing preservation after SRS for VS. Until further studies demonstrate durable tumor arrest with reduced dose protocols, routine tumor dose planning should not be modified to limit cochlear dose at the expense of tumor control.
Collapse
Affiliation(s)
- Jeffrey T. Jacob
- Department of Neurologic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Matthew L. Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Terry K. Schiefer
- Department of Neurologic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Bruce E. Pollock
- Department of Neurologic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Colin L. Driscoll
- Department of Neurologic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| |
Collapse
|
81
|
Treatment Outcomes in Patients Treated With CyberKnife Radiosurgery for Vestibular Schwannoma. Otol Neurotol 2014; 35:162-70. [DOI: 10.1097/mao.0b013e3182a435f5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
82
|
Clinical evaluation of CyberKnife in the treatment of vestibular schwannomas. BIOMED RESEARCH INTERNATIONAL 2013; 2013:297093. [PMID: 24312910 PMCID: PMC3842077 DOI: 10.1155/2013/297093] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 09/27/2013] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
Abstract
Objective. This study assessed the posttreatment tumor control and auditory function of vestibular schwannoma (VS) patients after CyberKnife (CK) and analyzed the possible prognostic factors of hearing loss. Methods. We retrospectively studied 117 VS patients, with Gardner-Robertson (GR) classification grades I to IV, who underwent CK between 2006 and 2012. Data including radiosurgery treatment parameters, pre- and postoperative tumor size, and auditory function were collected and examined. Results. With CK, 117 patients had excellent tumor control rates (99.1%), with a mean imaging followup of 61.1 months. Excluding 52 patients (GR III-IV pretreatment), 53 (81.5%) of the remaining 65 patients (initial GR I-II) maintained GR I or II hearing after CK, with a mean audiometric followup of 64.5 months. Twelve patients experienced hearing degradation (91.6% were GR II pretreatment); they appeared to have significantly larger tumor sizes, significantly smaller cochlear sizes, and higher prescribed cochlear doses, compared to the patients with preserved hearing. Conclusion. Our data showed that CK treatment provided an excellent tumor control rate and a comparable hearing preservation rate in VS patients. Patients with pretreatment GR II hearing levels, larger tumor volumes, smaller cochlear sizes, and higher prescribed cochlear doses may have poor hearing prognoses.
Collapse
|
83
|
Link MJ, Pollock BE. Chasing the Holy Grail of Vestibular Schwannoma Management. World Neurosurg 2013; 80:276-8. [DOI: 10.1016/j.wneu.2012.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 06/12/2012] [Indexed: 10/28/2022]
|
84
|
Yu YL, Lee MS, Juan CJ, Hueng DY. Calculating the tumor volume of acoustic neuromas: Comparison of ABC/2 formula with planimetry method. Clin Neurol Neurosurg 2013; 115:1371-4. [DOI: 10.1016/j.clineuro.2012.12.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 12/12/2012] [Accepted: 12/26/2012] [Indexed: 10/27/2022]
|
85
|
Morimoto M, Yoshioka Y, Kotsuma T, Adachi K, Shiomi H, Suzuki O, Seo Y, Koizumi M, Kagawa N, Kinoshita M, Hashimoto N, Ogawa K. Hypofractionated stereotactic radiation therapy in three to five fractions for vestibular schwannoma. Jpn J Clin Oncol 2013; 43:805-12. [PMID: 23780990 DOI: 10.1093/jjco/hyt082] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To retrospectively examine the outcomes of hypofractionated stereotactic radiation therapy in three to five fractions for vestibular schwannomas. METHODS Twenty-five patients with 26 vestibular schwannomas were treated with hypofractionated stereotactic radiation therapy using a CyberKnife. The vestibular schwannomas of 5 patients were associated with type II neurofibromatosis. The median follow-up time was 80 months (range: 6-167); the median planning target volume was 2.6 cm(3) (0.3-15.4); and the median prescribed dose (≥D90) was 21 Gy in three fractions (18-25 Gy in three to five fractions). Progression was defined as ≥2 mm 3-dimensional post-treatment tumor enlargement excluding transient expansion. Progression or any death was counted as an event in progression-free survival rates, whereas only progression was counted in progression-free rates. RESULTS The 7-year progression-free survival and progression-free rates were 78 and 95%, respectively. Late adverse events (≥3 months) with grades based on Common Terminology Criteria for Adverse Events, v4.03 were observed in 6 patients: Grade 3 hydrocephalus in one patient, Grade 2 facial nerve disorders in two and Grade 1-2 tinnitus in three. In total, 12 out of 25 patients maintained pure tone averages ≤50 dB before hypofractionated stereotactic radiation therapy, and 6 of these 12 patients (50%) maintained pure tone averages at this level at the final audiometric follow-up after hypofractionated stereotactic radiation therapy. However, gradient deterioration of pure tone average was observed in 11 of these 12 patients. The mean pure tone averages before hypofractionated stereotactic radiation therapy and at the final follow-up for the aforementioned 12 patients were 29.8 and 57.1 dB, respectively. CONCLUSIONS Treating vestibular schwannomas with hypofractionated stereotactic radiation therapy in three to five fractions may prevent tumor progression with tolerable toxicity. However, gradient deterioration of pure tone average was observed.
