Clinicopathologic growth factors in vestibular schwannomas: a morphological and immunohistochemical study of 69 tumours

Single-cell transcriptomes reveal the heterogeneity and microenvironment of vestibular schwannoma

BACKGROUND

Vestibular schwannoma (VS) is the most common benign tumor in the cerebellopontine angle and internal auditory canal. Illustrating the heterogeneous cellular components of VS could provide insights into its various growth patterns.

METHODS

Single-cell RNA sequencing was used to profile transcriptomes from 7 VS samples and 2 normal nerves. Multiplex immunofluorescence was employed to verify the data set results. Bulk RNA sequencing was conducted on 5 normal nerves and 44 VS samples to generate a prediction model for VS growth.

RESULTS

A total of 83 611 cells were annotated as 14 distinct cell types. We uncovered the heterogeneity in distinct VS tumors. A subset of Schwann cells with the vascular endothelial growth factor biomarker was significantly associated with fast VS growth through mRNA catabolism and peptide biosynthesis. The macrophages in the normal nerves were largely of the M2 phenotype, while no significant differences in the proportions of M1 and M2 macrophages were found between slow-growing and fast-growing VS. The normal spatial distribution of fibroblasts and vascular cells was destroyed in VS. The communications between Schwann cells and vascular cells were strengthened in VS compared with those in the normal nerve. Three cell clusters were significantly associated with fast VS growth and could refine the growth classification in bulk RNA.

CONCLUSIONS

Our findings offer novel insights into the VS microenvironment at the single-cell level. It may enhance our understanding of the different clinical phenotypes of VS and help predict growth characteristics. Molecular subtypes should be included in the treatment considerations.

The comparable tumour microenvironment in sporadic and NF2-related schwannomatosis vestibular schwannoma

Bilateral vestibular schwannoma is the hallmark of NF2-related schwannomatosis, a rare tumour predisposition syndrome associated with a lifetime of surgical interventions, radiotherapy and off-label use of the anti-angiogenic drug bevacizumab. Unilateral vestibular schwannoma develops sporadically in non-NF2-related schwannomatosis patients for which there are no drug treatment options available. Tumour-infiltrating immune cells such as macrophages and T-cells correlate with increased vestibular schwannoma growth, which is suggested to be similar in sporadic and NF2-related schwannomatosis tumours. However, differences between NF2-related schwannomatosis and the more common sporadic disease include NF2-related schwannomatosis patients presenting an increased number of tumours, multiple tumour types and younger age at diagnosis. A comparison of the tumour microenvironment in sporadic and NF2-related schwannomatosis tumours is therefore required to underpin the development of immunotherapeutic targets, identify the possibility of extrapolating ex vivo data from sporadic vestibular schwannoma to NF2-related schwannomatosis and help inform clinical trial design with the feasibility of co-recruiting sporadic and NF2-related schwannomatosis patients. This study drew together bulk transcriptomic data from three published Affymetrix microarray datasets to compare the gene expression profiles of sporadic and NF2-related schwannomatosis vestibular schwannoma and subsequently deconvolved to predict the abundances of distinct tumour immune microenvironment populations. Data were validated using quantitative PCR and Hyperion imaging mass cytometry. Comparative bioinformatic analyses revealed close similarities in NF2-related schwannomatosis and sporadic vestibular schwannoma tumours across the three datasets. Significant inflammatory markers and signalling pathways were closely matched in NF2-related schwannomatosis and sporadic vestibular schwannoma, relating to the proliferation of macrophages, angiogenesis and inflammation. Bulk transcriptomic and imaging mass cytometry data identified macrophages as the most abundant immune population in vestibular schwannoma, comprising one-third of the cell mass in both NF2-related schwannomatosis and sporadic tumours. Importantly, there were no robust significant differences in signalling pathways, gene expression, cell type abundance or imaging mass cytometry staining between NF2-related schwannomatosis and sporadic vestibular schwannoma. These data indicate strong similarities in the tumour immune microenvironment of NF2-related schwannomatosis and sporadic vestibular schwannoma.

Tumor Microenvironment in Sporadic Vestibular Schwannoma: A Systematic, Narrative Review

Although diagnosis and treatment of vestibular schwannomas (VSs) improved in recent years, no factors have yet been identified as being capable of predicting tumor growth. Molecular rearrangements occur in neoplasms before any macroscopic morphological changes become visible, and the former are the underlying cause of disease behavior. Tumor microenvironment (TME) encompasses cellular and non-cellular elements interacting together, resulting in a complex and dynamic key of tumorigenesis, drug response, and treatment outcome. The aim of this systematic, narrative review was to assess the level of knowledge on TME implicated in the biology, behavior, and prognosis of sporadic VSs. A search (updated to November 2022) was run in Scopus, PubMed, and Web of Science electronic databases according to the PRISMA guidelines, retrieving 624 titles. After full-text evaluation and application of inclusion/exclusion criteria, 37 articles were included. VS microenvironment is determined by the interplay of a dynamic ecosystem of stromal and immune cells which produce and remodel extracellular matrix, vascular networks, and promote tumor growth. However, evidence is still conflicting. Further studies will enhance our understanding of VS biology by investigating TME-related biomarkers able to predict tumor growth and recognize immunological and molecular factors that could be potential therapeutic targets for medical treatment.

Increased Circulating Chemokines and Macrophage Recruitment in Growing Vestibular Schwannomas

BACKGROUND

There is evidence that macrophage infiltration in the tumor microenvironment promotes vestibular schwannoma (VS) growth. Efficacy of bevacizumab in NF2-associated VS demonstrates the value of therapies targeting the microvascular tumor microenvironment, and tumor-associated macrophages (TAMs) may represent another druggable target.

OBJECTIVE

To characterize the relationship between growth, TAM infiltration, and circulating monocyte chemokines in a large cohort of patients with VS.

