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Lassaletta L, Acle Cervera L, Altuna X, Amilibia Cabeza E, Arístegui Ruiz M, Batuecas Caletrio Á, Benítez Del Rosario J, Cabanillas Farpón R, Costales Marcos M, Escada P, Espinosa-Sánchez JM, García Leal R, Gavilán J, Gómez Martínez J, González-Aguado R, Martinez-Glez V, Guerra Jiménez G, Harguindey Antolí-Candela A, Hernández García BJ, Orús Dotú C, Polo López R, Manrique M, Martín Sanz E, Martínez Álvarez R, Martínez H, Martínez-Martínez M, Rey-Martinez J, Ropero Romero F, Santa Cruz Ruiz S, Vallejo LÁ, Soto Varela A, Varela-Nieto I, Morales Puebla JM. Clinical practice guideline on the management of vestibular schwannoma. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2024; 75:108-128. [PMID: 38346489 DOI: 10.1016/j.otoeng.2023.10.005] [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: 08/23/2023] [Accepted: 10/19/2023] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Vestibular schwannoma (VS) is the most common tumour of the cerebellopontine angle. The greater accessibility to radiological tests has increased its diagnosis. Taking into account the characteristics of the tumour, the symptoms and the age of the patient, three therapeutic strategies have been proposed: observation, surgery or radiotherapy. Choosing the most appropriate for each patient is a frequent source of controversy. MATERIAL AND METHODS This paper includes an exhaustive literature review of issues related to VS that can serve as a clinical guide in the management of patients with these lesions. The presentation has been oriented in the form of questions that the clinician usually asks himself and the answers have been written and/or reviewed by a panel of national and international experts consulted by the Otology Commission of the SEORL-CCC. RESULTS A list has been compiled containing the 13 most controversial thematic blocks on the management of VS in the form of 50 questions, and answers to all of them have been sought through a systematic literature review (articles published on PubMed and Cochrane Library between 1992 and 2023 related to each thematic area). Thirty-three experts, led by the Otology Committee of SEORL-CCC, have analyzed and discussed all the answers. In Annex 1, 14 additional questions divided into 4 thematic areas can be found. CONCLUSIONS This clinical practice guideline on the management of VS offers agreed answers to the most common questions that are asked about this tumour. The absence of sufficient prospective studies means that the levels of evidence on the subject are generally medium or low. This fact increases the interest of this type of clinical practice guidelines prepared by experts.
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Affiliation(s)
- Luis Lassaletta
- Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain.
| | | | - Xabier Altuna
- Servicio de Otorrinolaringología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
| | - Emilio Amilibia Cabeza
- Servicio de Otorrinolaringología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Miguel Arístegui Ruiz
- Servicio de Otorrinolaringología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Ángel Batuecas Caletrio
- Servicio de Otorrinolaringología, Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca, Salamanca, Spain
| | - Jesús Benítez Del Rosario
- Servicio de Otorrinolaringología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | - María Costales Marcos
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Pedro Escada
- Servicio de Otorrinolaringología, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Juan Manuel Espinosa-Sánchez
- Servicio de Otorrinolaringología, Hospital Universitario Virgen de las Nieves, Instituto de Investigación Biosanitaria (ibs.GRANADA), Granada, Spain
| | - Roberto García Leal
- Servicio de Neurocirugía, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Gavilán
- Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Justo Gómez Martínez
- Servicio de Otorrinolaringología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Rocío González-Aguado
- Servicio de Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Victor Martinez-Glez
- Center for Genomic Medicine, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autónoma de Barcelona, Sabadell, Barcelona, Spain
| | - Gloria Guerra Jiménez
- Servicio de Otorrinolaringología, Complejo Hospitalario Universitario Insular Materno Infantil de las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | | | - Cesar Orús Dotú
- Servicio de Otorrinolaringología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Rubén Polo López
- Servicio de Otorrinolaringología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Manuel Manrique
- Servicio de Otorrinolaringología, Clínica Universitaria de Navarra, Pamplona, Navarra, Spain
| | - Eduardo Martín Sanz
- Servicio de Otorrinolaringología, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | | | - Henry Martínez
- Servicio de Otorrinolaringología, Hospital Universitario Clínica San Rafael, Sur Bogotá D. C., Colombia; Servicio de Otorrinolaringología, Hospital San José, Bogotá, Colombia
| | | | - Jorge Rey-Martinez
- Servicio de Otorrinolaringología, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, Spain
| | | | - Santiago Santa Cruz Ruiz
- Servicio de Otorrinolaringología, Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca, Salamanca, Spain
| | - Luis Ángel Vallejo
- Servicio de Otorrinolaringología, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Andrés Soto Varela
- Servicio de Otorrinolaringología, Departamento de Cirugía y Especialidades Médico-Quirúrgicas, Complexo Hospitalario Universitario de Santiago, Universidade de Santiago de Compostela, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, A Coruña, Spain
| | - Isabel Varela-Nieto
- Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras, Instituto de Salud Carlos III, Madrid, Spain; Grupo de Audición y Mielinopatías, Instituto de Investigaciones Biomédicas Alberto Sols, CSIC-UAM, CIBERER-ISCIII, Madrid, Spain
| | - José Manuel Morales Puebla
- Servicio de Otorrinolaringología, Hospital Universitario La Paz, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras, Instituto de Salud Carlos III, Madrid, Spain
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Szymoniuk M, Kochański M, Wilk K, Miazga D, Kanonik O, Dryla A, Kamieniak P. Stereotactic radiosurgery for Koos grade IV vestibular schwannoma: a systematic review and meta-analysis. Acta Neurochir (Wien) 2024; 166:101. [PMID: 38393397 DOI: 10.1007/s00701-024-05995-2] [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: 11/05/2023] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a well-established treatment option for Koos stage I-III vestibular schwannomas (VS), often used as the first line of treatment or after subtotal resection. However, the optimal treatment for Koos-IV VS remains unclear. Therefore, our study aimed to evaluate the effectiveness of SRS as a primary treatment for large VS classified as Koos-IV. METHODS A systematic search was performed on December 28th, 2022, based on PubMed, Web of Science, and Scopus according to the PRISMA statement. The review was updated on September 7th, 2023. The risk of bias was assessed using the NIH Quality Assessment Tool. The R software (ver. 4.3.2) was used for all quantitative analyses and preparation of the forest plots. Publication bias and sensitivity analysis were performed to evaluate the reliability of the obtained results. RESULTS Among 2941 screened records, ten studies (1398 patients) have been included in quantitative synthesis. The overall tumor control rate was 90.7% (95%CI 86.3-94.4). Kaplan-Meier estimates of tumor control at 2, 6, and 10 years were 96.0% (95% CI 92.9-97.6%), 88.8% (95% CI 86.9-89.8%), and 84.5% (95% CI, 81.2-85.8%), respectively. The overall hearing preservation rate was 56.5% (95%CI 37-75.1). Kaplan-Meier estimates of hearing preservation rate at 2, 6, and 10 years were 77.1% (95% CI 67.9-82.5%), 53.5% (95% CI 44.2-58.5%), and 38.1% (95% CI 23.4-40.7%), respectively. The overall facial nerve preservation rate was 100% (95%CI 99.9-100.0). The overall trigeminal neuropathy rate reached 5.7% (95%CI 2.9-9.2). The overall rate of new-onset hydrocephalus was 5.6% (95%CI 3-9). The overall rates of worsening or new-onset tinnitus and vertigo were 6.8% (95%CI 4.2-10.0) and 9.1% (95%CI 2.1-19.6) respectively. No publication bias was detected according to the used methods. CONCLUSIONS Our systematic review and meta-analysis demonstrated a high overall tumor control rate, excellent facial nerve preservation, and low incidence of new-onset or worsened tinnitus and vertigo. However, several drawbacks associated with SRS should be noted, such as the presence of post-SRS hydrocephalus risk, mediocre long-term hearing preservation, and the lack of immediate tumor decompression. Nevertheless, the use of SRS may be beneficial in appropriately selected cases of Koos-IV VS. Moreover, further prospective studies directly comparing SRS with surgery are necessary to determine the optimal treatment for large VS and verify our results on a higher level of evidence. Registration and protocol: CRD42023389856.
