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Vasconcellos FDN, Vilela MAD, Pichardo-Rojas P, Mashiach E, Almeida T, Fiedler AM, Gorbachev J, Wheeler E, Bandopadhay J, Alzate JD, Cordeiro JG, Benjamin C. Comparative analysis of upfront stereotactic radiosurgery and watchful waiting in the management of newly diagnosed vestibular schwannomas: a systematic review and meta-analysis. Neurosurg Rev 2024; 47:307. [PMID: 38980428 DOI: 10.1007/s10143-024-02552-4] [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: 04/16/2024] [Revised: 06/07/2024] [Accepted: 07/03/2024] [Indexed: 07/10/2024]
Abstract
Vestibular schwannomas (VS) are benign intracranial tumors posing significant management challenges. This study aims to compare the outcomes of stereotactic radiosurgery (SRS) and watchful waiting (WW) in the management of newly diagnosed VS, integrating findings from both retrospective and the pioneering V-REX prospective trial. Adhering to PRISMA guidelines, a systematic review was conducted using MEDLINE, Embase, and Cochrane databases. Studies directly comparing SRS with WW for newly diagnosed VS were included. Primary outcomes focused on hearing preservation assessed through the AAO-HNS or Gardner-Robertson hearing classification scales and tumor progression, with secondary outcomes focusing on neurological symptoms, and the need for further treatment. Thirteen studies encompassing 1,635 patients (WW: 891; SRS: 744) were included.While no significant difference was found in serviceable hearing loss at last follow-up (RR = 1.51, [95%CI: 0.98, 2.32], p = 0.06), significant differences favoring WW were observed in pure tone audiometry (PTA) (MD = -13.51 [95%CI: -22.66, -4.37], p = 0.004) and word recognition score (WRS) (MD = 20.48 [95%CI: 9.72, 31.25], p = 0.0002). Analysis of tumor progression indicated no overall significant difference in risk between SRS and WW (RR = 0.40, [95%CI 0.07, 2.40], p = 0.32), but subgroup analysis suggested a lower risk with SRS in certain contexts. The need for further treatments favored SRS (RR = 0.24, [95%CI: 0.07, 0.74], p = 0.007). No significant differences were found in tinnitus and imbalance between the two groups. This comprehensive analysis suggests no marked difference in functional hearing preservation between SRS and WW in managing VS. However, untreated tumors commonly necessitate additional interventions. These findings highlight the need for individualized treatment decisions and underscore the importance of continued monitoring. The study advocates for further prospective trials to refine management strategies for VS.
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Affiliation(s)
| | - Marcos Antônio Dias Vilela
- Department of Neurosurgery, Faculdade de Medicina de São José do Rio Preto, FAMERP, São José do Rio Preto, SP, Brazil
| | | | - Elad Mashiach
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Timoteo Almeida
- Department of Neurosurgery, University of Miami, Miami, FL, USA
| | | | - Jowah Gorbachev
- Vivian L. Smith Neurosurgery Department, UTHealth Houston, Houston, TX, USA
| | - Ellery Wheeler
- Vivian L. Smith Neurosurgery Department, UTHealth Houston, Houston, TX, USA
| | - Josh Bandopadhay
- Vivian L. Smith Neurosurgery Department, UTHealth Houston, Houston, TX, USA
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Wang SSY, Horstmann G, van Eck A, Tatagiba M, Naros G. Likelihood-of-harm/help of microsurgery compared to radiosurgery in large vestibular schwannoma. J Neurooncol 2024:10.1007/s11060-024-04732-0. [PMID: 38951458 DOI: 10.1007/s11060-024-04732-0] [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: 04/30/2024] [Accepted: 05/31/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE It has been shown that in large vestibular schwannomas (VS), radiosurgery (SRS) is inferior with respect to tumor control compared to microsurgical resection (SURGERY). However, SURGERY poses a significantly higher risk of facial-function deterioration (FFD). The aim of this study was to illustrate the effectiveness in terms of number-needed-to-treat/operate (NNO), number-needed-to-harm (NNH), and likelihood-of-harm/help (LHH) by comparing both treatment modalities in large VS. METHODS This was a retrospective, dual-center cohort study. Tumor size was classified by Hannover Classification. Absolute risk reduction and risk increase were used to derive additional estimates of treatment effectiveness, namely NNO and NNH. LHH was then calculated by a quotient of NNH/NNO to illustrate the risk-benefit-ratio of SURGERY. RESULTS Four hundred and forty-nine patients treated met the inclusion criteria. The incidence of tumor recurrence was significantly higher in SRS (14%), compared to SURGERY (3%) resulting in ARR of 11% and NNO of 10. At the same time, SURGERY was related to a significant risk of FFD resulting in an NNH of 12. Overall, the LHH calculated at 1.20 was favored SURGERY, especially in patients under the age of 40 years (LHH = 2.40), cystic VS (LHH = 4.33), and Hannover T3a (LHH = 1.83) and T3b (LHH = 1.80). CONCLUSIONS Due to a poorer response of large VS to SRS, SURGERY is superior with respect to tumor control. One tumor recurrence can be prevented, when 10 patients are treated by SURGERY instead of SRS. Thus, LHH portrays the benefit of SURGERY in large VS even when taking raised FFD into account.
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Affiliation(s)
- Sophie Shih-Yüng Wang
- Department of Neurosurgery, Eberhard Karls University, Hoppe-Seyler-Strasse 3, Tubingen, Germany.
| | | | | | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University, Hoppe-Seyler-Strasse 3, Tubingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, Eberhard Karls University, Hoppe-Seyler-Strasse 3, Tubingen, Germany
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Wang SSY, Rizk A, Ebner FH, van Eck A, Naros G, Horstmann G, Tatagiba M. Cystic vestibular schwannoma - a subgroup analysis from a comparative study between radiosurgery and microsurgery. Neurosurg Rev 2024; 47:291. [PMID: 38914785 PMCID: PMC11196330 DOI: 10.1007/s10143-024-02495-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/26/2024]
Abstract
Some vestibular schwannoma (VS) show cystic morphology. It is known that these cystic VS bear different risk profiles compared to solid VS in surgical treatment. Still, there has not been a direct comparative study comparing both SRS and SURGERY effectiveness in cystic VS. This retrospective bi-center cohort study aims to analyze the management of cystic VS compared to solid VS in a dual center study with both microsurgery (SURGERY) and stereotactic radiosurgery (SRS). Cystic morphology was defined as presence of any T2-hyperintense and Gadolinium-contrast-negative cyst of any size in the pre-interventional MRI. A matched subgroup analysis was carried out by determining a subgroup of matched SURGERY-treated solid VS and SRS-treated solid VS. Functional status, and post-interventional tumor volume size was then compared. From 2005 to 2011, N = 901 patients with primary and solitary VS were treated in both study sites. Of these, 6% showed cystic morphology. The incidence of cystic VS increased with tumor size: 1.75% in Koos I, 4.07% in Koos II, 4.84% in Koos III, and the highest incidence with 15.43% in Koos IV. Shunt-Dependency was significantly more often in cystic VS compared to solid VS (p = 0.024) and patients with cystic VS presented with significantly worse Charlson Comorbidity Index (CCI) compared to solid VS (p < 0.001). The rate of GTR was 87% in cystic VS and therefore significantly lower, compared to 96% in solid VS (p = 0.037). The incidence of dynamic volume change (decrease and increase) after SRS was significantly more common in cystic VS compared to the matched solid VS (p = 0.042). The incidence of tumor progression with SRS in cystic VS was 25%. When comparing EOR in the SURGERY-treated cystic to solid VS, the rate for tumor recurrence was significantly lower in GTR with 4% compared to STR with 50% (p = 0.042). Tumor control in cystic VS is superior in SURGERY, when treated with a high extent of resection grade, compared to SRS. Therapeutic response of SRS was worse in cystic compared to solid VS. However, when cystic VS was treated surgically, the rate of GTR is lower compared to the overall, and solid VS cohort. The significantly higher number of patients with relevant post-operative facial palsy in cystic VS is accredited to the increased tumor size not its sole cystic morphology. Cystic VS should be surgically treated in specialized centers.
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Affiliation(s)
- Sophie Shih-Yüng Wang
- Department of Neurosurgery, Eberhard Karls University, Hoppe- Seyler-Strasse 3, Tubingen, Germany.
| | - Ahmed Rizk
- Department of Neurosurgery, Eberhard Karls University, Hoppe- Seyler-Strasse 3, Tubingen, Germany
- Department of Neurosurgery, Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Florian H Ebner
- Department of Neurosurgery, Eberhard Karls University, Hoppe- Seyler-Strasse 3, Tubingen, Germany
- Department of Neurosurgery, Alfried Krupp Hospital, Essen, Germany
| | | | - Georgios Naros
- Department of Neurosurgery, Eberhard Karls University, Hoppe- Seyler-Strasse 3, Tubingen, Germany
| | | | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University, Hoppe- Seyler-Strasse 3, Tubingen, Germany
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Koç İ, Yüce Sarı S, Yazıcı G, Kapucu Y, Kıratlı H, Zorlu F. Role of hypofractionated stereotactic radiotherapy for primary optic nerve sheath meningioma. Neurooncol Pract 2024; 11:150-156. [PMID: 38496921 PMCID: PMC10940822 DOI: 10.1093/nop/npad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Background Optic nerve sheath meningiomas (ONSM) are rare tumors potentially causing visual deficits. This study aims to report the anatomic and visual outcomes of patients with primary ONSM treated with hypofractionated stereotactic radiotherapy (HF-SRT). Methods Data of 36 patients treated with HF-SRT between 2008 and 2019 were retrospectively collected. The clinical target volume (CTV) was equal to the gross tumor volume and a 2 mm was added for the planning target volume. All responses other than progression were accepted as local control (LC). The VA grading was performed under 3 groups to provide an even distribution; 20/400 or worse, 20/40-20/400, and 20/40 or better. Results Median HF-SRT dose was 25 Gy and the median CTV was 1.94 cc. After a median of 106 months of follow-up, the tumor regressed in 23 (64%), was stable in 9 (25%), and progressed in 4 (11%) eyes. The overall rate of LC was 89% with 2-, 5-, 10-, and 15-year rate of 100%, 94%, 84%, and 84%, respectively. Treatment-related late toxicity rate was 11%. The VA was stable in 27 (75%) eyes, improved in 5 (14%) eyes, and worsened in 4 (11%) eyes, respectively, after HF-SRT. Female gender was the only independent predictor of an improved VA. Conclusions Hypofractionated stereotactic radiotherapy is a safe and satisfactory treatment option for primary ONSM without severe toxicity. It may be advisable to commence treatment before an established visual deficit of 20/400 or worse occurs, to make the most of the functional benefit.
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Affiliation(s)
- İrem Koç
- Ocular Oncology Service, Department of Ophthalmology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Sezin Yüce Sarı
- Department of Radiation Oncology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Gözde Yazıcı
- Department of Radiation Oncology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Yasemin Kapucu
- Ocular Oncology Service, Department of Ophthalmology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Hayyam Kıratlı
- Ocular Oncology Service, Department of Ophthalmology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Faruk Zorlu
- Department of Radiation Oncology, Hacettepe University School of Medicine, Ankara, Turkey
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Esser J, Walger M, Pollet N, Klußmann JP, Ruge M, Goldbrunner R, Lüers JC. [Vestibular Schwannoma: Factors in Therapy Decision-Making]. Laryngorhinootologie 2024; 103:176-186. [PMID: 38128578 DOI: 10.1055/a-2222-0878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
The treatment of vestibular schwannomas (VS) has always posed a challenge for physicians. Three essential treatment principles are available: wait-and-scan, surgery, and stereotactic radiotherapy. In addition to the type of treatment, decisions must be made regarding the optimal timing of therapy, the combination of different treatment modalities, the potential surgical approach, and the type and intensity of radiation. Factors influencing the therapy decision include tumor location and size or stage, patient age, comorbidities, symptoms, postoperative hearing rehabilitation options, patient preferences, and, not least, the experience of the surgeons and the personnel and technical capabilities of the clinical site. This article begins with a brief overview of vestibular schwannomas, then outlines the fundamental interdisciplinary treatment options, and finally discusses the ENT (ear, nose, and throat)-relevant factors in the therapy decision.