METHODS

Immunostaining for Iba1 (macrophages), CD31 (endothelium), and fibrinogen (permeability) was performed on 101 growing and 19 static sporadic VS. The concentrations of monocyte-specific chemokines were measured in the plasma of 50 patients with growing VS and 25 patients with static VS.

RESULTS

The Iba1 + cell count was significantly higher in growing as compared with static VS (592 vs 226/×20 HPF, P =<0.001). Similarly, the CD31 + % surface area was higher in growing VS (2.19% vs 1.32%, P = .01). There was a positive correlation between TAM infiltration and VS growth rate, which persisted after controlling for the effect of tumor volume (aR2 = 0.263, P =<0.001). The plasma concentrations of several monocytic chemokines were higher in patients with growing rather than static VS.

CONCLUSION

There is a strong positive correlation between TAM infiltration and volumetric growth of VS, and this relationship is independent of tumor size. There is a colinear relationship between TAM infiltration and tumor vascularity, implying that inflammation and angiogenesis are interlinked in VS. Chemokines known to induce monocyte chemotaxis are found in higher concentrations in patients with growing VS, suggestive of a potential pathophysiological mechanism.

Sporadic Vestibular Schwannoma Size and Location Do not Correlate With the Severity of Hearing Loss at Initial Presentation

Vestibular schwannoma (VS) is a non-malignant intracranial neoplasm arising from the vestibular branch of the 8th cranial nerve; sensorineural hearing loss (SNHL) is the most common associated symptom. Understanding whether VS imaging characteristics at the time of VS diagnosis can be associated with severity of VS-induced SNHL can impact patient counseling and define promising areas for future research. Patients diagnosed with VS at Massachusetts Eye and Ear (MEE) from 1994 through 2018 were analyzed if magnetic resonance imaging at VS presentation and sequential audiometry were available. Results were compared with original studies available in PubMed, written in English, on VS imaging characteristics and their impact on hearing in patients. A total of 477 patients with unilateral VS from the MEE database demonstrated no significant correlation between any features of tumor imaging at the time of VS diagnosis, such as VS size, impaction or location, and any hearing loss metric. Twenty-three published studies on the impact of VS imaging characteristics on patient hearing met inclusion criteria, with six solely involving NF2 patients and three including both sporadic and NF2-related VS patients. Fifteen studies reported a significant relationship between SNHL and at least one VS imaging characteristic; however, these trends were universally limited to NF2 patients or involved small patient populations, and were not reproduced in larger studies. Taken together, SNHL in sporadic VS patients is not readily associated solely with any tumor imaging characteristics. This finding motivates future studies to define how VS microenvironment and secreted molecules influence VS-induced SNHL.

Identification of key biomarkers and immune infiltration in sporadic vestibular schwannoma basing transcriptome-wide profiling

BACKGROUND

Vestibular schwannoma (VS) is a common intracranial tumor, with 95% of the cases being sporadic vestibular schwannoma (SVS). The purposed of this study was identifying genes responsible for inflammation in SVS and clarifying its underlying immune mechanisms.

METHODS

Transcriptional sequencing datasets (GSE141801 and GSE108237) from the Gene Expression Omnibus (GEO) database were used in this study. The candidate modules closely related to SVS and hub genes were screened out by weighted gene co-expression network analysis. Τhe sensitivity and specificity of the hub genes for SVS prediction were evaluated by ROC curve analysis. The CIBERSORT algorithm was subsequently applied to analyze the immune infiltration between SVS and controls. Finally, biological signaling pathways involved in the hub genes were identified via gene set enrichment analysis.

RESULTS

A total of 39 significantly enriched in myelination and collagen-containing extracellular matrix DEGs were identified at the screening step. Three hub genes (MAPK8IP1, SLC36A2, and OR2AT4) were identified, which mainly enriched in pathways of melanogenesis, GnRH, and calcium signaling pathways. Compared with normal nerves, SVS tissue contained a higher proportion of T cells, monocytes and activated dendritic cells, whereas proportions of M2 macrophages were lower.

CONCLUSIONS

The intergrated analysis revealed the pattern of immune cell infiltration in SVS and provided a crucial molecular foundation to enhance understanding of SVS. Hub genes MAPK8IP1, SLC36A2 and OR2AT4 are potential biomarkers and therapeutic targets to facilitate the accurate diagnosis, prognosis and therapy of SVS.

Comparison of the Signal Intensity of Vestibular Schwannoma Between Growing and Nongrowing Tumors

OBJECTIVES/HYPOTHESIS

To determine the relationship between signal intensity on gadolinium (Gd)-enhanced magnetic resonance images and growth of vestibular schwannomas (VSs).

STUDY DESIGN

Cross-sectional study.

METHODS

In this cross-sectional study, we retrospectively reviewed the data of 31 patients with VSs who underwent magnetic resonance imaging (MRI). The mean signal intensities within the regions of interest in the tumor, pons, and temporal muscles were measured on Gd-enhanced T1-weighted MRI. Relative intensity ratios were calculated as follows: T/N pons ratio (T/Np) is the tumor signal intensity/pons signal intensity and T/N muscle ratio (T/Nm) is the tumor signal intensity/temporal muscle signal intensity. Volume measurements were used to assess the tumor size. Growth rate was determined by assessing previous imaging studies. Growing VS was defined as a tumor with a growth rate >100 mm³ /year.

