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Schmitt WR, Carlson ML, Giannini C, Driscoll CLW, Link MJ. Radiation-Induced Sarcoma in a Large Vestibular Schwannoma Following Stereotactic Radiosurgery: Case Report. Neurosurgery 2011; 68:E840-6; discussion E846. [DOI: 10.1227/neu.0b013e31820780b1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
AbstractBACKGROUND AND IMPORTANCE:Stereotactic radiosurgery (SRS) has been employed with increasing frequency in the treatment of benign intracranial tumors. While the risk for radiation-induced malignancy has been well studied for fractionated external beam radiation, reports of SRS-associated malignancy have only begun to emerge over the past 10 years.CLINICAL PRESENTATION:We present a case of a rapidly enlarging, presumed sporadic vestibular schwannoma in a 51-year-old man treated with SRS. Serial imaging over the next 7.5 years demonstrated good radiographic response with consistent involution of the tumor. The patient then developed rapid neurologic deterioration and sustained tumor growth on follow-up imaging. The tumor was resected via a translabyrinthine approach, and pathologic analysis demonstrated undifferentiated high-grade pleomorphic sarcoma (UHGPS).CONCLUSION:This is the first report of undifferentiated high-grade pleomorphic sarcoma (formerly called malignant fibrous histiocytoma) following SRS. This case demonstrates the difficulty of establishing malignant degeneration of a neoplasm following SRS without pretreatment tissue diagnosis. Patients with presumed benign tumors should be counseled about the rare risk of malignant transformation prior to undertaking SRS.
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Affiliation(s)
- William R Schmitt
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Caterina Giannini
- Department of Laboratory Medicine and Anatomic Pathology, Mayo Clinic, Rochester, Minnesota
| | - Colin LW Driscoll
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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102
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Radiotherapy for Vestibular Schwannomas: A Critical Review. Int J Radiat Oncol Biol Phys 2011; 79:985-97. [DOI: 10.1016/j.ijrobp.2010.10.010] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 10/01/2010] [Accepted: 10/08/2010] [Indexed: 11/18/2022]
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103
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Arthurs BJ, Fairbanks RK, Demakas JJ, Lamoreaux WT, Giddings NA, Mackay AR, Cooke BS, Elaimy AL, Lee CM. A review of treatment modalities for vestibular schwannoma. Neurosurg Rev 2011; 34:265-77; discussion 277-9. [DOI: 10.1007/s10143-011-0307-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 09/22/2010] [Accepted: 11/10/2010] [Indexed: 10/18/2022]
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Stereotactic radiation treatment of vestibular schwannoma: indications, limitations, and outcomes. Curr Opin Otolaryngol Head Neck Surg 2011; 18:351-6. [PMID: 20613529 DOI: 10.1097/moo.0b013e32833c71a2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Stereotactic radiation treatment is an increasingly performed procedure for patients with vestibular schwannoma and other benign skull base tumors. During the past 30 years, advancements in stereotactic imaging, radiation delivery techniques, and dose planning have improved overall patient outcomes. The specific role of radiation in current management strategies for vestibular schwannoma continues to evolve as long-term outcome data are analyzed and standardized studies are performed. The recent literature regarding the indications, limitations, and outcomes for stereotactic radiation treatment is reviewed. RECENT FINDINGS Systematic reviews of the Gamma Knife literature demonstrate improved overall outcomes with radiation doses below 13 Gy. Observation of small vestibular schwannomas is recommended over early radiation or microsurgical intervention. Radiation may be used as adjunctive therapy for large tumors and in certain postradiation treatment failures. Stereotactic radiosurgery and fractionated radiotherapy are equally effective treatment modalities. SUMMARY Long-term outcome data will ultimately define future indications and limitations for the use of stereotactic radiation with benign skull base lesions. Current evidence supports its use for small to medium sized primary and recurrent vestibular schwannomas with optimal dosing below 13 Gy. It is also recommended for adjunctive therapy, recurrent tumors, in poor surgical candidates, and for those who do not desire observation or surgery.
