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Shrivastava M, Emmanouil B, Mathew R, Halliday D, Parry A, Halliday J, Mackeith S. Stereotactic Radiosurgery and Radiotherapy for Vestibular Schwannoma in NF2-Related Schwannomatosis. Laryngoscope 2024; 134:2364-2371. [PMID: 37983868 DOI: 10.1002/lary.31180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/11/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES To determine the long-term control rates and hearing outcomes for growing vestibular schwannoma in NF2-related schwannomatosis (NF2) treated with stereotactic radiosurgery (SRS) and fractionated radiotherapy (FRT). METHODS Retrospective review of all patients treated with SRS/FRT between 1986 and2021 from a tertiary NF2 unit. Overall tumor control was defined as: (1) growth control (growth failure was defined as growth in any dimension of 3 millimetres or more from baseline post-SRS/FRT), and (2) treatment control (no need for further intervention). Loss of serviceable hearing was defined as a drop in speech discrimination score below 50% after SRS/FRT. RESULTS There were 81 cases, with a mean duration of follow-up of 125 months. Overall control rate was 72% (58/81), with 80% (65/81) growth control and 74% (60/81) treatment control. There was a 5-year actuarial survival of 77% and 10-year survival of 71%. Forty-three percent (30/69) of cases did not have serviceable hearing at baseline. Of those remaining, 49% (19/39) preserved serviceable hearing during follow-up at a mean of 106 months. Actuarial survival for preservation of serviceable hearing at 5 and 10 years was 69% and 53%. There were poorer outcomes with increasing genetic severity, and with baseline tumor size >3 cm. No cases of SRS/FRT-related malignancy were identified at a mean follow-up of 10 years. CONCLUSION Stereotactic radiosurgery/fractionated radiotherapy are an effective option to treat growing vestibular schwannoma in patients with NF2 with the potential for hearing preservation in a proportion of patients. LEVEL OF EVIDENCE 4-Case Series Laryngoscope, 134:2364-2371, 2024.
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Affiliation(s)
- Manu Shrivastava
- Department of Ear, Nose and Throat Surgery, Oxford University Hospitals, Oxford, UK
| | - Beatrice Emmanouil
- NHS England, Wellington House, London, UK
- Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rajeev Mathew
- Department of Ear, Nose and Throat Surgery, Oxford University Hospitals, Oxford, UK
| | | | - Allyson Parry
- Department of Neurology, Oxford University Hospitals, Oxford, UK
| | - Jane Halliday
- Department of Neurosurgery, Oxford University Hospitals, Oxford, UK
| | - Samuel Mackeith
- Department of Ear, Nose and Throat Surgery, Oxford University Hospitals, Oxford, UK
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Shinya Y, Teranishi Y, Hasegawa H, Miyawaki S, Sugiyama T, Shin M, Kawashima M, Umekawa M, Katano A, Nakatomi H, Saito N. Long-term outcomes of stereotactic radiosurgery for intracranial schwannoma in neurofibromatosis type 2: a genetic analysis perspective. J Neurooncol 2024; 166:185-194. [PMID: 38151698 DOI: 10.1007/s11060-023-04530-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/04/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE Neurofibromatosis type 2 (NF2) is intractable because of multiple tumors involving the nervous system and is clinically diverse and genotype-dependent. Stereotactic radiosurgery (SRS) for NF2-associated schwannomas remains controversial. We aimed to investigate the association between radiosurgical outcomes and mutation types in NF2-associated schwannomas. METHODS This single-institute retrospective study included consecutive NF2 patients with intracranial schwannomas treated with SRS. The patients' types of germline mutations ("Truncating," "Large deletion," "Splice site," "Missense," and "Mosaic") and Halliday's genetic severity scores were examined, and the associations with progression-free rate (PFR) and overall survival (OS) were analyzed. RESULTS The study enrolled 14 patients with NF2 with 22 associated intracranial schwannomas (median follow-up, 102 months). The PFRs in the entire cohort were 95% at 5 years and 90% at 10-20 years. The PFRs tended to be worse in patients with truncating mutation exons 2-13 than in those with other mutation types (91% at 5 years and 82% at 10-20 years vs. 100% at 10-20 years, P = 0.140). The OSs were 89% for patients aged 40 years and 74% for those aged 60 years in the entire cohort and significantly lower in genetic severity group 3 than in the other groups (100% vs. 50% for those aged 35 years; P = 0.016). CONCLUSION SRS achieved excellent PFR for NF2-associated intracranial schwannomas in the mild (group 2A) and moderate (group 2B) groups. SRS necessitates careful consideration for the severe group (group 3), especially in cases with NF2 truncating mutation exons 2-13.
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Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yu Teranishi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, 162-8655, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Masahiro Shin
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Puataweepong P, Dhanacha M, Ruangkanchanasetr R, Boonyawan K, Hansasuta A, Saetia K, Yongvithisatid P. Long-term clinical outcomes of stereotactic radiotherapy for bilateral vestibular schwannomas in neurofibromatosis type 2 patients. J Neurooncol 2023; 164:587-595. [PMID: 37702975 DOI: 10.1007/s11060-023-04430-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/19/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE The evidence for treating patients with neurofibromatosis 2-related vestibular schwannoma (VS-NF2) using hypofractionated stereotactic radiation therapy (HSRT) is limited. This study aimed to investigate clinical outcomes in patients with VS-NF2 treated with Robotic HSRT. METHODS We retrospectively analyzed 25 NF2 patients with 48 VSs who were treated using Robotic HSRT at Ramathibodi Hospital from January 2009 to January 2020. RESULTS Median follow-up was 98 months (range, 24-155 months). Median tumor volume was 2.3 cm3 (range, 0.4-28.3 cm3). Median prescribed dose was 18 Gy (range, 18-25 Gy) in three fractions (range, 3-5). The 5- and 10-year local control rates were 87% and 80%, respectively. The 5- and 10-year hearing preservation rates were 59% and 35%, respectively. Three patients developed new symptoms associated with transient volume expansion after treatment: hydrocephalus in one, facial weakness in one, and ataxia in one. No patient developed worsening of trigeminal nerve function. No histologically confirmed of radiation induced malignancy was reported in the study. CONCLUSIONS Robotic HSRT demonstrated excellent long-term tumor control with a low non-auditory complication rate in patients with VS-NF2. However, preservation of hearing remains a major concern.
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Affiliation(s)
- Putipun Puataweepong
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Mantana Dhanacha
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rawee Ruangkanchanasetr
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Keeratikarn Boonyawan
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ake Hansasuta
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kriangsak Saetia
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpan Yongvithisatid
- Radiosurgery Unit, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Sri Krishna GS, Pahwa B, Jagdevan A, Singh M, Kale S, Agrawal D. Tumor Control and Hearing Preservation After Gamma Knife Radiosurgery for Vestibular Schwannomas in Neurofibromatosis Type 2-A Retrospective Analysis of 133 Tumors. World Neurosurg 2023; 171:e820-e827. [PMID: 36587894 DOI: 10.1016/j.wneu.2022.12.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE This study was conducted with the aim to estimate long-term tumor control and hearing preservation rates in patients with neurofibromatosis 2 (NF2)-related vestibular schwannoma (VS), document retreatment success rate, and assess the associated predictive factors. METHODS This was a retrospective analysis of patients with NF2-associated VS who underwent Gamma Knife radiosurgery (GKRS) between 2009 and 2020 and had a minimum follow-up of 1 year. Loss of tumor control was defined as greater than 10% increase in volume in more than one follow-up imaging or the need for retreatment in the form of repeat GKRS or surgery. The Kaplan-Meier method was used to evaluate actuarial tumor control and hearing preservation rates. RESULTS In total, 85 patients with 133 VSs were included in the study. The mean age was 29.8 years. In total, 57 tumors showed tumor regression, 35 showed stable disease, and 23 progressed in size at last follow up. Actuarial tumor control rates after 1, 3, 5, and 9 years were 95%, 79%, 75%, and 55%, respectively, with overall tumor control rate being 85%. Hearing worsened in 39 patients, and facial nerve dysfunction occurred in 4 patients. Five tumors underwent retreatment with GKRS at a median duration of 27.6 months (19-36 months) following the first GKRS. CONCLUSIONS This is the largest radiosurgical series of NF2-associated VS reported to date. GKRS provides a high rate of long-term local tumor control with a low risk of neurologic deprivation for patients with these tumors. The need for retreatment with GKRS, although low, is associated with good tumor control and lesser complications.
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Affiliation(s)
| | - Bhavya Pahwa
- University College of Medical Sciences and GTB Hospital, New Delhi, India
| | - Aman Jagdevan
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
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Lin J, Li SW, Zhang J, Chu FH, Li CZ, Bie ZX, Tang HL, Gao S, Li P, Liao MT, Xin TX, Zhao F, Liu PN, Ding X. Qu-Du-San-Jie decoction induces growth inhibition and vascular normalization in NF2-associated vestibular schwannoma. Front Pharmacol 2022; 13:941854. [PMID: 36059985 PMCID: PMC9437245 DOI: 10.3389/fphar.2022.941854] [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] [Received: 05/11/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Neurofibromatosis type 2 (NF2) is a rare genetic syndrome that predisposes individuals to develop bilateral vestibular schwannomas (VSs) causing a high risk of life-threatening neurological complications. Traditional treatment options for NF2-associated VS usually cause neurological damage, and to date, there are no FDA-approved pharmacotherapies for NF2. The aim of this study was to evaluate the antitumor efficacy of Qu-Du-San-Jie (QDSJ) decoction, a traditional Chinese medicine formula, on NF2-associated VS and to investigate the potential underlying mechanisms.Methods: Ultra high-performance liquid chromatography-mass spectroscopy (UHPLC-MS) analysis was performed to identify the components of QDSJ and their targets. To determine the relationships between the putative targets of QDSJ and the differential genes of NF2-associated VS, the drug-disease crossover genes were screened using the UHPLC-MS data combined with our previous gene expression profiling data. The differentially expressed genes were imported into the STRING database to generate a PPI network. Differentially expressed gene targets and pathways were identified using GO and KEGG pathway enrichment analyses. The in vitro and in vivo drug efficacy of QDSJ decoction was tested using a patient-derived schwannoma cell line and a patient-derived xenograft mouse model, respectively. H&E staining, immunochemistry, and immunofluorescence staining were used to evaluate the cell proliferation and tumor vessels.Results: A total of 133 compounds were identified in QDSJ decoction using UHPLC-MS analysis. Network pharmacology showed that the regulation of necroptosis, apoptosis, cell cycle, angiogenesis, adherens junction, and neuroactive ligand-receptor interaction could be associated with the efficacy of QDSJ in treating NF2-associated VS. Treatment with QDSJ induced necrotic cell death and apoptosis of schwannoma cells in vitro and suppressed the tumor growth in vivo. Histopathological analysis revealed areas of cell necrosis and enlarged tumor blood vessels in the QDSJ-treated tumors. The numbers of cells positive for Cyclin D1 and Ki-67 were significantly reduced in QDSJ-treated tumors compared to control tumors. Immunofluorescence staining of CD31 and αSMA showed a decreased number and density of tumor vessels and normalized vessel structure in QDSJ-treated tumors.Conclusion: Our study demonstrates that QDSJ decoction shows significant antitumor activity against NF2-associated schwannoma and is a possible candidate for future clinical trials.