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Affiliation(s)
- Julia Esser
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, DE 50937, Germany
| | - Martin Walger
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, DE 50937, Germany
| | - Naomi Pollet
- Universität zu Köln, Medizinische Fakultät, Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf und Hals-Chirurgie, Uniklinik Köln, Köln, DE 50937, Germany
| | - Jens Peter Klußmann
- Klinik und Poliklinik für HNO-Heilkunde, Kopf- und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, DE 50937, Germany
| | - Maximilian Ruge
- Klinik für Stereotaxie und Funktionelle Neurochirurgie, Universität zu Köln Medizinische Fakultät, Köln, Germany
| | - Roland Goldbrunner
- Universität zu Köln, Medizinische Fakultät, Zentrum für Neurochirurgie, Klinik für Allgemeine Neurochirurgie, Universität zu Köln Medizinische Fakultät, Köln, Germany
| | - Jan Christoffer Lüers
- Klinik und Poliklinik für HNO-Heilkunde, Kopf- und Hals-Chirurgie, Universität zu Köln Medizinische Fakultät, Köln, Germany
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Kang H, Ji SY, Kim C, Koo J, Song J, Choi BY, Hwang K, Han JH. Hearing preservation after stereotactic radiosurgery for sporadic intracanalicular vestibular schwannomas classified as Koos grade 1. Cancer Med 2024; 13:e6990. [PMID: 38348957 PMCID: PMC10839155 DOI: 10.1002/cam4.6990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/19/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION The mechanism of hearing loss following stereotactic radiosurgery (SRS) for vestibular schwannomas (VSs) remains unclear. There is conflicting evidence regarding cochlear nerve damage by transient volume expansion of VSs after radiosurgery and radiation-induced cochlear damage. This study aimed to investigate whether there is a specific patient population that can achieve definite hearing preservation after SRS for VSs. METHODS A total of 37 consecutive patients with sporadic unilateral intracanalicular VSs and serviceable hearing (Gardner-Roberson [G-R] class I or II) were treated with SRS from 2009 to 2023. This is a retrospective study. Survival analysis with Cox regression for hearing deterioration was performed. RESULTS The median age was 55 years old. The median tumor volume was 0.089 cm3 , and the median marginal dose was 12.0 Gy. Nonserviceable hearing deterioration occurred in 9 patients (24.3%), with a median onset of 11.9 months after SRS. The actuarial rates of serviceable hearing preservation were 86%, 82%, and 70% at 1, 2, and 3 years after SRS, respectively. In a multivariate analysis, only baseline pure tone average > 30 dB increased the risk of nonserviceable hearing deterioration with significant hazard ratio. There were 13 patients with petit VSs whose tumor volume was smaller than 0.05 cm3 , and 11 of them were treated by a 4-mm single shot with a marginal dose of 12 Gy. None of the 13 patients had nonserviceable hearing deterioration. CONCLUSIONS Petit VSs that can be treated with 4-mm single or double shots with a marginal dose of 12 Gy may achieve hearing preservation after SRS.
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Affiliation(s)
- Ho Kang
- Department of NeurosurgerySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
| | - So Young Ji
- Department of NeurosurgerySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
| | - Chae‐Yong Kim
- Department of NeurosurgerySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
| | - Ja‐Won Koo
- Department of OtorhinolaryngologySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
| | - Jae‐Jin Song
- Department of OtorhinolaryngologySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
| | - Byung Yoon Choi
- Department of OtorhinolaryngologySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
| | - Kihwan Hwang
- Department of NeurosurgerySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
| | - Jung Ho Han
- Department of NeurosurgerySeoul National University Bundang Hospital, Seoul National University College of MedicineSeongnam‐siKorea
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Shinya Y, Teranishi Y, Hasegawa H, Miyawaki S, Sugiyama T, Shin M, Kawashima M, Umekawa M, Katano A, Nakatomi H, Saito N. Long-term outcomes of stereotactic radiosurgery for intracranial schwannoma in neurofibromatosis type 2: a genetic analysis perspective. J Neurooncol 2024; 166:185-194. [PMID: 38151698 DOI: 10.1007/s11060-023-04530-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/04/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE Neurofibromatosis type 2 (NF2) is intractable because of multiple tumors involving the nervous system and is clinically diverse and genotype-dependent. Stereotactic radiosurgery (SRS) for NF2-associated schwannomas remains controversial. We aimed to investigate the association between radiosurgical outcomes and mutation types in NF2-associated schwannomas. METHODS This single-institute retrospective study included consecutive NF2 patients with intracranial schwannomas treated with SRS. The patients' types of germline mutations ("Truncating," "Large deletion," "Splice site," "Missense," and "Mosaic") and Halliday's genetic severity scores were examined, and the associations with progression-free rate (PFR) and overall survival (OS) were analyzed. RESULTS The study enrolled 14 patients with NF2 with 22 associated intracranial schwannomas (median follow-up, 102 months). The PFRs in the entire cohort were 95% at 5 years and 90% at 10-20 years. The PFRs tended to be worse in patients with truncating mutation exons 2-13 than in those with other mutation types (91% at 5 years and 82% at 10-20 years vs. 100% at 10-20 years, P = 0.140). The OSs were 89% for patients aged 40 years and 74% for those aged 60 years in the entire cohort and significantly lower in genetic severity group 3 than in the other groups (100% vs. 50% for those aged 35 years; P = 0.016). CONCLUSION SRS achieved excellent PFR for NF2-associated intracranial schwannomas in the mild (group 2A) and moderate (group 2B) groups. SRS necessitates careful consideration for the severe group (group 3), especially in cases with NF2 truncating mutation exons 2-13.
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Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Yu Teranishi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, 162-8655, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, 305-8575, Japan
| | - Masahiro Shin
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Huang CY, Peng SJ, Yang HC, Wu HM, Chen CJ, Wang MC, Hu YS, Lin CJ, Shiau CY, Guo WY, Chung WY, Pan DHC, Lee CC. Association Between Pseudoprogression of Vestibular Schwannoma After Radiosurgery and Radiological Features of Solid and Cystic Components. Neurosurgery 2023; 93:1383-1392. [PMID: 37432016 DOI: 10.1227/neu.0000000000002599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pathophysiology of vestibular schwannoma (VS) pseudoprogression after Gamma Knife radiosurgery (GKRS) remains unclear. Radiological features in pretreatment magnetic resonance images may help predict VS pseudoprogression. This study used VS radiological features quantified using an automated segmentation algorithm to predict pseudoprogression after GKRS treatment. METHODS This is a retrospective study comprising 330 patients with VS who received GKRS. After image preprocessing and T2W/contrast-enhanced T1-weighted image (CET1W) image generation, with fuzzy C-means clustering, VSs were segmented into solid and cystic components and classified as solid and cystic. Relevant radiological features were then extracted. The response to GKRS was classified into "nonpseudoprogression" and "pseudoprogression/fluctuation". The Z test for two proportions was used to compare solid and cystic VS for the likelihood of pseudoprogression/fluctuation. Logistic regression was used to assess the correlation between clinical variables and radiological features and response to GKRS. RESULTS The likelihood of pseudoprogression/fluctuation after GKRS was significantly higher for solid VS compared with cystic VS (55% vs 31%, P < .001). For the entire VS cohort, multivariable logistic regression revealed that a lower mean tumor signal intensity (SI) in T2W/CET1W images was associated with pseudoprogression/fluctuation after GKRS ( P = .001). For the solid VS subgroup, a lower mean tumor SI in T2W/CET1W images ( P = .035) was associated with pseudoprogression/fluctuation after GKRS. For the cystic VS subgroup, a lower mean SI of the cystic component in T2W/CET1W images ( P = .040) was associated with pseudoprogression/fluctuation after GKRS. CONCLUSION Pseudoprogression is more likely to occur in solid VS compared with cystic VS. Quantitative radiological features in pretreatment magnetic resonance images were associated with pseudoprogression after GKRS. In T2W/CET1W images, solid VS with a lower mean tumor SI and cystic VS with a lower mean SI of cystic component were more likely to have pseudoprogression after GKRS. These radiological features can help predict the likelihood of pseudoprogression after GKRS.
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Affiliation(s)
- Chih-Ying Huang
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei , Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston , Texas , USA
| | - Mao-Che Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Cheng-Ying Shiau
- Cancer Center, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei , Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei , Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
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Shah F, Hamilton LOW, Yiannakis CP, Slim MAM, Kontorinis G. A systematic review and meta-analysis of stereotactic radiosurgery as a primary treatment in fast-growing vestibular schwannomas. J Laryngol Otol 2023; 137:1193-1199. [PMID: 37194631 DOI: 10.1017/s0022215123000786] [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] [Indexed: 05/18/2023]
Abstract
BACKGROUND Stereotactic radiosurgery has been shown to be an effective method of managing vestibular schwannomas. The primary aim here is to establish the impact of pre-treatment fast-growing vestibular schwannomas on the efficacy of stereotactic radiosurgery. METHODS PubMed, Medline and Embase databases were used. The ROBINS-I ('Risk Of Bias In Non-randomised Studies - of Interventions') tool was utilised to assess for risk of bias. Proportionate meta-analysis and sub-analysis for fast-growing tumours were performed to explore the success rate of stereotactic radiosurgery in stabilising or decreasing the tumour burden in vestibular schwannomas. RESULTS Four moderate risk studies were included in the analysis. Overall, 91 per cent (95 per cent confidence interval = 0.83-0.97, p < 0.01, I2 = 80 per cent) of the tumours demonstrated successful size reduction or stabilisation following stereotactic radiosurgery. Nevertheless, the efficacy of stereotactic radiosurgery in reducing or stabilising fast-growing vestibular schwannomas decreased by 79 per cent (95 per cent confidence interval = 0.64-0.91, p = 0.11, I2 = 62 per cent). CONCLUSION Stereotactic radiosurgery has a statistically significant success rate in stabilising or decreasing the vestibular schwannoma size. This success rate is diminished in fast-growing vestibular schwannomas.
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Affiliation(s)
- Faizan Shah
- ENT Department, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
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10
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Silva VAR, Lavinsky J, Pauna HF, Vianna MF, Santos VM, Ikino CMY, Sampaio ALL, Tardim Lopes P, Lamounier P, Maranhão ASDA, Soares VYR, Polanski JF, Denaro MMDC, Chone CT, Bento RF, Castilho AM. Brazilian Society of Otology task force - Vestibular Schwannoma ‒ evaluation and treatment. Braz J Otorhinolaryngol 2023; 89:101313. [PMID: 37813009 PMCID: PMC10563065 DOI: 10.1016/j.bjorl.2023.101313] [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: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To review the literature on the diagnosis and treatment of vestibular schwannoma. METHODS Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on vestibular schwannoma were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions. RESULTS The topics were divided into 2 parts: (1) Diagnosis - audiologic, electrophysiologic tests, and imaging; (2) Treatment - wait and scan protocols, surgery, radiosurgery/radiotherapy, and systemic therapy. CONCLUSIONS Decision making in VS treatment has become more challenging. MRI can diagnose increasingly smaller tumors, which has disastrous consequences for the patients and their families. It is important to develop an individualized approach for each case, which highly depends on the experience of each surgical team.