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Affiliation(s)
- Michał Szymoniuk
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Ul. Jaczewskiego 8, 20-954, Lublin, Poland.
| | - Marek Kochański
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Ul. Jaczewskiego 8, 20-954, Lublin, Poland
| | - Karolina Wilk
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Ul. Jaczewskiego 8, 20-954, Lublin, Poland
| | - Dominika Miazga
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Ul. Jaczewskiego 8, 20-954, Lublin, Poland
| | - Oliwia Kanonik
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Ul. Jaczewskiego 8, 20-954, Lublin, Poland
| | - Aleksandra Dryla
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Ul. Jaczewskiego 8, 20-954, Lublin, Poland
| | - Piotr Kamieniak
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, Ul. Jaczewskiego 8, 20-954, Lublin, Poland
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Bin-Alamer O, Abou-Al-Shaar H, Mallela AN, Kallos JA, Deng H, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Peker S, Samanci Y, Lee CC, Yang HC, Mathieu D, Tripathi M, Mantziaris G, Mullapudi A, Urgosik D, Liscak R, Bowden GN, Zaki P, Wegner RE, Shepard MJ, Sheehan JP, Niranjan A, Hadjipanayis CG, Lunsford LD. Intratumoral Hemorrhage in Vestibular Schwannomas After Stereotactic Radiosurgery: Multi-Institutional Study. Neurosurgery 2024; 94:289-296. [PMID: 37581440 DOI: 10.1227/neu.0000000000002627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/01/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intratumoral hemorrhage (ITH) in vestibular schwannoma (VS) after stereotactic radiosurgery (SRS) is exceedingly rare. The aim of this study was to define its incidence and describe its management and outcomes in this subset of patients. METHODS A retrospective multi-institutional study was conducted, screening 9565 patients with VS managed with SRS at 10 centers affiliated with the International Radiosurgery Research Foundation. RESULTS A total of 25 patients developed ITH (cumulative incidence of 0.26%) after SRS management, with a median ITH size of 1.2 cm 3 . Most of the patients had Koos grade II-IV VS, and the median age was 62 years. After ITH development, 21 patients were observed, 2 had urgent surgical intervention, and 2 were initially observed and had late resection because of delayed hemorrhagic expansion and/or clinical deterioration. The histopathology of the resected tumors showed typical, benign VS histology without sclerosis, along with chronic inflammatory cells and multiple fragments of hemorrhage. At the last follow-up, 17 patients improved and 8 remained clinically stable. CONCLUSION ITH after SRS for VS is extremely rare but has various clinical manifestations and severity. The management paradigm should be individualized based on patient-specific factors, rapidity of clinical and/or radiographic progression, ITH expansion, and overall patient condition.
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Affiliation(s)
- Othman Bin-Alamer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hussam Abou-Al-Shaar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Arka N Mallela
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Justiss A Kallos
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Benha University, Qalubya , Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Ain Shams University, Cairo , Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Ain Shams University, Cairo , Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Clinical Oncology Department, Ain Shams University, Cairo , Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Neurosurgery Department, Ain Shams University, Cairo , Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo , Egypt
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo , Egypt
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei , Taiwan
- School of Medicine, National Yang-Ming University, Taipei , Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei , Taiwan
- School of Medicine, National Yang-Ming University, Taipei , Taiwan
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke , Quebec , Canada
| | - Manjul Tripathi
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh , India
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Abhishek Mullapudi
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Dusan Urgosik
- Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Roman Liscak
- Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Greg N Bowden
- Department of Neurosurgery, University of Alberta, Edmonton , Canada
| | - Peter Zaki
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh , Pennsylvania , USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Allegheny Health Network, Pittsburgh , Pennsylvania , USA
| | - Matthew J Shepard
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - Constantinos G Hadjipanayis
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh , Pennsylvania , USA
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Pisani D, Gioacchini FM, Chiarella G, Astorina A, Ricciardiello F, Scarpa A, Re M, Viola P. Vestibular Impairment in Patients with Vestibular Schwannoma: A Journey through the Pitfalls of Current Literature. Audiol Res 2023; 13:285-303. [PMID: 37102775 PMCID: PMC10135541 DOI: 10.3390/audiolres13020025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/17/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023] Open
Abstract
Vestibular Schwannoma is the most common tumour of Ponto Cerebellar Angle and is capable of strongly impacting the patient's quality of life. In recent decades, the proposals for the management of the disease have multiplied, just as the diagnostic capacity has improved. While in the past, the primary objective was the preservation of the facial function, and subsequently also of the auditory function, the attention to the vestibular symptomatology, which appears to be one of the main indicators of deterioration of quality of life, is still unsatisfactory. Many authors have tried to provide guidance on the best possible management strategy, but a universally recognized guideline is still lacking. This article offers an overview of the disease and the proposals which have advanced in the last twenty years, evaluating their qualities and defects in a critical reading.
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Affiliation(s)
- Davide Pisani
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Federico Maria Gioacchini
- Ear, Nose, and Throat Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Via Conca 71, 60020 Ancona, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Alessia Astorina
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | | | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, 84084 Salerno, Italy
| | - Massimo Re
- Ear, Nose, and Throat Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Via Conca 71, 60020 Ancona, Italy
| | - Pasquale Viola
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
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Management of Sporadic Vestibular Schwannomas in Children—Volumetric Analysis and Clinical Outcome Assessment. CHILDREN 2022; 9:children9040490. [PMID: 35455534 PMCID: PMC9032576 DOI: 10.3390/children9040490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022]
Abstract
Vestibular schwannomas (VS) usually manifest between the 5th and 8th decade of life. Most pediatric cases are associated with Neurofibromatosis type 2 and sporadic VS are rare in this age group. Few case series have been published. We report on our institutional series of sporadic VS in children. We included all cases between 2003 and 2021; 28 of 1635 patients harbored a sporadic VS and were younger than 21 years old. A retrospective review of clinical parameters and surgical data as well as outcomes was performed. All procedures were performed via a retrosigmoid approach. Preoperative imaging was assessed, and tumor volumetry was performed. Mean follow-up was 28 months, symptomatology was diverse. Most children and adolescents presented with hearing loss and tinnitus. All cases with multiple preoperative magnetic resonance imaging scans showed volumetric tumor growth between 1 and 18%/month (mean 8.9 ± 5.6%). Cystic tumor morphology and bone erosion was seen in larger tumors. Gross total resection was possible in 78% of patients and no recurrence was observed. All patients with subtotal resection showed tumor regrowth. Sporadic VS in children are rare and present with a high clinical variability. Surgical resection is the primary therapy and is feasible with favorable results comparable to the adult age group.
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Is salvage surgery for large vestibular schwannomas after failed gamma knife radiosurgery more challenging? Neurosurg Rev 2021; 45:751-761. [PMID: 34269934 DOI: 10.1007/s10143-021-01604-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/19/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
In order to verify whether a previous gamma knife surgery (GKS) treatment could influence the oncological and functional outcome in large vestibular schwannoma (VS) surgery, we have compared group of patients operated on for large VS after failed GKS to a group of genuine VS that underwent the same functional nerve-sparing resection technique regimen in the same period. Single center retrospective cohort study of 23 consecutive GKS failure and 170 genuine VS patients operated on between April 2003 and March 2019. After resection, patients were allocated to a Wait-&-rescan or an upfront GKS policy. At last follow-up examination, the facial nerve function was good (House-Brackmann grades I or II) in 95% of the GKS failure and 84% of the genuine VS patients (p = .25). The median volume of tumor residue was .56 cc in the GKS failure group and .62 cc in the genuine VS group (p = .70). Tumor control was achieved in 91% and 83% of cases with a mean follow-up of 74 and 63 months in the GKS failure and the genuine VS populations, respectively. The 1-, 5-, and 7-year progression-free survival were 100%, 95%, and 85% respectively in the GKS failure group and 97%, 80%, and 81% in the genuine VS group (p = .27). Despite significant modifications of the microsurgical environment associated to salvage surgery after GKS failure, a functional nerve-sparing resection is an effective strategy to optimize the results on facial nerve function, with similar long-term tumor control to those observed in the genuine VS population.
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Tawfik KO, Khan UA, Friedman RA. Treatment of Small Vestibular Schwannomas. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-020-00326-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Régis J, Hamdi H, Loundou A, Merly L, Castillo L, Balossier A, Spatola G. Clinical evaluation of a real-time inverse planning for Gamma Knife radiosurgery by convex optimization: a prospective comparative trial in a series of vestibular schwannoma patients. Acta Neurochir (Wien) 2021; 163:981-989. [PMID: 33398540 DOI: 10.1007/s00701-020-04695-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) inverse dose planning is currently far from competing effectively with the quality of dose planning developed by experienced experts. A new inverse planning (IP) method based on « efficient convex optimization algorithms » is proposed, providing high-quality dose plans in real time. MATERIALS AND METHODS Eighty-six patients treated by GKRS for vestibular schwannomas (VS) were recruited. The treatment plans created by the first author, who has 27 years of experience and has developed and delivered more than 15,000 dose plans, served as reference. A first set of basic constraints determined by default led the IP for an initial real-time dose plan. Additional constraints were interactively proposed by the planner to take other parameters into account. A second optimized plan was then calculated by the IP. The primary endpoint was the Paddick Conformity Index (PCI). The statistical analysis was planned on a non-inferiority trial design. Coverage, selectivity, and gradient indexes, dose at the organ(s) at risk, and 12 Gy isodose line volume were compared. RESULTS After a single run of the IP, the PCI was shown to be non-inferior to that of the "expert." For the expert and the IP, respectively, the median coverage index was 0.99 and 0.98, the median selectivity index 0.92 and 0.90, the median gradient index 2.95 and 2.84, the median dose at the modiolus of the cochlea 2.83 Gy and 2.86 Gy, the median number of shots 14.31 and 24.13, and the median beam-on time 46.20 min and 26.77 min. In a few specific cases, advanced tools of the IP were used to generate a second run by adding new constraints either globally (for higher selectivity) or locally, in order to increase or decrease these constraints focally. CONCLUSION These preliminary results showed that this new IP method based on « efficient convex optimization algorithms », called IntuitivePlan®, provided high-quality dose plans in real time with excellent coverage, selectivity, and gradient indexes with optimized beam-on time. If the new IP evaluated here is able to compete in real time with the quality of the treatment plans of an expert with extensive radiosurgical experience, this could allow new planners/radiosurgeons with limited or no experience to immediately provide patients with high-quality GKRS for benign and malignant lesions.