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Abstract
AIM To undertake a systematic review of the literature on acoustic neuroma growth. Predictors of growth were also explored. MATERIALS AND METHODS A comprehensive search was conducted to identify the relevant literature. The search yielded 2,455 papers. All titles were reviewed by 2 of the authors, and finally, 41 papers were found reporting data pertinent to growth. RESULTS The percentage of acoustic neuromas exhibiting growth ranges widely from 18 to 73%. The percentage of tumors reported not to grow for some years after diagnosis ranges from 9 to 75%. Some (usually less than 10%, but up to 22%) may get smaller. No reliable predictors of growth have been identified. The mean growth rate for all tumors varies between 1 and 2 mm/yr, and for only those that grow, between 2 and 4 mm/yr. However, there are cases with significant regression or exceptional growth (exceeding 18 mm/yr). There are various patterns of growth, and a tumor that shows growth may stop doing so and vice versa. Finally, some tumors that have been stable for many years can exhibit tumor growth. CONCLUSION The growth pattern of acoustic neuromas is variable and incompletely understood. As much as 75% of tumors have been reported to show no growth, supporting a "wait and rescan" policy in many patients, although there are no reliable predictors of tumor behavior, and some tumors may grow rapidly. Primary longitudinal studies are needed to better define the natural history and limit unnecessary interventions.
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Morrison D. Management of patients with acoustic neuromas: a Markov decision analysis. Laryngoscope 2010; 120:783-90. [PMID: 20213657 DOI: 10.1002/lary.20819] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS The management of patients with small (<1.5 cm) acoustic neuromas is controversial. Immediate treatment via microsurgical resection or radiosurgery is often advocated. A period of observation is sometimes advised followed by microsurgery or radiosurgery for tumors that demonstrate growth during the observation period. The purpose of this study is to calculate quality-adjusted life expectancy for the most commonly applied management strategies in hypothetical cohorts of patients of various ages. STUDY DESIGN Markov decision analysis; societal perspective. METHODS Assumptions used in creating this model and event probabilities were obtained from a thorough literature review. Key parameters were identified and defined by the best available evidence. The main outcome measure is the benefit derived from each management strategy in quality-adjusted life years (QALYs). Sensitivity analysis was used to define benchmark performance information for these parameters. RESULTS The benefit of a period of observation followed by radiosurgery, if needed, for significant tumor growth is greater then all other strategies for all age groups and both sexes. When compared to observation followed by microsurgery, the additional benefit is small. QALY totals for the two immediate treatment groups were significantly lower than that for the observation groups. CONCLUSIONS For patients of all ages, a period of observation during which tumor growth and hearing thresholds are closely monitored is the superior strategy. For tumors that grow substantially or when hearing deteriorates, definitive management via radiosurgery is recommended.
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Affiliation(s)
- Daniel Morrison
- Section of Otolaryngology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Hsu PW, Chang CN, Lee ST, Huang YC, Chen HC, Wang CC, Hsu YH, Tseng CK, Chen YL, Wei KC. Outcomes of 75 patients over 12 years treated for acoustic neuromas with linear accelerator-based radiosurgery. J Clin Neurosci 2010; 17:556-60. [PMID: 20227884 DOI: 10.1016/j.jocn.2009.09.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 09/18/2009] [Accepted: 09/21/2009] [Indexed: 11/26/2022]
Abstract
The aim of this study was to investigate the efficacy of linear accelerator (LINAC)-based radiosurgery in the treatment of acoustic neuromas. In this retrospective study, we enrolled 75 patients with non-neurofibromatosis type 2 acoustic neuromas who were followed-up for more than 5years. The 75 patients were divided into 3 groups: patients with a newly diagnosed tumor; those with a residual tumor; and those with a recurrent tumor. The average follow-up period was 97.8months. The overall tumor progression-free rate was 92%, and corresponding rates among those with newly diagnosed tumors was 100%, residual tumors was 84.4%, and recurrent tumors was 92.8% (p=0.028). Lesion localization using CT scans correlated with a higher tendency for tumor progression than lesion localization using CT-MRI fusion images (15.6% versus 2.4%, respectively). Residual tumors treated with radiosurgery have a higher progression rate, and careful lesion localization using CT-MRI image fusion is required.
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Affiliation(s)
- Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, 5 Fu-Hsing St., Kweishan, Taoyuan 333, Taiwan
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Asymmetric sensorineural hearing loss caused by vestibular schwannoma: Characteristic imaging features before and after treatment with stereotactic radiosurgery. Radiol Case Rep 2010; 5:437. [PMID: 27307865 PMCID: PMC4898225 DOI: 10.2484/rcr.v5i2.437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We report the case of a 71-year-old man who presented with a 2-year history of progressive left-sided hearing loss caused by a cerebellopontine angle mass lesion with classic imaging characteristics of a vestibular schwannoma. Vestibular schwannomas are typically diagnosed on dedicated MRI of the internal auditory canals obtained for asymmetric sensorineural hearing loss, as in this case. We review the characteristic imaging features of vestibular schwannomas that enable their differentiation from other mass lesions of the cerebellopontine angle cistern, allowing for treatment with stereotactic radiosurgery in this case.