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Affiliation(s)
- Vagner Antonio Rodrigues Silva
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Campinas, SP, Brazil; Sociedade Brasileira de Otologia - SBO
| | - Joel Lavinsky
- Sociedade Brasileira de Otologia - SBO; Universidade Federal do Rio Grande do Sul (UFRGS), Departamento de Ciências Morfológicas, Porto Alegre, RS, Brazil
| | - Henrique Furlan Pauna
- Hospital Universitário Cajuru, Departamento de Otorrinolaringologia, Curitiba, PR, Brazil
| | - Melissa Ferreira Vianna
- Sociedade Brasileira de Otologia - SBO; Irmandade Santa Casa de Misericórdia de São Paulo, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Vanessa Mazanek Santos
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Curitiba, PR, Brazil
| | - Cláudio Márcio Yudi Ikino
- Universidade Federal de Santa Catarina, Hospital Universitário, Departamento de Cirurgia, Florianópolis, SC, Brazil
| | - André Luiz Lopes Sampaio
- Sociedade Brasileira de Otologia - SBO; Universidade de Brasília (UnB), Faculdade de Medicina, Laboratório de Ensino e Pesquisa em Otorrinolaringologia, Brasília, DF, Brazil
| | - Paula Tardim Lopes
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Pauliana Lamounier
- Centro de Reabilitação e Readaptação Dr. Henrique Santillo (CRER), Departamento de Otorrinolaringologia, Goiânia, GO, Brazil
| | - André Souza de Albuquerque Maranhão
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | - Vitor Yamashiro Rocha Soares
- Hospital Flavio Santos e Hospital Getúlio Vargas, Grupo de Otologia e Base Lateral do Crânio, Teresina, PI, Brazil
| | - José Fernando Polanski
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Curitiba, PR, Brazil; Faculdade Evangélica Mackenzie do Paraná, Faculdade de Medicina, Curitiba, PR, Brazil
| | | | - Carlos Takahiro Chone
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Campinas, SP, Brazil
| | - Ricardo Ferreira Bento
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), Departamento de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Arthur Menino Castilho
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas (FCM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Campinas, SP, Brazil; Sociedade Brasileira de Otologia - SBO.
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11
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Lee TK, Kim YJ, Jung TY, Moon KS, Kim IY, Jung S. From the perspective of pseudo-progression rather than treatment failure, how long should we wait before considering treatment failure if large cystic enlargement occurs after Gamma Knife radiosurgery for vestibular schwannoma?: insight into pseudoprogression based on two case reports. Acta Neurochir (Wien) 2023; 165:2105-2109. [PMID: 37421424 DOI: 10.1007/s00701-023-05684-6] [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: 12/30/2022] [Accepted: 03/07/2023] [Indexed: 07/10/2023]
Abstract
Gamma knife radiosurgery (GKRS) has been accepted as a safe and effective treatment for vestibular schwannoma (VS). However, during follow-up, tumor expansion induced by irradiation can occur, and diagnosis of failure in radiosurgery for VS is still controversial. Tumor expansion with cystic enlargement causes some confusion regarding whether further treatment should be performed. We analyzed more than 10 years of clinical findings and imaging of patients with VS with cystic enlargement after GKRS. A 49-year-old male with hearing impairment was treated with GKRS (12 Gy; isodose, 50%) for a left VS with a preoperative tumor volume of 0.8 cc. The tumor size increased with cystic changes from the third year after GKRS, reaching a volume of 10.8 cc at 5 years after GKRS. At the 6th year of follow-up, the tumor volume started to decrease, up to 0.3 cc by the 14th year of follow-up. A 52-year-old female with hearing impairment and left facial numbness was treated with GKRS for a left VS (13 Gy; isodose, 50%). The preoperative tumor volume was 6.3 cc, which started to increase with cystic enlargement from the first year after GKRS, and reaching 18.2 cc by 5 years after GKRS. The tumor maintained a cystic pattern with slight changes in size, but no other neurologic symptoms developed during the follow-up period. After 6 years of GKRS, tumor regression was observed, eventually reaching a volume of 3.2 cc by the 13th year of follow-up. In both cases, persistent cystic enlargement in VS was observed at 5 years after GKRS, after which the tumors began to stabilize. After more than 10 years of GKRS, the tumor volume was less than that before GKRS. Enlargement with large cystic formation in the first 3-5 years after GKRS has been considered as treatment failure. However, our cases show that further treatment for cystic enlargement should be deferred for at least 10 years, especially in patients without neurological deterioration, as inadequate surgery can be prevented within that period.
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Affiliation(s)
- Tae-Kyu Lee
- Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Hwasun, 58128, Republic of Korea
| | - Yeong-Jin Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Hwasun, 58128, Republic of Korea
| | - Tae-Young Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Hwasun, 58128, Republic of Korea
| | - Kyung-Sub Moon
- Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Hwasun, 58128, Republic of Korea
| | - In-Young Kim
- Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Hwasun, 58128, Republic of Korea
| | - Shin Jung
- Department of Neurosurgery, Chonnam National University Hwasun Hospital and Medical School, Jeollanam-do, Hwasun, 58128, Republic of Korea.
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12
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Hsu PW, Lee CC, Huang YC, Wei KC, Chen HC, Wang CC, Yip PK, Liu ZH. Correlation between initial tumor enlargement and magnetic resonance imaging characteristics following linear accelerator-based stereotactic radiosurgery for acoustic neuromas. Strahlenther Onkol 2023; 199:718-726. [PMID: 36326857 DOI: 10.1007/s00066-022-02011-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Initial tumor enlargement (or pseudoprogression) instead of true tumor progression is a common phenomenon in patients with acoustic neuromas who are treated with stereotactic radiosurgery (SRS). This phenomenon can affect clinical decision-making and patient management. This study assessed the correlation between initial tumor enlargement and magnetic resonance imaging characteristics in patients with acoustic neuromas who were treated with linear accelerator (LINAC)-based SRS. The long-term tumor control outcomes were also analyzed. MATERIALS AND METHODS In total, 330 patients with sporadic acoustic neuromas who were treated with LINAC SRS between March 2006 and March 2020 were retrospectively evaluated to assess their initial tumor enlargement. The tumors were divided into homogeneously enhanced, heterogeneously enhanced, and cystic types based on the morphological characteristics noted on magnetic resonance images. Tumor control was assessed in 275 patients with a follow-up duration of more than 2 years. RESULTS Initial enlargement was observed in 137 of 330 (41.5%) tumors as early as 3 months after LINAC SRS. Data analysis revealed that postoperative tumors with a residual volume lower than 2.5 cm3 had a lower incidence of initial enlargement (p = 0.039). No correlation was noted between the initial enlargement and morphological characteristics of tumors. In patients with a mean follow-up duration of 82.8 ± 37.2 months, heterogeneously enhanced tumors exhibited a lower control rate than homogeneously enhanced and cystic tumors (p = 0.045). No correlation was noted between initial enlargement and tumor control. CONCLUSION Initial enlargement can occur as early as 3 months after SRS. Postoperative residual tumors with a volume lower than 2.5 cm3 exhibit a lower incidence of initial enlargement. Heterogeneously enhanced tumors have a lower local control rate.
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Affiliation(s)
- Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, No. 5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan
| | - Cheng-Chi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, No. 5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan
| | - Yin-Cheng Huang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, No. 5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan
| | - Kuo-Chen Wei
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, No. 5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan
| | - Hsien-Chih Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, Keelung, Taiwan
| | - Chun-Chieh Wang
- Department of Radiation Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Ping K Yip
- Barts and The London , School of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London, UK
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, No. 5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan.
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13
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Holtzman AL, Dagan R, Mendenhall WM. Proton Radiotherapy for Skull-Base Malignancies. Oral Maxillofac Surg Clin North Am 2023:S1042-3699(23)00005-5. [PMID: 37005171 DOI: 10.1016/j.coms.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Proton therapy (PT) is a form of highly conformal external-beam radiotherapy used to mitigate acute and late effects following radiotherapy. Indications for treatment include both benign and malignant skull-base and central nervous system pathologies. Studies have demonstrated that PT shows promising results in minimizing neurocognitive decline and reducing second malignancies with low rates of central nervous system necrosis. Future directions and advances in biologic optimization may provide additional benefits beyond the physical properties of particle dosimetry.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL 32206, USA.
| | - Roi Dagan
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL 32206, USA
| | - William M Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, 2015 North Jefferson Street, Jacksonville, FL 32206, USA
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14
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Pseudoprogression of Vestibular Schwannoma after Stereotactic Radiosurgery with Cyberknife ®: Proposal for New Response Criteria. Cancers (Basel) 2023; 15:cancers15051496. [PMID: 36900290 PMCID: PMC10000564 DOI: 10.3390/cancers15051496] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/05/2023] Open
Abstract
(1) Background: Transient increase in volume of vestibular schwannomas (VS) after stereotactic radiosurgery (SRS) is common and complicates differentiation between treatment-related changes (pseudoprogression, PP) and tumor recurrence (progressive disease, PD). (2) Methods: Patients with unilateral VS (n = 63) underwent single fraction robotic-guided SRS. Volume changes were classified according to existing RANO criteria. A new response type, PP, with a >20% transient increase in volume was defined and divided into early (within the first 12 months) and late (>12 months) occurrence. (3) Results: The median age was 56 (range: 20-82) years, the median initial tumor volume was 1.5 (range: 0.1-8.6) cm3. The median radiological and clinical follow-up time was 66 (range: 24-103) months. Partial response was observed in 36% (n = 23), stable disease in 35% (n = 22) and PP in 29% (n = 18) of patients. The latter occurred early (16%, n = 10) or late (13%, n = 8). Using these criteria, no case of PD was observed. (4) Conclusion: Any volume increase after SRS for vs. assumed to be PD turned out to be early or late PP. Therefore, we propose modifying RANO criteria for SRS of VS, which may affect the management of vs. during follow-up in favor of further observation.
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15
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Dhayalan D, Perry A, Graffeo CS, Tveiten ØV, Muñoz Casabella A, Pollock BE, Driscoll CLW, Carlson ML, Link MJ, Lund-Johansen M. Salvage radiosurgery following subtotal resection of vestibular schwannomas: does timing influence tumor control? J Neurosurg 2023; 138:420-429. [PMID: 35907189 DOI: 10.3171/2022.5.jns22249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The goal of microsurgical resection of vestibular schwannoma (VS) is gross-total resection (GTR) to provide oncological cure. However, a popular strategy is to halt the resection if the surgical team feels the risk of cranial nerve injury is imminent, achieving a maximally safe subtotal resection (STR) instead. The tumor remnant can then be treated with stereotactic radiosurgery (SRS) once the patient has recovered from the immediate postoperative period, or it can be followed with serial imaging and treated with SRS in a delayed fashion if residual tumor growth is seen. In this study, the authors evaluated the efficacy of this multimodality approach, particularly the influence of timing and dose of SRS on radiological tumor control, need for salvage treatment, and cranial nerve function. METHODS VS patients treated with initial microsurgery and subsequent radiosurgery were retrospectively included from two tertiary treatment centers and dichotomized depending on whether SRS was given upfront (defined as before 12 months) or later. Radiological tumor control was defined as less than 20% tumor volume expansion and oncological tumor control as an absence of salvage treatment. Facial and cochlear nerve functions were assessed after surgery, at the time of SRS, and at last follow-up. Finally, a systematic literature review was conducted according to PRISMA guidelines. RESULTS A total of 110 VS patients underwent SRS following microsurgical resection, with a mean preradiosurgical tumor volume of 2.2 cm3 (SD 2.5 cm3) and mean post-SRS follow-up time of 5.8 years (SD 4.1 years). The overall radiological tumor control and oncological tumor control were 77.3% and 90.9%, respectively. Thirty-five patients (31.8%) received upfront SRS, while 75 patients (68.2%) were observed for a minimum of 12 months prior to SRS. The timing of SRS did not influence the radiological tumor control (p = 0.869), the oncological tumor control (p = 0.560), or facial nerve (p = 0.413) or cochlear nerve (p = 0.954) function. An escalated marginal dose (> 12 Gy) was associated with greater tumor shrinkage (p = 0.020) and superior radiological tumor control (p = 0.020), but it did not influence the risk of salvage treatment (p = 0.904) or facial (p = 0.351) or cochlear (p = 0.601) nerve deterioration. CONCLUSIONS Delayed SRS after close observation of residuals following STR is a safe alternative to upfront SRS regarding tumor control and cranial nerve preservation in selected patients.