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Affiliation(s)
- Jean Régis
- Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Aix-Marseille Université, Hôpital de la Timone, APHM, Marseille, France.
- Service de Neurochirurgie Fonctionnelle & Radiochirurgie, Hôpital d'adulte de la Timone, 264 Bvd Saint Pierre, 13 285, Marseille Cedex 05, France.
| | - Hussein Hamdi
- Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Aix-Marseille Université, Hôpital de la Timone, APHM, Marseille, France
| | - Anderson Loundou
- Departement of Biostatistic, Aix-Marseille Université, Marseille, France
| | - Louise Merly
- Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Aix-Marseille Université, Hôpital de la Timone, APHM, Marseille, France
| | - Laura Castillo
- Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Aix-Marseille Université, Hôpital de la Timone, APHM, Marseille, France
| | - Anne Balossier
- Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Aix-Marseille Université, Hôpital de la Timone, APHM, Marseille, France
| | - Giorgio Spatola
- Institut de Neuroscience des Systèmes, Functional Neurosurgery and Radiosurgery Department, Aix-Marseille Université, Hôpital de la Timone, APHM, Marseille, France
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Ermiş E, Anschuetz L, Leiser D, Poel R, Raabe A, Manser P, Aebersold DM, Caversaccio M, Mantokoudis G, Abu-Isa J, Wagner F, Herrmann E. Vestibular dose correlates with dizziness after radiosurgery for the treatment of vestibular schwannoma. Radiat Oncol 2021; 16:61. [PMID: 33771181 PMCID: PMC7995572 DOI: 10.1186/s13014-021-01793-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/18/2021] [Indexed: 11/20/2022] Open
Abstract
Background Stereotactic radiosurgery (SRS) has been recognized as a first-line treatment option for small to moderate sized vestibular schwannoma (VS). Our aim is to evaluate the impact of SRS doses and other patient and disease characteristics on vestibular function in patients with VS. Methods Data on VS patients treated with single-fraction SRS to 12 Gy were retrospectively reviewed. No dose constraints were given to the vestibule during optimization in treatment planning. Patient and tumor characteristics, pre- and post-SRS vestibular examination results and patient-reported dizziness were assessed from patient records. Results Fifty-three patients were analyzed. Median follow-up was 32 months (range, 6–79). The median minimum, mean and maximum vestibular doses were 2.6 ± 1.6 Gy, 6.7 ± 2.8 Gy, and 11 ± 3.6 Gy, respectively. On univariate analysis, Koos grade (p = 0.04; OR: 3.45; 95% CI 1.01–11.81), tumor volume (median 6.1 cm3; range, 0.8–38; p = 0.01; OR: 4.85; 95% CI 1.43–16.49), presence of pre-SRS dizziness (p = 0.02; OR: 3.98; 95% CI 1.19–13.24) and minimum vestibular dose (p = 0.033; OR: 1.55; 95% CI 1.03–2.32) showed a significant association with patient-reported dizziness. On multivariate analysis, minimum vestibular dose remained significant (p = 0.02; OR: 1.75; 95% CI 1.05–2.89). Patients with improved caloric function had received significantly lower mean (1.5 ± 0.7 Gy, p = 0.01) and maximum doses (4 ± 1.5 Gy, p = 0.01) to the vestibule. Conclusions Our results reveal that 5 Gy and above minimum vestibular doses significantly worsened dizziness. Additionally, mean and maximum doses received by the vestibule were significantly lower in patients who had improved caloric function. Further investigations are needed to determine dose-volume parameters and their effects on vestibular toxicity.
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Affiliation(s)
- Ekin Ermiş
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominic Leiser
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.,Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Robert Poel
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics, Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Janine Abu-Isa
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Evelyn Herrmann
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland. .,Department of Radiation Oncology, Hôpital Riviera-Chablais, Rennaz, Switzerland.
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10
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Ogino A, Lunsford LD, Long H, Johnson S, Faramand A, Niranjan A, Flickinger JC, Kano H. Stereotactic radiosurgery as the primary management for patients with Koos grade IV vestibular schwannomas. J Neurosurg 2021; 135:1058-1066. [PMID: 33578383 DOI: 10.3171/2020.8.jns201832] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While extensive long-term outcome studies support the role of stereotactic radiosurgery (SRS) for smaller-volume vestibular schwannomas (VSs), its role in the management for larger-volume tumors remains controversial. METHODS Between 1987 and 2017, the authors performed single-session SRS on 170 patients with previously untreated Koos grade IV VSs (volumes ranged from 5 to 20 cm3). The median tumor volume was 7.4 cm3. The median maximum extracanalicular tumor diameter was 27.5 mm. All tumors compressed the middle cerebellar peduncle and distorted the fourth ventricle. Ninety-three patients were male, 77 were female, and the median age was 61 years. Sixty-two patients had serviceable hearing (Gardner-Robertson [GR] grades I and II). The median margin dose was 12.5 Gy. RESULTS At a median follow-up of 5.1 years, the progression-free survival rates of VSs treated with a margin dose ≥ 12.0 Gy were 98.4% at 3 years, 95.3% at 5 years, and 90.7% at 10 years. In contrast, the tumor control rate after delivery of a margin dose < 12.0 Gy was 76.9% at 3, 5, and 10 years. The hearing preservation rates in patients with serviceable hearing at the time of SRS were 58.1% at 3 years, 50.3% at 5 years, and 35.9% at 7 years. Younger age (< 60 years, p = 0.036) and initial GR grade I (p = 0.006) were associated with improved serviceable hearing preservation rate. Seven patients (4%) developed facial neuropathy during the follow-up interval. A smaller tumor volume (< 10 cm3, p = 0.002) and a lower margin dose (≤ 13.0 Gy, p < 0.001) were associated with preservation of facial nerve function. The probability of delayed facial neuropathy when the margin dose was ≤ 13.0 Gy was 1.1% at 10 years. Nine patients (5%) required a ventriculoperitoneal shunt because of delayed symptomatic hydrocephalus. Fifteen patients (9%) developed detectable trigeminal neuropathy. Delayed resection was performed in 4% of patients. CONCLUSIONS Even for larger-volume VSs, single-session SRS prevented the need for delayed resection in almost 90% at 10 years. For patients with minimal symptoms of tumor mass effect, SRS should be considered an effective alternative to surgery in most patients, especially those with advanced age or medical comorbidities.
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Affiliation(s)
- Akiyoshi Ogino
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and.,4Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - L Dade Lunsford
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Hao Long
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | | | - Andrew Faramand
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - John C Flickinger
- 2Radiation Oncology, and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Hideyuki Kano
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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11
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Combs SE, Baumert BG, Bendszus M, Bozzao A, Brada M, Fariselli L, Fiorentino A, Ganswindt U, Grosu AL, Lagerwaard FL, Niyazi M, Nyholm T, Paddick I, Weber DC, Belka C, Minniti G. ESTRO ACROP guideline for target volume delineation of skull base tumors. Radiother Oncol 2020; 156:80-94. [PMID: 33309848 DOI: 10.1016/j.radonc.2020.11.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE For skull base tumors, target definition is the key to safe high-dose treatments because surrounding normal tissues are very sensitive to radiation. In the present work we established a joint ESTRO ACROP guideline for the target volume definition of skull base tumors. MATERIAL AND METHODS A comprehensive literature search was conducted in PubMed using various combinations of the following medical subjects headings (MeSH) and free-text words: "radiation therapy" or "stereotactic radiosurgery" or "proton therapy" or "particle beam therapy" and "skull base neoplasms" "pituitary neoplasms", "meningioma", "craniopharyngioma", "chordoma", "chondrosarcoma", "acoustic neuroma/vestibular schwannoma", "organs at risk", "gross tumor volume", "clinical tumor volume", "planning tumor volume", "target volume", "target delineation", "dose constraints". The ACROP committee identified sixteen European experts in close interaction with the ESTRO clinical committee who analyzed and discussed the body of evidence concerning target delineation. RESULTS All experts agree that magnetic resonance (MR) images with high three-dimensional spatial accuracy and tissue-contrast definition, both T2-weighted and volumetric T1-weighted sequences, are required to improve target delineation. In detail, several key issues were identified and discussed: i) radiation techniques and immobilization, ii) imaging techniques and target delineation, and iii) technical aspects of radiation treatments including planning techniques and dose-fractionation schedules. Specific target delineation issues with regard to different skull base tumors, including pituitary adenomas, meningiomas, craniopharyngiomas, acoustic neuromas, chordomas and chondrosarcomas are presented. CONCLUSIONS This ESTRO ACROP guideline achieved detailed recommendations on target volume definition for skull base tumors, as well as comprehensive advice about imaging modalities and radiation techniques.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany; Institute of Radiation Medicine, Department of Radiation Sciences, Helmholtz Zentrum München, Munich, Germany; German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany
| | - Brigitta G Baumert
- Institute of Radiation Oncology, Cantonal Hospital Graubuenden, Chur, Switzerland
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | - Alessandro Bozzao
- Dipartimento NESMOS, Università Sapienza Roma, Azienda Ospedaliera Sant'Andrea, Rome, Italy
| | - Michael Brada
- Department of Radiation Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, United Kingdom
| | - Laura Fariselli
- Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle fonti, Italy
| | - Ute Ganswindt
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Faculty, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany
| | - Frank L Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, The Netherlands
| | - Maximilian Niyazi
- German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany; Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Tufve Nyholm
- Department of Radiation Sciences, Radiation Physics, Umeå University, Umeå, Sweden
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | | | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; IRCCS Neuromed, Pozzilli, Italy.