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von Eckardstein KL, Beatty CW, Driscoll CLW, Link MJ. Spontaneous regression of vestibular schwannomas after resection of contralateral tumor in neurofibromatosis Type 2. J Neurosurg 2010; 112:158-62. [DOI: 10.3171/2009.5.jns09240] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report on 2 patients with bilateral vestibular schwannomas (VSs) who underwent unilateral surgical tumor removal. One patient was followed up for 4 years, the other for 9; in both cases, the contralateral VS regressed markedly without any additional treatment during the follow-up period. Serial MR imaging was performed to monitor the untreated tumor, which in both cases involved the only hearing ear. The tumors were assessed volumetrically. The contralateral tumors appeared to enlarge mildly at initial follow-up and then, with no treatment, regressed (to 23% of the original maximum volume in Case 1 and to 15% of the original maximum in Case 2). The largest posterior fossa diameter decreased from 30.1 mm to 18.6 mm in Case 1 over 4 years and from 27 mm to 16 mm over 8 years in Case 2. Hearing declined only mildly during follow-up in both patients.These cases demonstrate the first well-documented, long-term, spontaneous VS regressions in patients with neurofibromatosis Type 2. They underline the importance of careful observation of VS involving the only hearing ear in the management of bilateral VS to determine the natural growth pattern of the tumors. The mechanism of the dramatic spontaneous tumor regression is uncertain.
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Affiliation(s)
| | | | - Colin L. W. Driscoll
- 1Departments of Neurologic Surgery and
- 2Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Michael J. Link
- 1Departments of Neurologic Surgery and
- 2Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
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110
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Vestibular schwannoma: role of conservative management. The Journal of Laryngology & Otology 2009; 124:251-7. [DOI: 10.1017/s0022215109992362] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:To assess the outcome of conservative management of vestibular schwannoma.Study design:Observational study.Setting:Tertiary referral centre.Patients:Four hundred and thirty-six patients with vestibular schwannoma (490 tumours), including 327 sporadic tumours and 163 tumours in 109 patients with neurofibromatosis type two.Main outcome measures:The relationship of tumour growth to tumour size at presentation, and to certain demographic features.Results:The initial tumour size was significantly larger in the neurofibromatosis type two group (11 mm) than in the sporadic vestibular schwannoma group (5.1 mm). In both groups, 68 per cent of tumours did not grow during follow up (mean 3.6 years; range one to 14 years). The mean growth rate was 1.1 mm/year (range 0–15 mm/year) for sporadic tumours and 1.7 mm/year (range 0–18 mm/year) for neurofibromatosis type two tumours. The tumour growth rate correlated positively with tumour size in the sporadic tumour group, and correlated negatively with age in the neurofibromatosis type two group.Conclusion:Two-thirds of vestibular schwannomas did not grow. Radiological surveillance is an acceptable approach in carefully selected patients. Once a sporadic vestibular schwannoma reaches 2 cm in intracranial diameter, it is likely to continue growing. We do not recommend conservative management for sporadic tumours with an intracranial diameter of 1.5 cm or more. Vestibular schwannoma management is more complex in patients with neurofibromatosis type two.
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111
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Franzin A, Spatola G, Serra C, Picozzi P, Medone M, Milani D, Castellazzi P, Mortini P. Evaluation of hearing function after Gamma Knife surgery of vestibular schwannomas. Neurosurg Focus 2009; 27:E3. [DOI: 10.3171/2009.9.focus09196] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Due to technological advances in neuroradiology in recent years, incidental diagnoses of vestibular schwannomas (VSs) have increased. The aim of this study was to evaluate the hearing function after treatment with Gamma Knife surgery (GKS) for VSs in patients adequately selected with “good” or “useful” hearing before treatment and to assess the possible predictive factors for hearing function preservation.
Methods
Of all patients treated in the authors' hospital between 2001 and 2007, they retrospectively studied 50 patients with a unilateral VS in whom there was serviceable hearing (Gardner-Robertson [GR] Class I or II). Additional inclusion criteria were: no Type 2 neurofibromatosis, no previous treatment, and at least 6 months' follow-up of neuroradiological and audiological data. The median patient age was 54 years (range 24–78 years). The median tumor volume was 0.73 ml (range 0.03–6.6 ml), and the median radiation dose to the tumor margin was 13 Gy (range 12–16 Gy) with an isodose of 50%.