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Affiliation(s)
- Jie Lin
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Shi-Wei Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Zhang
- Department of Neural Reconstruction, Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Fu-Hao Chu
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
- Research Center for Spleen and Stomach Diseases of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
- Institute of Regulatory Science for Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Cheng-Ze Li
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Zhi-Xu Bie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Han-Lu Tang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shan Gao
- School of Chinese Materia Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Ping Li
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Meng-Ting Liao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Tian-Xi Xin
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Fu Zhao
- Department of Neural Reconstruction, Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- *Correspondence: Fu Zhao, ; Pi-Nan Liu, ; Xia Ding,
| | - Pi-Nan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neural Reconstruction, Beijing Key Laboratory of Central Nervous System Injury, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- *Correspondence: Fu Zhao, ; Pi-Nan Liu, ; Xia Ding,
| | - Xia Ding
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
- Research Center for Spleen and Stomach Diseases of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- *Correspondence: Fu Zhao, ; Pi-Nan Liu, ; Xia Ding,
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Umekawa M, Shinya Y, Hasegawa H, Kawashima M, Shin M, Katano A, Minamitani M, Kashio A, Kondo K, Saito N. Stereotactic radiosurgery ensures an effective and safe long-term control of Koos grade IV vestibular schwannomas: a single-center, retrospective, cohort study. J Neurooncol 2022; 159:201-209. [PMID: 35729368 DOI: 10.1007/s11060-022-04058-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is a standard treatment modality for vestibular schwannomas (VSs). However, there is a paucity of data on tumor control and neurological preservation for larger VSs. We aimed to investigate the long-term effectiveness of SRS for Koos grade IV compared with I-III VSs. METHODS We included 452 patients with VSs (50 Koos grade IV and 402 Koos grade I‒III) who were treated with SRS at our institution from 1990 to 2021. Tumor control and functional preservation were calculated using the Kaplan-Meier method and compared between groups with the log-rank test. RESULTS The median post-SRS follow-up period was 68 months. Progression-free survival rates were 91% at 5 and 10 years for Koos grade IV VSs, and 95% and 92%, respectively, for Koos grade I‒III VSs (p = 0.278). In Koos grade IV VSs, functional preservation rates of the facial and trigeminal nerves were both 96% at 5 years (both 98% for Koos grade I‒III VSs; facial, p = 0.410; trigeminal, p = 0.107). Hearing preservation rates were 61% at 5 years for Koos grade IV VSs and 78% for Koos grade I-III VSs (p = 0.645). Symptomatic transient tumor expansion was more common with Koos grade IV VSs (8.0% vs. 2.5%, p = 0.034), although all related symptoms diminished in accordance with tumor shrinkage. CONCLUSION SRS may contribute to long-term tumor control and adequate neurological preservation in the treatment of Koos grade IV VSs, comparable to those in the treatment of Koos grade I‒III VSs.
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Affiliation(s)
- Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan.
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masanari Minamitani
- Department of Radiology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Akinori Kashio
- Department of Otorhinolaryngology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Kenji Kondo
- Department of Otorhinolaryngology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
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Tosi U, Maayan O, An A, Lavieri MET, Guadix SW, DeRosa AP, Christos PJ, Pannullo S, Stieg PE, Brandmaier A, Knisely JPS, Ramakrishna R. Stereotactic radiosurgery for vestibular schwannomas in neurofibromatosis type 2 patients: a systematic review and meta-analysis. J Neurooncol 2022; 156:431-441. [PMID: 35040021 DOI: 10.1007/s11060-021-03910-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/22/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Neurofibromatosis type 2 (NF2) is characterized by often bilateral vestibular schwannomas (VS) that result in progressive hearing loss and compression of nearby brainstem structures causing cranial nerve palsies. Treatment of these tumors remains challenging, as both surgical removal and expectant management can result in symptom progression. Stereotactic radiosurgery (SRS) has been investigated for the management of NF2-associated VS; however, the role, promises, and pitfalls of this treatment modality remain unclear. METHODS Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Reviews were searched for studies assessing SRS outcome in NF2-associated VS only. Primary endpoints included tumor control, serviceable hearing, presence of tinnitus, and cranial nerve V and VII symptoms. RESULTS A total of 16 studies (589 patients harboring 750 tumors) were analyzed. Clinical tumor control was achieved in 88% of cases (95% CI 80-95%); salvage surgery was needed in 8% (95% CI 4-13%) of cases. Treatment resulted in a worsening of pre-treatment serviceable hearing (OR = 0.26, p < 0.01), increased facial nerve (OR = 1.62, p < 0.01) and trigeminal nerve (OR = 1.42, p = 0.07) impairment. The incidence of vestibular symptoms and hydrocephalus were not consistently reported and thus could not be assessed. CONCLUSIONS The treatment of NF2-associated VS continues to pose a challenge, as current SRS regimens result in impaired hearing and worse cranial nerve comorbidities, despite achieving high tumor control. It remains unclear if these findings have to be regarded as treatment complications or, rather, continued disease progression.
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Affiliation(s)
- Umberto Tosi
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Omri Maayan
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Anjile An
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Miguel E Tusa Lavieri
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Sergio W Guadix
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Antonio P DeRosa
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | - Paul J Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Susan Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | | | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA.
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Aftahy AK, Groll M, Barz M, Bernhardt D, Combs SE, Meyer B, Negwer C, Gempt J. Surgical Management of Jugular Foramen Schwannomas. Cancers (Basel) 2021; 13:cancers13164218. [PMID: 34439372 PMCID: PMC8393280 DOI: 10.3390/cancers13164218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 01/10/2023] Open
Abstract
Simple Summary Treatments of jugular foramen schwannomas may be challenging due to critical anatomical relations and the involvement of different aspects of the skull base. Advances in microsurgery have led to improved outcomes over recent decades, whereas in contrast, some advocate stereotactic radiotherapy as an effective therapy, controlling the tumor volume with few complications. In this manuscript, we present the outcomes and adverse events in a contemporary cohort and discuss surgical advantages and disadvantages of different performed classic skull base approaches. Abstract Background: Resection of jugular foramen schwannomas (JFSs) with minimal cranial nerve (CN) injury remains difficult. Reoperations in this vital region are associated with severe CN deficits. Methods: We performed a retrospective analysis at a tertiary neurosurgical center of patients who underwent surgery for JFSs between June 2007 and May 2020. We included nine patients (median age 60 years, 77.8% female, 22.2% male). Preoperative symptoms included hearing loss (66.6%), headache (44.4%), hoarseness (33.3%), dysphagia (44.4%), hypoglossal nerve palsy (22.2%), facial nerve palsy (33.3%), extinguished gag reflex (22.2%), and cerebellar dysfunction (44.4%). We observed Type A, B, C, and D tumors in 3, 1, 1, and 4 patients, respectively. A total of 77.8% (7/9) underwent a retrosigmoid approach, and 33.3% (3/9) underwent an extreme lateral infrajugular transcondylar (ELITE) approach. Gross total resection (GTR) was achieved in all cases. The rate of shunt-dependent hydrocephalus was 22.2% (2/9). No further complications requiring surgical intervention occurred during follow-up. The median follow-up time was 16.5 months (range 3–84 months). Conclusions: Considering the satisfying outcome, the GTR of JFSs is feasible in performing well-known skull base approaches. Additional invasive and complicated approaches were not needed. Radiosurgery may be an effective alternative for selected patients.
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Affiliation(s)
- Amir Kaywan Aftahy
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (M.G.); (M.B.); (B.M.); (C.N.); (J.G.)
- Correspondence: ; Tel.: +49-89-4140-2151; Fax: +49-89-4140-4889
| | - Maximilian Groll
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (M.G.); (M.B.); (B.M.); (C.N.); (J.G.)
| | - Melanie Barz
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (M.G.); (M.B.); (B.M.); (C.N.); (J.G.)
| | - Denise Bernhardt
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (D.B.); (S.E.C.)
| | - Stephanie E. Combs
- Department of Radiation Oncology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (D.B.); (S.E.C.)
- Department of Radiation Sciences (DRS), Institute of Radiation Medicine (IRM), Helmholtz Zentrum München (HMGU), Ingolstädter Landstraße Ingolstädter Landstraße 1, 85764 Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Sites Munich, 80333 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (M.G.); (M.B.); (B.M.); (C.N.); (J.G.)
| | - Chiara Negwer
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (M.G.); (M.B.); (B.M.); (C.N.); (J.G.)
| | - Jens Gempt
- Department of Neurosurgery, School of Medicine, Klinikum rechts der Isar, Technical University Munich, 80333 Munich, Germany; (M.G.); (M.B.); (B.M.); (C.N.); (J.G.)
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Ardern-Holmes S, White C, Bahure S, So S, McCowage G, Hovey E, Troon S, De Souza P, Simes J, Slancar M, Dexter M, Wong M. The Effect of Bevacizumab on Vestibular Schwannoma Related to Neurofibromatosis Type 2. AUSTRALASIAN JOURNAL OF NEUROSCIENCE 2021. [DOI: 10.21307/ajon-2021-002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Surgical Outcome of Trigeminal Schwannomas. Cancers (Basel) 2021; 13:cancers13061310. [PMID: 33804067 PMCID: PMC8002014 DOI: 10.3390/cancers13061310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 01/10/2023] Open
Abstract
Simple Summary Trigeminal schwannomas are the most common among non-vestibular schwannomas. Treatment of trigeminal schwannomas may be challenging due to critical anatomical relations and involvement of different aspects of the skull base. Advances in microsurgery have led to improved outcomes over the last decades, whereas in contrast, some advocate stereotactic radiotherapy as an effective therapy, controlling the tumor volume with few complications. In this manuscript, we present outcome and adverse events in a contemporary cohort of trigeminal schwannomas and discuss surgical advantages and disadvantages of different performed classic skull-base approaches. Abstract (1) Background: As resection of trigeminal schwannomas is challenging, due to anatomical involvement of the anterior, middle and posterior fossa, the appropriate approach is important. We report our experience with surgical resection of trigeminal schwannomas by simple and classic skull-base approaches. (2) Methods: We performed a retrospective single-center study including patients who underwent surgery for trigeminal schwannoma tumors between June 2007 and May 2020, concentrating on surgical technique, extent of resection, postoperative outcome and complications. (3) Results: We included 13 patients (median age 57.5 with range of 36-83 years, 53.8% (7/13) female. The most common preoperative clinical presentations were facial pain in six (46.2%), hypoacusis in four (30.8%), trigeminal nerve hypesthesia in 11 (V1 46.2% (6/13), V2 (61.5% (8/13), V3 46.2% (6/13)) and headache in three (23.1%) patients. In three cases, the tumor was resected in a two-stage technique. The intradural subtemporal approach was performed in six cases, the extradural technique in two cases, the retrosigmoid approach in five cases, a Kawase approach in two cases and the transnasal endoscopic approach in one case. The gross total resection rate was 76.9% (10/13) and the median follow-up time 24.0 (0–136) months. Three (23.1%) patients developed postoperative anesthesia in at least one branch of the trigeminal nerve. Trigeminal motor function was preserved in 11 (84.6%) patients. Ten of the 11 patients (76.9%) who reported decreased gustation, cerebellar ataxia, visual impairment, or headache improved postoperatively. Two (15.4%) patients exhibited minimal facial palsy (House and Brackmann II–III), which resolved during the follow-up. The total adverse event rate requiring surgical intervention during follow-up was 7.7%. Surgery-related mortality was 0%. (4) Conclusions: Trigeminal schwannomas are rare benign lesions with intra- and extracranial extension. Considering the low operative morbidity and satisfying functional outcome, gross total resection of trigeminal schwannomas is achievable by classic, but also individually tailored approaches. More invasive or combined techniques were not needed with meticulous surgical planning.