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12
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Equivalent Efficacy and Safety of Radiosurgery for Cystic and Solid Vestibular Schwannomas: A Systematic Review. World Neurosurg 2020; 146:322-331.e1. [PMID: 33212274 DOI: 10.1016/j.wneu.2020.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Cystic vestibular schwannomas (VS) are associated with unpredictable growth behavior and potentially worse surgical outcomes compared with their solid counterparts. Growth control and potential adverse effects of radiosurgery for cystic VS have created concerns surrounding this modality. We sought to compare the treatment efficacy and safety profile of radiosurgery between cystic and solid VS through a systematic review. METHODS PubMed, EMBASE, Web of Science, and Cochrane were searched for related terms and studies reporting radiosurgical outcomes of cystic and solid VS. A meta-analysis was performed to compare the rates of tumor control. Random-effect models with generic inverse variance method was used to calculate overall pooled estimates. Study quality was assessed with the Newcastle Ottawa Criteria. RESULTS In total, 2989 studies were retrieved, and 6 including 1358 VS (79.89% solid; 20.11% cystic, median follow-up range 31.8-150 months) were selected. The median maximal dose was 25 Gy (range, 13-36 Gy) and the median marginal tumor dose was 12 Gy (10-18 Gy). There was no difference between cystic and solid VS (risk ratio, 1.02; 95% confidence interval 0.94-1.10; P = 0.69; I2 = 78%). Transient enlargement of cystic tumors may be associated with trigeminal or facial neuropathy. CONCLUSIONS The evidence collected by this study suggests that radiosurgery for cystic VS exhibits effective tumor control probabilities similar to solid VS. Consensus definitions and standard criteria are needed in the future to better understand the patterns of tumor growth and response to treatment following radiosurgery for cystic VS, as well as long-term neurological and functional outcomes.
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13
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Rueß D, Pöhlmann L, Grau S, Hamisch C, Hoevels M, Treuer H, Baues C, Kocher M, Ruge M. Outcome and toxicity analysis of single dose stereotactic radiosurgery in vestibular schwannoma based on the Koos grading system. Sci Rep 2020; 10:9309. [PMID: 32518238 PMCID: PMC7283483 DOI: 10.1038/s41598-020-66213-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/18/2020] [Indexed: 11/09/2022] Open
Abstract
Stereotactic radiosurgery (SRS) has evolved as widely accepted treatment option for small-sized (Koos I up to II) vestibular schwannoma (VS). For larger tumors (prevalent Koos VI), microsurgery or combined treatment strategies are mostly recommended. However, in patients not suited for microsurgery, SRS might also be an alternative to balance tumor control, hearing preservation and adverse effects. The purpose of this analysis was to evaluate the efficacy and toxicity of SRS for VS with regard to different Koos grades. All patients with untreated VS who received SRS at our center were included. Outcome analysis included tumor control, preservation of serviceable hearing based on median pure tone averages (PTA), and procedure-related adverse events rated by the Common Terminology Criteria for Adverse Events (CTCAE; v4.03) classification. In total, 258 patients (median age 58 years, range 21-84) were identified with a mean follow-up of 52 months (range 3-228 months). Mean tumor volume was 1.8 ml (range 0.1-18.5). The mean marginal dose was 12.3 Gy ± 0.6 (range 11-13.5). The cohort was divided into two groups: A (Koos grades I and II, n = 186) and B (Koos grades III and IV, n = 72). The actuarial tumor control rate was 98% after 2 years and 90% after 5 and 10 years. Koos grading did not show a significant impact on tumor control (p = 0.632) or hearing preservation (p = 0.231). After SRS, 18 patients (7%) had new transient or permanent symptoms classified by the CTCAE. The actuarial rate of CTCAE-free survival was not related to Koos grading (p = 0.093). Based on this selected population of Koos grade III and IV VS without or with only mild symptoms from brainstem compression, SRS can be recommended as the primary therapy with the advantage of low morbidity and satisfactory tumor control. The overall hearing preservation rate and toxicity of SRS was influenced by age and cannot be predicted by tumor volume or Koos grading alone.
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Affiliation(s)
- Daniel Rueß
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany.
| | - Lea Pöhlmann
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Stefan Grau
- Department of General Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christina Hamisch
- Department of General Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Mauritius Hoevels
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Harald Treuer
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Baues
- Institute of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - Martin Kocher
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Maximillian Ruge
- Department of Stereotaxy and functional Neurosurgery, Centre of Neurosurgery, University Hospital of Cologne, Cologne, Germany
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14
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Dzierzęcki S, Turek G, Czapski B, Dyttus‐Cebulok K, Tomasiuk R, Kaczor S, Ząbek M. Gamma knife surgery in the treatment of intracanalicular vestibular schwannomas. Acta Neurol Scand 2020; 141:415-422. [PMID: 31922606 DOI: 10.1111/ane.13220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 12/24/2019] [Accepted: 01/05/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE According to the literature, gamma knife surgery (GKS) is a promising method for intracanalicular vestibular schwannoma (IVS) management, providing excellent tumor growth control rates (91%-100%) and good hearing preservation rates (41%-76%), but this evidence originates primarily from a small series of patients. The aim of this study was to present the outcomes of GKS in the largest group of patients with IVS studied to date, with particular emphasis on the long-term outcomes of treatment. METHODS The study included 136 consecutive patients with unilateral IVS, who underwent GKS in 2011-2015. Mean age of the patients was 54 ± 12.6 years. All patients were operated on with a 192-source cobalt-60 gamma knife unit. All patients had complete follow-up documentation and the mean duration of the follow-up was 52 ± 13.8 months (6-83 months). Neurological status (facial and trigeminal nerve), hearing and instability/dizziness presence were determined prior to GKS, immediately after the procedure, and during the follow-up visits. RESULTS Tumor growth control was obtained in 124/136 (~91.2%) patients. Hearing improvement was observed in 32/136 (23.5%) patients, and there was a distinct cluster of 9 patients (6.6%) regaining serviceable hearing after GKS, whereas in 36 patients (26.5%) was stable. Four patients developed facial nerve dysfunction, including 3 periodic hemifacial spasm and 1 partial paresis, which resolved spontaneously within 12 months of GKS. None of the operated patients showed new, debilitating neurological deficits, including trigeminal sensory disturbances or hydrocephalus. CONCLUSIONS GKS is a highly effective treatment for IVS, associated with low morbidity and good tumor growth control.
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Affiliation(s)
- Sebastian Dzierzęcki
- Department of Neurosurgery Postgraduate Medical Centre Warsaw Poland
- Gamma Knife Centre Warsaw Poland
| | - Grzegorz Turek
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
| | - Bartosz Czapski
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
| | - Katarzyna Dyttus‐Cebulok
- Gamma Knife Centre Warsaw Poland
- Department of Radiation Oncology Maria Sklodowska‐Curie Institute of Oncology Warsaw Poland
| | - Ryszard Tomasiuk
- Department of Laboratory Diagnostics Brodno Masovian Hospital Warsaw Poland
| | - Szymon Kaczor
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
| | - Mirosław Ząbek
- Department of Neurosurgery Postgraduate Medical Centre Warsaw Poland
- Gamma Knife Centre Warsaw Poland
- Department of Neurosurgery Brodno Masovian Hospital Warsaw Poland
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15
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Iorio-Morin C, Liscak R, Vladyka V, Kano H, Jacobs RC, Lunsford LD, Cohen-Inbar O, Sheehan J, Emad R, Karim KA, El-Shehaby A, Reda WA, Lee CC, Pai FY, Wolf A, Kondziolka D, Grills I, Lee KC, Mathieu D. Repeat Stereotactic Radiosurgery for Progressive or Recurrent Vestibular Schwannomas. Neurosurgery 2020; 85:535-542. [PMID: 30189018 DOI: 10.1093/neuros/nyy416] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 08/07/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a highly effective management approach for patients with vestibular schwannomas (VS), with 10-yr control rates up 98%. When it fails, however, few data are available to guide management. OBJECTIVE To perform a retrospective analysis of patients who underwent 2 SRS procedures on the same VS to assess the safety and efficacy of this practice. METHODS This study was opened to centers of the International Gamma Knife Research Foundation (IGKRF). Data collected included patient characteristics, clinical symptoms at the time of SRS, radiosurgery dosimetric data, imaging response, clinical evolution, and survival. Actuarial analyses of tumor responses were performed. RESULTS Seventy-six patients from 8 IGKRF centers were identified. Median follow-up from the second SRS was 51.7 mo. Progression after the first SRS occurred at a median of 43 mo. Repeat SRS was performed using a median dose of 12 Gy. Actuarial tumor control rates at 2, 5, and 10 yr following the second SRS were 98.6%, 92.2%, and 92.2%, respectively. Useful hearing was present in 30%, 8%, and 5% of patients at first SRS, second SRS, and last follow-up, respectively. Seventy-five percent of patients reported stable or improved symptoms following the second SRS. Worsening of facial nerve function attributable to SRS occurred in 7% of cases. There were no reports of radionecrosis, radiation-associated edema requiring corticosteroids, radiation-related neoplasia, or death attributable to the repeat SRS procedure. CONCLUSION Patients with progressing VS after radiosurgery can be safely and effectively managed using a second SRS procedure.