Results
Patient age, tumor volume, and presenting symptoms were found to correlate with hearing function. At a median of 36 months after radiosurgery, tumor growth control was 96% and no patient required any other additional treatment. Serviceable hearing was preserved in 34 patients (68%): 21 (62%) with GR Class I hearing and 13 (38%) with GR Class II hearing. The remaining 16 patients had poor hearing function:15 with GR Class III and 1 with GR Class IV hearing function. In 19 (58%) of 33 patients with GR Class I function before GKS the same class was maintained posttreatment; 29 (88%) maintained functional hearing (GR Class I or II). In all patients with an intracanalicular lesion, functional hearing was maintained. Significant prognostic factors for maintaining serviceable hearing were GR Class I function before treatment, symptoms at presentation, patient age younger than 54 years, and Koos Stage T1 disease.
Conclusions
The results of the study show that the probability of preserving functional hearing in patients undergoing GKS treatment for unilateral VSs is very high. Patients with GR Class I, age younger than 54 years, with presenting symptoms other than hearing loss, and a Koos Stage T1 tumor have better prognosis. The prescribed dose of 13 Gy appears to represent an excellent compromise between controlling the disease and preserving auditory function.
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112
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Yoshimoto Y, Tanaka Y. Biological heterogeneity and length-biased sampling in asymptomatic neurosurgical patients. Br J Neurosurg 2009; 22:368-72. [DOI: 10.1080/02688690801942916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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113
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Sugita-Kitajima A, Koizuka I. Evaluation of the vestibulo-ocular reflex using sinusoidal off-vertical axis rotation in patients with acoustic neurinoma. Neurosci Lett 2009; 462:6-9. [PMID: 19560514 DOI: 10.1016/j.neulet.2009.06.078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Revised: 05/20/2009] [Accepted: 06/19/2009] [Indexed: 10/20/2022]
Abstract
The vestibulo-ocular reflex (VOR) was studied to examine the utility of off-vertical axis rotation (OVAR) in the diagnosis of acoustic neurinoma. Subjects were sinusoidally rotated with eyes open in complete darkness at frequencies of 0.4 and 0.8 Hz with a maximum angular velocity of 60 degrees /s at either earth-vertical axis rotation (EVAR) or OVAR. Thirteen patients with acoustic neurinomas were investigated. Results showed that VOR gain during OVAR at 0.8 Hz and in a 30 degrees nose-up position in patients with internal auditory canal tumors was significantly less than the gain measured during EVAR. The VOR gain measured from all patients (including those with tumors extending to the cerebellopontine angle) was not significantly different when the patients were subjected to EVAR and OVAR. These observations were possibly due to superior vestibular nerve dysfunction. We concluded that certain stimulating parameters--patient's nose tilted up 30 degrees; sinusoidal OVAR at 0.8 Hz and 60 degrees /s maximum angular head velocity--were useful for evaluating vestibular function in patients suffering from an acoustic neurinoma located within the internal auditory canal.
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Affiliation(s)
- Akemi Sugita-Kitajima
- Department of Otolaryngology, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511, Japan.
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Plotkin SR, Halpin C, Blakeley JO, Slattery WH, Welling DB, Chang SM, Loeffler JS, Harris GJ, Sorensen AG, McKenna MJ, Barker FG. Suggested response criteria for phase II antitumor drug studies for neurofibromatosis type 2 related vestibular schwannoma. J Neurooncol 2009; 93:61-77. [PMID: 19430883 DOI: 10.1007/s11060-009-9867-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 03/16/2009] [Indexed: 01/31/2023]
Abstract
Neurofibromatosis type 2 (NF2) is a tumor suppressor gene syndrome characterized by multiple schwannomas, especially vestibular schwannomas (VS), and meningiomas. Anticancer drug trials are now being explored, but there are no standardized endpoints in NF2. We review the challenges of NF2 clinical trials and suggest possible response criteria for use in initial phase II studies. We suggest two main response criteria in such trials. Objective radiographic response is defined as a durable 20% or greater reduction in VS volume based on post-contrast T1-weighted MRI images collected with 3 mm or finer cuts through the internal auditory canal. Hearing response is defined as a statistically significant improvement in word recognition scores using 50-word recorded lists in audiology. A possible composite endpoint incorporating both radiographic response and hearing response is outlined. We emphasize pitfalls in response assessment and suggest guidelines to minimize misinterpretations of response. We also identify research goals in NF2 to facilitate future trial conduct, such as identifying the expectations for time to tumor progression and time to measurable hearing loss in untreated NF2-related VS, and the relation of both endpoints to patient prognostic factors (such as age, baseline tumor volume, and measures of disease severity). These data would facilitate future use of endpoints based on stability of tumor size and hearing, which might be more appropriate for testing certain drugs. We encourage adoption of standardized endpoints early in the development of phase II trials for this population to facilitate comparison of results across trials of different agents.