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Long-Term Outcomes of Stereotactic Radiosurgery for Trigeminal, Facial, and Jugular Foramen Schwannoma in Comparison with Vestibular Schwannoma. Cancers (Basel) 2021; 13:cancers13051140. [PMID: 33799972 PMCID: PMC7961475 DOI: 10.3390/cancers13051140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/27/2021] [Accepted: 03/05/2021] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Intracranial schwannomas are benign intracranial neoplasms. Vestibular schwannomas (VS) account for 90% of intracranial schwannomas; whereas the other cranial nerve schwannomas, such as trigeminal (TS), facial (FS), and jugular foramen schwannoma (JFS), account for 10% of all cases. Stereotactic radiosurgery (SRS) is a minimally invasive treatment for small to medium VS and known to provide excellent long-term tumor control; however, there remains a paucity of evidence regarding SRS for TS, FS, and JFS due to the rarity of these tumors. We investigated the radiosurgical outcomes of these non-vestibular schwannomas and compared them to those of VS through matched cohort analysis. Abstract Stereotactic radiosurgery (SRS) is known to provide excellent tumor control with functional preservation for vestibular schwannomas (VS), but its efficacy in the other major intracranial schwannomas including trigeminal (TS), facial (FS), and jugular foramen schwannomas (JFS) has not been established yet due to their rarity. We retrospectively analyzed data of 514 consecutive patients who had intracranial schwannomas (460 VS, 22 TS, 7 FS, and 25 JFS) and underwent SRS. The 5- and 10-year tumor control rates were 97% and 94% for VS, 100% and 100% for TS, 80% and 80% for FS, and 100% and 80% for JFS. Radiation-induced complications included one hydrocephalus for TS (4.5%), no cases for FS (0%), and one hydrocephalus and one lower palsy for JFS (8.0%). Through matched cohort analysis between patients with VS and each of the non-VS, we found no statistical difference in tumor control and radiation-induced adverse events. SRS seems to provide long-term tumor control with functional preservation for TS, FS and JFS and the efficacies are similar to VS.
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Fujii M, Kobayakawa M, Saito K, Inano A, Morita A, Hasegawa M, Mukasa A, Mitsuhara T, Goto T, Yamaguchi S, Tamiya T, Nakatomi H, Oya S, Takahashi F, Sato T, Bakhit M. Rationale and Design of BeatNF2 Trial: A Clinical Trial to Assess the Efficacy and Safety of Bevacizumab in Patients with Neurofibromatosis Type 2 Related Vestibular Schwannoma. ACTA ACUST UNITED AC 2021; 28:726-739. [PMID: 33572546 PMCID: PMC7985777 DOI: 10.3390/curroncol28010071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 11/16/2022]
Abstract
Simple Summary Neurofibromatosis type 2 (NF2) is a rare genetic hereditary disease characterized by multiple central nervous system tumors, most frequently bilateral vestibular schwannomas (VSs). No chemotherapeutic agents are available for clinical use, and surgery and radiotherapy are the only therapeutic options available now. Still, neither treatment option alleviates hearing loss in patients with NF2 and VS; they may even exacerbate it. However, bevacizumab has been reported to be effective in suppressing the tumor’s growth and has shown unprecedented efficacy in improving hearing. We describe a new ongoing and novel clinical trial, BeatNF2, a randomized, double-blinded, placebo-controlled, multicenter trial to assess bevacizumab’s efficacy and safety in patients with NF2. The study’s primary endpoint is improved hearing function 24 weeks after the beginning of the treatment protocol. Abstract Neurofibromatosis type 2 (NF2) causes bilateral vestibular schwannomas (VSs), leading to deafness. VS is treated by surgery or radiation, but neither treatments prevent hearing loss. Bevacizumab was found to be effective in suppressing the tumor’s growth and may help to improve hearing. We are conducting a randomized, double-blind, multicenter clinical trial to verify the efficacy and safety of bevacizumab in NF2-related VS. The primary objective is to evaluate the efficacy of bevacizumab in improving hearing in the affected ear. One of the secondary objectives is to evaluate bevacizumab’s efficacy in rechallenge treatment in relapsed cases. Sixty patients will randomly receive either bevacizumab or a placebo and will be clinically observed for 48 weeks in the initial intervention phase. In the first half (24 weeks), they will receive either 5 mg/kg of bevacizumab or a placebo drug. In the second half, all patients will receive 5 mg/kg of bevacizumab. If hearing function deteriorated in a patient who had shown improvement during the first phase, a rechallenge dose with bevacizumab would be offered.
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Affiliation(s)
- Masazumi Fujii
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
- Correspondence: ; Tel.: +81-24-547-1268
| | - Masao Kobayakawa
- Medical Research Center, Fukushima Medical University, Fukushima 960-1247, Japan; (M.K.); (A.I.)
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
| | - Akihiro Inano
- Medical Research Center, Fukushima Medical University, Fukushima 960-1247, Japan; (M.K.); (A.I.)
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Bunkyo-Ku, Tokyo 113-8602, Japan;
| | - Mitsuhiro Hasegawa
- Department of Neurosurgery, Fujita Health University, Toyoake 470-1192, Japan;
| | - Akitake Mukasa
- Department of Neurosurgery, Kumamoto University, Kumamoto 860-8555, Japan;
| | - Takafumi Mitsuhara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 739-8511, Japan;
| | - Takeo Goto
- Department of Neurosurgery, Osaka City University, Osaka 558-8585, Japan;
| | - Shigeru Yamaguchi
- Department of Neurosurgery, Hokkaido University, Sapporo 060-0808, Japan;
| | - Takashi Tamiya
- Department of Neurosurgery, Kagawa University, Takamatsu 760-0016, Japan;
| | - Hirofumi Nakatomi
- Department of Neurosurgery, University of Tokyo, Bunkyo-Ku, Tokyo 113-8654, Japan;
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Kawagoe 350-8550, Japan;
| | - Fumiaki Takahashi
- Center for Liberal Arts and Sciences, Iwate Medical University, Morioka 020-0023, Japan;
| | - Taku Sato
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
| | - Mudathir Bakhit
- Department of Neurosurgery, Fukushima Medical University, Fukushima 960-1247, Japan; (K.S.); (T.S.); (M.B.)
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Farschtschi S, Mautner VF, McLean ACL, Schulz A, Friedrich RE, Rosahl SK. The Neurofibromatoses. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:354-360. [PMID: 32657748 DOI: 10.3238/arztebl.2020.0354] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 04/18/2019] [Accepted: 03/20/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Neurofibromatosis of types 1 and 2 (NF1, NF2) and schwannomatosis are the diseases that make up the neurofibromatosis spectrum. With respective incidences of 1 in 3000, 1 in 33 000, and 1 in 60 000 births, they form part of the group of rare tumor-suppressor syndromes. They give rise to a greater tumor burden for the nervous system than any other type of neoplastic disease. New approaches to symptomatic treatment are emerging. METHODS This review is based on articles retrieved by a selective literature search on the pathogenesis, diagnosis, and treatment of the neurofibromatoses. RESULTS NF1 and NF2 are monogenic diseases, while the genetics of schwannomatosis is complex. The three entities are clinically and pathophysiologically distinct. An important aspect of their tumor biology is the alternation of growth phases and growth pauses. Correlations between genotypes and phenotypes are variable, while new mutations and genetic mosaics are common. Ninety-nine percent of patients with NF1 have six or more café-au-lait spots by the age of 12 months; 90-95% of patients with NF2 develop bilateral vestibular schwannomas. In schwannomatosis, pain is the most prominent symptom; two-thirds of those affected develop spinal schwannomas. The severity and prognosis of these disorders are not closely correlated with the radiological findings; rather, neurologic deficits, malignant transformation, and psychosocial stress are of greater clinical importance. Advances in knowledge of pathophysiology have led to the development of targeted treatment approaches. Examples include the off-label treatment of vestibular schwannomas with bevacizumab and of plexiform neurofibromas with MEK inhibitors. CONCLUSION Patients with neurofibromatoses need individualized care. They should be treated in centers of expertise where interdisciplinary consultation is available and new types of pharmacotherapy can be provided.
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Affiliation(s)
- Said Farschtschi
- International Center for Neurofibromatoses (ICNF), Department of Neurology, University MedicalCenter Hamburg-Eppendorf
| | - Victor-Felix Mautner
- International Center for Neurofibromatoses (ICNF), Department of Neurology, University MedicalCenter Hamburg-Eppendorf
| | | | | | - Reinhard E Friedrich
- Department of Oromaxillofacial Surgery, University Medical Center Hamburg-Eppendorf
| | - Steffen K Rosahl
- Neurofibromatosis Center, Department of Neurosurgery, Helios Hospital Erfurt
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Yao L, Alahmari M, Temel Y, Hovinga K. Therapy of Sporadic and NF2-Related Vestibular Schwannoma. Cancers (Basel) 2020; 12:cancers12040835. [PMID: 32244314 PMCID: PMC7226024 DOI: 10.3390/cancers12040835] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022] Open
Abstract
Vestibular schwannoma (VS) is a benign primary brain tumor that occurs sporadic or as part of a genetic syndrome. The most common cause is the mutation of the NF2 tumor suppressor gene that is involved in the production of the protein merlin. Merlin plays a role in cell growth and cell adhesion. In patients with NF2, the VSs arise bilaterally and coincide with other brain tumors. In sporadic VS, the tumor is typically unilateral and does not coincide in combination with other tumors. MRI is the standard imaging technique and can be used to assess the size and aspect of the tumor as well as the progression of disease. The preferred management of large VS in both VS types is surgery with or without adjuvant radiation. The management for the medium- or small-sized VS includes wait and scan, radiotherapy and/or surgery. This choice depends on the preference of the patient and institutional protocols. The outcomes of surgical and radiotherapy treatments are improving due to progress in surgical equipment/approaches, advances in radiation delivery techniques and dose optimizations protocols. The main purpose of the management of VS is preserving function as long as possible in combination with tumor control.
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Affiliation(s)
- Longping Yao
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
| | - Mohammed Alahmari
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
- Department of Radiology, King Fahad Hospital of Imam Abdulrahman Bin Faisal University, P.O. Box 40046, 31952 AL-Khobar, Saudi Arabia
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
| | - Koos Hovinga
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
- Correspondence: ; Tel.: +31-43-387-50-01
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Long-Term Outcomes of Stereotactic Radiosurgery for Vestibular Schwannoma Associated with Neurofibromatosis Type 2 in Comparison to Sporadic Schwannoma. Cancers (Basel) 2019; 11:cancers11101498. [PMID: 31591325 PMCID: PMC6827030 DOI: 10.3390/cancers11101498] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 11/17/2022] Open
Abstract
The efficacy of radiosurgery for neurofibromatosis type 2 (NF2)-associated vestibular schwannoma (VS) remains debatable. We retrospectively analyzed radiosurgical outcomes for NF2-associated VS compared to sporadic VS using our database of 422 consecutive VS patients. Twenty-five patients with 30 NF2-associated VSs with a mean follow-up of 121 months were identified. NF2-associated VSs exhibited excellent tumor control (10-year cumulative rate, 92% vs. 92% in sporadic VSs; p = 0.945) and worse overall survival (73% vs. 97%; p = 0.005), mainly due to tumor progression other than the treated VSs. The presence of NF2 was not associated with failed tumor control via multivariate Cox proportional hazard analyses. No difference in radiation-induced adverse events (RAEs) was confirmed between cohorts, and prescription dose (hazard ratio 8.30, 95% confidence interval 3.19-21.62, p < 0.001) was confirmed as a risk for cranial nerve injuries via multivariate analysis. Further analysis after propensity score matching using age, volume, and sex as covariates showed that NF2-associated VSs exhibited excellent local control (100% vs. 93%; p = 0.240) and worse overall survival (67% vs. 100%; p = 0.002) with no significant difference in RAEs. Excellent long-term tumor control and minimal invasiveness may make radiosurgery a favorable therapeutic option for NF2 patients with small to medium VS, preferably with non-functional hearing or deafness in combination with postoperative tumor growth or progressive non-operated tumors, or with functional hearing by patients' wish.