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Affiliation(s)
- Dhanushan Dhayalan
- 1Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,3Department of Clinical Medicine, University of Bergen, Norway; and
| | - Avital Perry
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Bruce E Pollock
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Colin L W Driscoll
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Morten Lund-Johansen
- 1Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,3Department of Clinical Medicine, University of Bergen, Norway; and
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Hypofractionated stereotactic radiotherapy for large vestibular schwannomas and the impact of pre-radiation debulking surgery on dosimetry and clinical outcomes. JOURNAL OF RADIOTHERAPY IN PRACTICE 2023. [DOI: 10.1017/s1460396922000383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Abstract
Introduction:
This study was aimed to evaluate the outcomes of patients with large (>2 cm in great diameter) vestibular schwannomas (VSs) treated with hypofractionated stereotactic radiotherapy (HFSRT) compared to small (<2 cm) ones and the impact of debulking surgery prior to radiation for large VSs.
Methods:
Fifty-nine patients with VSs treated with HFSRT (25 Gy in 5 fractions) were evaluated by tumour size and surgical status. Patients were divided based on tumour size: small VSs (n = 42) and large VSs (n = 17). The large group was further divided into the groups of pre-treatment debulking surgery (n = 8) and no surgery (n = 9). Rates of tumour control, brainstem necrosis and neurologic dysfunction were assessed following treatment. Pre-surgical magnetic resonance imaging (MRI) were used to generate hypothetical HFSRT plans to compare the effect of debulking surgery on dosimetry. Normal tissue complication probability (NTCP) modelling was performed to compare toxicity probabilities with and without surgical debulking in large VSs.
Results:
There was no statistical difference of tumour control rate between small and large VSs with 100% for small tumours and 94·1% for large tumours (p = 0·12), respectively. In large VSs patient, the tumour control rate of HFSRT was 100% (8/8) for surgically debulked patients and 89% (8/9) for non-surgically debulked patients (p = 0·35). There were no patients who experienced brainstem necrosis or progression of facial and trigeminal nerve symptoms after HFSRT in the entire groups of patients. Surgical debulking large VSs did not change the maximum point dose of brainstem (p = 0·98), but significantly decreased volumes of VSs and changed the minimum dose to the hottest 0·5 cc of tumour (p = 0·016) as well as the volume receiving at least 23 Gy (p = 0·023). NTCP modelling revealed very low rates (average < 1%) of brainstem toxicity with or without surgical debulking, but there was a significant difference favoring surgery (p < 0·05).
Conclusions:
HFSRT is a safe and effective treatment for both small and large VSs and is a viable option for patients with large VSs who cannot undergo surgery, if NTCP of pre-debulking HFSRT dosimetry is lower.
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Tatagiba M, Wang SS, Rizk A, Ebner F, van Eck ATCJ, Naros G, Horstmann G. A comparative study of microsurgery and gamma knife radiosurgery in vestibular schwannoma evaluating tumor control and functional outcome. Neurooncol Adv 2023; 5:vdad146. [PMID: 38024239 PMCID: PMC10681278 DOI: 10.1093/noajnl/vdad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background Both stereotactic radiosurgery (SRS) and microsurgical resection (SURGERY) are available as treatment options for sporadic vestibular schwannoma (VS). There are very few direct comparative studies comparing both treatment modalities in large cohorts allowing detailed subgroup analysis. This present study aimed to compare the nuances in the treatment of VS by SURGERY and SRS in 2 highly specialized neurosurgical centers. Methods This is a retrospective bicentric cohort study. Data from patients treated between 2005 and 2011 were collected retrospectively. Recurrence-free survival (RFS) was assessed radiographically by contrast-enhanced magnetic resonance imaging. Results The study population included N = 901 patients with a mean follow-up of 7 years. Overall, the incidence of recurrence was 7% after SURGERY, and 11% after SRS with superior tumor control in SURGERY in the Kaplan-Meier-analysis (P = 0.031). In small tumors (Koos I and II), tumor control was equivalent in both treatment arms. In large VS (Koos III and IV), however, RFS was superior in SURGERY. The extent of resection correlated with RFS (P < .001). Facial and hearing deterioration was similar in both treatment arms in small VS, but more pronounced in SURGERY of large VS. Tinnitus, vertigo, imbalance, and trigeminal symptoms were more often improved by SURGERY than SRS. Conclusions SRS can achieve similar tumor control compared to SURGERY in smaller VS (Koos I and II)-with similar postinterventional morbidities. In large VS (Koos III and IV), long-term tumor control of SRS is inferior to SURGERY. Based on these results, we suggest that if combination therapy is chosen, the residual tumor should not exceed the size of Koos II.
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Affiliation(s)
- Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | - Sophie S Wang
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | - Ahmed Rizk
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | - Florian Ebner
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | | | - Georgios Naros
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
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Dabhi N, Pikis S, Mantziaris G, Tripathi M, Warnick R, Peker S, Samanci Y, Berger A, Bernstein K, Kondziolka D, Niranjan A, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for the treatment of hypoglossal schwannoma: a multi-institutional retrospective study. Acta Neurochir (Wien) 2022; 164:2473-2481. [PMID: 35347448 DOI: 10.1007/s00701-022-05187-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: 01/30/2022] [Accepted: 03/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical removal has been performed as the first line treatment for symptomatic or enlarging hypoglossal schwannomas (HS). Stereotactic radiosurgery (SRS) offers a minimally invasive approach that may afford long-term tumor control for patients with HS particularly those who refuse or are unfit for surgery. This study evaluates outcomes after SRS performed for both newly diagnosed and residual tumors after incomplete resection. METHODS This retrospective, multi-institutional study involved patients treated with adjuvant or primary SRS for HS. The study end-points included local tumor response, clinical outcomes, and procedure-related complications. All the patients had Gamma Knife SRS. RESULTS The cohort included 12 patients (five females), median age at SRS 49.5 years (range, 37-76)]. The median tumor target volume was 5.9 cm3 (range, 0.7-27.23). At median imaging follow-up of 37 months (range, 6-153), tumor control was achieved in 11 patients. Tumor enlargement that was managed with surgical resection was noted at the 6-month follow-up in one patient. At median clinical follow-up of 30.5 months (range, 6-157), stability, or improvement of all pre-SRS signs and symptoms was noted in nine patients. Two patients experienced worsening of at least one pre-existing symptoms or sign. New-onset trapezius weakness was noted in one patient and tongue atrophy in two patients. CONCLUSION Single-fraction SRS appears to be a safe and effective upfront and adjuvant treatment option for HS. SRS may be recommended as an alternative to surgery for patients presenting with HS or as an adjuvant treatment following subtotal resection and at HS recurrence.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ronald Warnick
- Gamma Knife Center, The Jewish Hospital, Cincinnati, OH, USA
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Assaf Berger
- Department of Neurosurgery, New York University Langone, New York, NY, USA
| | - Kenneth Bernstein
- Department of Radiation Oncology, New York University Langone, New York, NY, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone, New York, NY, USA
| | - Ajay Niranjan
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, 22908, USA.
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19
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Jung IH, Chang KW, Park SH, Jung HH, Chang JH, Chang JW, Chang WS. Pseudoprogression and peritumoral edema due to intratumoral necrosis after Gamma knife radiosurgery for meningioma. Sci Rep 2022; 12:13663. [PMID: 35953695 PMCID: PMC9372131 DOI: 10.1038/s41598-022-17813-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/01/2022] [Indexed: 11/09/2022] Open
Abstract
Peritumoral cerebral edema is reported to be a side effect that can occur after stereotactic radiosurgery. We aimed to determine whether intratumoral necrosis (ITN) is a risk factor for peritumoral edema (PTE) when gamma knife radiosurgery (GKRS) is performed in patients with meningioma. In addition, we propose the concept of pseudoprogression: a temporary volume expansion that can occur after GKRS in the natural course of meningioma with ITN. This retrospective study included 127 patients who underwent GKRS for convexity meningioma between January 2019 and December 2020. Risk factors for PTE and ITN were investigated using logistic regression analysis. Analysis of variance was used to determine whether changes in tumor volume were statistically significant. After GKRS, ITN was observed in 34 (26.8%) patients, and PTE was observed in 10 (7.9%) patients. When postoperative ITN occurred after GKRS, the incidence of postoperative PTE was 18.970-fold (p = 0.009) greater. When a 70% dose volume ≥ 1 cc was used, the possibility of ITN was 5.892-fold (p < 0.001) higher. On average, meningiomas with ITN increased in volume by 128.5% at 6 months after GKRS and then decreased to 94.6% at 12 months. When performing GKRS in meningioma, a 70% dose volume ≥ 1 cc is a risk factor for ITN. At 6 months after GKRS, meningiomas with ITN may experience a transient volume expansion and PTE, which are characteristics of pseudoprogression. These characteristics typically improve at 12 months following GKRS.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.,Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.,Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Kyung Won Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - So Hee Park
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Brain Tumor Center, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea.
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20
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Kellish AS, Miskiel S, Gaughan J, Barshay V, Kim TW, Gutowski CJ. Reliability and accuracy in radiographic measurements of musculoskeletal tumors. J Orthop Res 2022; 40:1654-1660. [PMID: 34717012 DOI: 10.1002/jor.25197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/21/2021] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
Tumor size and growth are important parameters when evaluating bone and soft tissue neoplasms. There are no reports comparing the intra- and interobserver reliability among physicians in their evaluation of musculoskeletal (MSK) tumor imaging. This study investigates the accuracy and precision of measurements made by orthopedic and radiology physicians in different stages of training. Blinded magnetic resonance imaging (MRI) scans from six patients, three soft tissue, and three bone tumors were selected: each case included an "old" and "new" scan that was performed at least 3 months apart. Fourteen participants were selected, representing varying levels of education and experience, including two of each of the following: medical students, orthopedic and radiology residents, oncology and nononcologic orthopedic attendings, and MSK and non-MSK radiology attendings. Participants compared the old and new studies, recording tumor size in the transverse, cranial-caudal, and anterior-posterior dimensions, and determined if the tumor was stable or unstable. The MRI's official report served as the "gold standard." Average intraobserver variability (|Trial 1 - Trial 2|/[(Trial 1 + Trial 2)/2])) in size measurements was 11.08% (0.00%-68.62%). The lowest variability was recorded by the MSK radiologist 1 (6.16%), and the greatest variability by Orthopedic Surgery Resident 1 (16.70%). Participants correctly determined stability 82% of the time (71%-100%). Only MSK radiologists correctly determined stability in over 90% of cases. There is considerable variability and inaccuracy in MRI-based measurements of MSK tumors. These findings motivate opportunities for improving MSK imaging education of radiology and orthopedic residents. Physicians ordering MRI scans should evaluate them themselves, instead of relying on the radiology report alone, to inform clinical decision-making.
