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Flores-Milan G, Rainone GJ, Piper K, Peto I, Danner C, Allen KP, Liu SS, van Loveren H, Agazzi S. Temporal lobe injury with middle fossa approach to intracanalicular vestibular schwannomas: a systematic review. Neurosurg Rev 2024; 47:188. [PMID: 38658423 DOI: 10.1007/s10143-024-02425-w] [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: 03/11/2024] [Revised: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 04/26/2024]
Abstract
There are several surgical approaches for vestibular schwannoma (VS) resection. However, management has gradually shifted from microsurgical resection, toward surveillance and radiosurgery. One of the arguments against microsurgery via the middle fossa approach (MFA) is the risk of temporal lobe retraction injury or sequelae. Here, we sought to evaluate the incidence of temporal lobe retraction injury or sequela from a MFA via a systematic review of the existing literature. This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Relevant studies reporting temporal lobe injury or sequela during MFA for VS were identified. Data was aggregated and subsequently analyzed to evaluate the incidence of temporal lobe injury. 22 studies were included for statistical analysis, encompassing 1522 patients that underwent VS resection via MFA. The overall rate of temporal lobe sequelae from this approach was 0.7%. The rate of CSF leak was 5.9%. The rate of wound infection was 0.6%. Meningitis occurred in 1.6% of patients. With the MFA, 92% of patients had good facial outcomes, and 54.9% had hearing preservation. Our series and literature review support that temporal lobe retraction injury or sequelae is an infrequent complication from an MFA for intracanalicular VS resection.
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Affiliation(s)
- Gabriel Flores-Milan
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA
| | - Gersham J Rainone
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA.
| | - Keaton Piper
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA
| | - Ivo Peto
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA
| | - Christopher Danner
- Tampa Bay Hearing and Balance Center, 5 Tampa General Cir, Ste 610, Tampa, FL, USA
| | - Kyle P Allen
- Tampa Bay Hearing and Balance Center, 5 Tampa General Cir, Ste 610, Tampa, FL, USA
| | - Shih Sing Liu
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA
| | - Harry van Loveren
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL, USA
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Nandoliya KR, Winterhalter EJ, Karras CL, Khazanchi R, Youngblood MW, Texakalidis P, Chandler JP, Magill ST. Repeat Surgery for Vestibular Schwannomas: An Institutional Case Series. J Neurol Surg Rep 2023; 84:e140-e143. [PMID: 37900579 PMCID: PMC10611534 DOI: 10.1055/s-0043-1776124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 09/03/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Vestibular schwannomas (VSs) are treated with microsurgery and/or radiosurgery. Repeat resection is rare, and few studies have reported postoperative outcomes. The objective of this study was to describe clinical characteristics and outcomes in patients undergoing repeat surgery for VS. Methods All adult (≥ 18 years) patients undergoing VS resection between 2003 and 2022 at our institution were retrospectively reviewed to identify patients who underwent repeat surgery of an ipsilateral VS following prior gross-total (GTR) or subtotal resection. Patient, radiographic, and clinical characteristics were reviewed. Primary outcomes were postoperative tumor volume, extent of resection, postoperative cranial nerve deficits, and time to further tumor progression. Results Of 102 patients undergoing VS resection, 6 (5.9%) had undergone repeat surgery. Median (range) follow-up was 20 (5-117) months. Three patients were female. Median age was 56 (36-60) years. Median pre- and postoperative tumor volumes were 8.2 (1.8-28.2) cm 3 and 0.4 (0-3.8) cm 3 . GTR was achieved in two patients. Four patients had higher House-Brackmann scores at last follow-up, but none had tumor progression. Conclusion In this small cohort of patients, repeat resection of recurrent or progressive VS can effectively reduce tumor volume with acceptable perioperative outcomes.