RESULTS

The mean (standard deviation) T/Np and T/Nm were 1.47 (0.27) and 1.50 (0.24), respectively, in nongrowing tumors and 1.78 (0.17) and 1.90 (0.12), respectively, in growing tumors. The T/Np and T/Nm differed significantly between the two groups (T/Np, P < .001; T/Nm, P < .001). Receiver operating characteristic curve analysis showed that cutoffs of 1.56 and 1.76 for T/Np (93.33% sensitivity, 75.00% specificity) and T/Nm (100.00% sensitivity, 93.75% specificity), respectively, could be used to diagnose a growth rate of >100 mm³ /year. The area under the curve was 0.85 (95% confidence interval, 0.70-1.00) for T/Np and 0.94 (0.82-1.00) for T/Nm.

CONCLUSION

Growing VSs show higher signal intensities on Gd-enhanced MRI. Thus, measuring the signal intensity of VS on Gd-enhanced MRI may aid in predicting VS growth.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Macrophage and Lymphocyte Infiltration Is Associated with Volumetric Tumor Size but Not with Volumetric Growth in the Tübingen Schwannoma Cohort

Most patients with vestibular schwannomas can be cured with microsurgical resection, or tumor growth can be stabilized by radiotherapy in certain cases. Recurrence is rare but usually difficult to treat. Treatment alternatives to local therapies are not established. There is growing evidence of the role of inflammatory processes in schwannomas, which may be exploitable by targeted innovative therapies. To further define the impact of inflammation with tumor growth in vestibular schwannoma, we performed immunohistochemical analyses of CD3, CD8, CD68 and CD163 to assess lymphocyte and macrophage infiltration in 923 tumor tissue samples of surgically resected vestibular schwannomas. An inflammatory score was compared with tumor size and volumetric growth. We observed a significantly larger preoperative tumor size with increased expression rates of CD3, CD8, CD68 and CD163 (p < 0.0001, p < 0.0001, p = 0.0015 and p < 0.0001, respectively), but no differences in percentual volumetric tumor growth. When all four markers were combined as an inflammatory score, tumors with high inflammatory infiltration showed slower percentual growth in a multivariate analysis, including MIB1 expression (p = 0.0249). We conclude that inflammatory cell infiltration increases with larger tumor size but is associated with slower percentual volumetric tumor growth.

Beyond Antoni: A Surgeon's Guide to the Vestibular Schwannoma Microenvironment

Introduction Vestibular schwannomas (VS) are histologically benign tumors arising from cranial nerve VIII. Far from a homogenous proliferation of Schwann cells, mounting evidence has highlighted the complex nature of the inflammatory microenvironment in these tumors.

Methods A review of the literature pertaining to inflammation, inflammatory molecular pathways, and immune-related therapeutic targets in VS was performed. Relevant studies published up to June 2020 were identified based on a literature search in the PubMed and MEDLINE databases and the findings were synthesized into a concise narrative review of the topic.

Results The VS microenvironment is characterized by a dense infiltrate of inflammatory cells, particularly macrophages. Significantly higher levels of immune cell infiltration are observed in growing versus static tumors, and there is a demonstrable interplay between inflammation and angiogenesis in growing VS. While further mechanistic studies are required to ascertain the exact role of inflammation in angiogenesis, tumor growth, and Schwann cell control, we are beginning to understand the key molecular pathways driving this inflammatory microenvironment, and how these processes can be monitored and targeted in vivo.

Conclusion Observational research has revealed a complex and heterogeneous tumor microenvironment in VS. The functional landscape and roles of macrophages and other immune cells in the VS inflammatory infiltrate are, however, yet to be established. The antiangiogenic drug bevacizumab has shown the efficacy of targeted molecular therapies in VS and there is hope that agents targeting another major component of the VS microenvironment, inflammation, will also find a place in their future management.

The impact of the MIB-1 index on facial nerve outcomes in vestibular schwannoma surgery

Background

Facial nerve palsy is a severe morbid condition that occurs after vestibular schwannoma (VS) surgery. The objective of this study was to evaluate facial nerve outcomes based on surgical techniques, tumour size, and immunohistochemical factors.

Methods

One hundred eighteen patients with VS were retrospectively analysed. Gross total resection (GTR) was achieved in 83 patients, and subtotal resection (STR) was achieved in 35 patients. Follow-up was 60 months (median). Facial nerve outcomes were assessed for 24 months after surgery. Analysis of the MIB-1 index was performed in 114 patients (97%) to evaluate recurrence and facial nerve outcomes.

Results

Immediately after surgery, 16 of 35 patients (45.7%) with STR and 21 of 83 patients (25.3%) with GTR had a good (House-Brackmann (HB) score ≤ 2) facial nerve outcome (p = 0.029). Semi-sitting positioning (p = 0.002) and tumour size class of 3 (> 4 cm) were also associated with worse HB outcomes after 2 years (p = 0.004) in univariate analyses. The MIB-1 index was significantly correlated with diffuse infiltration of tumour-associated CD45⁺ lymphocytes (r = 0.63, p = 0.015) and CD68⁺ macrophages (r = 0.43, p = 0.021). ROC analysis found an AUC of 0.73 (95% CI = 0.60–0.86, p = 0.003) for the MIB-1 index in predicting poor facial nerve outcomes. Binary logistic regression analysis revealed an MIB-1 index ≥ 5% (16/28 (57.1%) vs. 5/40 (12.5%); p < 0.001, OR = 14.0, 95% CI = 3.2–61.1) and a tumour size class of 3 (6/8 (75.0%) vs. 2/8 (25.0%); p = 0.01, OR = 14.56, 95% CI = 1.9–113.4) were predictors of poor HB scores (≥ 3) after 1 year.

Conclusions

An MIB-1 index ≥ 5% seems to predict worse long-term facial nerve outcomes in VS surgery.