Collapse
Affiliation(s)
- Masahiro Morimoto
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
86
|
Carlson ML, Jacob JT, Pollock BE, Neff BA, Tombers NM, Driscoll CLW, Link MJ. Long-term hearing outcomes following stereotactic radiosurgery for vestibular schwannoma: patterns of hearing loss and variables influencing audiometric decline. J Neurosurg 2013; 118:579-87. [DOI: 10.3171/2012.9.jns12919] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The goals of this retrospective cohort study were as follows: 1) to describe the long-term prevalence and timing of hearing deterioration following low-dose (12- to 13-Gy marginal dose) stereotactic radiosurgery (SRS) for vestibular schwannoma (VS); and 2) to identify clinical variables associated with long-term preservation of useful hearing following treatment.
Methods
Patients with serviceable hearing who underwent SRS for VS between 1997 and 2002 were studied. Data including radiosurgery treatment plans, tumor characteristics, pre- and posttreatment pure tone average, speech discrimination scores, and American Academy of Otolaryngology–Head and Neck Surgery hearing class were collected. Time to nonserviceable hearing was estimated using the Kaplan-Meier method. Univariate and multivariate associations with time to nonserviceable hearing were evaluated using Cox proportional hazards regression models.
Results
Forty-four patients met the study criteria and were included. The median duration of audiometric follow-up was 9.3 years. Thirty-six patients developed nonserviceable hearing at a mean of 4.2 years following SRS. The Kaplan-Meier estimated rates of serviceable hearing at 1, 3, 5, 7, and 10 years following SRS were 80%, 55%, 48%, 38%, and 23%, respectively. Multivariate analysis revealed that pretreatment ipsilateral pure tone average (p < 0.001) and tumor size (p = 0.009) were statistically significantly associated with time to nonserviceable hearing.
Conclusions
Durable hearing preservation a decade after low-dose SRS for VS occurs in less than one-fourth of patients. Variables including preoperative hearing capacity and tumor size may be used to predict hearing outcomes following treatment. These findings may assist in pretreatment risk disclosure. Furthermore, these data demonstrate the importance of long-term follow-up when reporting audiometric outcomes following SRS for VS.
Collapse
Affiliation(s)
| | | | - Bruce E. Pollock
- 2Neurologic Surgery, and
- 3Radiation Oncology, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Brian A. Neff
- 1Departments of Otolaryngology-Head and Neck Surgery,
| | | | | | - Michael J. Link
- 1Departments of Otolaryngology-Head and Neck Surgery,
- 2Neurologic Surgery, and
| |
Collapse
|
87
|
Hasegawa T, Kida Y, Kato T, Iizuka H, Kuramitsu S, Yamamoto T. Long-term safety and efficacy of stereotactic radiosurgery for vestibular schwannomas: evaluation of 440 patients more than 10 years after treatment with Gamma Knife surgery. J Neurosurg 2013; 118:557-65. [PMID: 23140152 DOI: 10.3171/2012.10.jns12523] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Little is known about long-term outcomes, including tumor control and adverse radiation effects, in patients harboring vestibular schwannomas (VSs) treated with stereotactic radiosurgery > 10 years previously. The aim of this study was to confirm whether Gamma Knife surgery (GKS) for VSs continues to be safe and effective > 10 years after treatment.