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Affiliation(s)
- Alec S Kellish
- Departmnent of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Philadelphia, USA
| | - Sandra Miskiel
- Department of Orthopaedics, Cooper University Hospital, Camden, New Jersey, USA
| | - John Gaughan
- Department of Orthopaedics, Cooper University Hospital, Camden, New Jersey, USA
| | - Veniamin Barshay
- Department of Radiology, Cooper University Hospital, Camden, New Jersey, USA
| | - Tae W Kim
- Department of Orthopaedics, Cooper University Hospital, Camden, New Jersey, USA
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21
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Umekawa M, Shinya Y, Hasegawa H, Kawashima M, Shin M, Katano A, Minamitani M, Kashio A, Kondo K, Saito N. Stereotactic radiosurgery ensures an effective and safe long-term control of Koos grade IV vestibular schwannomas: a single-center, retrospective, cohort study. J Neurooncol 2022; 159:201-209. [PMID: 35729368 DOI: 10.1007/s11060-022-04058-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is a standard treatment modality for vestibular schwannomas (VSs). However, there is a paucity of data on tumor control and neurological preservation for larger VSs. We aimed to investigate the long-term effectiveness of SRS for Koos grade IV compared with I-III VSs. METHODS We included 452 patients with VSs (50 Koos grade IV and 402 Koos grade I‒III) who were treated with SRS at our institution from 1990 to 2021. Tumor control and functional preservation were calculated using the Kaplan-Meier method and compared between groups with the log-rank test. RESULTS The median post-SRS follow-up period was 68 months. Progression-free survival rates were 91% at 5 and 10 years for Koos grade IV VSs, and 95% and 92%, respectively, for Koos grade I‒III VSs (p = 0.278). In Koos grade IV VSs, functional preservation rates of the facial and trigeminal nerves were both 96% at 5 years (both 98% for Koos grade I‒III VSs; facial, p = 0.410; trigeminal, p = 0.107). Hearing preservation rates were 61% at 5 years for Koos grade IV VSs and 78% for Koos grade I-III VSs (p = 0.645). Symptomatic transient tumor expansion was more common with Koos grade IV VSs (8.0% vs. 2.5%, p = 0.034), although all related symptoms diminished in accordance with tumor shrinkage. CONCLUSION SRS may contribute to long-term tumor control and adequate neurological preservation in the treatment of Koos grade IV VSs, comparable to those in the treatment of Koos grade I‒III VSs.
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Affiliation(s)
- Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan.
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Masanari Minamitani
- Department of Radiology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Akinori Kashio
- Department of Otorhinolaryngology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Kenji Kondo
- Department of Otorhinolaryngology, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, 113-8655, Japan
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22
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Early-onset adverse events after stereotactic radiosurgery for jugular foramen schwannoma: a mid-term follow-up single-center review of 46 cases. Radiat Oncol 2022; 17:89. [PMID: 35525985 PMCID: PMC9077941 DOI: 10.1186/s13014-022-02057-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Recently, stereotacitc radiosurgery (SRS) has been in the spotlight as an alternative therapeutic option for jugular foramen schwannomas (JFS). While most reported studies focus on the long-term efficacy and safety issues of SRS, none describe the early-onset adverse events (eAEs). We aimed to investigate the incidence, clinical characteristics, and mid-term outcomes of eAEs occurring within six months after SRS for JFS. Methods In this retrospective review, patients who underwent at least six months of follow-up were included among all patients with JFS who have performed SRS at our institution between July 2008 and November 2019. And eAEs were defined as a newly developed neurological deficit or aggravation of pre-existing symptoms during the first six months after SRS. Results Forty-six patients were included in the analysis. The median follow-up period was 50 months (range 9–136). The overall tumor control rate was 91.3%, and the actuarial 3-, 5-, and 10-year progression-free survival rates were 97.8%, 93.8%, and 76.9%, respectively. Of the 46 patients, 16 had eAEs, and the median time to onset of eAEs was one month (range 1–6 months), and the predominant symptoms were lower cranial nerve dysfunctions. Thirteen of 16 patients showed improved eAE symptoms during the follow-up period, and the median resolution time was six months (range 1–52). In 11 (68.8%) of 16 patients with eAEs, transient expansions were observed with a mean of 3.6 months after the onset of eAEs, and the mean difference between the initial tumor volume and the transient expansion volume was more prominent in the patients with eAEs (3.2 cm3 vs. 1.0 cm3; p = 0.057). In univariate analysis, dumbbell-shaped tumors (OR 10.56; p = 0.004) and initial tumor volume (OR 1.32; p = 0.033) were significantly associated with the occurrence of eAEs. Conclusions Although acute adverse events after SRS for JFS are not rare, these acute effects were not permanent and mostly improved with the steroid treatment. Dumbell-shaped and large-volume tumors are significant predictive factors for the occurrence of eAEs. And the transient expansion also seems to be closely related to eAEs. Therefore, clinicians need to be more cautious when treating these patients and closely monitor the occurrence of eAEs.
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23
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Hwang I, Choi SH, Kim JW, Yeon EK, Lee JY, Yoo RE, Kang KM, Yun TJ, Kim JH, Sohn CH. Response prediction of vestibular schwannoma after gamma-knife radiosurgery using pretreatment dynamic contrast-enhanced MRI: a prospective study. Eur Radiol 2022; 32:3734-3743. [PMID: 35084518 DOI: 10.1007/s00330-021-08517-1] [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: 06/07/2021] [Revised: 11/09/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES There are few known predictive factors for response to gamma-knife radiosurgery (GKRS) in vestibular schwannoma (VS). We investigated the predictive role of pretreatment dynamic contrast-enhanced (DCE)-MRI parameters regarding the tumor response after GKRS in sporadic VS. METHODS This single-center prospective study enrolled participants between April 2017 and February 2019. We performed a volumetric measurement of DCE-MRI-derived parameters before GKRS. The tumor volume was measured in a follow-up MRI. The pharmacokinetic parameters were compared between responders and nonresponders according to 20% or more tumor volume reduction. Stepwise multivariable logistic regression analyses were performed, and the diagnostic performance of DCE-MRI parameters for the prediction of tumor response was evaluated by receiver operating characteristic curve analysis. RESULTS Ultimately, 35 participants (21 women, 52 ± 12 years) were included. There were 22 (62.9%) responders with a mean follow-up interval of 30.2 ± 5.7 months. Ktrans (0.036 min-1 vs. 0.057 min-1, p = .008) and initial area under the time-concentration curve within 90 s (IAUC90) (84.4 vs. 143.6, p = .003) showed significant differences between responders and nonresponders. Ktrans (OR = 0.96, p = .021) and IAUC90 (OR = 0.97, p = .004) were significant differentiating variables in each multivariable model with clinical variables for tumor response prediction. Ktrans showed a sensitivity of 81.8% and a specificity of 69.2%, and IAUC90 showed a sensitivity of 100% and a specificity of 53.8% for tumor response prediction. CONCLUSION DCE-MRI (particularly Ktrans and IAUC90) has the potential to be a predictive factor for tumor response in VS after GKRS. KEY POINTS •Pretreatment prediction of gamma-knife radiosurgery response in vestibular schwannoma is still challenging. •Dynamic contrast-enhanced MRI could have predictive value for the response of vestibular schwannoma after gamma-knife radiosurgery.
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Affiliation(s)
- Inpyeong Hwang
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seung Hong Choi
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea. .,Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Center for Nanoparticle Research, Institute for Basic Science (IBS), Seoul, 08826, Republic of Korea.
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eung Koo Yeon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ji Ye Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Roh-Eul Yoo
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Koung Mi Kang
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae Jin Yun
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hoon Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Ho Sohn
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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24
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Özer H, Yazol M, Erdoğan N, Emmez ÖH, Kurt G, Öner AY. Dynamic contrast-enhanced magnetic resonance imaging for evaluating early response to radiosurgery in patients with vestibular schwannoma. Jpn J Radiol 2022; 40:678-688. [PMID: 35038116 DOI: 10.1007/s11604-021-01245-y] [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: 10/11/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aimed to use dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) to evaluate early treatment response in vestibular schwannoma (VS) patients after radiosurgery. METHODS Twenty-four VS patients who underwent gamma knife radiosurgery were prospectively followed up for at least four years. DCE-MRI sequences, in addition to standard MRI protocol, were obtained prior to radiosurgery, at 3 and 6 months. Conventionally, treatment responses based on tumor volume changes were classified as regression or stable (RS), transient tumor enlargement (TTE), and continuous tumor enlargement (CTE). DCE-MRI parameters, such as Ktrans, Kep and Ve, were compared according to follow-up periods and between groups. The diagnostic performance was tested using receiver operating characteristic (ROC) curves. RESULTS Changes in tumor volume were as follows at the last 48 months of follow-up: RS in 11 patients (45.8%), TTE in 10 patients (41.7%), and CTE in three patients (12.5%). The median time required to distinguish TTE from CTE using conventional MRI was 12 months (range 9-18). The Ktrans and Ve were significantly decreased in patients with RS and TTE at 3 and 6 months, but did not differ significantly in patients with CTE. There were no significant differences in Ktrans and Ve between patients with RS and TTE at 3 and 6 months. Both Ktrans and Ve demonstrated high diagnostic performance in evaluating early treatment response to radiosurgery in patients with VS. CONCLUSION DCE-MRI may aid in the monitoring and early prediction of treatment response in patients with VS following radiosurgery.
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Affiliation(s)
- Halil Özer
- Department of Radiology, Gazi University Faculty of Medicine, Beşevler, 06500, Ankara, Turkey.
| | - Merve Yazol
- Department of Radiology, Gazi University Faculty of Medicine, Beşevler, 06500, Ankara, Turkey
| | - Nesrin Erdoğan
- Department of Radiology, Gazi University Faculty of Medicine, Beşevler, 06500, Ankara, Turkey
| | - Ömer Hakan Emmez
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Gökhan Kurt
- Department of Neurosurgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ali Yusuf Öner
- Department of Radiology, Gazi University Faculty of Medicine, Beşevler, 06500, Ankara, Turkey
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25
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Fouard O, Daisne JF, Wanet M, Regnier M, Gustin T. Long-term volumetric analysis of vestibular schwannomas following stereotactic radiotherapy: Practical implications for follow-up. Clin Transl Radiat Oncol 2022; 33:1-6. [PMID: 34977365 PMCID: PMC8688865 DOI: 10.1016/j.ctro.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022] Open
Abstract
Pseudoprogression may be a late phenomenon after radiosurgery. Loss of central contrast enhancement is not predictive of tumor control. No decision of salvage therapy should be made until the 6th year post-treatment.
Background and purpose Transient tumor swelling is a well-known phenomenon following radiotherapy for vestibular schwannomas (VS). We analyzed the long-term volumetric changes of VS after LINAC radiosurgery, in order to determine a time interval during which a true tumor progression can be distinguished from a pseudoprogression. Methods Among 63 patients with VS treated by one fraction or fractionated radiotherapy, we selected 52 of them who had a minimal follow-up of 5 years. Maximal axial diameter and three-dimensional tumor volume were measured on each MRI scan. Volume changes were interpreted using different error margins ranging from 10 to 20%. Patients were categorized according to the tumor evolution pattern over time. Results Median follow-up was 83 months. One tumor (1.9%) remained stable and 26.9% had continuous shrinkage. Applying an error margin of 13%, a transient tumor enlargement was observed in 63.5% of patients, with a first peak at 6–12 months and a late peak at 3–4 years. A true progression was suspected in 4 (7.7%) patients, tumor regrowth starting after the 3rd or 4th year post-treatment. Only one patient required salvage radiotherapy. Conclusion Transient swelling of VS following radiotherapy is generally an early phenomenon but may occur late. In the first 5 years, a true tumor progression cannot be differentiated from a pseudoprogression. A significant tumor expansion observed on 3 sequential MRI scans after the 3rd year may be suggestive of treatment failure. Long-term follow-up is therefore mandatory and no decision of salvage treatment should be made until the 6th year.