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Affiliation(s)
- Khizar R. Nandoliya
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Emily J. Winterhalter
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Constantine L. Karras
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Rushmin Khazanchi
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Mark W. Youngblood
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Pavlos Texakalidis
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - James P. Chandler
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Stephen T. Magill
- Department of Neurological Surgery, Malnati Brain Tumor Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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Zanoletti E, Concheri S, Tealdo G, Cazzador D, Denaro L, d’Avella D, Mazzoni A. Early surgery and definitive cure in small sporadic vestibular schwannoma. ACTA OTORHINOLARYNGOLOGICA ITALICA 2022; 42:481-486. [DOI: 10.14639/0392-100x-n2322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/08/2022] [Indexed: 12/24/2022]
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Yeole U, Prabhuraj AR, Arivazhagan A, Narasingarao KVL, Vazhayil V, Bhat D, Srinivas D, Govindswamy B, Sampath S. Gamma Knife Radiosurgery for Large Vestibular Schwannoma More Than 10 cm3: A Single-Center Indian Study. Skull Base Surg 2022; 83:e343-e352. [DOI: 10.1055/s-0041-1729977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/27/2021] [Indexed: 10/17/2022]
Abstract
Abstract
Introduction Gamma Knife radiosurgery (GKRS) is an effective treatment for benign vestibular schwannomas (VSs). The established cutoffs have recently been challenged, as recent literature expanded the horizon of GKRS to larger tumors. Even though microsurgery remains the primary option for large VS, GKRS can provide reasonable tumor control and is more likely to avoid cranial neuropathies associated with open surgery.
Methods We analyzed patients with VS with volume exceeding 10 cm3 who underwent GKRS at our center from January 2006 to December 2016. Clinicoradiological and radiosurgical data were collected from medical records for statistical analysis. Follow-up was performed every 6 months with a clinical assessment along with magnetic resonance imaging (MRI) of the brain and audiometric evaluation in patients with serviceable hearing.
Results The study included 34 patients (18 males and 16 females) with an average age of 45.5 years. The mean tumor volume was 10.9 cm3 (standard deviation [SD], ± 0.83), with a median tumor dose of 12 Gy (interquartile range, 11.5–12) and a mean follow-up of 34.7 months (SD, ± 23.8). Tumor response was graded as regression in 50%, stable in 44.1%, and increase or GKRS failure in 2 cases (5.8%). Treatment failure was noted in five cases (14.7%), requiring microsurgical excision and a ventriculoperitoneal shunt post-GKRS. The tumor control rate for the cohort is 85.3%, with a facial preservation rate of 96% (24/25) and hearing loss in all (5/5), while three patients developed new-onset hypoesthesia. We noted that gait ataxia and involvement of cranial nerve V or VII at initial presentation were associated with GKRS failure in univariate analysis.
Conclusion Microsurgery should remain the first-choice treatment option for large VSs. GKRS is a viable alternative with good tumor control and improved or stabilized cranial neuropathies with a low complication rate.
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Affiliation(s)
- Ujwal Yeole
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - A. R. Prabhuraj
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Arimappamagan Arivazhagan
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - K. V. L. Narasingarao
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Vikas Vazhayil
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Bhanumathi Govindswamy
- Division of Radiation Oncology, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Somanna Sampath
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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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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A R P, Yeole U, Arimappamagan A, Rao KVLN, Bhat DI, Dwarakanath S, Govindswamy B, Somanna S. Effect of Gamma Knife Radiosurgery on Vestibular Schwannoma with Serviceable Hearing: A Single-Center Indian Study. World Neurosurg 2019; 127:e114-e123. [PMID: 30862586 DOI: 10.1016/j.wneu.2019.02.169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is an established treatment modality for vestibular schwannomas (VSs). The tumor control and hearing preservation rates suggest that GKRS is a good alternative treatment for small- and medium-size VS. Data are lacking from India regarding GKRS for VSs. Our aim was to find the hearing preservation and tumor control rates and the factors contributing to these. METHODS In a retrospective 9-year study period, 87 patients had undergone GKRS for unilateral VS with Gardner-Robertson (GR) class I or II serviceable hearing. All 87 had been evaluated with magnetic resonance imaging and audiometry before GKRS and during follow-up to assess for the factors influencing tumor control and hearing preservation. RESULTS Of the 87 patients, 77 with a minimum follow-up of 2 years and magnetic resonance imaging and audiometry evaluations available were included in the present study. The median follow-up period was 30 months. The tumor control rate and hearing preservation rate was 96.1% and 79.2%, respectively. Hearing preservation was not affected by the tumor volume. However, age >40 years, pre-GKRS pure tone average <30 decibels, speech discrimination score >85%, pre-GKRS Gardner-Robertson grade I hearing, mean cochlear dose <4 Gy, and pre-GKRS Ohata class of laterality C, D, E were significant on univariate analysis. The multivariate analysis revealed that age >40 years (P = 0.017), pre-GKRS pure tone average <30 decibels (P = 0.002), and Gardner-Robertson class I (P = 0.001) were significant factors. No patient developed cranial nerve dysfunction, hydrocephalus, or malignant degeneration. CONCLUSION For most patients with small VSs, GKRS will be an effective alternative treatment to microsurgery with retained serviceable hearing and good tumor control.