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Abstract
OBJECTIVE To review the demographics, treatment modalities, and survival of children with vestibular schwannomas. STUDY DESIGN Analysis using the Surveillance, Epidemiology, and End Results (SEER) database. SUBJECTS AND METHODS Pediatric patients from birth to 18 years in the SEER database were included from 2004 to 2014 based on a diagnosis of vestibular schwannoma using the primary site International Classification of Diseases (ICD) O-3 code of C72.4: acoustic nerve and the ICD O-3 histology codes of 9540/1: neurofibromatosis, Not Otherwise Specified (NOS); 9560/0: neurilemoma, NOS; or 9570/0: neuroma, NOS. RESULTS One hundred forty-eight pediatric vestibular schwannomas (VSs) cases were identified. The mean age at diagnosis was 13.9 years (range, 4.0-18.0). Eighty-five (57.4%) patients were women. Seventy-seven (52.0%) patients had isolated unilateral VSs while 71 (48.0%) patients had either bilateral VSs or unilateral VSs with other brain, spinal cord, or cranial nerve tumors. Eighty two (55.4%) patients received surgical resection only, 45 (30.4%) received no treatment, 6 (4.1%) received radiation only, and 12 (8.1%) received surgery and radiation. The median tumor size for patients who received no treatment was 9.5 mm (interquartile range [IQR]: 8.0) compared with 33.5 mm (IQR: 23.0) for patients who received surgical care and 41.0 mm (IQR: 1.5) for patients who received both surgery and radiation (p < 0.001). The 5-year overall survival rate was 97%. CONCLUSION Pediatric VSs tend to be diagnosed in adolescence. No men or women predominance was appreciated. Treatment varied according to tumor size. Survival rates for children with vestibular schwannomas are excellent. These data may assist healthcare providers when counseling children with vestibular schwannomas and their families.
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Przybylowski CJ, Baranoski JF, Paisan GM, Chapple KM, Meeusen AJ, Sorensen S, Almefty KK, Porter RW. CyberKnife radiosurgery for acoustic neuromas: Tumor control and clinical outcomes. J Clin Neurosci 2019; 63:72-76. [DOI: 10.1016/j.jocn.2019.01.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
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Peyre M, Bernardeschi D, Sterkers O, Kalamarides M. Natural history of vestibular schwannomas and hearing loss in NF2 patients. Neurochirurgie 2018; 64:342-347. [DOI: 10.1016/j.neuchi.2015.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/22/2015] [Accepted: 03/29/2015] [Indexed: 10/23/2022]
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Long-term results of Gamma-knife stereotactic radiosurgery for vestibular schwannomas in patients with type 2 neurofibromatosis. Neurochirurgie 2018; 64:355-363. [DOI: 10.1016/j.neuchi.2016.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 03/17/2016] [Accepted: 03/31/2016] [Indexed: 11/19/2022]
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Bilateral Spontaneous Regression of Vestibular Schwannoma in Neurofibromatosis Type 2. World Neurosurg 2018; 113:195-197. [PMID: 29477000 DOI: 10.1016/j.wneu.2018.02.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/10/2018] [Accepted: 02/12/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with neurofibromatosis type 2 and bilateral vestibular schwannoma (VS) are frequently treated surgically for any tumor progression, and often repeated surgery or radiation treatment is even considered. Some VS progression occurs without the development of new clinical symptoms, or it does not progress in size over many years, even in the absence of any specific treatment. CASE DESCRIPTION A 61-year-old male patient with neurofibromatosis type 2 presented with bilateral VS. In a long-term follow-up, both had increased in size but also showed bilateral spontaneous regression during an 11-year follow-up period with a "watch-and-wait" strategy. CONCLUSIONS We emphasize conservative treatment ("watch and wait") in older patients even with long-term tumor progression without significant compression-related clinical symptoms.
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Wagner J, Welzel T, Habermehl D, Debus J, Combs SE. Radiotherapy in Patients with Vestibular Schwannoma and Neurofibromatosis Type 2: Clinical Results and Review of the Literature. TUMORI JOURNAL 2018; 100:189-94. [DOI: 10.1177/030089161410000212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and Background To evaluate the long-term outcome of patients with vestibular schwannoma (VS) and neurofibromatosis type 2 (NF2) treated with fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS). Patients and Methods Sixteen VS in 14 patients with NF2 were treated with FSRT (n = 14) and SRS (n = 2). Patients with tumor progression and/or progression of clinical symptoms were selected for treatment. For patients treated with FSRT a median total dose of 57.6 Gy was prescribed with a median fractionation of 5 × 1.8 Gy per week. For patients who underwent SRS a median single dose of 17 Gy was prescribed to the 80% isodose. Results FSRT and SRS were well tolerated. Local control rate was 94% for a median follow-up time of 131 months; 2- and 5-year progression-free survival were 100%. The probability of maintaining the pretreatment hearing level was 44%. Useful hearing preservation was 33%. Cranial nerve toxicity was moderate. Trigeminal nerve function worsened in 2 patients (12%) and facial nerve function in 3 patients (19%). One patient developed a new tinnitus. Conclusion FSRT and SRS are both safe and effective noninvasive and minimally invasive treatment options for patients with VS in the setting of NF2. The long-term local control rates are excellent. Functional hearing preservation is worse in patients with VS and NF2 than in patients with sporadic VS.
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Affiliation(s)
- Johanna Wagner
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg
| | - Daniel Habermehl
- Department of Radiation Oncology, Technical University Hospital of Munich, Munich, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University Hospital of Munich, Munich, Germany
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Nguyen T, Duong C, Sheppard JP, Lee SJ, Kishan AU, Lee P, Tenn S, Chin R, Kaprealian TB, Yang I. Hypo-fractionated stereotactic radiotherapy of five fractions with linear accelerator for vestibular schwannomas: A systematic review and meta-analysis. Clin Neurol Neurosurg 2018; 166:116-123. [PMID: 29414150 DOI: 10.1016/j.clineuro.2018.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/31/2017] [Accepted: 01/07/2018] [Indexed: 10/18/2022]
Abstract
Vestibular schwannomas (VS) are benign tumors stemming from the eighth cranial nerve. Treatment options for VS include conservative management, microsurgery, stereotactic radiosurgery, and fractionated radiotherapy. Though microsurgery has been the standard of care for larger lesions, hypo-fractionated stereotactic radiotherapy (hypo-FSRT) is an emerging modality. However, its clinical efficacy and safety have yet to be established. We conducted a systematic review and meta-analysis of manuscripts indexed in PubMed, Scopus, Web of Science, Embase, and Cochrane databases reporting outcomes of VS cases treated with hypo-FSRT. Five studies representing a total of 228 patients were identified. Across studies, the pooled rates of tumor control, hearing, facial nerve, and trigeminal nerve preservation were 95%, 37%, 97%, and 98%. No instances of malignant induction were observed at median follow-up of 34.8 months. Complications included trigeminal neuropathy (n = 3), maxillary paresthesia (n = 1), neuralgia (n = 1), vestibular dysfunction (n = 1), radionecrosis (n = 1), and hydrocephalus (n = 1). Hypo-FSRT may be another useful approach to manage VS, but studies with extended follow-up times are required to establish long-term safety.
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Affiliation(s)
- Thien Nguyen
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Courtney Duong
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States
| | - John P Sheppard
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Seung Jin Lee
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Amar U Kishan
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Percy Lee
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Stephen Tenn
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Robert Chin
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Tania B Kaprealian
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Isaac Yang
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Head and Neck Surgery, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States; Los Angeles Biomedical Research Institute, Los Angeles (UCLA), Los Angeles, CA, United States; Harbor-UCLA Medical Center, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States.
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Rosahl S, Bohr C, Lell M, Hamm K, Iro H. Diagnostics and therapy of vestibular schwannomas - an interdisciplinary challenge. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2017; 16:Doc03. [PMID: 29279723 PMCID: PMC5738934 DOI: 10.3205/cto000142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vestibular schwannomas (VS) expand slowly in the internal auditory canal, in the cerebellopontine angle, inside the cochlear and the labyrinth. Larger tumors can displace and compress the brainstem. With an annual incidence of 1:100,000 vestibular schwannoma represent 6-7% of all intracranial tumors. In the cerebellopontine angle they are by far the most neoplasm with 90% of all lesions located in this region. Magnetic resonance imaging (MRI), audiometry, and vestibular diagnostics are the mainstays of the clinical workup for patients harboring tumors. The first part of this paper delivers an overview of tumor stages, the most common grading scales for facial nerve function and hearing as well as a short introduction to the examination of vestibular function. Upholding or improving quality of life is the central concern in counseling and treating a patient with vestibular schwannoma. Preservation of neuronal function is essential and the management options - watchful waiting, microsurgery and stereotactic radiation - should be custom-tailored to the individual situation of the patient. Continuing interdisciplinary exchange is important to monitor treatment quality and to improve treatment results. Recently, several articles and reviews have been published on the topic of vestibular schwannoma. On the occasion of the 88th annual meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck surgery a special volume of the journal "HNO" will be printed. Hence this presentation has been designed to deviate from the traditional standard which commonly consists of a pure literature review. The current paper was conceptually woven around a series of interdisciplinary cases that outline examples for every stage of the disease that show characteristic results for management options to date. Systematic clinical decision pathways have been deduced from our experience and from results reported in the literature. These pathways are graphically outlined after the case presentations. Important criteria for decision making are size and growth rate of the tumor, hearing of the patient and the probability of total tumor resection with preservation of hearing and facial nerve function, age and comorbidity of the patient, best possible control of vertigo and tinnitus and last but not least the patient's preference and choice. In addition to this, the experience and the results of a given center with each treatment modality will figure in the decision making process. We will discuss findings that are reported in the literature regarding facial nerve function, hearing, vertigo, tinnitus, and headache and reflect on recent studies on their influence on the patient's quality of life. Vertigo plays an essential role in this framework since it is an independent predictor of quality of life and a patient's dependence on social welfare. Pathognomonic bilateral vestibular schwannomas that occur in patients suffering from neurofibromatosis typ-2 (NF2) differ from spontaneous unilateral tumors in their biologic behavior. Treatment of neurofibromatosis type-2 patients requires a multidisciplinary team, especially because of the multitude of separate intracranial and spinal lesions. Off-label chemotherapy with Bevacizumab can stabilize tumor size of vestibular schwannomas and even improve hearing over longer periods of time. Hearing rehabilitation in NF2 patients can be achieved with cochlear and auditory brainstem implants.