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Affiliation(s)
- Christian Iorio-Morin
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
| | | | | | - Hideyuki Kano
- Department of Neurological Surgery, Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rachel C Jacobs
- Department of Neurological Surgery, Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, Center for Image-Guided Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Reem Emad
- National Cancer Institute, Cairo University, Gamma Knife Center Cairo, Cairo, Egypt
| | - Khalid Abdel Karim
- Clinical Oncology Department, Ain Shams University, Gamma Knife Center Cairo, Cairo, Egypt
| | - Amr El-Shehaby
- Neurosurgery Department, Ain Shams University, Gamma Knife Center Cairo, Cairo, Egypt
| | - Wael A Reda
- Neurosurgery Department, Ain Shams University, Gamma Knife Center Cairo, Cairo, Egypt
| | - Cheng-Chia Lee
- Taipei Veterans General Hospital Neurological Institute, Taipei, Taiwan
| | - Fu-Yuan Pai
- Taipei Veterans General Hospital Neurological Institute, Taipei, Taiwan
| | - Amparo Wolf
- New York University Langone Medical Center, New York, New York
| | | | - Inga Grills
- Beaumont Gamma Knife Center, Royal Oak, Michigan
| | - Kuei C Lee
- Beaumont Gamma Knife Center, Royal Oak, Michigan
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec, Canada
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16
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Mezey G, Cahill J, Rowe JG, Yianni J, Bhattacharyya D, Walton L, Rodgers J, Radatz MWR. A Retrospective Analysis of the Role of Single-Session Gamma Knife Stereotactic Radiosurgery in Sporadic Vestibular Schwannomas with Tumor Volumes Greater Than 10 cm3: Is It Worth Stretching the Boundaries? Stereotact Funct Neurosurg 2020; 98:85-94. [PMID: 32160612 DOI: 10.1159/000504857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/18/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the role of single-session Gamma Knife stereotactic radiosurgery (GK-SRS) in the treatment of vestibular schwannomas (VSs) with volumes of greater 10 cm3. METHODS A retrospective analysis was performed of 103 patients treated with single-session GK-SRS between 1993 and 2011 with a mean follow-up of 6.2 years ± 4.4 SD. Treatment, clinical and outcome details were recorded and assessed. RESULTS Eighty-one (78.6%) patients achieved radiological control with slow progression in a further 5 (4.9%) patients, who did not require further treatment. Linear measurements did not correlate well with volume, which can predict outcome following treatment more precisely. 2.9% of patients developed a new facial paresis, 5.8% trigeminal numbness and 2.9% facial pain. In all, 26 (25.2%) patients who were tested preserved some level of hearing following treatment. CONCLUSIONS The overall radiological control rate in this study was 78.6%, while tumor volumes less than 20 cm3 can be safely treated with single-stage GK-SRS with an expected control rate of 83.2% without unacceptable morbidity rates. GK-SRS can be utilized as a first-line treatment option in patients with large-volume VSs especially in whom surgery is unattractive.
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Affiliation(s)
- Geza Mezey
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom,
| | - Julian Cahill
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom
| | - Jeremy G Rowe
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom
| | - John Yianni
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom
| | - Debapriya Bhattacharyya
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom
| | - Lee Walton
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom
| | - Joanne Rodgers
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom
| | - Matthias W R Radatz
- Department of Stereotactic Radiosurgery, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, National Centre for Stereotactic Radiosurgery, Sheffield, United Kingdom
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Johnson S, Kano H, Faramand A, Niranjan A, Flickinger JC, Lunsford LD. Predicting hearing outcomes before primary radiosurgery for vestibular schwannomas. J Neurosurg 2019; 133:1235-1241. [PMID: 31491764 DOI: 10.3171/2019.5.jns182765] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Optimizing outcomes in the management of patients with vestibular schwannomas (VSs) requires consideration of the patient's goals. Earlier recognition of VS by imaging has led to an evolution in management. Stereotactic radiosurgery (SRS) has emerged as a frequently used strategy designed to reduce management risks, obtain long-term tumor control, and preserve current neurological function. The authors analyzed features that impact hearing preservation rates in patients with serviceable hearing prior to SRS. METHODS The study included 307 patients who had serviceable hearing (Gardner-Robertson hearing scale [GR] grade 1 or 2, speech discrimination score ≥ 50%, pure tone average ≤ 50 dB) at the time of SRS. The authors evaluated parameters that included age, tumor volume, hearing status, disequilibrium, tinnitus, Koos class, sex, and tumor margin dose. The Pittsburgh Hearing Prediction Score (PHPS) was evaluated as a method to predict long-term hearing outcomes in these cases. RESULTS At a median of 7.6 years after SRS (range 1-23 years), tumor control was achieved in 95% of patients. The overall serviceable hearing preservation rate was 77.8% at 3 years, 68.8% at 5 years, and 51.8% at 10 years. The PHPS assigns a total of 5 points based on patient age (1 point if < 45 years, 2 points if 45-59 years, and 3 points if ≥ 60 years), tumor volume (0 points if < 1.2 cm3, 1 point if ≥ 1.2 cm3), and GR grade (0 points if grade 1 hearing, 1 point if grade 2 hearing) The serviceable hearing preservation rate was 92.3% at 10 years in patients whose score total was 1. In contrast, none of the patients whose PHPS was 5 maintained serviceable hearing at 10 years (p < 0.001). CONCLUSIONS SRS resulted in a high rate of long-term tumor control and cranial nerve preservation. The PHPS helped to predict long-term hearing preservation rates in patients who underwent SRS when they still had serviceable hearing. The best long-term hearing preservation rates were found in younger patients with smaller tumor volumes.
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Affiliation(s)
- Stephen Johnson
- Departments of1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- Departments of1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew Faramand
- Departments of1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ajay Niranjan
- Departments of1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John C Flickinger
- 2Radiation Oncology, and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Departments of1Neurological Surgery and
- 3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Texture Analysis of Standard Magnetic Resonance Images to Predict Response to Gamma Knife Radiosurgery in Vestibular Schwannomas. World Neurosurg 2019; 132:e228-e234. [PMID: 31493607 DOI: 10.1016/j.wneu.2019.08.193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/23/2019] [Accepted: 08/24/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To search for texture features of routine magnetic resonance imaging to predict tumor volume reduction and transient versus permanent tumor progression of vestibular schwannomas treated by Gamma Knife stereotactic radiosurgery. MATERIALS AND METHODS Included were 23 patients with vestibular schwannomas treated in our center and followed over a period of 23.7-80.3 months (mean 42.7). Magnetic resonance imaging was performed on a 3-Tesla scanner and included T1-weighted images with and without contrast enhancement, T2-weighted, and fluid-attenuated inversion recovery images. Volumetric results were followed longitudinally over time and correlated to texture features as mean, minimum, maximum, standard deviation, skewness, and kurtosis of normalized signals taken from regions of interest covering the total tumor volume. RESULTS In total, 14 tumors showed early progression during the first 5-18 months (2 cases permanent, 12 cases transient), whereas 9 tumors regressed immediately after SRS. Kurtosis of T2-weighted image intensity values turned out to predict progression best with a sensitivity and specificity of 71% and 78%. From all texture feature parameters, only the minimum of the normalized T2-weighted image intensity values correlated significantly to the final reduction of tumor volume per month (correlation coefficient = -0.634, P < 0.05, corrected for false discovery rate). CONCLUSIONS Texture feature analysis helps to predict permanent versus transient enlargement and final volume reduction of schwannomas after SRS. Thus, alternative treatment strategies might be considered, mainly in large tumors, where further clinical deterioration cannot be excluded. To confirm these results, a prospective study including more cases and a longer follow-up period is necessary.