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Affiliation(s)
- O Fouard
- Neurosurgery Department, CHU UCL Namur site Godinne, Université Catholique de Louvain, Yvoir, Belgium
| | - J F Daisne
- Radiation Oncology Department, CHU UCL Namur Site Sainte-Elisabeth, Université Catholique de Louvain, Namur, Belgium.,Radiation Oncology Department, University Hospitals Leuven, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Oncology and Leuven Cancer Institute, Katholieke Universiteit Leuven, Leuven, Belgium
| | - M Wanet
- Radiation Oncology Department, CHU UCL Namur Site Sainte-Elisabeth, Université Catholique de Louvain, Namur, Belgium
| | - M Regnier
- Scientific Support Unit, CHU UCL Namur, Université catholique de Louvain, Namur, Belgium
| | - T Gustin
- Neurosurgery Department, CHU UCL Namur site Godinne, Université Catholique de Louvain, Yvoir, Belgium
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26
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Totten DJ, Sherry AD, Manzoor NF, Perkins EL, Cass ND, Khattab MH, Cmelak AJ, Haynes DS, Aulino JM. Diameter-Based Volumetric Models May Inadequately Calculate Jugular Paraganglioma Volume Following Sub-Total Resection. Otol Neurotol 2021; 42:e1339-e1345. [PMID: 34149025 DOI: 10.1097/mao.0000000000003226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As gross total resection of jugular paragangliomas (JPs) may result in cranial nerve deficits, JPs are increasingly managed with subtotal resection (STR) with postoperative radiological monitoring. However, the validity of commonly used diameter-based models that calculate postoperative volume to determine residual tumor growth is dubious. The purpose of this study was to assess the accuracy of these models compared to manual volumetric slice-by-slice segmentation. METHODS A senior neuroradiologist measured volumes via slice-by-slice segmentation of JPs pre- and postoperatively from patients who underwent STR from 2007 to 2019. Volumes from three linear-based models were calculated. Models with absolute percent error (APE) > 20% were considered unsatisfactory based on a common volumetric definition for residual growth. Bland-Altman plots were used to evaluate reproducibility, and Wilcoxon matched-pairs signed rank test evaluated model bias. RESULTS Twenty-one patients were included. Median postoperative APE exceeded the established 20% threshold for each of the volumetric models as cuboidal, ellipsoidal, and spherical model APE were 63%, 28%, and 27%, respectively. The postoperative cuboidal model had significant systematic bias overestimating volume (p = 0.002) whereas the postoperative ellipsoidal and spherical models lacked systematic bias (p = 0.11 and p = 0.82). CONCLUSION Cuboidal, ellipsoidal, and spherical models do not provide accurate assessments of postoperative JP tumor volume and may result in salvage therapies that are unnecessary or inappropriately withheld due to inaccurate assessment of residual tumor growth. While more time-consuming, slice-by-slice segmentation by an experienced neuroradiologist provides a substantially more accurate and precise measurement of tumor volume that may optimize clinical management.
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Affiliation(s)
| | | | - Nauman F Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Elizabeth L Perkins
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Nathan D Cass
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center
| | - David S Haynes
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center
| | - Joseph M Aulino
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
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27
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Thielhelm TP, Goncalves S, Welford SM, Mellon EA, Cohen ER, Nourbakhsh A, Fernandez-Valle C, Telischi F, Ivan ME, Dinh CT. Understanding the Radiobiology of Vestibular Schwannomas to Overcome Radiation Resistance. Cancers (Basel) 2021; 13:4575. [PMID: 34572805 PMCID: PMC8467596 DOI: 10.3390/cancers13184575] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
Vestibular schwannomas (VS) are benign tumors arising from cranial nerve VIII that account for 8-10% of all intracranial tumors and are the most common tumors of the cerebellopontine angle. These tumors are typically managed with observation, radiation therapy, or microsurgical resection. Of the VS that are irradiated, there is a subset of tumors that are radioresistant and continue to grow; the mechanisms behind this phenomenon are not fully understood. In this review, the authors summarize how radiation causes cellular and DNA injury that can activate (1) checkpoints in the cell cycle to initiate cell cycle arrest and DNA repair and (2) key events that lead to cell death. In addition, we discuss the current knowledge of VS radiobiology and how it may contribute to clinical outcomes. A better understanding of VS radiobiology can help optimize existing treatment protocols and lead to new therapies to overcome radioresistance.
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Affiliation(s)
- Torin P Thielhelm
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Stefania Goncalves
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Scott M Welford
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Eric A Mellon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Erin R Cohen
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Aida Nourbakhsh
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Cristina Fernandez-Valle
- Burnett School of Biomedical Sciences, University of Central Florida College of Medicine, Orlando, FL 32816, USA
| | - Fred Telischi
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Christine T Dinh
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Tufts Medical Center Experience With Long-Term Follow-Up of Vestibular Schwannoma Treated With Gamma Knife Stereotactic Radiosurgery: Novel Finding of Delayed Pseudoprogression. Adv Radiat Oncol 2021; 6:100687. [PMID: 34409200 PMCID: PMC8360957 DOI: 10.1016/j.adro.2021.100687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Our purpose was to evaluate the long-term outcomes of patients with vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (GKSRS) with modern techniques, with attention to posttreatment tumor growth dynamics, dosimetric predictors, and late toxicities. Methods and Materials One hundred twelve patients with VS were treated with GKSRS with a median dose of 12.5 Gy to the 50% isodose line treated between 2004 and 2015, with patients followed up to 15 years. Target and organ-at-risk doses were recorded, and tumor diameter/volume, audiologic decline, and trigeminal/facial nerve preservation were tracked from treatment onward. Results GKSRS yielded local control of 5, 10, and 15 years at 96.9%, 90.0%, and 87.1% respectively. Pseudoprogression was found in 45%, with a novel pattern detected with peak swelling at 31 months. Pseudoprogression was associated with smaller tumor diameter at treatment and fewer treatment isocenters, but not with the development of any toxicity, nor was it predicted by any dosimetric factor. Median time to hearing loss was 3.4 years with actuarial hearing preservation at 2, 5, and 10 years of 66.5%, 43.1%, and 37.6%, with rate of hearing loss correlating with maximum cochlea and modiolus doses. Trigeminal and facial nerve preservation rates were 92.7% and 97.6%, respectively. Increasing maximum tumor dose was associated with facial paresthesia. Conclusions Modern GKSRS is a safe and effective treatment for VS on long-term follow-up, with high levels of facial and trigeminal nerve preservation. A novel pattern of pseudoprogression has been identified suggesting longer imaging follow-up may be needed before initiating salvage in those without symptomatic progression. Several tumor and dosimetric predictors have been suggested for the development of different toxicities, requiring further evaluation.
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Lewis D, McHugh DJ, Li KL, Zhu X, Mcbain C, Lloyd SK, Jackson A, Pathmanaban ON, King AT, Coope DJ. Detection of early changes in the post-radiosurgery vestibular schwannoma microenvironment using multinuclear MRI. Sci Rep 2021; 11:15712. [PMID: 34344960 PMCID: PMC8333359 DOI: 10.1038/s41598-021-95022-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/05/2021] [Indexed: 01/01/2023] Open
Abstract
Stereotactic radiosurgery (SRS) is an established, effective therapy against vestibular schwannoma (VS). The mechanisms of tumour response are, however, unknown and in this study we sought to evaluate changes in the irradiated VS tumour microenvironment through a multinuclear MRI approach. Five patients with growing sporadic VS underwent a multi-timepoint comprehensive MRI protocol, which included diffusion tensor imaging (DTI), dynamic contrast-enhanced (DCE) MRI and a spiral 23Na-MRI acquisition for total sodium concentration (TSC) quantification. Post-treatment voxelwise changes in TSC, DTI metrics and DCE-MRI derived microvascular biomarkers (Ktrans, ve and vp) were evaluated and compared against pre-treatment values. Changes in tumour TSC and microvascular parameters were observable as early as 2 weeks post-treatment, preceding changes in structural imaging. At 6 months post-treatment there were significant voxelwise increases in tumour TSC (p < 0.001) and mean diffusivity (p < 0.001, repeated-measures ANOVA) with marked decreases in tumour microvascular parameters (p < 0.001, repeated-measures ANOVA). This study presents the first in vivo evaluation of alterations in the VS tumour microenvironment following SRS, demonstrating that changes in tumour sodium homeostasis and microvascular parameters can be imaged as early as 2 weeks following treatment. Future studies should seek to investigate these clinically relevant MRI metrics as early biomarkers of SRS response.
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Affiliation(s)
- Daniel Lewis
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK.
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK.
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK.
| | - Damien J McHugh
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Ka-Loh Li
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK
| | - Xiaoping Zhu
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK
| | - Catherine Mcbain
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Department of Clinical Oncology, Christie NHS Foundation Trust, Manchester, UK
| | - Simon K Lloyd
- Department of Otolaryngology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Otolaryngology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alan Jackson
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Andrew T King
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - David J Coope
- Dept. of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Stott Lane, Salford, Greater Manchester, M6 8HD, UK
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK
- Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, School of Biological Sciences, University of Manchester, Manchester, UK
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Bojrab DI, Fritz CG, Lin KF, Schutt CA, Hong RS, Babu SC, Chen PY, Maitz A, Bojrab DI. Pre-existing Vestibular Symptoms Are Associated With Acute Vestibular Symptoms After Gamma Knife Therapy for Vestibular Schwannoma. Otol Neurotol 2021; 42:912-917. [PMID: 33591068 DOI: 10.1097/mao.0000000000003064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify pretreatment variables associated with the development of acute vestibular symptoms after Gamma Knife (GK) treatment for Vestibular Schwannoma (VS). STUDY DESIGN Retrospective case series. SETTING Tertiary neurotology referral center. PATIENTS Patients treated with GK radiosurgery for VS between March 2007 and March 2017 were considered for this study. Patients with neurofibromatosis type II, previous VS surgery, follow-up less than 6 months, or the lack of T2 magnetic resonance imaging (MRI) sequences from the day of treatment were excluded. MAIN OUTCOME MEASURES The presence of acute vestibular symptoms arising within 6 months after GK was the main outcome variable. Tumor, patient, and treatment characteristics were gathered from the medical record. RESULTS In total, 98 patients met inclusion criteria. The incidence of acute vestibular symptoms occurring within 6 months after GK treatment was 46.9%. Post-GK vestibular symptoms were reported at a significantly higher frequency among subjects who had reported vestibular symptoms before their treatment (p = 0.001). Tumor size was not associated with a propensity to develop acute vestibular symptoms (p = 0.397). The likelihood of receiving a referral to vestibular rehabilitation services was not significantly different among patients with larger versus smaller tumor size, as defined by 1.6 cm and 1.4 cm thresholds (p = 0.896, p = 0.654). CONCLUSIONS Inquiries aimed at revealing a history of vestibular complaints may prove useful in counseling patients on the likelihood of experiencing acute vestibular symptoms after treatment of Vestibular Schwannoma with Gamma Knife therapy.
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Affiliation(s)
| | - Christian G Fritz
- Michigan Ear Institute, Farmington Hills
- Oakland University William Beaumont School of Medicine, Rochester
| | | | | | | | | | - Peter Y Chen
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Ann Maitz
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
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Wirsching HG, Steiner L, Becker D, Regli L, Andratschke N, Kulcsar Z, Roth P, Weller M. Increase in contrast-enhancing volume of irradiated meningiomas reflects tumor progression and not pseudoprogression. Neuro Oncol 2021; 23:1612-1613. [PMID: 34145883 DOI: 10.1093/neuonc/noab119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hans-Georg Wirsching
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Lea Steiner
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Denise Becker
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Patrick Roth
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
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Cesme DH, Alkan A, Sari L, Kaya A, Yurtsever I, Alkan G, Seyithanoglu MH, Hatiboglu MA. The Effectiveness of Diffusion Tensor Imaging in Determining Radiological Response after Radiosurgery in Patients with Vestibular Schwannoma. Curr Med Imaging 2021; 17:602-607. [PMID: 33504315 DOI: 10.2174/1573405617666210127160848] [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: 06/24/2020] [Revised: 11/09/2020] [Accepted: 11/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The effectiveness of Diffusion Tensor Imaging (DTI) in demonstrating functional changes in the tumor in determining the response to treatment after radiosurgery in patients with vestibular schwannoma (VS) is not clear yet. OBJECTIVE The study aimed to determine the change in total tumor volume (TTV) in terms of radiological response in patients who had VS and were treated with radiosurgery and investigated the relationship between the TTV, follow-up times and DTI parameters. METHODS Thirty-one patients were assessed using DTI and MRI. TTV, apparent diffusion coefficient (ADC), and fractional anisotropy (FA) were calculated. Patients were divided into three groups: those who responded to the treatment (group 1) (n=11), those who did not (group 0) (n=9) and those who remained stable (group 2) (n=11). RESULTS The mean duration of follow-up was 28.81±14 months. ADC values increased in patients with VS after radiosurgery (p=0.004). There was no statistical difference in the FA values. A significant reduction in TTV after radiosurgery was detected in group 1 (p=0.003). ADC values increased significantly after radiosurgery in group 2 (p=0.04). Although there were no significant differences, ADC values after radiosurgery increased in group 1 and group 0. CONCLUSIONS ADC values continuously increase due to radiation damage in the period before the tumor volume shrinks after radiosurgery. We think that it is not appropriate to diagnose inadequate treatment or progression only when TTV is evaluated in terms of response to treatment in the early period after radiosurgery.