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Affiliation(s)
- Steffen Rosahl
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
| | - Christopher Bohr
- Department of Otolaryngology, University Hospital of Erlangen, Germany
| | - Michael Lell
- Institute for Radiology and Nuclear Medicine, Hospital of Nuremberg, Germany
| | - Klaus Hamm
- Cyberknife Center of Central Germany, Erfurt, Germany
| | - Heinrich Iro
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
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Chung LK, Nguyen TP, Sheppard JP, Lagman C, Tenn S, Lee P, Kaprealian T, Chin R, Gopen Q, Yang I. A Systematic Review of Radiosurgery Versus Surgery for Neurofibromatosis Type 2 Vestibular Schwannomas. World Neurosurg 2017; 109:47-58. [PMID: 28882713 DOI: 10.1016/j.wneu.2017.08.159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Neurofibromatosis type 2 (NF2) is an autosomal dominant disease characterized by bilateral vestibular schwannomas (VSs). NF2-associated VSs (NF2-VSs) are routinely treated with microsurgery; however, stereotactic radiosurgery (SRS) has emerged as an effective alternative in recent decades. To elucidate the role of SRS in NF2-VSs, a systematic review of the literature was conducted to compare outcomes of SRS versus surgery. METHODS PubMed, Web of Science, Scopus, Embase, and Cochrane databases were queried using relevant search terms. Retrospective studies investigating outcomes of NF2-VS patients treated with either SRS or surgery were included. Single-patient case reports were excluded. Outcome measures between the SRS and surgery groups were compared using χ2 2-sample tests for equality of proportions on the pooled patient data. RESULTS A total of 974 patients (485 SRS, 489 surgery) were identified. The mean 5-year local control rate for SRS was 75.1%, and the mean recurrence rate for surgery was 8.1%. The mean hearing and facial nerve preservation rates were 40.1% and 92.3%, respectively, for SRS and 52.0% and 75.7%, respectively, for surgery. Rates of hearing preservation were higher after surgery than after SRS (P = 0.006), whereas rates of facial nerve preservation were higher after SRS than after surgery (P < 0.001). CONCLUSIONS SRS appears to be a safe and effective alternative to surgery for NF2-VS. Although rates of hearing preservation were higher in the surgery cohorts, SRS demonstrated high rates of local control and significantly lower facial nerve complications. Certain patients may therefore benefit more from SRS than surgery.
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Affiliation(s)
- Lawrance K Chung
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Thien P Nguyen
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - John P Sheppard
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Carlito Lagman
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Stephen Tenn
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA
| | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California, USA
| | - Tania Kaprealian
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California, USA
| | - Robert Chin
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA
| | - Quinton Gopen
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA; Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California, USA.
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25
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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.
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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.
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26
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The efficacy of lapatinib and nilotinib in combination with radiation therapy in a model of NF2 associated peripheral schwannoma. J Neurooncol 2017; 135:47-56. [PMID: 28735458 DOI: 10.1007/s11060-017-2567-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
Abstract
Neurofibromatosis type 2 (NF2), a neurogenetic condition manifest by peripheral nerve sheath tumors (PNST) throughout the neuroaxis for which there are no approved therapies. In vitro and in vivo studies presented here examine agents targeting signaling pathways, angiogenesis, and DNA repair mechanisms. In vitro dose response assays demonstrated potent activity of lapatinib and nilotinib against the mouse schwannoma SC4 (Nf2 -/-) cell line. We then examined the efficacy of everolimus, nilotinib, lapatinib, bevacizumab and radiation (RT) as mono- and combination therapies in flank and sciatic nerve in vivo NF2-PNST models. Data were analyzed using generalized linear models, two sample T-tests and paired T-tests, and linear regression models. SC4(Nf2 -/-) cells implanted in the flank or sciatic nerve showed similar rates of growth (p = 0.9748). Lapatinib, nilotinib and RT significantly reduced tumor growth rate versus controls in the in vivo flank model (p = 0.0025, 0.0062, and 0.009, respectively) whereas bevacizumab and everolimus did not. The best performers were tested in the in vivo sciatic nerve model of NF2 associated PNST, where chemoradiation outperformed nilotinib or lapatinib as single agents (nilotinib vs. nilotinib + RT, p = 0.0001; lapatinib versus lapatinib + RT, p < 0.0001) with no observed toxicity. There was no re-growth of tumors even 14 days after treatment was stopped. The combination of either lapatinib or nilotinib with RT resulted in greater delays in tumor growth rate than any modality alone. This data suggest that concurrent low dose RT and targeted therapy may have a role in addressing progressive PNST in patients with NF2.
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Abstract
Neurofibromatosis (NF) encompasses a group of distinct genetic disorders in which affected children and adults are prone to the development of benign and malignant tumors of the nervous system. The purpose of this review is to discuss the spectrum of CNS tumors arising in individuals with NF type 1 (NF1) and NF type 2 (NF2), their pathogenic etiologies, and the rational treatment options for people with these neoplasms. This article is a review of preclinical and clinical data focused on the treatment of the most common CNS tumors encountered in children and adults with NF1 and NF2. Although children with NF1 are at risk for developing low-grade gliomas of the optic pathway and brainstem, individuals with NF2 typically manifest low-grade tumors affecting the cranial nerves (vestibular schwannomas), meninges (meningiomas), and spinal cord (ependymomas). With the identification of the NF1 and NF2 genes, molecularly targeted therapies are beginning to emerge, as a result of a deeper understanding of the mechanisms underlying NF1 and NF2 protein function. As we enter into an era of precision oncology, a more comprehensive awareness of the factors that increase the risk of developing CNS cancers in affected individuals, coupled with a greater appreciation of the cellular and molecular determinants that maintain tumor growth, will undoubtedly yield more effective therapies for these cancer predisposition syndromes.
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Affiliation(s)
- Jian Campian
- All authors: Washington University School of Medicine, St. Louis, MO
| | - David H Gutmann
- All authors: Washington University School of Medicine, St. Louis, MO
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28
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Lloyd SKW, King AT, Rutherford SA, Hammerbeck-Ward CL, Freeman SRM, Mawman DJ, O'Driscoll M, Evans DG. Hearing optimisation in neurofibromatosis type 2: A systematic review. Clin Otolaryngol 2017; 42:1329-1337. [PMID: 28371358 DOI: 10.1111/coa.12882] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is common for patients with neurofibromatosis type 2 to develop bilateral profound hearing loss hearing loss, and this is one of the main determinants of quality of life in this patient group. OBJECTIVES The aim of this systematic review was to review the current literature regarding hearing outcomes of treatments for vestibular schwannomas in neurofibromatosis type 2 including conservative and medical management, radiotherapy, hearing preservation surgery and auditory implantation in order to determine the most effective way of preserving or rehabilitating hearing. SEARCH STRATEGY A MESH search in PubMed using search terms (('Neurofibromatosis 2' [Mesh]) AND 'Neuroma, Acoustic'[Mesh]) AND 'Hearing Loss' [Mesh] was performed. A search using keywords was also performed. Studies with adequate hearing outcome data were included. With the exception of the cochlear implant studies (cohort size was very small), case studies were excluded. EVALUATION METHOD The GRADE system was used to assess quality of publication. Formal statistical analysis of data was not performed because of very heterogenous data reporting. RESULTS Conservative management offers the best chance of hearing preservation in stable tumours. The use of bevacizumab probably improves the likelihood of hearing preservation in growing tumours in the short term and is probably more effective than hearing preservation surgery and radiotherapy in preserving hearing. Of the hearing preservation interventions, hearing preservation surgery probably offers better hearing preservation rates than radiotherapy for small tumours but recurrence rates for hearing preservation surgery were high. For patients with profound hearing loss, cochlear implantation provides significantly better auditory outcomes than auditory brainstem implantation. Patients with untreated stable tumours are likely to achieve the best outcomes from cochlear implantation. Those who have had their tumours treated with surgery or radiotherapy do not gain as much benefit from cochlear implantation than those with untreated tumours. CONCLUSIONS This review summarises the current literature related to hearing preservation/rehabilitation in patients with NF2. Whilst it provides indicative data, the quality of the data was low and should be interpreted with care. It is also important to consider that the management of vestibular schwannomas in NF2 is complex and decision-making is determined by many factors, not just the need to preserve hearing.
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Affiliation(s)
- S K W Lloyd
- Department of Otolaryngology, Salford Royal Hospital NHS Foundation Trust, Manchester, UK.,Department of Otolaryngology, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,School of Medical Sciences, University of Manchester, Manchester, UK
| | - A T King
- Department of Neurosurgery, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - S A Rutherford
- Department of Neurosurgery, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - C L Hammerbeck-Ward
- Department of Neurosurgery, Salford Royal Hospital NHS Foundation Trust, Manchester, UK
| | - S R M Freeman
- Department of Otolaryngology, Salford Royal Hospital NHS Foundation Trust, Manchester, UK.,Department of Otolaryngology, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - D J Mawman
- Richard Ramsden Auditory Implant Centre, Central Manchester NHS Foundation Trust, Manchester, UK
| | - M O'Driscoll
- Richard Ramsden Auditory Implant Centre, Central Manchester NHS Foundation Trust, Manchester, UK
| | - D G Evans
- Department of Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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29
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Kruyt IJ, Verheul JB, Hanssens PEJ, Kunst HPM. Gamma Knife radiosurgery for treatment of growing vestibular schwannomas in patients with neurofibromatosis Type 2: a matched cohort study with sporadic vestibular schwannomas. J Neurosurg 2017; 128:49-59. [PMID: 28128697 DOI: 10.3171/2016.9.jns161463] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Neurofibromatosis Type 2 (NF2) is a tumor syndrome characterized by an autosomal dominant pattern of inheritance. The hallmark of NF2 is the development of bilateral vestibular schwannomas (VSs), generally by 30 years of age. One of the first-line treatment options for small to medium-large VSs is radiosurgery. Although radiosurgery shows excellent results in sporadic VS, its use in NF2-related VS is still a topic of dispute. The aim of this study was to evaluate long-term tumor control, hearing preservation rates, and factors influencing outcome of optimally dosed, contemporary Gamma Knife radiosurgery (GKRS) for growing VSs in patients with NF2 and compare the findings to data obtained in patients with sporadic VS also treated by means of GKRS. METHODS The authors performed a retrospective analysis of 47 growing VSs in 34 NF2 patients who underwent GKRS treatment performed with either the Model C or Perfexion Leksell Gamma Knife, with a median margin dose of 11 Gy. Actuarial tumor control rates were estimated using the Kaplan-Meier method. For patient- and treatment-related factors, a Cox proportional hazards model was used to identify predictors of outcome. Trigeminal, facial, and vestibulocochlear nerve function were assessed before and after treatment. NF2-related VS patients were matched 1:1 with sporadic VS patients who were treated in the same institute, and the same indications for treatment, definitions, and dosimetry were used in order to compare outcomes. RESULTS Actuarial tumor control rates in NF2 patients after 1, 3, 5, and 8 years were 98%, 89%, 87%, and 87%, respectively. Phenotype and tumor volume had significant hazard rates of 0.086 and 22.99, respectively, showing that Feiling-Gardner phenotype and a tumor volume not exceeding 6 cm3 both were associated with significantly better outcome. Actuarial rates of serviceable hearing preservation after 1, 3, 5, and 7 years were 95%, 82%, 59%, and 33%, respectively. None of the patients experienced worsening of trigeminal nerve function. Facial nerve function worsened in 1 patient (2.5%). No significant differences in tumor control, hearing preservation, or complications were found in comparing the results of GKRS for NF2-related VS versus GKRS for sporadic VS. CONCLUSIONS With modern GKRS, the use of low margin doses for treating growing VSs in patients with NF2 demonstrates good long-term tumor control rates. Feiling-Gardner phenotype and tumor volume smaller than 6 cm3 seem to be independently associated with prolonged progression-free survival, highlighting the clinical importance of phenotype assessment before GKRS treatment. In addition, no significant differences in tumor control rates or complications were found in the matched-control cohort analysis comparing GKRS for VS in patients with NF2 and GKRS for sporadic VS. These results show that GKRS is a valid treatment option for NF2-related VS, in addition to being a good option for sporadic VS, particularly in patients with the Feiling-Gardner phenotype and/or tumors that are small to medium in size. Larger tumors in patients with the Wishart phenotype appear to respond poorly to radiosurgery, and other treatment modalities should therefore be considered in such cases.