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Tuleasca C, George M, Maire R, Schiappacasse L, Marguet M, Daniel RT, Levivier M. Letter: Cystic Vestibular Schwannomas Respond Best to Radiosurgery. Neurosurgery 2019; 81:E80-E82. [PMID: 28945909 DOI: 10.1093/neuros/nyx462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Constantin Tuleasca
- Department of Clinical Neurosciences Neurosurgery Service and Gamma Knife Center Lausanne University Hospital (CHUV) Lausanne, Switzerland.,Signal Processing Laboratory (LTS 5) Ecole Polytechnique Fédérale de Lausanne (EPFL) Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM) University of Lausanne Lausanne, Switzerland
| | - Mercy George
- Department of ENT surgery CHUV, University of Lausanne Lausanne, Switzerland
| | - Raphael Maire
- Department of ENT surgery CHUV, University of Lausanne Lausanne, Switzerland
| | - Luis Schiappacasse
- Radiation Oncology Service CHUV, University of Lausanne Lausanne, Switzerland
| | - Maud Marguet
- Institute of Radiation Physics University of Lausanne Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences Neurosurgery Service and Gamma Knife Center Lausanne University Hospital (CHUV) Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM) University of Lausanne Lausanne, Switzerland
| | - Marc Levivier
- Department of Clinical Neurosciences Neurosurgery Service and Gamma Knife Center Lausanne University Hospital (CHUV) Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM) University of Lausanne Lausanne, Switzerland
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20
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Ros-Sanjuán Á, Iglesias-Moroño S, Troya-Castilla M, Márquez-Márquez B, Herruzo-Cabrera I, Arráez-Sánchez MÁ. LINAC radiosurgery treatment for vestibular schwannoma. Neurocirugia (Astur) 2019; 30:179-187. [PMID: 30770322 DOI: 10.1016/j.neucir.2018.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/15/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aims of our study were to evaluate tumour response in a series of patients with vestibular schwannoma (VS) treated with linear accelerator stereotactic radiosurgery (LINAC-RS), to describe the complications and to analyze the variables associated with the response to treatment. MATERIAL AND METHODS This retrospective descriptive study included 64 patients treated from 2010 to 2016 with a minimum follow-up of one year, excluding patients with neurofibromatosis. Clinical-radiological parameters were evaluated. The treatment was performed using LINAC-RS. The prescribed dose was 12Gy at 90% isodose. RESULTS The mean age at treatment was 53 years, 56% were women. Ninety-eight percent of the patients had hearing loss, 71% with grade III according to the Gardner-Robertson Classification. The mean volume at treatment was 2.92cc and the mean follow-up, 40.95 months. The overall therapeutic success was 90%, reaching 100% at 12 and 24 months, and 86% after 36 months of follow-up. The radiological result was significantly related to the initial tumour volume (p<0.037). In 20 patients there was evidence of transient tumour growth compatible with pseudoprogression. Acute complications were present in 37.5%, and transitory complications in 50%. Chronic complications were found in 20%, with 84% being permanent. The rate of acute complications was lower in patients with regression (p<0.016). Chronic complications were more frequent in the 41-60 year old age group (p<0.040). CONCLUSIONS In our study, the overall tumour control was in accordance with other published series. The radiological result significantly related to the tumour volume at the commencement of treatment. The rate of acute complications was lower in patients with regression.
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Affiliation(s)
- Ángela Ros-Sanjuán
- Department of Neurosurgery, Regional University Hospital of Malaga, Malaga, Spain.
| | - Sara Iglesias-Moroño
- Department of Neurosurgery, Regional University Hospital of Malaga, Malaga, Spain
| | - Marta Troya-Castilla
- Department of Neurosurgery, Regional University Hospital of Malaga, Malaga, Spain
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21
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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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22
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Abstract
Stereotactic radiosurgery (SRS) maintains an important role in managing vestibular schwannoma (VS). Long-term clinical data have clearly established the safety and efficacy of the procedure for managing Koos low grade to intermediate grade VS. Historically, the procedure was developed via a multidisciplinary approach that involves physicians (eg, neurosurgeons and radiation oncologists) as well as clinical specialists (eg, radiation physicists). In this paper, we have reviewed current technical and clinical practices of SRS for VS from a procedural specialist’s perspective and from a clinician’s perspective.
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Affiliation(s)
- Steve Braunstein
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA,
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA,
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23
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Troude L, Boucekine M, Montava M, Lavieille JP, Régis JM, Roche PH. Adjunctive Gamma Knife Surgery or Wait and Scan Policy After Optimal Resection of Large Vestibular Schwannomas: Clinical and Radiologic Outcomes. World Neurosurg 2018; 118:e895-e905. [DOI: 10.1016/j.wneu.2018.07.093] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
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24
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Daniel RT, Tuleasca C, Rocca A, George M, Pralong E, Schiappacasse L, Zeverino M, Maire R, Messerer M, Levivier M. The Changing Paradigm for the Surgical Treatment of Large Vestibular Schwannomas. J Neurol Surg B Skull Base 2018; 79:S362-S370. [PMID: 30210991 DOI: 10.1055/s-0038-1668540] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022] Open
Abstract
Objective Planned subtotal resection followed by Gamma Knife surgery (GKS) in patients with large vestibular schwannoma (VS) has emerged during the past decade, with the aim of a better functional outcome for facial and cochlear function. Methods We prospectively collected patient data, surgical, and dosimetric parameters of a consecutive series of patients treated by this method at Lausanne University Hospital during the past 8 years. Results A consecutive series of 47 patients were treated between July 2010 and January 2018. The mean follow-up after surgery was 37.5 months (median: 36, range: 0.5-96). Mean presurgical tumor volume was 11.8 mL (1.47-34.9). Postoperative status showed normal facial nerve function (House-Brackmann I) in all patients. In a subgroup of 28 patients, with serviceable hearing before surgery and in which cochlear nerve preservation was attempted at surgery, 26 (92.8%) retained serviceable hearing. Nineteen had good or excellent hearing (Gardner-Robertson class 1) before surgery, and 16 (84.2%) retained it after surgery. Mean duration between surgery and GKS was 6 months (median: 5, range: 3-13.9). Mean residual volume as compared with the preoperative one at GKS was 31%. Mean marginal dose was 12 Gy (11-12). Mean follow-up after GKS was 34.4 months (6-84). Conclusion Our data show excellent results in large VS management with a combined approach of microsurgical subtotal resection and GKS on the residual tumor, with regard to the functional outcome and tumor control. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control.
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Affiliation(s)
- Roy Thomas Daniel
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
| | - Constantin Tuleasca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Medical Image Analysis Laboratory (MIAL), Lausanne University Hospital, Lausanne, VauD, Switzerland.,Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne, Lausanne, VauD, Switzerland
| | - Alda Rocca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland
| | - Mercy George
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Department of Otorhinolaryngology/Head & Neck Surgery, Lausanne University Hospital, Lausanne, VauD, Switzerland
| | - Etienne Pralong
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
| | - Luis Schiappacasse
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Radiation Oncology Service, Lausanne, VauD, Switzerland
| | - Michele Zeverino
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Institute of Radiation Physics, Lausanne University Hospital (CHUV), Lausanne, VauD, Switzerland
| | - Raphael Maire
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Department of Otorhinolaryngology/Head & Neck Surgery, Lausanne University Hospital, Lausanne, VauD, Switzerland
| | - Mahmoud Messerer
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
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25
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Nagy G, Yianni J, Bhattacharyya D, Rowe JG, Kemeny AA, Radatz MWR. Repeat Radiosurgery Treatment After Cavernous Malformation Radiosurgery. World Neurosurg 2018; 118:e296-e303. [PMID: 29969736 DOI: 10.1016/j.wneu.2018.06.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Of cavernous malformations (CMs) treated with radiosurgery (RS), 5% bleed after 2-year initial latency period. This rate is similar to failure rate of RS for other pathologies, which often require repeat RS for favorable outcome. The aim of this pilot study was to define failure of CM RS and to assess safety of second RS. METHODS Retrospective analysis was performed of 7 of 345 CMs retreated with RS; 6 CMs were deep-seated, and 1 was superficial. Median time between the 2 treatments was 8 years (range, 3-16 years), and median follow-up time after second RS was 3 years (range, 1-9 years). RESULTS Following the 2-year latency period after RS, 6% of deep-seated and 5% of hemispheric CMs, and 6% of deep-seated and 2% of hemispheric lesions caused transient neurologic deficits without hemorrhage. A second treatment was indicated for rebleed in 5 cases and for recurrent transient neurologic deficits in 2 cases. Prescribed dose was 15 Gy (range, 12-20 Gy) at first treatment and 12 Gy (range, 12-18 Gy) at second treatment. Target volumes were 692 mm3 (range, 54-2400 mm3) and 935 mm3 (range, 150-1550 mm3) at first and second treatments, respectively, and treatment volumes were 811 mm3 (range, 79-2500 mm3) and 962 mm3 (range, 194-1750 mm3), respectively. Differences in treatment parameters were not significant. Reason for failure was inaccurate target definition in only 2 cases. There were no bleeds, morbidity, or mortality after second RS. CONCLUSIONS Second RS applied to previously treated CMs is safe and may be effective. Further investigations are needed to verify these findings and assess long-term benefit of second RS.
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Affiliation(s)
- Gábor Nagy
- National Institute of Clinical Neurosciences, Budapest, Hungary
| | - John Yianni
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Debapriya Bhattacharyya
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Jeremy G Rowe
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | | | - Matthias W R Radatz
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom.