Methods
A total of 440 patients with VS (including neurofibromatosis Type 2) treated with GKS between May 1991 and December 2000 were evaluable. Of these, 347 patients (79%) underwent GKS as an initial treatment and 93 (21%) had undergone prior resection. Three hundred fifty-eight patients (81%) had a solid tumor and 82 (19%) had a cystic tumor. The median tumor volume was 2.8 cm3 and the median marginal dose was 12.8 Gy.
Results
The median follow-up period was 12.5 years. The actuarial 5- and ≥ 10-year progression-free survival was 93% and 92%, respectively. No patient developed treatment failure > 10 years after treatment. According to multivariate analysis, significant factors related to worse progression-free survival included brainstem compression with a deviation of the fourth ventricle (p < 0.0001), marginal dose ≤ 13 Gy (p = 0.01), prior treatment (p = 0.02), and female sex (p = 0.02). Of 287 patients treated at a recent optimum dose of ≤ 13 Gy, 3 (1%) developed facial palsy, including 2 with transient palsy and 1 with persistent palsy after a second GKS, and 3 (1%) developed facial numbness, including 2 with transient and 1 with persistent facial numbness. The actuarial 10-year facial nerve preservation rate was 97% in the high marginal dose group (> 13 Gy) and 100% in the low marginal dose group (≤ 13 Gy). Ten patients (2.3%) developed delayed cyst formation. One patient alone developed malignant transformation, indicating an incidence of 0.3%.
Conclusions
In this study GKS was a safe and effective treatment for the majority of patients followed > 10 years after treatment. Special attention should be paid to cyst formation and malignant transformation as late adverse radiation effects, although they appeared to be rare. However, it is necessary to collect further long-term follow-up data before making conclusions about the long-term safety and efficacy of GKS, especially for young patients with VSs.
Collapse
|
88
|
Kondziolka D, Mousavi SH, Kano H, Flickinger JC, Lunsford LD. The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation? Neurosurg Focus 2013; 33:E8. [PMID: 22937859 DOI: 10.3171/2012.6.focus12192] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Management recommendations for patients with smaller-volume or newly diagnosed vestibular schwannomas (< 4 cm(3)) need to be based on an understanding of the anticipated natural history of the tumor and the side effects it produces. The natural history can then be compared with the risks and benefits of therapeutic intervention using a minimally invasive strategy such as stereotactic radiosurgery (SRS). METHODS The authors reviewed the emerging literature stemming from recent recommendations to "wait and scan" (observation) and compared this strategy with published outcomes after early intervention using SRS or results from matched cohort studies of resection and SRS. RESULTS Various retrospective studies indicate that vestibular schwannomas grow at a rate of 0-3.9 mm per year and double in volume between 1.65 and 4.4 years. Stereotactic radiosurgery arrests growth in up to 98% of patients when studied at intervals of 10-15 years. Most patients who select "wait and scan" note gradually decreasing hearing function leading to the loss of useful hearing by 5 years. In contrast, current studies indicate that 3-5 years after Gamma Knife surgery, 61%-80% of patients maintain useful hearing (speech discrimination score > 50%, pure tone average < 50). CONCLUSIONS Based on published data on both volume and hearing preservation for both strategies, the authors devised a management recommendation for patients with small vestibular schwannomas. When resection is not chosen by the patient, the authors believe that early SRS intervention, in contrast to observation, results in long-term tumor control and improved rates of hearing preservation.