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Affiliation(s)
- Scott R Plotkin
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
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van de Langenberg R, de Bondt BJ, Nelemans PJ, Baumert BG, Stokroos RJ. Follow-up assessment of vestibular schwannomas: volume quantification versus two-dimensional measurements. Neuroradiology 2009; 51:517-24. [PMID: 19418046 PMCID: PMC2710491 DOI: 10.1007/s00234-009-0529-4] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Accepted: 04/13/2009] [Indexed: 11/24/2022]
Abstract
Introduction A conservative treatment strategy is often proposed as a primary treatment option in the management of vestibular schwannomas (VS). In this “wait and scan” policy, audiovestibular symptoms are monitored regularly, and VS growth is measured on consecutive magnetic resonance images (MRI). The aim of this study is validation of two-dimensional versus volume MRI assessment in the longitudinal follow-up of VS and to define tumor growth beyond measurement error. Methods MRI scans of 68 consecutive patients with VS were analyzed retrospectively. Two-dimensional and volume measurements on contrast enhanced (CE) T1- and T2-weighted images were performed independently by two readers. Smallest detectable differences (SDD) were calculated, and intraclass correlation coefficients (ICCs) were determined for both assessment methods. Results Two-dimensional and volume measurements both showed best reproducibility on CE T1-weighted images. SDD for differences relative to baseline MRI [SDD (%)] for two-dimensional measurements had a higher interobserver error compared to volume measurements (40% versus 19.7%), which decreases when tumor size increases. The ICC for two-dimensional measurements in three directions was 0.947, 0.974, and 0.978 and for volume measurements 0.999. Conclusion Volume measurements are more accurate compared to two-dimensional measurements for the evaluation of VS growth. These measurements are assessed preferably on CE T1-weighted images. SDD (%) strongly depends on VS size. SDD between consecutive scans exceeds the common clinical applied criterion of 1 or 2 mm growth to define growth.
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Affiliation(s)
- Rick van de Langenberg
- Department of Otorhinolaryngology-Head and Neck Surgery, Maastricht University Medical Center, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
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Guiding patients through the choices for treating vestibular schwannomas: balancing options and ensuring informed consent. 2007. Neurosurg Clin N Am 2008; 19:379-92, viii. [PMID: 18534346 DOI: 10.1016/j.nec.2008.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Counseling patients who are diagnosed with vestibular schwannomas, formerly known as acoustic neuromas, can be challenging. The health care provider has the responsibility to explain, in understandable language, to the patient or legal representative the proposed treatment options, risks and complications associated with each form of treatment, and alternatives to treatment, including no therapy. Patients should be encouraged to gather information before making a treatment decision. For the physicians managing these patients, information should be delivered in a balanced way to ensure patient understanding of their options leading to adequate informed consent.
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117
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Analysis of causes for late presentation of Indian patients with vestibular schwannoma. The Journal of Laryngology & Otology 2008; 123:502-8. [PMID: 18808730 DOI: 10.1017/s0022215108003575] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the causes of delay in diagnosis and treatment of Indian patients with vestibular schwannomas. METHODS In a prospective study from 2003 to 2005, 50 patients with a confirmed diagnosis of vestibular schwannoma were interviewed to determine the causes for (1) the delay between the patient noting the initial symptom and the definitive diagnosis, and (2) the reasons for delayed diagnosis. RESULTS In 90 per cent of patients, the initial symptom was either hearing loss (62 per cent), vertigo (24 per cent) or tinnitus (4 per cent). However, most patients had been diagnosed and had presented for surgery only after neurological symptoms had became apparent. The delay between the initial medical consultation and the final diagnosis ranged from one month to 204 months (mean +/- standard deviation, 32.2 +/- 38.9 months). After the patient had noted symptoms, the diagnosis of vestibular schwannoma was delayed due to doctor-related causes in 80 per cent of cases, and due to patient-related causes in 20 per cent. Delay following diagnosis was minimal. CONCLUSIONS Delay in the diagnosis of vestibular schwannoma in Indian patients is due to both doctor- and patient-related factors.