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Affiliation(s)
- Ivo J Kruyt
- 1Department of ENT, Donders Center for Neurosciences, Radboudumc, Nijmegen; and
| | - Jeroen B Verheul
- 2Gamma Knife Center Tilburg, St. Elisabeth Hospital, Tilburg, The Netherlands
| | | | - Henricus P M Kunst
- 1Department of ENT, Donders Center for Neurosciences, Radboudumc, Nijmegen; and
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30
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Bernardeschi D, Peyre M, Collin M, Smail M, Sterkers O, Kalamarides M. Internal Auditory Canal Decompression for Hearing Maintenance in Neurofibromatosis Type 2 Patients. Neurosurgery 2015; 79:370-7. [DOI: 10.1227/neu.0000000000001125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
In neurofibromatosis type 2 (NF2), multiple therapeutic options are available to prevent bilateral hearing loss that significantly affects the quality of life of patients.
OBJECTIVE:
To evaluate the morbidity and functional results of internal auditory canal (IAC) decompression in NF2 patients with an only hearing ear.
METHODS:
Twenty-one NF2 patients operated on for IAC decompression in a 3-year period with a minimum follow-up of 1 year were included in this retrospective study. They presented unilateral deafness due to previous contralateral vestibular schwannoma removal in 16 patients or contralateral hearing loss due to the tumor in 5 patients. Hearing level was of class A (American Academy of Otolaryngology-Head and Neck Surgery classification) in 7 patients, B in 8 patients, C in 1 patient, and D in 5 patients. Pure-tone average and speech discrimination score evaluations were performed at 6 days, 1 year, and during the follow-up. Eight patients had postoperative chemotherapy.
RESULTS:
No case of facial nerve palsy was observed. In the early postoperative period; all patients maintained the hearing class of the preoperative period. At 1-year follow-up, all but 3 patients maintained their hearing scores; at last follow-up (mean follow-up, 23 + 8 months; range, 12-44 months), hearing classes remained stable with only 1 patient worsening from class B to C and 1 patient improving from class D to B.
CONCLUSION:
Decompression of IAC seems to be a useful procedure for hearing maintenance in NF2 patients, with very low morbidity. Ideal timing and association with chemotherapy should be evaluated in the future.
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Affiliation(s)
- Daniele Bernardeschi
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- INSERM UMR-S 1159, Réhabilitation Chirurgicale Mini-invasive et Robotisée de l'audition, Paris, France
| | - Matthieu Peyre
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Neurosurgery Department, Paris, France
| | - Michael Collin
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
| | - Mustapha Smail
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
| | - Olivier Sterkers
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- INSERM UMR-S 1159, Réhabilitation Chirurgicale Mini-invasive et Robotisée de l'audition, Paris, France
| | - Michel Kalamarides
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Neurosurgery Department, Paris, France
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31
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Li H, Hao SY, Wang L, Li D, Wu Z, Zhang LW, Zhang JT. Factors influencing the growth rate of vestibular schwannoma in patients with neurofibromatosis type 2. Acta Neurochir (Wien) 2015; 157:1983-90. [PMID: 26287269 DOI: 10.1007/s00701-015-2542-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neurofibromatosis type 2 (NF2) is a devastating disease with no well-accepted management guidelines. Better understanding of the disease process provides the basis for how or when to initiate treatment. Only few studies have addressed the factors influencing the growth rate of NF2-related vestibular schwannomas (VSs), and these studies have reported variable results. This study aimed to assess the clinical factors influencing the growth rate of NF2-related VSs. METHODS The medical records of 66 patients (totalling 74 VSs) were retrospectively analysed. The tumours were measured according to a two-component box model. The tumour growth rate was estimated by linear regression analysis of the changes in VS volumes over time. The clinical characteristics of all the patients were recorded. The relationship between the tumour growth rate and clinical factors were analysed. Linear regression, Pearson's correlation and Student's t-test were conducted using the SPSS 19.0 statistical package. RESULTS The median follow-up duration was 4.9 years. The VSs growth rate was highly correlated with the initial VS volume (r = 0.97, p < 0.01). However, it was inversely correlated with the age at symptom onset (r = -0.41, p < 0.01). The average VS growth rate in patients with spinal tumours was 13.18 cm(3)/year compared with 0.19 cm(3)/year in patients without spinal tumours (p < 0.01). The VS growth rate in patients who had resection of a contralateral VS was slightly higher than that of patients with untreated VSs (p < 0.01). Other factors including sex, vestibular symptom, presence of other cranial schwannomas, family history and dermal abnormalities did not affect the VS growth rate. CONCLUSIONS The potential clinical factors influencing the VS growth rate are the age at symptom onset, initial tumour volume and presence of spinal tumours. Surgical resection of VSs might accelerate the growth rate of contralateral tumours. The effects of these factors require further experimental confirmation.
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Nowak A, Dziedzic T, Czernicki T, Kunert P, Morawski K, Niemczyk K, Marchel A. Strategy for the surgical treatment of vestibular schwannomas in patients with neurofibromatosis type 2. Neurol Neurochir Pol 2015; 49:295-301. [PMID: 26377980 DOI: 10.1016/j.pjnns.2015.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 06/20/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Guidelines for appropriate management of vestibular schwannomas in NF2 patients are controversial. In this paper we reviewed our experience with patients with NF2 for the results of surgical treatment with particular reference to hearing and facial nerve preservation. METHODS We included in the study 30 patients (16 women and 14 men) with the diagnosis of NF2 treated in our department between 1998 and 2014 who underwent surgery for vestibular schwannoma removal with a follow-up for at least 1 year. In 3 cases, the vestibular schwannomas were unilateral. Six patients with bilateral vestibular schwannomas underwent unilateral procedure. Therefore, 51 acoustic tumors were studied in 30 patients. RESULTS No operative death we noted. Significant deterioration to the non-functional level occurred in 19 out of 22 cases with well-preserved preoperative hearing. Only three ears maintained their preoperative good hearing. Hearing was preserved in cases of small schwannoma not exceeding 2 cm. Among 21 patients who underwent bilateral operations hearing was preserved in 3 out of 7 cases when smaller tumor or better hearing level side was attempted at first surgery. In contrary none of the 14 patients retained hearing when the first operation concerned the worse-hearing ear. Among 14 tumors up to 2 cm there was only one case of moderately severe facial nerve dysfunction (House-Brackmann Grade IV) in the long follow-up. CONCLUSION Early surgical intervention for vestibular schwannoma in NF2 patient is a viable management strategy to maintain hearing function and preserve facial nerve function.
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Affiliation(s)
- Arkadiusz Nowak
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Poland.
| | - Tomasz Dziedzic
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Poland
| | | | | | - Krzysztof Morawski
- Katedra i Klinika Otolaryngologii, Warszawski Uniwersytet Medyczny, Poland
| | - Kazimierz Niemczyk
- Katedra i Klinika Otolaryngologii, Warszawski Uniwersytet Medyczny, Poland
| | - Andrzej Marchel
- Klinika Neurochirurgii, Warszawski Uniwersytet Medyczny, Poland
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Stivaros SM, Stemmer-Rachamimov AO, Alston R, Plotkin SR, Nadol JB, Quesnel A, O'Malley J, Whitfield GA, McCabe MG, Freeman SR, Lloyd SK, Wright NB, Kilday JP, Kamaly-Asl ID, Mills SJ, Rutherford SA, King AT, Evans DG. Multiple synchronous sites of origin of vestibular schwannomas in neurofibromatosis Type 2. J Med Genet 2015; 52:557-62. [PMID: 26104281 PMCID: PMC4518745 DOI: 10.1136/jmedgenet-2015-103050] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 04/25/2015] [Indexed: 11/16/2022]
Abstract
Background Neurofibromatosis Type 2 (NF2) is a dominantly inherited tumour syndrome with a phenotype which includes bilateral vestibular (eighth cranial nerve) schwannomas. Conventional thinking suggests that these tumours originate at a single point along the superior division of the eighth nerve. Methods High resolution MRI was performed in children genetically proven to have NF2. The superior vestibular nerve (SVN) and inferior vestibular nerve (IVN) were visualised along their course with points of tumour origin calculated as a percentage relative to the length of the nerve. Results Out of 41 patients assessed, 7 patients had no identifiable eighth cranial nerve disease. In 16 patients there was complete filling of the internal auditory meatus by a tumour mass such that its specific neural origin could not be determined. In the remaining 18 cases, 86 discrete separate foci of tumour origin on the SVN or IVN could be identified including 23 tumours on the right SVN, 26 tumours on the right IVN, 18 tumours on the left SVN and 19 tumours on the left IVN. Discussion This study, examining the origins of vestibular schwannomas in NF2, refutes their origin as being from a single site on the transition zone of the superior division of the vestibular nerve. We hypothesise a relationship between the number of tumour foci, tumour biology and aggressiveness of disease. The development of targeted drug therapies in addition to bevacizumab are therefore essential to improve prognosis and quality of life in patients with NF2 given the shortcomings of surgery and radiation treatments when dealing with the multifocality of the disease.
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Affiliation(s)
- Stavros M Stivaros
- Academic Unit of Paediatric Radiology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK Centre for Imaging Sciences, Institute of Population Health, University of Manchester, Manchester, UK Children's Brain Tumour Research Network, Royal Manchester Children's Hospital, Manchester, UK
| | - Anat O Stemmer-Rachamimov
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Alston
- National Drug Evidence Centre (NDEC), Centre for Epidemiology, Institute of Population Health, University of Manchester, Manchester, UK
| | - Scott R Plotkin
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph B Nadol
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Alicia Quesnel
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Jennifer O'Malley
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Gillian A Whitfield
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
| | - Martin G McCabe
- Centre for Paediatric, Teenage and Young Adult Cancer, Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | - Simon R Freeman
- Department of Otolaryngology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Simon K Lloyd
- Department of Otolaryngology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Neville B Wright
- Academic Unit of Paediatric Radiology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - John-Paul Kilday
- Children's Brain Tumour Research Network, Royal Manchester Children's Hospital, Manchester, UK
| | - Ian D Kamaly-Asl
- Children's Brain Tumour Research Network, Royal Manchester Children's Hospital, Manchester, UK Department of Paediatric Neurosurgery, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Samantha J Mills
- Department of Neuroradiology, Salford NHS Foundation Trust Hospital, Salford, Greater Manchester, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Salford Royal Hospital, Salford, Greater Manchester, UK
| | - Andrew T King
- Department of Neurosurgery, Salford Royal Hospital, Salford, Greater Manchester, UK
| | - D Gareth Evans
- Department of Genomic Medicine, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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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.