Collapse
Affiliation(s)
- Douglas Kondziolka
- The Center for Image Guided Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA.
| | | | | | | | | |
Collapse
|
89
|
Combs SE, Welzel T, Kessel K, Habermehl D, Rieken S, Schramm O, Debus J. Hearing preservation after radiotherapy for vestibular schwannomas is comparable to hearing deterioration in healthy adults and is accompanied by local tumor control and a highly preserved quality of life (QOL) as patients' self-reported outcome. Radiother Oncol 2013; 106:175-80. [PMID: 23333012 DOI: 10.1016/j.radonc.2012.12.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 12/07/2012] [Accepted: 12/09/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate long-term results and patients' self-reported outcome of high-precision photon radiotherapy for the treatment of patients with vestibular schwannoma (VS). METHODS AND MATERIALS We treated 246 patients with 248 VS with fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS). For FSRT, a median total dose of 57.6 Gy was prescribed in median single doses of 1.8 Gy, for SRS, a median dose of 13 Gy/80% isodose was applied. Of all patients, 51 patients died during follow-up. To evaluate long-term toxicity and QOL, we sent out a questionnaire to all living patients; of these, 81 patients (42%) sent back the questionnaire. RESULTS Median local control was 84 months, actuarial local control rates for both groups (SRS and FSRT) were 98% after 2, 95% after 5, and 93% after 10 years; there was no statistical difference between FSRT and SRS. Hearing deterioration was significantly higher in the SRS group than the FSRT group. However, when comparing FSRT to SRS with doses ≤ 13 Gy, hearing preservation is comparable. In patients with useful hearing, hearing preservation was 89.7% at 1 year, 84.7% at 3 years, 76.5% at 5 years, and 68.6% at 10 years. After 10 years of follow-up, hearing deterioration can be observed in both subgroups. In the FSRT group, facial nerve toxicity rate was 1.6%. Trigeminal nerve toxicity was observed in 2.1% after FSRT. Overall QOL was unchanged in 47% of the patients after RT, and 31% reported an improvement in QOL during follow-up. CONCLUSION Patients' self-reported outcome confirms good results with respect to tumor control and QOL after FSRT or SRS in patients with VS. SRS can be associated with higher side effect following a dose-dependency. In long-term follow-up, hearing deterioration is most likely attributed to normal aging, but not treatment-related.
Collapse
Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany.
| | | | | | | | | | | | | |
Collapse
|
90
|
|
91
|
DeMonte F, Gidley PW. Hearing preservation surgery for vestibular schwannoma: experience with the middle fossa approach. Neurosurg Focus 2012; 33:E10. [PMID: 22937844 DOI: 10.3171/2012.7.focus12172] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECT In the early 1960s William F. House developed the middle fossa approach for the removal of small vestibular schwannomas (VSs) with the preservation of hearing. It is the best approach for tumors that extend laterally to the fundus of the internal auditory canal, although it does have the potential disadvantage of increased facial nerve manipulation, especially for tumors arising from the inferior vestibular nerve. The aim of this study was to monitor the hearing preservation and facial nerve outcomes of this approach. METHODS A prospective database was constructed, and data were retrospectively reviewed. RESULTS Between December 2004 and January 2012, 30 patients with small VSs underwent surgery via a middle fossa approach for hearing preservation. The patients consisted of 13 men and 17 women with a mean age of 46 years. Tumor size ranged from 7 to 19 mm. Gross-total resection was accomplished in 25 of 30 patients. Preoperative hearing was American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Class A in 21 patients, Class B in 5, Class C in 3, and undocumented in 1. Postoperatively, hearing was graded as AAO-HNS Class A in 15 patients, Class B in 7, Class C in 1, Class D in 2, and undocumented in 5. Facial nerve function was House-Brackmann (HB) Grade I in all patients preoperatively. Postoperatively, facial nerve function was HB Grade I in 28 patients, Grade III in 1, and Grade IV in 1. There were 3 complications: CSF leakage in 1 patient, superficial wound infection in 1, and extradural hematoma (asymptomatic) in 1. The overall hearing preservation rate of at least 73% and HB Grade I facial nerve outcome of 93% in this cohort are in keeping with other contemporary reports. CONCLUSIONS The middle fossa approach for the resection of small VSs with hearing preservation is a viable and relatively safe option. It should be considered among the various options available for the management of small, growing VSs.
Collapse
Affiliation(s)
- Franco DeMonte
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
| | | |
Collapse
|