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Affiliation(s)
- Prabhuraj A R
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India.
| | - Ujwal Yeole
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | | | - K V L Narasinga Rao
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Srinivas Dwarakanath
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Bhanumathi Govindswamy
- Division of Radiation Oncology, Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Sampath Somanna
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, India
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Shinoura N, Midorikawa A, Hiromitsu K, Saito S, Yamada R. Preservation of cranial nerve function following awake surgery for benign brain tumors in 22 consecutive patients. J Clin Neurosci 2019; 61:189-195. [PMID: 30782318 DOI: 10.1016/j.jocn.2018.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/07/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Preservation of cranial nerve function in patients with benign tumors such as meningiomas and vestibular schwannomas remains difficult following microsurgery. METHODS In this study, awake surgery was performed in 22 consecutive patients with meningiomas or vestibular schwannomas that compressed cranial nerves (I-XII). Improved, unchanged, or deteriorated cranial nerve function after surgery was evaluated. RESULTS The function of 44 cranial nerves in 22 consecutive patients who underwent awake surgery for meningiomas or vestibular schwannomas improved, was unchanged, or deteriorated in eight, 35, and one nerves, respectively. Regarding the function of the olfactory (Ist) nerve, which is difficult to preserve, hyposmia improved after surgery in two patients with olfactory groove meningiomas. Regarding the auditory (VIIIth) nerve, which is also difficult to preserve, the function was improved, unchanged, or deteriorated after surgery in two, 11, and one patients, respectively, with cerebello-pontine angle meningiomas or vestibular schwannomas. In all patients with serviceable auditory function before surgery, function was preserved after surgery. In the same patients, the function of the facial (VIIth) nerve was also preserved after surgery in all patients. CONCLUSIONS These results suggest that awake surgery for benign brain tumors such as meningiomas and vestibular schwannomas is associated with low patient morbidity regarding cranial nerve function.
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Affiliation(s)
- Nobusada Shinoura
- Department of Neurosurgery, Komagome Metropolitan Hospital, 3-18-22 Hon-komagome, Bunkyo-ku, Tokyo 113-8677, Japan.
| | - Akira Midorikawa
- Department of Psychology, Chuo University of Literature, 742-1 Higashi-nakano, Hachioji City, Tokyo 192-0393, Japan
| | - Kentaro Hiromitsu
- Department of Psychology, Chuo University of Literature, 742-1 Higashi-nakano, Hachioji City, Tokyo 192-0393, Japan
| | - Syoko Saito
- Department of Psychology, Chuo University of Literature, 742-1 Higashi-nakano, Hachioji City, Tokyo 192-0393, Japan
| | - Ryoji Yamada
- Department of Neurosurgery, Komagome Metropolitan Hospital, 3-18-22 Hon-komagome, Bunkyo-ku, Tokyo 113-8677, Japan
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Surgical outcome in smaller symptomatic vestibular schwannomas. Is there a role for surgery? Acta Neurochir (Wien) 2018; 160:2263-2275. [PMID: 30229403 DOI: 10.1007/s00701-018-3674-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Currently, there is no consensus in the initial management of small vestibular schwannomas (VSs). They are routinely watched and/or referred for radiosurgical treatment, although surgical removal is also an option. We hereby evaluate clinical outcomes of patients who have undergone surgical removal of smaller symptomatic VSs. METHODS Patients with vestibular schwannomas (grade T1-T3b according to Hannover classification) were reviewed. Patients with symptomatic tumors who underwent surgery were evaluated. Their preoperative hearing status was based on the guideline of the committee on hearing and equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) foundation. Their postoperative facial nerve function, hearing status, vestibular symptoms, and degree of tumor resection were assessed. RESULTS Thirty patients were selected for surgery via a retrosigmoid approach based on their age, symptoms, and their own decision-making after discussion of management options. Most patients presented with hearing loss. Seventeen patients had useful hearing preoperatively. Among them, 10 patients (59%) preserved useful hearing (class A or B) postoperatively. MRI at 1-year follow-up confirmed complete resection in 26/29 patients. Also, 29 patients (97%) had HB grade I-II, and 1 patient had HB III at 1-year follow-up. Except for 1 patient with CSF leak, 1 patient with delayed facial nerve palsy, and 2 patients with asymptomatic sigmoid sinus occlusion, there were no other new morbidities. CONCLUSION Although both observation and radiosurgery are valid options in the management of smaller size vestibular schwannomas, surgical treatment seems to offer a high rate of facial nerve preservation, a reasonable rate of hearing sparing, and a high total resection rate. Clinicians should consider surgical treatment as a valid option in the initial management of symptomatic small vestibular schwannomas in younger patients.