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26
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Lefranc M, Da Roz LM, Balossier A, Thomassin JM, Roche PH, Regis J. Place of Gamma Knife Stereotactic Radiosurgery in Grade 4 Vestibular Schwannoma Based on Case Series of 86 Patients with Long-Term Follow-Up. World Neurosurg 2018; 114:e1192-e1198. [DOI: 10.1016/j.wneu.2018.03.175] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/23/2018] [Accepted: 03/24/2018] [Indexed: 10/17/2022]
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27
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Kim JH, Jung HH, Chang JH, Chang JW, Park YG, Chang WS. Predictive Factors of Unfavorable Events After Gamma Knife Radiosurgery for Vestibular Schwannoma. World Neurosurg 2017; 107:175-184. [PMID: 28826715 DOI: 10.1016/j.wneu.2017.07.139] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKS) for the treatment of vestibular schwannoma (VS) introduces risks to the facial nerve and auditory perception and may involve post-treatment complications such as pseudoprogression, hydrocephalus, and other cranial neuropathies. This study of patients with VS who underwent GKS investigated radiosurgical results, focusing on post-treatment complications and identifying the factors that predict such complications. METHODS We undertook a retrospective review of all VS patients treated with the Perfexion Leksell Gamma Knife between November 2007 and October 2010 at our institution. Patients who underwent at least 12 months of clinical and radiologic assessments before and after GKS were included. RESULTS All 235 patients were included in the analyses reported here. The 5-year serviceable hearing and facial nerve preservation values were 73.9% and 94.3%, respectively. Following GKS, 43 patients (18.30%) showed pseudoprogression, 15 (6.38%) exhibited hydrocephalus, 22 (9.36%) showed trigeminal neuropathy, 14 (5.96%) showed vertigo, and 25 (10.64%) showed facial myokymia. According to multivariate analysis, solid tumor nature was significantly associated with pseudoprogression and patient age was significantly associated with hydrocephalus. Patients receiving margin doses ≥13 Gy had a significantly higher probability of loss of serviceable hearing. Patients with smaller tumors had a trigeminal nerve preservation rate comparable with patients harboring larger tumors. Patients receiving margin doses <13 Gy or older patients had a significantly higher probability of vestibular nerve dysfunction. CONCLUSIONS Further prospective studies should be designed to provide further insight into the exact relationship between the predictive factors we investigated and post-treatment complications.
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Affiliation(s)
- Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Korea
| | - Hyun Ho Jung
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Woo Chang
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Gou Park
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Won Seok Chang
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea.
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28
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Preserving normal facial nerve function and improving hearing outcome in large vestibular schwannomas with a combined approach: planned subtotal resection followed by gamma knife radiosurgery. Acta Neurochir (Wien) 2017; 159:1197-1211. [PMID: 28516364 PMCID: PMC5486604 DOI: 10.1007/s00701-017-3194-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/24/2017] [Indexed: 11/17/2022]
Abstract
Objective To perform planned subtotal resection followed by gamma knife surgery (GKRS) in a series of patients with large vestibular schwannoma (VS), aiming at an optimal functional outcome for facial and cochlear nerves. Methods Patient characteristics, surgical and dosimetric features, and outcome were collected prospectively at the time of treatment and during the follow-up. Results A consecutive series of 32 patients was treated between July 2010 and June 2016. Mean follow-up after surgery was 29 months (median 24, range 4–78). Mean presurgical tumor volume was 12.5 cm3 (range 1.47–34.9). Postoperative status showed normal facial nerve function (House–Brackmann I) in all patients. In a subgroup of 17 patients with serviceable hearing before surgery and in which cochlear nerve preservation was attempted at surgery, 16 (94.1%) retained serviceable hearing. Among them, 13 had normal hearing (Gardner–Robertson class 1) before surgery, and 10 (76.9%) retained normal hearing after surgery. Mean duration between surgery and GKRS was 6.3 months (range 3.8–13.9). Mean tumor volume at GKRS was 3.5 cm3 (range 0.5–12.8), corresponding to mean residual volume of 29.4% (range 6–46.7) of the preoperative volume. Mean marginal dose was 12 Gy (range 11–12). Mean follow-up after GKRS was 24 months (range 3–60). Following GKRS, there were no new neurological deficits, with facial and hearing functions remaining identical to those after surgery in all patients. Three patients presented with continuous growth after GKRS, were considered failures, and benefited from the same combined approach a second time. Conclusion Our data suggest that large VS management, with planned subtotal resection followed by GKRS, might yield an excellent clinical outcome, allowing the normal facial nerve and a high level of cochlear nerve functions to be retained. Our functional results with this approach in large VS are comparable with those obtained with GKRS alone in small- and medium-sized VS. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control.
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29
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Abstract
The incidence of brain tumors in the elderly population has increased over the last few decades. Current treatment includes surgery, radiotherapy and chemotherapy, but the optimal management of older patients with brain tumors remains a matter of debate, since aggressive radiation treatments in this population may be associated with high risks of neurological toxicity and deterioration of quality of life. For such patients, a careful clinical status assessment is mandatory both for clinical decision making and for designing randomized trials to adequately evaluate the optimal combination of radiotherapy and chemotherapy. Several randomized studies have demonstrated the efficacy and safety of chemotherapy for patients with glioblastoma or lymphoma; however, the use of radiotherapy given in association with chemotherapy or as salvage therapy remains an effective treatment option associated with survival benefit. Stereotactic techniques are increasingly used for the treatment of patients with brain metastases and benign tumors, including pituitary adenomas, meningiomas and acoustic neuromas. Although no randomized trials have proven the superiority of SRS over other radiation techniques in older patients with brain metastases or benign brain tumors, data extracted from recent randomized studies and large retrospective series suggest that SRS is an effective approach in such patients associated with survival advantages and toxicity profile similar to those observed in young adults. Future trials need to investigate the optimal radiation techniques and dose/fractionation schedules in older patients with brain tumors with regard to clinical outcomes, neurocognitive function, and quality of life.
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Affiliation(s)
- Giuseppe Minniti
- Department of Neurological Sciences, IRCCS Neuromed, Via Atinense, Pozzilli, (IS), Italy. .,UPMC San Pietro FBF, Radiotherapy Center, Rome, Italy.
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30
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Schumacher AJ, Lall RR, Lall RR, Nanney A, Ayer A, Sejpal S, Liu BP, Marymont M, Lee P, Bendok BR, Kalapurakal JA, Chandler JP. Low-Dose Gamma Knife Radiosurgery for Vestibular Schwannomas: Tumor Control and Cranial Nerve Function Preservation After 11 Gy. J Neurol Surg B Skull Base 2017; 78:2-10. [PMID: 28180036 DOI: 10.1055/s-0036-1584231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 04/19/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES This study aims to report tumor control rates and cranial nerve function after low dose (11.0 Gy) Gamma knife radiosurgery (GKRS) in patients with vestibular schwannomas. METHODS A retrospective chart review was performed on 30 consecutive patients with vestibular schwannomas treated from March 2004 to August 2010 with GKRS at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. The marginal dose for all patients was 11.0 Gy prescribed to the 50% isodose line. Median follow-up time was 42 months. The median treatment volume was 0.53 cm3. Hearing data were obtained from audiometry reports before and after radiosurgery. RESULTS The actuarial progression free survival (PFS) based on freedom from surgery was 100% at 5 years. PFS based on freedom from persistent growth was 91% at 5 years. One patient experienced tumor progression requiring resection at 87 months. Serviceable hearing, defined as Gardner-Robertson score of I-II, was preserved in 50% of patients. On univariate and multivariate analyses, only higher mean and maximum dose to the cochlea significantly decreased the proportion of patients with serviceable hearing. CONCLUSION Vestibular schwannomas can be treated with low doses (11.0 Gy) of GKRS with good tumor control and cranial nerve preservation.