The inflammatory microenvironment in vestibular schwannoma

Vestibular schwannomas are tumors arising from the vestibulocochlear nerve at the cerebellopontine angle. Their proximity to eloquent brainstem structures means that the pathology itself and the treatment thereof can be associated with significant morbidity. The vast majority of these tumors are sporadic, with the remainder arising as a result of the genetic syndrome Neurofibromatosis Type 2 or, more rarely, LZTR1-related schwannomatosis. The natural history of these tumors is extremely variable, with some tumors not displaying any evidence of growth, others demonstrating early, persistent growth and a small number growing following an extended period of indolence. Emerging evidence now suggests that far from representing Schwann cell proliferation only, the tumor microenvironment is complex, with inflammation proposed to play a key role in their growth. In this review, we provide an overview of this new evidence, including the role played by immune cell infiltration, the underlying molecular pathways involved, and biomarkers for detecting this inflammation in vivo. Given the limitations of current treatments, there is a pressing need for novel therapies to aid in the management of this condition, and we conclude by proposing areas for future research that could lead to the development of therapies targeted toward inflammation in vestibular schwannoma.

Inflammation and vascular permeability correlate with growth in sporadic vestibular schwannoma

BACKGROUND

Inflammation is hypothesized to be a key event in the growth of sporadic vestibular schwannoma (VS). In this study we sought to investigate the relationship between inflammation and tumor growth in vivo using the PET tracer 11C-(R)-PK11195 and dynamic contrast enhanced (DCE) MRI derived vascular biomarkers.

METHODS

Nineteen patients with sporadic VS (8 static, 7 growing, and 4 shrinking tumors) underwent prospective imaging with dynamic 11C-(R)-PK11195 PET and a comprehensive MR protocol, including high temporal resolution DCE-MRI in 15 patients. An intertumor comparison of 11C-(R)-PK11195 binding potential (BPND) and DCE-MRI derived vascular biomarkers (Ktrans, vp, ve) across the 3 different tumor growth cohorts was undertaken. Tissue of 8 tumors was examined with immunohistochemistry markers for inflammation (Iba1), neoplastic cells (S-100 protein), vessels (CD31), the PK11195 target translocator protein (TSPO), fibrinogen for vascular permeability, and proliferation (Ki-67). Results were correlated with PET and DCE-MRI data.

RESULTS

Compared with static tumors, growing VS displayed significantly higher mean 11C-(R)-PK11195 BPND (-0.07 vs 0.47, P = 0.020), and higher mean tumor Ktrans (0.06 vs 0.14, P = 0.004). Immunohistochemistry confirmed the imaging findings and demonstrated that TSPO is predominantly expressed in macrophages. Within growing VS, macrophages rather than tumor cells accounted for the majority of proliferating cells.

CONCLUSION

We present the first in vivo imaging evidence of increased inflammation within growing sporadic VS. Our results demonstrate that 11C-(R)-PK11195 specific binding and DCE-MRI derived parameters can be used as imaging biomarkers of inflammation and vascular permeability in this tumor group.

Differential NF2 Gene Status in Sporadic Vestibular Schwannomas and its Prognostic Impact on Tumour Growth Patterns

The great majority of sporadic vestibular schwannomas (VSs) are due to the inactivation of the NF2 gene. In this study, we found age-dependent differences in the clinical parameters of sporadic VSs. Young patients were characterized by progressive tumour behaviours, including earlier onset of initial symptoms, shorter symptom duration and larger tumour size. An increased rate of "two-hits" of both NF2 alleles, usually by mutation and allelic loss, was observed in young cases compared to older, and this correlated with the loss of protein and mRNA expression. In contrast, the tumours with a single mutation (referred to as 'one-hit') exhibited obvious expression levels. Moreover, a mixture of merlin-expressing tumour cells and non-expressing tumour cells was observed in 'one-hit' schwannomas, suggesting that a subset of 'one-hit' tumour cells was present in these tumours. To mimic the growth promoting effects by the second hit, we performed lentivirus-mediated NF2 knockdown in the 'one-hit' schwannoma cultures. Following the loss of NF2 expression, schwannoma cultures demonstrated increased proliferation rates. Above all, we have identified a correlation between the NF2 status and the growth patterns of sporadic VSs. The treatment decision-making, microsurgery or "wait and scan" strategy, should be carried out according to the tumour's genetic background.

Differential NF2 Gene Status in Sporadic Vestibular Schwannomas and its Prognostic Impact on Tumour Growth Patterns

The great majority of sporadic vestibular schwannomas (VSs) are due to the inactivation of the NF2 gene. In this study, we found age-dependent differences in the clinical parameters of sporadic VSs. Young patients were characterized by progressive tumour behaviours, including earlier onset of initial symptoms, shorter symptom duration and larger tumour size. An increased rate of “two-hits” of both NF2 alleles, usually by mutation and allelic loss, was observed in young cases compared to older, and this correlated with the loss of protein and mRNA expression. In contrast, the tumours with a single mutation (referred to as ‘one-hit’) exhibited obvious expression levels. Moreover, a mixture of merlin-expressing tumour cells and non-expressing tumour cells was observed in ‘one-hit’ schwannomas, suggesting that a subset of ‘one-hit’ tumour cells was present in these tumours. To mimic the growth promoting effects by the second hit, we performed lentivirus-mediated NF2 knockdown in the ‘one-hit’ schwannoma cultures. Following the loss of NF2 expression, schwannoma cultures demonstrated increased proliferation rates. Above all, we have identified a correlation between the NF2 status and the growth patterns of sporadic VSs. The treatment decision-making, microsurgery or “wait and scan” strategy, should be carried out according to the tumour’s genetic background.

Clinical, Morphologic, and Pathologic Features Associated With Increased FDG Uptake in Schwannoma

OBJECTIVE

The objective of this study was to investigate the clinical, morphologic, and pathologic features associated with increased ¹⁸F-FDG uptake in benign schwannomas.