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Vestibular schwannoma and hearing preservation: Usefulness of level specific CE-Chirp ABR monitoring. A retrospective study on 25 cases with preoperative socially useful hearing. Clin Neurol Neurosurg 2018; 165:108-115. [DOI: 10.1016/j.clineuro.2018.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/04/2018] [Accepted: 01/09/2018] [Indexed: 12/15/2022]
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10
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Shinoura N, Midorikawa A, Hiromitsu K, Saito S, Yamada R. Preservation of hearing following awake surgery via the retrosigmoid approach for vestibular schwannomas in eight consecutive patients. Acta Neurochir (Wien) 2017; 159:1579-1585. [PMID: 28674732 DOI: 10.1007/s00701-017-3235-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/31/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hearing preservation in patients with vestibular schwannomas remains difficult by microsurgery or radiosurgery. METHOD In this study, awake surgery via the retrosigmoid approach was performed for vestibular schwannomas (volume, 11.6 ± 11.2 ml; range, 1.3-26.4 ml) in eight consecutive patients with preoperative quartering of pure tone audiometry (PTA) of 53 ± 27 dB. RESULTS After surgery, hearing was preserved in seven patients and improved in one patient. The postoperative quartering PTA was 51 ± 21 dB. Serviceable hearing (class A + B + C) using the American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification was preserved in all patients. Preoperative useful hearing (AAO-HNS class A + B) was observed in three patients, and useful hearing was preserved in all three of these patients after surgery. In addition, useful facial nerve function (House-Blackmann Grade 1) was preserved in all patients. CONCLUSIONS These results suggest that awake surgery for vestibular schwannomas is associated with low patient morbidity, including with respect to hearing and facial nerve function.
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Kessel KA, Fischer H, Vogel MME, Oechsner M, Bier H, Meyer B, Combs SE. Fractionated vs. single-fraction stereotactic radiotherapy in patients with vestibular schwannoma : Hearing preservation and patients' self-reported outcome based on an established questionnaire. Strahlenther Onkol 2016; 193:192-199. [PMID: 27803960 DOI: 10.1007/s00066-016-1070-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Stereotactic radiotherapy (RT) has been established as a valid treatment alternative in patients with vestibular schwannoma (VS). There is ongoing controversy regarding the optimal fractionation. Hearing preservation may be the primary goal for patients with VS, followed by maintenance of quality of life (QoL). METHODS From 2002 to 2015, 184 patients with VS were treated with radiosurgery (RS) or fractionated stereotactic radiotherapy (FSRT). A survey on current symptoms and QoL was conducted between February and June 2016. RESULTS Median follow-up after RT was 7.5 years (range 0-14.4 years). Mean overall survival (OS) after RT was 31.1 years, with 94 and 87% survival at 5 and 10 years, respectively [corrected]. Mean progression-free survival (PFS) was 13.3 years, with 5‑ and 10-year PFS of 92%. Hearing could be preserved in RS patients for a median of 36.3 months (range 2.3-13.7 years). Hearing worsened in 17 (30%) cases. Median hearing preservation for FSRT was 48.7 months (range 0.0-13.8 years); 29 (23%) showed hearing deterioration. The difference in hearing preservation was not significant between RS and FSRT (p = 0.3). A total of 123/162 patients participated in the patient survey (return rate 76%). The results correlate well with the information documented in the patient files for tinnitus and facial and trigeminal nerve toxicity. Significant differences appeared regarding hearing impairment, gait uncertainty, and imbalance. CONCLUSION These data confirm that RS and FSRT are comparable in terms of local control for VS. RS should be reserved for smaller lesions, while FSRT can be offered independently of tumor size. Patient self-reported outcome during follow-up is of high value. The established questionnaire could be validated in the independent cohort.
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Affiliation(s)
- Kerstin A Kessel
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany. .,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany.
| | - Hanna Fischer
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany
| | - Marco M E Vogel
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany
| | - Henning Bier
- Department of Otorhinolaryngology, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University of Munich (TUM), Ismaninger Straße 22, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), Ismaninger Straße 22, 81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, Neuherberg, Germany
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