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Affiliation(s)
- Andrew J Schumacher
- Department of Radiation Oncology, Kaiser Permanente, Los Angeles, California, United States
| | - Rohan R Lall
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Rishi R Lall
- Department of Neurological Surgery, University of Texas Medical Branch, Galveston, Texas, United States
| | - Allan Nanney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Amit Ayer
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Samir Sejpal
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Benjamin P Liu
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Maryanne Marymont
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Plato Lee
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Bernard R Bendok
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - John A Kalapurakal
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - James P Chandler
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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31
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Bailo M, Boari N, Gagliardi F, Franzin A, Piloni M, Spina A, Gemma M, Vecchio AD, Bolognesi A, Mortini P. Gamma Knife Radiosurgery for Residual and Recurrent Vestibular Schwannomas After Previous Surgery: Clinical Results in a Series of 90 Patients and Review of the Literature. World Neurosurg 2017; 98:60-72. [DOI: 10.1016/j.wneu.2016.10.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 12/31/2022]
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Tuleasca C, George M, Faouzi M, Schiappacasse L, Leroy HA, Zeverino M, Daniel RT, Maire R, Levivier M. Acute clinical adverse radiation effects after Gamma Knife surgery for vestibular schwannomas. J Neurosurg 2016; 125:73-82. [DOI: 10.3171/2016.7.gks161496] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEVestibular schwannomas (VSs) represent a common indication of Gamma Knife surgery (GKS). While most studies focus on the long-term morbidity and adverse radiation effects (AREs), none describe the acute clinical AREs that might appear on a short-term basis. These types of events are investigated, and their incidence, type, and outcomes are reported in the present paper.METHODSThe included patients were treated between July 2010 and March 2016, underwent at least 6 months of follow-up, and presented with a disabling symptom during the first 6 months after GKS that affected their quality of life. The timing of appearance, as well as the type of main symptom and outcome, were noted. The prescribed dose was 12 Gy at the margin.RESULTSThirty-five (22%) of 159 patients who fulfilled the inclusion criteria had acute clinical AREs. The mean followup period was 30 months (range 6–49.2 months). The mean time of appearance was 37.9 days (median 31 days; range 3–110 days). In patients with de novo symptoms, the more frequent symptoms were vertigo (n = 4; 11.4%) and gait disturbance (n = 3; 8.6%). The exacerbation of a preexisting symptom was more frequently related to hearing loss (n = 10; 28.6%), followed by gait disturbance (n = 7; 20%) and vertigo (n = 3, 8.6%). In the univariate logistic regression analysis, the following factors were statistically significant: age (p = 0.002; odds ratio [OR] 0.96), hearing at baseline by Gardner-Robertson (GR) class (p = 0.006; OR 0.21), pure tone average at baseline (p = 0.006; OR 0.97), and Koos grade at baseline (with Koos Grade I used as a reference) (for Koos Grade II, OR 0.17 and p = 0.002; for Koos Grade III, OR 0.42 and p = 0.05). The following were not statistically significant but showed a tendency toward significance: the number of isocenters (p = 0.06; OR 0.94) and the maximal dose received by the cochlea (p = 0.07; OR 0.74). Fractional polynomial regression analysis showed a nonlinear relationship between the outcome and the radiation dose rate (minimum reached at a cutoff of 2.5 Gy/minute) and the maximal vestibular dose (maximum reached at a cutoff of 8 Gy), but the small sample size precludes a detailed analysis of the former. The clinical acute AREs disappeared in 32 (91.4%) patients during the first 6 months after appearance. Permanent and somewhat disabling morbidity was found in 3 cases (1.9% from the whole series): 1 each with complete hearing loss (GR Class I before and V after), hemifacial spasm (persistent but alleviated), and dysgeusia.CONCLUSIONSAcute effects after radiosurgery for VS are not rare. They concern predominantly de novo vertigo and gait disturbance and the exacerbation of preexistent hearing loss. In de novo vestibular symptoms, a vestibular dose of more than 8 Gy is thought to play a role. In most cases, none of these effects are permanent, and they will ultimately improve or disappear with steroid therapy. Permanent AREs remain very rare.
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Affiliation(s)
- Constantin Tuleasca
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 2Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL)
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Mercy George
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 4Department of ENT Surgery,
| | - Mohamed Faouzi
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 5Institute of Social and Preventive Medicine, and
| | - Luis Schiappacasse
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 6Radiation Oncology Service, Lausanne University Hospital (CHUV), Lausanne
| | - Henri-Arthur Leroy
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 7Division of Neurosurgery, Centre Hospitalier Régional Universitaire de Lille, France; and
| | | | - Roy Thomas Daniel
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Raphael Maire
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 4Department of ENT Surgery,
| | - Marc Levivier
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
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Gamma Knife Radiosurgery as Primary Treatment for Large Vestibular Schwannomas: Clinical Results at Long-Term Follow-Up in a Series of 59 Patients. World Neurosurg 2016; 95:487-501. [DOI: 10.1016/j.wneu.2016.07.117] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/27/2016] [Accepted: 07/30/2016] [Indexed: 12/19/2022]
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Ma L, Braunstein SE, Theodosopoulos PV, McDermott MW, Sneed PK. Inherent functional dependence among cochlear dose surrogates for stereotactic radiosurgery of vestibular schwannomas. Pract Radiat Oncol 2016; 7:e1-e7. [PMID: 27742557 DOI: 10.1016/j.prro.2016.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/25/2016] [Accepted: 08/15/2016] [Indexed: 12/31/2022]
Abstract
PURPOSE Various cochlear dose surrogates have been reported as associated with hearing outcome in studies of stereotactic radiosurgery (SRS) for vestibular schwannomas. In this study, we investigated whether an inherent functional relationship exists among these reported surrogates. METHODS AND MATERIALS A cohort of 85 serial patient cases treated with single-fraction stereotactic radiosurgery from 1997 through 2013 at our institution was analyzed. For all the cases, the mean prescription dose was 12.5 ± 0.3 Gy (range, 12-13 Gy) and mean target volume 1.32 ± 1.51 mL (range, 0.80-8.77 mL). The mean cochlea volume was 0.078 ± 0.016 mL (range, 0.048-0.131 mL; median, 0.076 mL). Correlation analysis among mean cochlear dose, point maximum dose and modiolus dose was performed and also parameterized with new variables such as the effective dose radius (EDR) as derived from a general dose fall-off model. RESULTS Weak correlation via linear regression was found between the point maximum dose and the mean cochlear dose (R2 = 0.719) as well as the modiolus dose (R2 = 0.568). However, when parameterized with EDR, a near-perfect correlation (P < .0001) via linear regression was found between the EDR for the point maximum dose and the EDR for the mean cochlear dose (R2 = 0.996), and with the EDR for the modiolus dose (R2 = 0.993). Such a result led to a functional formula relating these dose surrogates, yielding dose equivalence results such as: 12-Gy point maximum dose is equivalent to mean cochlear dose of 5.6 ± 0.1 Gy (95% confidence level), or modiolus dose of 6.0 ± 0.2 Gy (95% confidence level). CONCLUSIONS An inherent functional relationship was found among point maximum, modiolus, and mean cochlear doses for SRS of vestibular schwannomas. As such, clinical hearing outcome can be interchangeably analyzed or reported via any of these dose surrogates.
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Affiliation(s)
- Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, California.
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco, California
| | | | - Michael W McDermott
- Department of Neurosurgery, University of California, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, California
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Boari N, Bailo M, Gagliardi F, Franzin A, Gemma M, Vecchio AD, Bolognesi A, Picozzi P, Mortini P. Gamma Knife radiosurgery for vestibular schwannoma: clinical results at long-term follow-up in a series of 379 patients. J Neurosurg 2014; 121 Suppl:123-42. [DOI: 10.3171/2014.8.gks141506] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectSince the 1990s, Gamma Knife radiosurgery (GKRS) has become the first-line treatment option for small- to medium-size vestibular schwannomas (VSs), especially in patients without mass effect–related symptoms and with functional hearing. The aim of this study was to assess the safety and efficacy of GKRS, in terms of tumor control, hearing preservation, and complications, in a series of 379 consecutive patients treated for VS.MethodsOf 523 patients treated at the authors' institution for VS between 2001 and 2010, the authors included 379 who underwent GKRS as the primary treatment. These patients were not affected by Type 2 neurofibromatosis and had clinical follow-up of at least 36 months. Clinical follow-up (mean and median 75.7 and 69.5 months, respectively) was performed for all patients, whereas audiometric and quantitative radiological follow-up examinations were obtained for only 153 and 219 patients, respectively. The patients' ages ranged from 23 to 85 years (mean 59 years). The mean tumor volume was 1.94 ± 2.2 cm3 (median 1.2 cm3, range 0.013–14.3 cm3), and the median margin dose was 13 Gy (range 11–15 Gy). Parameters considered as determinants of the clinical outcome were long-term tumor control, hearing preservation, and complications. A statistical analysis was performed to correlate clinical outcomes with the radiological features of the tumor, dose-planning parameters, and patient characteristics.ResultsControl of the tumor with GKRS was achieved in 97.1% of the patients. In 82.7% of the patients, the tumor volume had decreased at the last follow-up, with a mean relative reduction of 34.1%. The rate of complications was very low, with most consisting of a transient worsening of preexisting symptoms. Patients who had vertigo, balance disorders, or facial or trigeminal impairment usually experienced a complete or at least significant symptom relief after treatment. However, no significant improvement was observed in patients previously reporting tinnitus. The overall rate of preservation of functional hearing at the long-term follow-up was 49%; in patients with hearing classified as Gardner-Robertson (GR) Class I, this value was 71% and reached 93% among cases of GR Class I hearing in patients younger than 55 years.ConclusionsGamma Knife radiosurgery is a safe and effective treatment for VS, achieving tumor control in 97.1% of cases and resulting in a very low morbidity rate. Younger GR Class I patients had a significantly higher probability of retaining functional hearing even at the 10-year follow-up; for this reason, the time between symptom onset, diagnosis, and treatment should be shortened to achieve better outcomes in functional hearing preservation.
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Affiliation(s)
| | | | | | | | | | | | - Angelo Bolognesi
- 4Service of Radiation Oncology, I.R.C.C.S. San Raffaele Hospital; and
| | | | - Pietro Mortini
- 1Department of Neurosurgery,
- 5Department of Neurosurgery, Vita-Salute San Raffaele University, Milan, Italy
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