MATERIALS AND METHODS

Twenty-two schwannomas in 22 patients (age range, 25-81 years) who had FDG PET or PET/CT scans and subsequently underwent surgical re-section were retrospectively analyzed. The maximum standardized uptake value (SUV_max) was compared with patient age, sex, tumor location (gastrointestinal vs nongastrointestinal origin), tumor size, gross appearance, intratumoral cellularity, intratumoral infiltration of inflammatory cells, presence of peritumoral lymphoid cuffs, and expression status of glucose transporters 1 and 3 on tumor cells.

RESULTS

The SUV_max of schwannomas ranged from 1.5 to 17.3 (median, 3.7). Significantly higher SUV_max was observed in gastrointestinal schwannomas (n = 4) compared with nongastrointestinal schwannomas (n = 18, p = 0.007) and in schwannomas with peritumoral lymphoid cuffs (n = 5) compared with those without peritumoral lymphoid cuffs (n = 17, p = 0.001). A significant correlation was seen between tumor location and the presence of peritumoral lymphoid cuffs (p < 0.001). Age, sex, tumor size, gross appearance, intratumoral cellularity, intratumoral inflammatory cell infiltration, and expression status of glucose transporters 1 and 3 on tumor cells had no significant correlation with SUV_max.

CONCLUSION

Gastrointestinal schwannomas and schwannomas with peritumoral lymphoid cuffs may be associated with elevated FDG uptake. Knowledge of the features of schwannomas associated with increased uptake may be helpful to avoid misinterpretation of benign schwannomas as malignancy.

Immunohistochemical Expression of Progesterone Receptors in Nonmeningothelial Central Nervous System Tumors

INTRODUCTION

Immunostaining of progesterone receptors (PRs) has been described as a prognostic factor related to recurrences in meningiomas. However, its expression in other primary intracranial tumors has been poorly studied. In this paper, we compare the pattern of expression of the receptor in meningiomas with that of nonmeningothelial intracranial tumors to evaluate its value in the diagnosis of the former.

MATERIALS AND METHODS

A total of 42 nonmeningothelial intracranial tumors (21 glioblastomas, 4 anaplastic oligodendrogliomas, 4 oligodendrogliomas, 1 pilomyxoid astrocytoma, 3 ependymomas, 8 schwannomas, 1 chordoid chordoma) and 32 meningiomas (1 rhabdoid, 1 papillary, 5 atypical, 7 with histologic features of more aggressive behavior, 1 microcyst, 8 meningothelial, 7 transitional, 2 fibroblastic) were studied for PR by immunohistochemistry.

RESULTS

About 73.8% of the nonmeningothelial tumors and 100% of the meningiomas were positive for the receptor, the difference being statistically significant (P=0.0017). The mean percentage of positive tumor cells per high-power field was frequently higher than 30% in meningiomas and lower than 10% in nonmeningothelial tumors (P=0.0001).

CONCLUSIONS

Although we detected that immunostaining for the PR is more frequently observed in meningiomas, we confirmed its expression in diverse nonmeningothelial primary intracranial tumors. Immunohistochemistry for PR would be useful in the diagnosis of meningioma only when its positivity shows a mean higher than 30% of the positive tumor cells per high-power field.

The role of vascular endothelial growth factor and vascular stability in diseases of the ear

OBJECTIVES/HYPOTHESIS

Vascular endothelial growth factor (VEGF) is a critical mediator of vascular permeability and angiogenesis and likely plays an important role in cochlear function and hearing. This review highlights the role of VEGF in hearing loss associated with vestibular schwannomas, otitis media with effusion, and sensorineural hearing loss.

STUDY DESIGN

PubMed literature review.

METHODS

A review of the literature was conducted to determine the role of VEGF in diseases affecting hearing.

RESULTS

Therapeutic efficacy has been demonstrated for the anti-VEGF agent bevacizumab in vestibular schwannomas, with tumor size reduction and hearing improvement in patients with neurofibromatosis type 2. The loss of functional Merlin, the protein product of the nf2 gene, results in a decrease in expression of the anti-angiogenic protein SEMA3F through a Rac-1-dependent mechanism, allowing VEGF to promote angiogenesis. Bevacizumab may therefore restore the angiogenic balance through inhibiting the relative increase in VEGF. Many of the clinical findings of otitis media with effusion can be reproduced by delivery of recombinant VEGF through transtympanic injection or submucosal osmotic pump. VEGF receptor inhibitors have been demonstrated to improve hearing in an animal model of otitis media with effusion. VEGF affects both the inner ear damage and repair processes in sensorineural hearing loss.

CONCLUSIONS

VEGF has an important role in vestibular schwannomas, otitis media with effusion, and sensorineural hearing loss.

Intratumoral hemorrhage, vessel density, and the inflammatory reaction contribute to volume increase of sporadic vestibular schwannomas

Vestibular schwannomas show a large variation in growth rate, making prediction and anticipation of tumor growth difficult. More accurate prediction of clinical behavior requires better understanding of tumor biological factors influencing tumor progression. Biological processes like intratumoral hemorrhage, cell proliferation, microvessel density, and inflammation were analyzed in order to determine their role in vestibular schwannoma development. Tumor specimens of 67 patients surgically treated for a histologically proven unilateral vestibular schwannoma were studied. Preoperative magnetic resonance imaging (MRI) scans were used to determine tumor size and to classify tumors as homogeneous, inhomogeneous, and cystic. Immunohistochemical studies evaluated cell proliferation (histone H3 and Ki-67), microvessel density (CD31), and inflammation (CD45 and CD68). Intratumoral hemorrhage was assessed by hemosiderin deposition. The expression patterns of these markers were compared with tumor size, tumor growth index, MRI appearance, patients’ age, and duration of symptoms. No relation between cell proliferation and clinical signs of tumor volume increase or MRI appearance was found. Intratumoral hemosiderin, microvessel density, and inflammation were significantly positively correlated with tumor size and the tumor growth index. Cystic and inhomogeneous tumors showed significantly more hemosiderin deposition than homogeneous tumors. The microvessel density was significantly higher in tumors with a high number of CD68-positive cells. The volume increase of vestibular schwannomas is not based on cell proliferation alone. Factors like intratumoral bleeding, (neo)vascularization, and intensity of the inflammatory reaction also influence tumor volume.