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Affiliation(s)
- Dilek Hacer Cesme
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Alpay Alkan
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Lutfullah Sari
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Ahmet Kaya
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Ismail Yurtsever
- Department of Radiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Gokberk Alkan
- Department of Otorhinolaryngology Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara, Turkey
| | | | - Mustafa Aziz Hatiboglu
- Department of Neurosurgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Lee WJ, Lee JI, Choi JW, Kong DS, Nam DH, Cho YS, Shin HJ, Seol HJ. Optimal Volume of the Residual Tumor to Predict Long-term Tumor Control Using Stereotactic Radiosurgery after Facial Nerve-preserving Surgery for Vestibular Schwannomas. J Korean Med Sci 2021; 36:e102. [PMID: 33904259 PMCID: PMC8076845 DOI: 10.3346/jkms.2021.36.e102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/03/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Intended subtotal resection (STR) followed by adjuvant gamma knife radiosurgery (GKRS) has emerged as an effective treatment option for facial nerve (FN) preservation in vestibular schwannomas (VSs). This study aimed to identify the optimal cut-off volume of residual VS to predict favorable outcomes in terms of both tumor control and FN preservation. METHODS This retrospective study assessed the patients who underwent adjuvant GKRS for residual VS after microsurgery. A total of 68 patients who had been followed up for ≥ 24 months after GKRS were included. Tumor progression was defined as an increase in tumor volume (TV) of ≥ 20%. House-Brackmann grades I and II were considered to indicate good FN function. RESULTS The median residual TV was 2.5 cm³ (range: 0.3-27.4). The median follow-up period after the first adjuvant GKRS was 64 months (range: 25.7-152.4). Eight (12%) patients showed tumor progression. In multivariate analyses, residual TV was associated with tumor progression (P = 0.003; hazard ratio [HR], 1.229; 95% confidence interval [CI], 1.075-1.405). A residual TV of 6.4 cm³ was identified as the cut-off volume for showing the greatest difference in progression-free survival (PFS). The 5-year PFS rates in the group with residual TVs of < 6.4 cm³ (54 patients) and that with residual TVs of ≥ 6.4 cm³ (14 patients) were 93.3% and 69.3%, respectively (P = 0.014). A good FN outcome was achieved in 57 (84%) patients. Residual TV was not associated with good FN function during the immediate postoperative period (P = 0.695; odds ratio [OR], 1.024; 95% CI, 0.908-1.156) or at the last follow-up (P = 0.755; OR, 0.980; 95% CI, 0.866-1.110). CONCLUSION In this study, residual TV was associated with tumor progression in VS after adjuvant GKRS following STR. As preservation of FN function is not correlated with the extent of resection, optimal volume reduction is imperative to achieve long-term tumor control. Our findings will help surgeons predict the prognosis of residual VS after FN-preserving surgery.
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Affiliation(s)
- Won Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Sun Cho
- Department of Otorhinolaryngology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Radiomics-Based Prediction of Long-Term Treatment Response of Vestibular Schwannomas Following Stereotactic Radiosurgery. Otol Neurotol 2021; 41:e1321-e1327. [PMID: 33492808 DOI: 10.1097/mao.0000000000002886] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is one of the treatment modalities for vestibular schwannomas (VSs). However, tumor progression can still occur after treatment. Currently, it remains unknown how to predict long-term SRS treatment outcome. This study investigates possible magnetic resonance imaging (MRI)-based predictors of long-term tumor control following SRS. STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Analysis was performed on a database containing 735 patients with unilateral VS, treated with SRS between June 2002 and December 2014. Using strict volumetric criteria for long-term tumor control and tumor progression, a total of 85 patients were included for tumor texture analysis. INTERVENTION(S) All patients underwent SRS and had at least 2 years of follow-up. MAIN OUTCOME MEASURE(S) Quantitative tumor texture features were extracted from conventional MRI scans. These features were supplied to a machine learning stage to train prediction models. Prediction accuracy, sensitivity, specificity, and area under the receiver operating curve (AUC) are evaluated. RESULTS Gray-level co-occurrence matrices, which capture statistics from specific MRI tumor texture features, obtained the best prediction scores: 0.77 accuracy, 0.71 sensitivity, 0.83 specificity, and 0.93 AUC. These prediction scores further improved to 0.83, 0.83, 0.82, and 0.99, respectively, for tumors larger than 5 cm. CONCLUSIONS Results of this study show the feasibility of predicting the long-term SRS treatment response of VS tumors on an individual basis, using MRI-based tumor texture features. These results can be exploited for further research into creating a clinical decision support system, facilitating physicians, and patients to select a personalized optimal treatment strategy.
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Pretreatment ADC predicts tumor control after Gamma Knife radiosurgery in solid vestibular schwannomas. Acta Neurochir (Wien) 2021; 163:1013-1019. [PMID: 33532869 DOI: 10.1007/s00701-021-04738-x] [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: 10/01/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Radiosurgery is a well-established treatment for vestibular schwannomas (VSs), but it is often difficult to identify which tumors will respond to treatment. We sought to determine whether pretreatment or posttreatment tumor apparent diffusion coefficient (ADC) values could predict tumor control in patients undergoing Gamma Knife radiosurgery (GKRS) and whether these values could differentiate between cases of pseudoprogression and cases of true progression in the early posttreatment period. METHODS We retrospectively identified patients who underwent GKRS for solid VSs between June 2008 and November 2016 and who had a minimum follow-up of 36 months. Pretreatment and posttreatment minimum, mean, and maximum ADC values were measured for the whole tumor volume and were compared between patients with tumor control and those with tumor progression. In patients with early posttreatment tumor enlargement, ADC values were compared between patients with pseudoprogression and those with true progression. RESULTS Of the 44 study patients, 34 (77.3%) demonstrated tumor control at final follow-up. Patients with tumor control had higher pretreatment minimum (1.35 vs 1.09; p = 0.008), mean (1.80 vs 1.45; p = 0.004), and maximum (2.41 vs 1.91; p = 0.011) ADC values than patients with tumor progression. ADC values did not differ between patients with pseudoprogression and those with true progression at early posttreatment follow-up. CONCLUSIONS ADC values may be helpful in predicting response to GKRS in patients with solid VSs but cannot predict which tumors will undergo pseudoprogression. Patients with higher pretreatment ADC values may be more likely to demonstrate posttreatment tumor control.
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Longitudinal Changes of Quality of Life and Hearing Following Radiosurgery for Vestibular Schwannoma. Cancers (Basel) 2021; 13:cancers13061315. [PMID: 33804061 PMCID: PMC7998632 DOI: 10.3390/cancers13061315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Since vestibular schwannomas are slow-growing tumors that can be controlled with different treatment modalities such as neurosurgery or radiotherapy, preserving quality of life is an important consideration. In this study, we analyzed how quality of life (QoL) changes for patients who receive stereotactic radiation in the months and years after treatment and if there is a correlation between changes in QoL and changes in hearing function. The results suggest that proper hearing of the unaffected ear might compensate for a hearing loss of the other ear due to the tumor or the treatment and in turn preserve QoL. However, this association should be confirmed in additional studies. Abstract Background: Most existing publications on quality of life (QoL) following stereotactic radiosurgery (SRS) for vestibular schwannomas (VS) gather information retrospectively by conducting surveys several years after treatment. The purpose of this study is therefore to provide longitudinal QoL data and assess how changes in hearing impact QoL. Methods: Patients completed the 12-item short-form (SF-12) health survey prior to treatment and at every follow-up visit. One hundred and seventy-five patients who had complete forms prior to treatment as well as at an early and at a late follow-up were included in the analysis. For 51 of these patients, longitudinal audiometry data were available. Results: Median follow-up was 7.2 years. Patients experienced a significant reduction in the physical composite score (PCS, p = 0.011) compared to before treatment. The mental composite score (MCS) increased significantly (p = 0.032). A decrease in PCS was not significantly correlated with an increased hearing threshold on the affected but rather on the unaffected ear (r(49) = −0.32, p = 0.023). Conclusions: It is unclear whether the decline in the PCS is due to treatment-related toxicity or the normal decline of PCS with age. Ensuring proper hearing on the untreated ear might be crucial to ensure good QoL for patients treated with SRS for VS, though this association should be confirmed in additional studies.
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Goldbrunner R, Weller M, Regis J, Lund-Johansen M, Stavrinou P, Reuss D, Evans DG, Lefranc F, Sallabanda K, Falini A, Axon P, Sterkers O, Fariselli L, Wick W, Tonn JC. EANO guideline on the diagnosis and treatment of vestibular schwannoma. Neuro Oncol 2021; 22:31-45. [PMID: 31504802 DOI: 10.1093/neuonc/noz153] [Citation(s) in RCA: 177] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The level of evidence to provide treatment recommendations for vestibular schwannoma is low compared with other intracranial neoplasms. Therefore, the vestibular schwannoma task force of the European Association of Neuro-Oncology assessed the data available in the literature and composed a set of recommendations for health care professionals. The radiological diagnosis of vestibular schwannoma is made by magnetic resonance imaging. Histological verification of the diagnosis is not always required. Current treatment options include observation, surgical resection, fractionated radiotherapy, and radiosurgery. The choice of treatment depends on clinical presentation, tumor size, and expertise of the treating center. In small tumors, observation has to be weighed against radiosurgery, in large tumors surgical decompression is mandatory, potentially followed by fractionated radiotherapy or radiosurgery. Except for bevacizumab in neurofibromatosis type 2, there is no role for pharmacotherapy.
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Affiliation(s)
- Roland Goldbrunner
- Center of Neurosurgery, Department of General Neurosurgery, University of Cologne, Cologne, Germany
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jean Regis
- Department of Functional and Stereotactic Neurosurgery and Radiosurgery, Timone University Hospital, Marseille, France
| | - Morten Lund-Johansen
- Department of Neurosurgery, Bergen University Hospital and Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Pantelis Stavrinou
- Center of Neurosurgery, Department of General Neurosurgery, University of Cologne, Cologne, Germany
| | - David Reuss
- Department of Neuropathology, University Hospital Heidelberg, Heidelberg, Germany
| | - D Gareth Evans
- Manchester Centre for Genomic Medicine and NW Laboratory Genetics Hub, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Florence Lefranc
- Department of Neurosurgery, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
| | - Kita Sallabanda
- Department of Neurosurgery, University Hospital San Carlos, Complutense University of Madrid, Madrid, Spain; University Hospital San Carlos, CyberKnife Centre, Genesiscare Madrid, Madrid, Spain
| | - Andrea Falini
- Department of Neuroradiology, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Patrick Axon
- Cambridge Skull Base Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Olivier Sterkers
- Department of Otolaryngology, Unit of Otology, Auditory implants and Skull Base Surgery, Public Assistance-Paris Hospital, Pitié-Salpêtrière Group Hospital, Paris, France
| | - Laura Fariselli
- Unit of Radiotherapy, Neurological Institute Carlo Best, Milan, Italy
| | - Wolfgang Wick
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Joerg-Christian Tonn
- Department of Neurosurgery Ludwig-Maximilians University and DKTK partner site, University of Munich, Munich, Germany
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Tosi U, Guadix S, An A, Wright D, Christos PJ, Pannullo S, Brandmaier A, Knisely JPS, Stieg PE, Ramakrishna R. Efficacy and comorbidities of hypofractionated and single-dose radiosurgery for vestibular schwannomas: a systematic review and meta-analysis. Neurooncol Pract 2021; 8:391-404. [PMID: 34277018 DOI: 10.1093/nop/npab009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Vestibular schwannomas (VS) are tumors of the cerebellopontine angle with significant morbidity, causing hearing loss, tinnitus, and trigeminal and facial nerve compromise. An effective alternative to microsurgical resection is stereotactic radiosurgery (SRS), which can be delivered in either single-fraction (SRS) or hypofractionated stereotactic radiotherapy (hSRT) (3-5 treatments) regimens. It remains unclear which fractionation regimen provides superior outcomes. Methods Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Reviews were searched for studies either comparing hSRT with SRS or focusing on hSRT alone in treating VS. Primary endpoints included tumor control, serviceable hearing, tinnitus, and cranial nerve V and VII symptoms. A random-effects analysis was employed to compare pre- and post-treatment effects (hSRT alone) or SRS and hSRT outcomes (two-arm studies). Results This analysis included 21 studies focusing on hSRT alone and 13 studies comparing SRS and hSRT. Significant heterogeneity was observed. Overall, when hSRT was analyzed alone, crude tumor control was achieved in 94% (95% CI: 88%, 99%) of 1571 patients. There was no difference between pre- and post-treatment odds ratios (OR) of tinnitus, facial, or trigeminal impairment. Serviceable hearing was diminished following hSRT (OR = 0.60, 95% CI: 0.44, 0.83). Comparison with SRS showed no difference with respect to tumor control, serviceable hearing, trigeminal or facial nerve impairment. Conclusions hSRT achieved excellent tumor control and, with the exception of serviceable hearing, did not result in worse post-treatment cranial nerve symptomatology. Analysis of comparative studies between hSRT and SRS did not reveal any significant difference in either tumor control or treatment morbidities.