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Strauss C, Bischoff B, Romstöck J, Rachinger J, Rampp S, Prell J. Hearing preservation in medial vestibular schwannomas. J Neurosurg 2008; 109:70-6. [DOI: 10.3171/jns/2008/109/7/0070] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Vestibular schwannomas (VSs) with no or little extension into the internal auditory canal have been addressed as a clinical subentity carrying a poor prognosis regarding hearing preservation, which is attributed to the initially asymptomatic intracisternal growth pattern. The goal in this study was to assess hearing preservation in patients who underwent surgery for medial VSs.
Methods
A consecutive series of 31 cases in 30 patients with medial VSs (mean size 31 mm) who underwent surgery between 1997 and 2005 via a suboccipitolateral route was evaluated with respect to pre- and postoperative cochlear nerve function, extent of tumor removal, and radiological findings. Intraoperative monitoring of brainstem auditory evoked potentials was performed in all patients with hearing. Patients were reevaluated at a mean of 30 months following surgery.
Results
Preoperative hearing function revealed American Academy of Otolaryngology–Head and Neck Surgery Foundation Classes A and B in 7 patients each, Class C in 4, and D in 9. Four patients presented with deafness. Hearing preservation was achieved in 10 patients (Classes A–C in 2 patients each, and Class D in 4 patients). Tumor removal was complete in all patients with hearing preservation, except for 2 patients with neurofibromatosis. In 4 patients a planned subtotal excision was performed due to the individual's age or underlying disease. In 1 patient a recurrent tumor was completely removed 3 years after the initial procedure.
Conclusions
The cochlear nerve in medial VSs requires special attention due to the atypical intracisternal growth pattern. Even in large tumors, hearing could be preserved in 37% of cases, since the cochlear nerve in medial schwannomas may not exhibit the adherence to the tumor capsule seen in tumors with comparable size involving the internal auditory canal.
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Affiliation(s)
- Christian Strauss
- 1Department of Neurosurgery, Martin Luther University of Halle–Wittenberg, Halle; and
| | - Barbara Bischoff
- 2Department of Neurosurgery, University of Erlangen–Nürnberg, Erlangen, Germany
| | - Johann Romstöck
- 2Department of Neurosurgery, University of Erlangen–Nürnberg, Erlangen, Germany
| | - Jens Rachinger
- 1Department of Neurosurgery, Martin Luther University of Halle–Wittenberg, Halle; and
| | - Stefan Rampp
- 1Department of Neurosurgery, Martin Luther University of Halle–Wittenberg, Halle; and
| | - Julian Prell
- 1Department of Neurosurgery, Martin Luther University of Halle–Wittenberg, Halle; and
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Harris GJ, Plotkin SR, MacCollin M, Bhat S, Urban T, Lev MH, Slattery WH. THREE-DIMENSIONAL VOLUMETRICS FOR TRACKING VESTIBULAR SCHWANNOMA GROWTH IN NEUROFIBROMATOSIS TYPE II. Neurosurgery 2008; 62:1314-9; discussion 1319-20. [DOI: 10.1227/01.neu.0000333303.79931.83] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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120
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Harris GJ, Plotkin SR, MacCollin M, Bhat S, Urban T, Lev MH, Slattery WH. THREE-DIMENSIONAL VOLUMETRICS FOR TRACKING VESTIBULAR SCHWANNOMA GROWTH IN NEUROFIBROMATOSIS TYPE II. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000316858.25606.8f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Likhterov I, Allbright RM, Selesnick SH. LINAC Radiosurgery and Radiotherapy Treatment of Acoustic Neuromas. Neurosurg Clin N Am 2008; 19:345-65, vii. [DOI: 10.1016/j.nec.2008.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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123
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Lü J, Zou J, Wu H, Cai L. Compensative Shuttling of Merlin to Phosphorylation on Serine 518 in Vestibular Schwannoma. Laryngoscope 2008; 118:169-74. [DOI: 10.1097/mlg.0b013e3181566594] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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124
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Nerve of Origin, Tumor Size, Hearing Preservation, and Facial Nerve Outcomes in 359 Vestibular Schwannoma Resections at a Tertiary Care Academic Center. Laryngoscope 2007; 117:2087-92. [DOI: 10.1097/mlg.0b013e3181453a07] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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125
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Likhterov I, Allbright RM, Selesnick SH. LINAC radiosurgery and radiotherapy treatment of acoustic neuromas. Otolaryngol Clin North Am 2007; 40:541-70, ix. [PMID: 17544695 DOI: 10.1016/j.otc.2007.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This article provides an introduction to radiation therapy as it applies to intracranial tumors. It also provides a review of the natural growth progression of acoustic neuromas and accuracy of tumor size determination. Literature on the use of linear accelerator stereotactic radiosurgery and fractionated radiotherapy in acoustic neuroma management is reviewed and summarized. Specifically, the rates of reported tumor control, hearing preservation, facial and trigeminal nerve complications, and hydrocephalus are analyzed. Although the complication rates associated with linear accelerator therapy are relatively low, hearing preservation is poor and acoustic neuroma control is variable.