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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.
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Dewan R, Pemov A, Kim HJ, Morgan KL, Vasquez RA, Chittiboina P, Wang X, Chandrasekharappa SC, Ray-Chaudhury A, Butman JA, Stewart DR, Asthagiri AR. Evidence of polyclonality in neurofibromatosis type 2-associated multilobulated vestibular schwannomas. Neuro Oncol 2015; 17:566-73. [PMID: 25452392 PMCID: PMC4483079 DOI: 10.1093/neuonc/nou317] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/20/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Neurofibromatosis type 2 (NF2) is a tumor syndrome that results from mutation of the NF2 tumor suppressor gene. The hallmark of NF2 is the presence of bilateral vestibular schwannoma (VS). Though NF2-associated and sporadic VS share identical histopathologic findings and cytogenetic alterations, NF2-associated VS often appears multilobulated, is less responsive to radiosurgery, and has worse surgical outcomes. Temporal bone autopsy specimens and MRI of the inner ear performed on NF2 patients suggest that multiple discrete tumors may be present within the labyrinth and cerebellopontine angle. METHODS Treatment-naïve ears in patients enrolled in a prospective NF2 natural history study (NIH#08-N-0044) were included for MRI analysis. T2-weighted and postcontrast T1-weighted MRIs were evaluated for the presence of multiple discrete tumors or a multilobulated mass. Peripheral blood (germline) and regional samples of tumor tissue were procured from consecutive patients enrolled in this study undergoing resection of a multilobulated VS (MVS). Histopathologic evaluation and genetic analysis (single nucleotide polymorphism array analysis, NF2 sequencing) were performed on each specimen. RESULTS Over half of NF2 ears harbored either an MVS (60/139 ears) or multiple discrete masses (19/139 ears). For 4 successive MVSs, genetic analysis revealed an admixture of cell populations, each with its own somatic NF2 mutation or deletion. CONCLUSIONS These findings suggest that the majority of NF2-associated VSs are polyclonal, such that the tumor mass represents a collision of multiple, distinct tumor clones. This explains the characteristic lobulated gross appearance of NF2-associated VS, and may also explain the substantially different treatment outcomes compared with sporadic VS.
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Affiliation(s)
| | | | - H. Jeffrey Kim
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
| | - Keaton L. Morgan
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
| | - Raul A. Vasquez
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
| | - Prashant Chittiboina
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
| | - Xiang Wang
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
| | - Settara C. Chandrasekharappa
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
| | - Abhik Ray-Chaudhury
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
| | - John A. Butman
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland (R.D., K.L.M., R.A.V., P.C., X.W., A.R.-C., A.R.A.); Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland (A.P., D.R.S.); Office of the Clinical Director, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (H.J.K.); Radiology and Imaging Sciences, The Clinical Center at the National Institutes of Health, National Institutes of Health, Bethesda, Maryland (J.A.B.); Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland (S.C.C.); Department of Neurosurgery, University of Virginia, CDW, Charlottesville, Virginia (A.R.A.)
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McCabe MG, Evans DG. Pathogenesis and management of type 2 neurofibromatosis. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1014800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Neurofibromatosis type 2 vestibular schwannoma treatment: a review of the literature, trends, and outcomes. Otol Neurotol 2015; 35:889-94. [PMID: 24675066 DOI: 10.1097/mao.0000000000000272] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Review the useful hearing preservation and tumor control outcomes of microsurgery (MS), stereotactic radiation (SR), conservative management (CM), and chemotherapy (ChT) for Neurofibromatosis type 2 vestibular schwannomas. DATA SOURCES Ovid MEDLINE was used to conduct a thorough search of English-language publications dating from 1948 to February 2013. STUDY SELECTION Patients must have had useful hearing at diagnosis and treated with one of the 4 treatments as their primary therapy. All sporadic vestibular schwannoma cases were excluded. DATA EXTRACTION A total of 19 articles were reviewed. Hearing preservation was defined as unchanged or improved useful hearing. Tumor control was defined as no change in size or tumor regression for SR, CM, and ChT-treated cases, and as no recurrence for MS treated cases. CONCLUSION Microsurgery seems to have the worse overall results, while SR has very good tumor control with poor useful hearing preservation. If a patient qualifies for CM, he is likely to show the most satisfactory results with the least treatment available. A close follow-up on ChT clinical trials and possible side-effects is warranted as preliminary short-term results are quite favorable. Additional long-term studies are required for a better understanding of this disease.
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Sun S, Liu A. Long-term follow-up studies of Gamma Knife surgery for patients with neurofibromatosis Type 2. J Neurosurg 2014; 121 Suppl:143-9. [DOI: 10.3171/2014.8.gks141503] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe aim of this study was to evaluate long-term clinical outcomes after Gamma Knife surgery (GKS) for patients with neurofibromatosis Type 2 (NF2) and the role of GKS in the management of NF2.MethodsFrom December 1994 through December 2008, a total of 46 patients (21 male, 25 female) with NF2 underwent GKS and follow-up evaluation for at least 5 years at the Gamma Knife Center of the Beijing Neurosurgical Institute. GKS was performed using the Leksell Gamma Knife Models B and C. The mean age of the patients was 30 years (range 13–59 years). A family history of NF2 was found for 9 (20%) patients. The NF2 phenotype was thought to be Wishart for 20 (44%) and Feiling-Gardner for 26 (56%) patients. Among these 46 patients, GKS was performed to treat 195 tumors (73 vestibular schwannomas and 122 other tumors including other schwannomas and meningiomas). For vestibular schwannomas, the mean volume was 5.1 cm3 (median 3.6 cm3, range 0.3–27.3 cm3), the mean margin dose was 12.9 Gy (range 10–14 Gy), and the mean maximum dose was 27.3 Gy (range 16.2–40 Gy). For other tumors, the mean volume was 1.7 cm3 (range 0.3–5.5 cm3), the mean margin dose was 13.3 Gy (range 11–14 Gy), and the mean maximum dose was 26.0 Gy (range 18.0–30.4 Gy). The median duration of follow-up was 109 months (range 8–195 months).ResultsFor the 73 vestibular schwannomas that underwent GKS, the latest follow-up MR images demonstrated regression of 30 (41%) tumors, stable size for 31 (43%) tumors, and enlargement of 12 (16%) tumors. The total rate of tumor control for bilateral vestibular schwannomas in patients with NF2 was 84%. Of the 122 other types of tumors that underwent GKS, 103 (85%) showed no tumor enlargement. The rate of serviceable hearing preservation after GKS was 31.9% (15/47). The actuarial rates for hearing preservation at 3 years, 5 years, 10 years, and 15 years were 98%, 93%, 44%, and 17%, respectively. Of the 46 patients, 22 (48%) became completely bilaterally deaf, 17 (37%) retained unilateral serviceable hearing, and 7 (15%) retained bilateral serviceable hearing. The mean history of the disease course was 12 years (range 5–38 years).ConclusionsGKS was confirmed to provide long-term local tumor control for small- to medium-sized vestibular schwannomas and other types of tumors, although vestibular schwannomas in patients with NF2 responded less well than did unilateral sporadic vestibular schwannomas. Phenotype is the most strongly predictive factor of final outcome after GKS for patients with NF2. The risk for loss of hearing is high, whereas the risk for other cranial nerve complications is low.
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Progress of hearing loss in neurofibromatosis type 2: implications for future management. Eur Arch Otorhinolaryngol 2014; 272:3143-50. [DOI: 10.1007/s00405-014-3317-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
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Gerganov VM, Giordano M, Elolf E, Osamah A, Amir S, Madjid S. Operative management of patients with radiosurgery-related trigeminal neuralgia: Analysis of the surgical morbidity and pain outcome. Clin Neurol Neurosurg 2014; 122:23-8. [DOI: 10.1016/j.clineuro.2014.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/02/2014] [Accepted: 04/13/2014] [Indexed: 11/25/2022]
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Choi JW, Lee JY, Phi JH, Wang KC, Chung HT, Paek SH, Kim DG, Park SH, Kim SK. Clinical course of vestibular schwannoma in pediatric neurofibromatosis Type 2. J Neurosurg Pediatr 2014; 13:650-7. [PMID: 24724714 DOI: 10.3171/2014.3.peds13455] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Neurofibromatosis Type 2 (NF2) is an autosomal-dominant inherited disease, characterized by multiple neoplasia syndromes, including meningioma, schwannoma, glioma, and ependymoma. In this report, the authors present their clinical experience with pediatric NF2 patients. In particular, they focused on the clinical course of vestibular schwannoma (VS), including the natural growth rate, tumor control, and functional hearing outcomes. METHODS From May 1988 to June 2012, the authors recruited patients who were younger than 18 years and fulfilled the Manchester criteria. In total, 25 patients were enrolled in this study. The authors analyzed the clinical course of these patients. In addition, they measured the natural growth rate of VS before any treatment in these children with NF2. Then, they evaluated the tumor control rate and functional hearing outcomes after the treatment of VS. RESULTS The mean age at the onset of NF2-related symptoms was 9.9 ± 4.5 years (mean ± SD, range 1-17 years). The mean age at the diagnosis of NF2 was 12.9 ± 2.9 years (range 5-17 years). The mean follow-up period was 89.3 months (range 12-311 months). As initial manifestations, nonvestibular symptoms were frequently observed in pediatric patients with NF2. The mean natural growth rate of VS was 0.33 ± 0.41 cm(3)/year (range 0-1.35 cm(3)/year). The tumor control rate of VS was 35.3% at 3 years after Gamma Knife surgery (GKS). The actuarial rate of useful hearing preservation was 67% in the 1st year and 53% in the 5th year after GKS. CONCLUSIONS Clinical manifestations in children with NF2 were highly variable, compared with their adult counterparts. The natural growth rate of VS in children is slow, and this oncological feature may explain the diverse clinical manifestations besides vestibular symptoms in children with NF2. The treatment outcome of GKS for VS in children with NF2 was not favorable compared with previous reports of affected adults.
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Niu NN, Niemierko A, Larvie M, Curtin H, Loeffler JS, McKenna MJ, Shih HA. Pretreatment Growth Rate Predicts Radiation Response in Vestibular Schwannomas. Int J Radiat Oncol Biol Phys 2014; 89:113-9. [DOI: 10.1016/j.ijrobp.2014.01.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 01/02/2014] [Accepted: 01/24/2014] [Indexed: 10/25/2022]
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Peyre M, Goutagny S, Bah A, Bernardeschi D, Larroque B, Sterkers O, Kalamarides M. Conservative management of bilateral vestibular schwannomas in neurofibromatosis type 2 patients: hearing and tumor growth results. Neurosurgery 2014; 72:907-13; discussion 914; quiz 914. [PMID: 23407292 DOI: 10.1227/neu.0b013e31828bae28] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As new treatment modalities develop for the management of vestibular schwannomas (VS) in patients with neurofibromatosis type 2, it remains crucial to ascertain the natural history of the disease. OBJECTIVE To determine the relationship between hearing and tumor growth in patients undergoing conservative VS management. METHODS Patients harboring bilateral VS with at least 1 year of radiological follow-up were selected. Conservative management was proposed based on the small tumor size and/or serviceable hearing at presentation. Tumor size was calculated by using the 2-component box model and reported as mean tumor diameter. Hearing was evaluated by using pure-tone average and the American Academy of Otololaryngologists and Head and Neck Surgery classification. RESULTS Forty-six patients harboring 92 VS were included. The mean clinical and radiological follow-up times were 6.0 and 4.2 years, respectively. The mean tumor diameter was 13 mm at presentation and 20 mm at the end of follow-up. Mean tumor growth rate was 1.8 mm/year. During follow-up, 17 patients (37%) underwent surgery for VS. Surgery-free rate for VS was 88% at 5 years. The number of patients with at least 1 serviceable ear was 39 (85%) at presentation and 34 (74%) at the end of follow-up, including 22 (66%) with binaural serviceable hearing maintained. There was no statistical correlation between tumor growth rate and preservation of serviceable hearing. Tumor growth rates and age at presentation were inversely correlated. CONCLUSION This study illustrates the high variability among neurofibromatosis type 2 patients regarding hearing status and VS growth rate and justifies the choice of initial conservative management in selected cases. ABBREVIATIONS : AAO-HNS, American Academy of Otololaryngologists and Head and Neck Surgery classificationMTD, mean tumor diameterNF2, neurofibromatosis type 2PTA, pure-tone averageSDS, speech discrimination scoreVS, vestibular schwannomas.