Immunohistochemical investigation of hormone receptors and vascular endothelial growth factor concentration in vestibular schwannoma

OBJECTIVES

To determine if a relationship exists between the presence of estrogen receptors (ER), progesterone receptors (PR), or vascular endothelial growth factor (VEGF) and the size, growth rate, and behavior of vestibular schwannoma tumors.

DESIGN

Nine tumor samples from young female patients with large vestibular schwannoma tumors were preselected because they were presumed to be faster growing, more aggressive tumors. Immunohistochemical staining was performed using monoclonal mouse antibodies to ER, PR, and VEGF.

RESULTS

The mean age of the study sample was 32.3 years, mean tumor size was 3.2 cm, and the average growth rate was 0.4 cm per 2 months. The results of immunohistochemical staining for ER and PR in all nine samples were unequivocally negative. Eight of nine tumor samples stained positive for VEGF, with five demonstrating low intensity and three demonstrating moderate intensity staining.

CONCLUSIONS

There is histopathological evidence for the expression of VEGF in vestibular schwannomas but not for ER and PR. Further studies are necessary to determine the role of VEGF and other molecular pathways in the growth of vestibular schwannomas and the application of anti-VEGF therapy as a potential treatment option in the future.

Estrogen receptor expression in sporadic vestibular schwannomas

HYPOTHESIS

We hypothesize that vestibular schwannomas (VSs) exhibit up-regulation of estrogen receptor (ER) at the protein level compared with control great auricular nerve (GAN).

BACKGROUND

It has been reported in the literature that VS occur more commonly in women and tend to be larger and more vascular in women, and growth rate can accelerate during pregnancy. The literature contains widely divergent results on ER expression in VS, however, varying from no detectable levels to detection of ER in all samples.

METHODS

Sixteen sporadic VS specimens were immediately snap-frozen after microsurgical excision and analyzed for phosphorylated and total levels of ERα with Western blot analysis. ERα expression levels were normalized to actin; then, relative expression to GAN was determined.

RESULTS

All VS specimens exhibited expression of both phosphorylated and total ERα. Total ERα expression in VS is equivalent to or slightly up-regulated compared with GAN. VS specimens exhibited more pronounced up-regulation of phosphorylated (i.e., activated) levels of ERα compared with GAN.

CONCLUSION

We have demonstrated that ERα expression in VS is equivalent to GAN. The phosphorylated form of the receptor is up-regulated compared with GAN, however, indicating a higher level of ERα activation in sporadic VS compared with normal nerve. Further investigation into antiestrogen therapy for VS is warranted.

Concordance of bilateral vestibular schwannoma growth and hearing changes in neurofibromatosis 2: neurofibromatosis 2 natural history consortium

OBJECTIVE

To examine the relationship between the amount of change in size and associated hearing in bilateral vestibular schwannomas (VSs) in persons with neurofibromatosis 2 (NF2).

STUDY DESIGN

Annual magnetic resonance imaging and audiological examinations were conducted on NF2 patients.

SUBJECTS

Fifty-two patients enrolled in the NF2 Natural History Consortium in whom both VSs were untreated. Magnetic resonance imaging and hearing exams were available for at least 2 time points 1 year apart. The 32 males and 20 females had a mean age at diagnosis of 26 years (SD = 18). In 19 (37%) subjects, the NF2 germline mutation could not be identified in the blood (mosaic).

OUTCOME MEASURES

Greatest diameter change in tumor size for each of the 2 tumors from first to second evaluation was determined. Differences in amounts of change between the 2 sides and in hearing (4-frequency pure-tone average) were evaluated using multivariate analysis of variance.

RESULTS

Overall, the VSs demonstrated significant average growth (p < 0.001), and hearing worsened significantly (p < 0.001) over 1 year. The amount of change in the bigger tumors was not associated with the amount of change in the smaller tumors within each patient. Vestibular schwannoma size changes were not associated with the corresponding hearing changes (Kendall's tau, p = not significant [n.s.]).

CONCLUSION

A significant 1-year change in VS size and hearing occurred in NF2 patients. Clinically, tumor change or hearing deterioration on one VS cannot be used to predict changes in the other VS. This suggests that, although NF2 is a Mendelian disease, the germline genotype-phenotype relationship may resemble that of complex disorders.

Expression of estrogen and progesterone receptors in vestibular schwannomas and their clinical significance

Objective

The objective was to determine the expression of estrogen and progesterone receptors in vestibular schwannomas as well as to determine predictive factors for estrogen and progesterone receptor positivity.

Materials and methods

The study included 100 cases of vestibular schwannomas operated from January 2006 to June 2009. The clinical details were noted from the medical case files. Formaldehyde-fixed parafiin-embedded archival vestibular schwannomas specimens were used for the immunohistochemical assessment of estrogen and progesterone receptors.

Results

Neither estrogen nor progesterone receptors could be detected in any of our cases by means of well known immunohistochemical method using well documented monoclonal antibodies. In the control specimens, a strongly positive reaction could be seen.

Conclusion

No estrogen and progesterone receptor could be found in any of our 100 cases of vestibular schwannomas. Hence our study does not support a causative role of estrogen and progesterone in the growth of vestibular schwannoma as well as hormonal manipulation in the treatment of this tumor.