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Affiliation(s)
- Ilya Likhterov
- Weill Cornell Medical College, 1305 York Avenue; 5th floor, New York, NY 10021, USA
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126
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Backous DD, Pham HT. Guiding patients through the choices for treating vestibular schwannomas: balancing options and ensuring informed consent. Otolaryngol Clin North Am 2007; 40:521-40, viii-ix. [PMID: 17544694 DOI: 10.1016/j.otc.2007.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Counseling patients who are diagnosed with vestibular schwannomas, formerly known as acoustic neuromas, can be challenging. The health care provider has the responsibility to explain, in understandable language, to the patient or legal representative the proposed treatment options, risks and complications associated with each form of treatment, and alternatives to treatment, including no therapy. Patients should be encouraged to gather information before making a treatment decision. For the physicians managing these patients, information should be delivered in a balanced way to ensure patient understanding of their options leading to adequate informed consent.
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Affiliation(s)
- Douglas D Backous
- Otology, Neurotology and Skull Base Surgery, Section of Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, X10-0N, Seattle, WA 98111-0900, USA.
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Vachhani JA, Friedman WA. Radiosurgery in patients with bilateral vestibular schwannomas. Stereotact Funct Neurosurg 2007; 85:273-8. [PMID: 17709979 DOI: 10.1159/000107359] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with bilateral vestibular schwannomas offer a unique opportunity to determine the effectiveness of radiosurgery. By using the untreated tumor as an internal control, one can determine whether radiosurgery was able to interrupt the natural history of the treated tumor. METHODS From September 1998 to November 2004, 13 patients with neurofibromatosis type 2 had 14 tumors treated with radiosurgery at the University of Florida. A retrospective analysis was performed on these patients. Actuarial statistics were used to analyze local control in both the treated and untreated tumor. RESULTS The average follow-up length was 38 months. One patient failed to send a follow-up MRI. Actuarial local control in the treated tumors was 100% at 1 year and 92% at 2 and 5 years. Only 1 of the treated tumors continued to grow. In the untreated tumors, actuarial local control was 100% at 1 year, 78% at 2 years and 21% at 5 years. None of the untreated tumors decreased in size. CONCLUSION In all but 1 patient with follow-up data, radiosurgery successfully prevented or reversed tumor growth. Additionally, half of the untreated tumors continued to grow. This study shows that radiosurgery alters the natural history of vestibular schwannomas.
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Affiliation(s)
- Jay A Vachhani
- Department of Neurosurgery, University of Florida, Gainesville, FL 32610, USA
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128
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Nouraei SAR, Huys QJM, Chatrath P, Powles J, Harcourt JP. Screening patients with sensorineural hearing loss for vestibular schwannoma using a Bayesian classifier. Clin Otolaryngol 2007; 32:248-54. [PMID: 17651265 DOI: 10.1111/j.1365-2273.2007.01460.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Selecting patients with asymmetrical sensorineural hearing loss for further investigation continues to pose clinical and medicolegal challenges, given the disparity between the number of symptomatic patients, and the low incidence of vestibular schwannoma as the underlying cause. We developed and validated a diagnostic model using a generalisation of neural networks, for detecting vestibular schwannomas from clinical and audiological data, and compared its performance with six previously published clinical and audiological decision-support screening protocols. DESIGN Probabilistic complex data classification using a neural network generalization. SETTINGS Tertiary referral lateral skull base and a computational neuroscience unit. PARTICIPANTS Clinical and audiometric details of 129 patients with, and as many age and sex-matched patients without vestibular schwannomas, as determined with magnetic resonance imaging. MAIN OUTCOME MEASURES The ability to diagnose a patient as having or not having vestibular schwannoma. RESULTS A Gaussian Process Ordinal Regression Classifier was trained and cross-validated to classify cases as 'with' or 'without' vestibular schwannoma, and its diagnostic performance was assessed using receiver operator characteristic plots. It proved possible to pre-select sensitivity and specificity, with an area under the curve of 0.8025. At 95% sensitivity, the trained system had a specificity of 56%, 30% better than audiological protocols with closest sensitivities. The sensitivities of previously-published audiological protocols ranged between 82-97%, and their specificities ranged between 15-61%. DISCUSSION The Gaussian Process ORdinal Regression Classifier increased the flexibility and specificity of the screening process for vestibular schwannoma when applied to a sample of matched patients with and without this condition. If applied prospectively, it could reduce the number of 'normal' magnetic resonance (MR) scans by as much as 30% without reducing detection sensitivity. Performance can be further improed through incorporating additional data domains. Current findings need to be reproduced using a larger dataset.