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Affiliation(s)
- Matthieu Peyre
- AP-HP, Hôpital Beaujon, Department of Neurosurgery, Clichy, France
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Mallory GW, Pollock BE, Foote RL, Carlson ML, Driscoll CL, Link MJ. Stereotactic Radiosurgery for Neurofibromatosis 2—Associated Vestibular Schwannomas. Neurosurgery 2013; 74:292-300; discussion 300-1. [DOI: 10.1227/neu.0000000000000264] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Management of neurofibromatosis type 2 (NF2)—associated vestibular schwannomas (VSs) remains controversial. Stereotactic radiosurgery (SRS) with conventional dosing is less effective for NF2-related VS compared with sporadic lesions.
OBJECTIVE:
To evaluate optimal SRS dose parameters for NF2-related VS and to report long-term outcomes.
METHODS:
A prospective database was reviewed and outcome measures, including radiographic progression, American Academy of Otolaryngology—Head and Neck Surgery hearing class, and facial nerve function, were analyzed. Progression-free survival was estimated with Kaplan-Meier methods. Associations between tumor progression and radiosurgical treatment parameters, tumor volume, and patient age were explored with the use of Cox proportional hazards regression.
RESULTS:
Between 1990 and 2010, 26 patients with 32 NF2-related VSs underwent SRS. Median marginal dose and tumor volume were 14 Gy and 2.7 cm3, respectively. Twenty-seven tumors (84%) showed no growth (median follow-up, 7.6 years). Kaplan-Meier estimates for 5- and 10-year progression-free survival were 85% and 80%, respectively. Cox proportional hazards demonstrated a significant inverse association between higher marginal doses and tumor progression (hazard ratio, 0.49; 95% confidence interval, 0.17-0.92; P = .02). Audiometric data were available in 30 ears, with 12 having class A/B hearing before SRS. Only 3 maintained serviceable hearing at the last follow-up. Four underwent cochlear implantation. Initially, 3 achieved open-set speech recognition, although only 1 experienced long-term benefit. Facial nerve function remained stable in 50% of cases.
CONCLUSION:
Higher marginal doses than commonly prescribed for sporadic VS were associated with improved tumor control in patients with NF2. Hearing outcomes were poor even when contemporary reduced marginal doses were used. However, SRS allows an anatomically preserved cochlear nerve and may permit hearing rehabilitation with cochlear implantation. Further consideration should be given to optimum dosing to achieve long-term control while maximizing functional outcomes.
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Affiliation(s)
- Grant W. Mallory
- Departments of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Bruce E. Pollock
- Departments of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
- Radiation Oncology, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Robert L. Foote
- Radiation Oncology, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Matthew L. Carlson
- Otolaryngology—Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Colin L. Driscoll
- Departments of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
- Otolaryngology—Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
| | - Michael J. Link
- Departments of Neurologic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
- Otolaryngology—Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota
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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.
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Affiliation(s)
- Masahiro Morimoto
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
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Lustgarten L. The impact of stereotactic radiosurgery in the management of neurofibromatosis type 2-related vestibular schwannomas. Surg Neurol Int 2013; 4:S151-5. [PMID: 23682341 PMCID: PMC3654776 DOI: 10.4103/2152-7806.110663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 02/25/2013] [Indexed: 11/14/2022] Open
Abstract
Although there is an ongoing debate about the ideal management of vestibular schwannomas, radiosurgical treatment has become popular in the past decade with good to excellent results reported. Given the young age at presentation, the bilateral nature of vestibular schwanomas, the presence of other associated central nervous system tumors, patients with neurofibromatosis Type 2 (NF2) are very complex and present significant management challenges. Although results do not seem to be as good as for patients with sporadic unilateral tumors, stereotactic radiosurgery has proven a safe, attractive, and effective management modality for NF2 vestibular schwannomas. An overview of the impact stereotactic radiosurgery has had in the management of these tumors is discussed.
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Affiliation(s)
- Leonardo Lustgarten
- Department of Neurosurgery Hospital Clinicas Caracas, Venezuela/Department of Radiation Oncology Hospital Clinicas Caracas, Venezuela/Gammaknife Unit, CDD Las Mercedes, Caracas, Venezuela
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Husseini ST, Piccirillo E, Taibah A, Almutair T, Sequino G, Sanna M. Salvage surgery of vestibular schwannoma after failed radiotherapy: the Gruppo Otologico experience and review of the literature. Am J Otolaryngol 2013. [PMID: 23177377 DOI: 10.1016/j.amjoto.2012.09.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The use of radiation therapy has largely widespread and becomes in many centers the preference modality of treatment for symptomatic patients who are old, medically unfit for surgical therapy, those who refuse surgery and in some recurrent or residual growing tumors. The risk of radiotherapy failure in the treatment of vestibular schwannoma might be underestimated in the literature. The purpose of this study is to show the Gruppo Otologico experience with salvage surgery to better understand the surgical outcomes and difficulties in treating vestibular schwannoma after failed radiotherapy. STUDY DESIGN Retrospective chart review of patients who required salvage surgery of vestibular schwannoma after failed radiotherapy. SETTINGS Quaternary referral otology and skull base center. RESULTS Between 1987 and 2010, 2500 cases of VS underwent surgical treatment at the Gruppo Otologico. Nineteen patients had received stereotactic radiation therapy before the surgical treatment. The interval time between radiotherapy and surgical salvage ranged from 1 to 10 years. In all the cases decision of surgery was taken following an increase in tumor size with or without new onset of symptoms. Complete tumor removal was achieved in 86.6% of the cases through a transotic, transcochlear or enlarged translabyrinthine approach with trans-apical extension. Difficult dissection of the tumor was encountered in 93.3% the cases. The facial nerve was anatomically preserved in 93.3% but its function was worsened in 73.3% of patients after at least 6 months of follow up. Malignant transformation of the vestibular schwannoma was encountered in one patient. CONCLUSION Complete surgical resection of VS is more difficult after radiotherapy with relatively poor facial nerve outcomes and nearly impossible hearing preservation. Patients who receive radiation therapy for the treatment of vestibular schwannoma should be made aware of its potential complications and risk of failure, especially in young patients and NF2 cases.
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Sadetzki S, Bruchim R, Oberman B, Armstrong GN, Lau CC, Claus EB, Barnholtz-Sloan JS, Il'yasova D, Schildkraut J, Johansen C, Houlston RS, Shete S, Amos CI, Bernstein JL, Olson SH, Jenkins RB, Lachance D, Vick NA, Merrell R, Wrensch M, Davis FG, McCarthy BJ, Lai R, Melin BS, Bondy ML. Description of selected characteristics of familial glioma patients - results from the Gliogene Consortium. Eur J Cancer 2013; 49:1335-45. [PMID: 23290425 DOI: 10.1016/j.ejca.2012.11.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND While certain inherited syndromes (e.g. Neurofibromatosis or Li-Fraumeni) are associated with an increased risk of glioma, most familial gliomas are non-syndromic. This study describes the demographic and clinical characteristics of the largest series of non-syndromic glioma families ascertained from 14 centres in the United States (US), Europe and Israel as part of the Gliogene Consortium. METHODS Families with 2 or more verified gliomas were recruited between January 2007 and February 2011. Distributions of demographic characteristics and clinical variables of gliomas in the families were described based on information derived from personal questionnaires. FINDINGS The study population comprised 841 glioma patients identified in 376 families (9797 individuals). There were more cases of glioma among males, with a male to female ratio of 1.25. In most families (83%), 2 gliomas were reported, with 3 and 4 gliomas in 13% and 3% of the families, respectively. For families with 2 gliomas, 57% were among 1st-degree relatives, and 31.5% among 2nd-degree relatives. Overall, the mean (±standard deviation [SD]) diagnosis age was 49.4 (±18.7) years. In 48% of families with 2 gliomas, at least one was diagnosed at <40y, and in 12% both were diagnosed under 40y of age. Most of these families (76%) had at least one grade IV glioblastoma multiforme (GBM), and in 32% both cases were grade IV gliomas. The most common glioma subtype was GBM (55%), followed by anaplastic astrocytoma (10%) and oligodendroglioma (8%). Individuals with grades I-II were on average 17y younger than those with grades III-IV. INTERPRETATION Familial glioma cases are similar to sporadic cases in terms of gender distribution, age, morphology and grade. Most familial gliomas appear to comprise clusters of two cases suggesting low penetrance, and that the risk of developing additional gliomas is probably low. These results should be useful in the counselling and clinical management of individuals with a family history of glioma.
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Affiliation(s)
- Siegal Sadetzki
- Cancer and Radiation Epidemiology Unit, Gertner Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Lloyd SKW, Evans DGR. Neurofibromatosis type 2 (NF2): diagnosis and management. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:957-67. [PMID: 23931824 DOI: 10.1016/b978-0-444-52902-2.00054-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Neurofibromatosis type 2 (NF2) is an autosomal dominant inherited tumor predisposition syndrome caused by mutations in the NF2 gene on chromosome 22. Affected individuals develop schwannomas typically involving both vestibular nerves leading to hearing loss and eventual deafness. Rehabilitation with brainstem implants and in some cases cochlear implants is improving this outcome. Schwannomas also occur on other cranial nerves, on spinal nerve roots and peripheral nerves, and intracutaneously as plaques. Cranial and spinal meningiomas and spinal ependymomas are other common tumors. Fifty to sixty percent of patients represent de novo mutations and as many as 33% of these are mosaic for the underlying disease causing mutation. Truncating mutations (nonsense, frameshift insertions/deletions) are the most frequent germline events and cause the most severe disease, whilst single and multiple exon deletions are common and are usually associated with milder NF2. Neurological deficits are a major feature of the condition and neurologists have a pivotal role in assigning symptoms to lesions and in managing neuropathies. NF2 represents a difficult management problem with most patients facing substantial morbidity and reduced life expectancy. Surgery remains the focus of current management although watchful waiting and occasionally radiation treatment have a role. We are seeing the advent of tailored drug therapies aimed at the genetic level and these are likely to provide huge improvements for this devastating, life-limiting condition.
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Affiliation(s)
- Simon K W Lloyd
- Salford Royal NHS Foundation Trust, Salford, and Department of Otolaryngology, Manchester Academic Health Science Centre, Central Manchester NHS Foundation Trust, Manchester Royal Infirmary, Manchester, UK
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