Schwannoma with monoclonal plasma cell infiltration

The authors report a very rare case of a vestibular schwannoma with an infiltrate of monoclonal plasma cells. A 45-year-old woman underwent routine excision of a presumed vestibular schwannoma. Histological analysis revealed the presence of a distinct lambda light chain restricted plasma cell population within the schwannoma. The light chain restriction and polymerase chain reaction-demonstrated monoclonality of the plasma cell population suggested the co-occurrence of a plasma cell neoplasm within a schwannoma. A search for systemic disease of plasma cell origin was unremarkable. A search of the literature suggests that this is the first report of such an occurrence.

Genetic determinants of hearing loss associated with vestibular schwannomas

HYPOTHESIS

The severity of hearing loss (HL) associated with vestibular schwannomas (VSs) is influenced by genes expressed by the VSs.

BACKGROUND

Hearing loss is the most common presenting symptoms in patients with VSs, yet its pathophysiology remains elusive. Previous studies have suggested that VSs cause HL not only by inducing degeneration of the auditory nerve by compression but also by promoting degeneration of the inner ear. This study aimed to determine whether there is a molecular basis for differences in HL associated with VSs.

METHODS

Surgical specimens of VSs were collected from 13 patients and were divided into a group associated with good (word recognition >70% and pure-tone average < or =30 dB) or poor hearing. Whole-genome expression profiling of VSs was performed with the Affymetrix GeneChip Human X3P Array. The expression of select genes was validated using real-time quantitative reverse transcription-polymerase chain reaction and immunohistochemistry. Because of a small sample size, exact nonparametric tests were used to assess the association between good versus poor hearing and specific histological features of the tumors and patient demographics.

RESULTS

Using gene set enrichment analysis, the chromosomal region 3q27 was found to be significantly different between the 2 groups of tumors. This region includes peroxisomal biogenesis factor 5-like gene, which was underexpressed in VSs with poor hearing. The expression of 3 other genes from different chromosomes was significantly different between the 2 groups: RAD54B, prostate-specific membrane antigen-like, and carcinoembryonic antigen.

CONCLUSION

This study identified several molecular alterations in VSs stratified by hearing. These alterations may determine the severity of HL associated with VSs and may represent potential therapeutic targets to prevent or reduce HL in theses patients.

Determination of the clinical growth index in unilateral vestibular schwannoma

OBJECTIVES

To analyze factors associated with the clinical growth index of sporadic unilateral vestibular schwannoma and to evaluate the validity of the index as an indicator of tumor growth.

DESIGN

A retrospective case review study.

PATIENTS AND METHODS

A series of 118 patients with unilateral vestibular schwannomas. Clinical growth index was calculated by dividing tumor size by the length of clinical history. Clinical growth index, tumor size, symptoms, and symptom duration were tested for a relationship with tumor location, patient sex, and age. All tests were performed for the total group and separately for three subgroups: intrameatal tumors (IT group, n = 46), intrameatal and extrameatal tumors (IET group, n = 60), and extrameatal tumors (ET group, n = 12).

RESULTS

Vestibular schwannoma diameter ranged from 3 to 40 mm (mean size, 14.3 +/- 7.6 mm). The maximum tumor diameter was significantly greater for the IET group (17.9 +/- 6.5 mm) and the ET group (19.3 +/- 8.5 mm) than for the IT group (8.5 +/- 4.3 mm) (p < 0.001). The mean clinical growth index was determined as being 31.3 +/- 55.7 mm/yr for the total group. A significantly lower clinical growth index was found for the IT group (14.7 +/- 25.3 mm/yr) compared with the IET group (41.9 +/- 69.2 mm/yr) and the ET group (43.3 +/- 52.4 mm/yr) (p = 0.031). A significantly negative correlation between the clinical growth index and the age of the patients was noted for both the total group (p = 0.010) and the IET group (p = 0.017). A significantly negative correlation between the tumor size and the age of the patients was determined for the ET group (p = 0.22).

CONCLUSIONS

This study demonstrates a lower clinical growth index and smaller tumors in the older population, supporting data previously presented by extensive radiological studies. Our findings might provide a rationale for the consideration of the clinical growth index to estimate vestibular schwannoma growth rate.

VEGF and VEGF receptor-1 concentration in vestibular schwannoma homogenates correlates to tumor growth rate

OBJECTIVE

Vascular endothelial growth factor (VEGF) is one of the most potent mediators of angiogenesis, which is a mandatory process during tumor growth. Immunohistochemical studies have demonstrated VEGF expression in vestibular schwannomas (VS), and a semi-quantitation of staining intensity indicated a correlation between tumor growth rate and VEGF expression. The present objectives were to determine the concentration of VEGF and the high-affinity receptor VEGFR-1 in VS homogenates and to examine a possible correlation with symptom duration, tumor size, or growth rate.

STUDY DESIGN, PATIENTS, AND METHODS

Prospective selection of 27 patients with VS growth determined by repeated magnetic resonance imaging. Patient files were reviewed for symptom duration and all magnetic resonance images reviewed for determination of tumor size and growth rate. ELISA was used for determination of the VEGF and VEGFR-1 concentration in tumor homogenates.

SETTING

Tertiary University Hospital Clinic.

RESULTS

All tumor homogenates contained VEGF and VEGFR-1. A significant correlation existed between the concentration of both VEGF and VEGFR-1 and tumor growth rate but not symptom duration or tumor size.

CONCLUSION

The concentration of VEGF and VEGFR-1 in VS homogenates correlates with tumor growth rate but not with tumor size or symptom duration. We conclude that VEGF and VEGFR-1 appear to be directly involved in the growth pattern of VS.

Size and Growth Rate of Sporadic Vestibular Schwannoma: Predictive Value of Information Available at Presentation

BACKGROUND

The current study examines the hypothesis that tumor growth rate in sporadic vestibular schwannoma could be in part predicted by data available at diagnosis, such as tumor volume, patient age, laterality, and sex.