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Affiliation(s)
- S A R Nouraei
- Department of Otolaryngology, Charing Cross Hospital, London, UK.
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129
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Myrseth E, Pedersen PH, Møller P, Lund-Johansen M. Treatment of vestibular schwannomas. Why, when and how? Acta Neurochir (Wien) 2007; 149:647-60; discussion 660. [PMID: 17558460 DOI: 10.1007/s00701-007-1179-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Accepted: 02/08/2007] [Indexed: 01/22/2023]
Abstract
Sporadic vestibular schwannoma (VS) causes unilateral hearing loss, tinnitus, vertigo and unsteadiness. In many cases, the tumour size may remain unchanged for many years following diagnosis, which is typically made by MRI. In the majority of cases the tumour is small, leaving the clinician and patient with the options of either serial scanning or active treatment by gamma knife radiosurgery (GKR) or microneurosurgery. Despite the vast number of published treatment reports, comparative studies are few, and evidence is no better than class III (May, 2006). The predominant clinical endpoints of VS treatment include tumour control, facial nerve function and hearing preservation. Less focus has been put on symptom relief and health-related quality of life (QOL). It is uncertain if treating a small tumour leaves the patient with a better chance of obtaining relief from future hearing loss, vertigo or tinnitus than by observing it without treatment. Recent data indicate that QOL is reduced in untreated VS patients, and may differ between patients who have been operated and patients treated with GKR. In the present paper we review the natural course and complaints of untreated VS patients, and the treatment alternatives and results. Furthermore, we review the literature concerning quality of life in patients with VS. Finally, we present our experience with a management strategy applied to more than 300 cases since 2001.
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Affiliation(s)
- E Myrseth
- Department of Neurosurgery, Institute of Surgical Science, Haukeland University Hospital, University of Bergen, Bergen, Norway.
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Yasumoto Y, Ito M. Spontaneous regression of a growing vestibular schwannoma. Neurol Med Chir (Tokyo) 2007; 46:601-4. [PMID: 17185887 DOI: 10.2176/nmc.46.601] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 75-year-old woman presented with a small right vestibular schwannoma which enlarged and then spontaneously regressed during conservative management. The tumor increased in size from 5.2 to 16.7 mm over 7 years with worsening symptoms of tinnitus, dizziness, and headache. The tumor then regressed to 8.2 mm and the symptoms improved for 4 years without further treatment. Changes in tumor growth should be carefully monitored during conservative management of patients with vestibular schwannoma.
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Affiliation(s)
- Yukimasa Yasumoto
- Department of Neurosurgery, Matsumura General Hospital, Iwaki, Fukushima, Japan.
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131
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Doherty JK, Friedman RA. Controversies in building a management algorithm for vestibular schwannomas. Curr Opin Otolaryngol Head Neck Surg 2006; 14:305-13. [PMID: 16974142 DOI: 10.1097/01.moo.0000244186.72645.d4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The present review examines the various mainstream treatment options, benefits and risks, and controversies involved in developing a management algorithm for treatment of vestibular schwannoma. RECENT FINDINGS Advances in microsurgery and radiosurgery have made tremendous contributions to management of vestibular schwannoma; however, considerable controversy still exists. The auditory and facial nerve functional outcomes have improved with use of intraoperative monitoring for vestibular schwannoma removal and with lower radiosurgery doses; however, risks to the facial and auditory nerves still exist. Observing vestibular schwannomas for growth with serial magnetic resonance imaging is an increasingly popular option for small vestibular schwannomas that allows patients to enjoy hearing and facial function. SUMMARY The risks and benefits of each treatment option must be weighed for each patient, and management decisions regarding vestibular schwannomas should be individualized for each patient depending on tumor anatomy, patient preferences, and symptoms.
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Affiliation(s)
- Joni K Doherty
- House Clinic and House Ear Institute, Los Angeles, California 90057, USA
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