METHODS

Tumor volumes and growth rates were calculated from serial magnetic resonance imaging data in a cohort of 50 patients (26 men and 24 women; mean age at presentation, 64.1 +/- 12.8 yr). Tumor volumes were measured using an algorithm that corrects for partial volume averaging errors and provides accurate estimates of tumor volume with known errors.

RESULTS

Examination of presentation data showed no relationship between tumor size at diagnosis and patient age, sex, or tumor laterality. Two measurements of tumor growth--absolute growth per annum and tumor volume doubling time--were studied, and neither showed any relationship with tumor size at presentation, patient age, tumor laterality, or sex.

CONCLUSION

The study represents a typical spectrum of patient ages and is of sufficient size in view of the distribution pattern of the variables to give a calculated statistical power in excess of 90% for each variable. This indicates that the clinical features available at presentation and diagnosis have no power to predict the expected behavior of sporadic vestibular schwannoma.

Co-expression of Transforming Growth Factor-β1 and Glial Cell Line–Derived Neurotrophic Factor in Vestibular Schwannoma

HYPOTHESIS

Transforming growth factor-beta1, glial cell line-derived neurotrophic factor, and their receptors are expressed in vestibular schwannoma, and the expression data correlate with the proliferation activity (Ki-67 labeling index) and the clinical growth rate of vestibular schwannoma tissue.

BACKGROUND

Glial cell line-derived neurotrophic factor is a potent growth factor for the central and peripheral nervous system. Recent results demonstrate that glial cell line-derived neurotrophic factor requires transforming growth factor-beta to exert its trophic effect on neural tissue. A functional role, including that in Schwann cell proliferation, is discussed for both transforming growth factor-beta1 and glial cell line-derived neurotrophic factor.

METHODS

Immunohistochemical analysis for transforming growth factor-beta1 and glial cell line-derived neurotrophic factor and their receptors TbetaR II, GFRalpha-1, and Ret was performed on formalin-fixed, paraffin-embedded archival surgical specimens. The Ki-67 labeling index (mean Ki-67 labeling index and highest Ki-67 labeling index for Antoni Type A and Type B regions) and the clinical growth rate of vestibular schwannoma were determined and correlated with the expression patterns of the examined neurotrophic factors and their receptors.

RESULTS

Results demonstrate co-expression of transforming growth factor-beta1 and glial cell line-derived neurotrophic factor with higher levels in Antoni Type A than in Antoni Type B regions. Ninety-five percent of vestibular schwannomas exhibited transforming growth factor-beta1 immunoreactivity, and glial cell line-derived neurotrophic factor expression was found in 100% of vestibular schwannoma specimens. Fifty percent of vestibular schwannoma displayed TbetaR II immunostaining, 100% showed positive reactions for GFRalpha-1, and 86% showed positive reactions for Ret. Statistical analysis revealed no significant correlation in neurotrophin expression related to sex, age, tumor size, clinical growth rate, or Ki-67-labeling indices.

CONCLUSIONS

Expression of transforming growth factor-beta1 and glial cell line-derived neurotrophic factor may suggest a biological role for both growth factors in vestibular schwannomas. Trophic transforming growth factor-beta/glial cell line-derived neurotrophic factor synergism seems possible and is underscored by co-expression of both neurotrophic factors and their receptors.

Immunohistochemical Demonstration of Vascular Endothelial Growth Factor in Vestibular Schwannomas Correlates to Tumor Growth Rate

OBJECTIVE

Vascular endothelial growth factor (VEGF) is one of the most potent mediators of angiogenesis, which is a mandatory process during tumor growth. The present objectives were to determine expression of VEGF in vestibular schwannomas by immunohistochemistry and to examine a possible correlation with symptom duration, tumor size, or growth rate.

STUDY DESIGN

Retrospective patient file review; immunohistochemistry and light microscopy of vestibular schwannomas removed by surgery.

METHODS

Vestibular schwannomas from 18 patients were immunolabelled using a polyclonal antibody against VEGF, followed by light microscopy and blinded semiquantitation of VEGF expression. Fifteen patients had a well-defined tumor growth rate defined by repeated preoperative magnetic resonance imaging scans.

RESULTS

All tumors showed expression of VEGF in the Schwann cell cytoplasm, with a more intense staining of the perinuclear region of some cells. The staining intensity varied from tumor to tumor, and semiquantitation revealed a significant correlation between VEGF expression and tumor growth rate, but not symptom duration or tumor size.

CONCLUSION

VEGF is expressed in vestibular schwannomas and the level of expression correlates positively with tumor growth rate, but not with tumor size and symptom duration. We conclude that VEGF seems to be a factor involved in the growth of vestibular schwannomas.

Is clinical growth index a reliable predictor of tumour growth in vestibular schwannomas?

We have assessed the clinical growth index as an indicator of tumour growth rate in 50 patients with a vestibular schwannoma. Clinical growth index was calculated by measuring the length of history and dividing it by the maximum tumour diameter. Total tumour volumes were also measured from all MRI examinations and an effective tumour volume doubling time was calculated. Radiological growth measurements demonstrated involution in 10/50 patients. The median volume doubling time was 1.65 years (range 20.9-46.3 months, skewness 1.72 years). The median clinical growth index was 0.030 cm per month (range 0-0.270 cm per month, skewness 2.398). There was no significant correlation between volume doubling time and clinical growth index. Identification of rapidly growing tumours with clinical growth index >0.025 cm/month had a positive predictive value of 61%, negative predictive value of 48%, false-positive rate of 30% and false-negative rate of 52%. In conclusion, we have shown that the growth rate of vestibular schwannoma is not related to the clinical growth index and we recommend that this measure should be abandoned in the clinical management of patients where conservative management regimes are being considered.