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Affiliation(s)
- Umberto Tosi
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Sergio Guadix
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Anjile An
- Division of Biostatistics and Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Drew Wright
- Samuel J. Woods Library, Weill Cornell Medicine, New York, New York, USA
| | - Paul J Christos
- Division of Biostatistics and Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Susan Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Jonathan P S Knisely
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
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Long J, Zhang Y, Huang X, Ren J, Zhong P, Wang B. A Review of Drug Therapy in Vestibular Schwannoma. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:75-85. [PMID: 33447015 PMCID: PMC7802892 DOI: 10.2147/dddt.s280069] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/11/2020] [Indexed: 12/13/2022]
Abstract
Vestibular schwannomas (VSs, also known as acoustic neuromas) are benign intracranial tumors commonly managed with observation, surgery, and radiotherapy. There is currently no approved pharmacotherapy for VS patients, which is why we conducted a detailed search of relevant literature from PubMed and Web of Science to explore recent advances and experiences in drug therapy. VSs feature a long course of disease that requires treatment to have minimal long-term side effects. Conventional chemotherapeutic agents are characterized by neurotoxicity or ototoxicity, poor effect on slow-growing tumors, and may induce new mutations in patients who have lost tumor suppressor function, and therefore are unsuitable for treating VSs. Along with the well-investigated molecular pathophysiology of VS and the increasingly accessible technology such as drug repositioning platform, many molecular targeted inhibitors have been identified and shown certain therapeutic effects in preclinical experiments or clinical trials.
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Affiliation(s)
- Jianfei Long
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Yu Zhang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Xiang Huang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Junwei Ren
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Ping Zhong
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Bin Wang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
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A Mohamed S, Adlung A, Ruder AM, Hoesl MAU, Schad L, Groden C, Giordano FA, Neumaier-Probst E. MRI Detection of Changes in Tissue Sodium Concentration in Brain Metastases after Stereotactic Radiosurgery: A Feasibility Study. J Neuroimaging 2020; 31:297-305. [PMID: 33351997 DOI: 10.1111/jon.12823] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND PURPOSE To date, treatment response to stereotactic radiosurgery (SRS) in brain metastases (BM) can only be determined by MRI evaluation of contrast-enhancing lesions in a long-time follow-up. Sodium MRI has been a subject of immense interest in imaging research as the measure of tissue sodium concentration (TSC) can give valuable quantitative information on cell viability. We aimed to analyze the longitudinal changes of TSC in BM measured with 23 Na MRI before and after SRS for assessment of early local tumor effects. METHODS Seven patients with a total of 12 previously untreated BM underwent SRS with 22 Gy. In addition to a standard MRI protocol including dynamic susceptibility-weighted contrast-enhanced perfusion, a 23 Na MRI was performed at three time points: (I) 2 days before, (II) 5 days, and (III) 40 days after SRS. Nine BMs were evaluated. The absolute TSC in the BM, the respective peritumoral edemas, and the normal-appearing corresponding contralateral brain area were assessed and the relative TSC were correlated to the changes in BM longest axial diameters. RESULTS TSC was elevated in nine BM at baseline before SRS with a mean of 73.4 ± 12.3 mM. A further increase in TSC was observed 5 days after SRS in all the nine BM with a mean of 86.9 ± 13 mM. Eight of nine BM showed a mean 60.6 ± 13.3% decrease in the longest axial diameter 40 days after SRS; at this time point, the TSC also had decreased to a mean 65.1 ± 7.9 mM. In contrast, one of the nine BM had a 13.4% increase in the largest axial diameter at time point III. The TSC of this BM showed a further TSC increase of 80.1 mM 40 days after SRS. CONCLUSION Changes in TSC using 23 Na MRI shows the possible capability to detect radiobiological changes in BM after SRS.
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Affiliation(s)
- Sherif A Mohamed
- Department of Neuroradiology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne Adlung
- Department of Computer Assisted Clinical Medicine, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Arne M Ruder
- Department of Radiation Oncology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Michaela A U Hoesl
- Department of Computer Assisted Clinical Medicine, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Lothar Schad
- Department of Computer Assisted Clinical Medicine, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Groden
- Department of Neuroradiology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Eva Neumaier-Probst
- Department of Neuroradiology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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Clinical outcomes of fractionated stereotactic radiosurgery in treating perioptic meningiomas and schwannomas: A single-institutional experience. J Clin Neurosci 2020; 81:409-415. [PMID: 33222952 DOI: 10.1016/j.jocn.2020.09.058] [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: 04/12/2020] [Revised: 09/06/2020] [Accepted: 09/28/2020] [Indexed: 11/24/2022]
Abstract
Application of radiosurgery to the newly diagnosed or post-operative residual perioptic lesions has been proved to improve tumor control. However, risk of vision injury induced by radiosurgery may increase substantially if the radiation dose is too high or tumor is close to the optic apparatus. The purpose of this study was to evaluate the safety and the effectiveness of fractionated stereotactic radiosurgery (FSRS) for perioptic tumors. We retrospectively analyzed 60 consecutive patients with 53 meningiomas and 7 schwannomas treated with FSRS between October 2007 and February 2020. We administered a marginal dose of 6-7 Gy (mean 6.8 Gy) per fraction and delivered 3 fractions in 3 consecutive days. The median tumor volume was 6.31 cm3 (range 0.3-58.23 cm3). The mean minimum lesion-optic distance (MLOD) is 0.85 mm (range 0-3 mm). After mean follow-up period of 69.6 months (range 6.82-156.32 months; median 58.9 months), the tumor control rates at 1, 3, 5, 8 and 13 years were 98.3%, 93.4%, 90.60%, 88.4% and 88.4%, respectively. Four out of the 60 tumors (6.7%) experienced a transient volume increase after FSRS. None of the patients developed visual impairment related to radiation induced optic neuropathy (RION) after FSRS. In conclusion, FSRS offers an alternative treatment option in treating perioptic meningiomas and schwannomas with acceptable tumor control rates and good visual preservation in the present study.
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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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Yang HC, Wu CC, Lee CC, Huang HE, Lee WK, Chung WY, Wu HM, Guo WY, Wu YT, Lu CF. Prediction of pseudoprogression and long-term outcome of vestibular schwannoma after Gamma Knife radiosurgery based on preradiosurgical MR radiomics. Radiother Oncol 2020; 155:123-130. [PMID: 33161011 DOI: 10.1016/j.radonc.2020.10.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Gamma Knife radiosurgery (GKRS) is a safe and effective treatment modality with a long-term tumor control rate over 90% for vestibular schwannoma (VS). However, numerous tumors may undergo a transient pseudoprogression during 6-18 months after GKRS followed by a long-term volume reduction. The aim of this study is to determine whether the radiomics analysis based on preradiosurgical MRI data could predict the pseudoprogression and long-term outcome of VS after GKRS. MATERIALS AND METHODS A longitudinal dataset of patients with VS treated by single GKRS were retrospectively collected. Overall 336 patients with no previous craniotomy for tumor removal and a median of 65-month follow-up period after radiosurgery were finally included in this study. In total 1763 radiomic features were extracted from the multiparameteric MRI data before GKRS followed by the machine-learning classification. RESULTS We constructed a two-level machine-learning model to predict the long-term outcome and the occurrence of transient pseudoprogression after GKRS separately. The prediction of long-term outcome achieved an accuracy of 88.4% based on five radiomic features describing the variation of T2-weighted intensity and inhomogeneity of contrast enhancement in tumor. The prediction of transient pseudoprogression achieved an accuracy of 85.0% based on another five radiomic features associated with the inhomogeneous hypointensity pattern of contrast enhancement and the variation of T2-weighted intensity. CONCLUSION The proposed machine-learning model based on the preradiosurgical MR radiomics provides a potential to predict the pseudoprogression and long-term outcome of VS after GKRS, which can benefit the treatment strategy in clinical practice.
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Affiliation(s)
- Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Chun Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Huai-En Huang
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Department of Medical Imaging, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Wei-Kai Lee
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Yu-Te Wu
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan; Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan.
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Prediction of Vestibular Schwannoma Enlargement After Radiosurgery Using Tumor Shape and MRI Texture Features. Otol Neurotol 2020; 42:e348-e354. [DOI: 10.1097/mao.0000000000002938] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Killeen DE, Tolisano AM, Isaacson B, Kutz JW, Barnett S, Wardak Z, Hunter JB. Vestibular Schwannoma Tumor Size and Growth Rate Predict Response with Gamma Knife Stereotactic Radiosurgery. J Neurol Surg B Skull Base 2020; 83:11-18. [DOI: 10.1055/s-0040-1716677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/25/2020] [Indexed: 12/19/2022] Open
Abstract
Abstract
Objective The aim of this study is to determine if pretreatment growth of sporadic vestibular schwannomas (VS) predicts postradiosurgery response.
Methods This study was a retrospective chart review at a tertiary referral center of patients with VS that had at least two pretreatment magnetic resonance imaging (MRI) studies at least 6 months apart and underwent Gamma Knife radiosurgery with a minimum of 14 months postradiosurgery imaging surveillance. Tumor linear measurements and volumetric segmentation were assessed before and after radiosurgery. The main outcome measure was persistent enlargement following radiosurgery, defined as 2 mm enlargement in greatest axial diameter or 20% enlargement in volume without size regression.
Results Thirty-five patients met the inclusion criteria. Patients were observed for median pre- and posttreatment intervals of 29.5 and 40.6 months, respectively. Median dose to the tumor margin was 13 Gy. Postradiosurgery enlargement occurred in six (17.1%) and nine (25.7%) patients based on linear and volumetric enlargement definitions, respectively. Pseudoprogression—defined as tumor enlargement—followed by linear or volumetric regression that occurred in 34.3% of tumors, reaching a maximum size at a median time of 6.3 months (3.3–8.4) postradiosurgery. When controlling for age, gender, and radiation dose, preradiosurgery tumor volume less than 0.3 cm3 (odds ratio [OR]: 59.7, p = 0.012) and preradiosurgery tumor diameter growth rate greater than or equal to 2.5 mm/year (OR: 19.3, p = 0.045) were associated with persistent postradiosurgery tumor enlargement.
Conclusion Smaller pretreatment tumor volume and greater linear tumor growth rates were associated with postradiosurgery tumor enlargement when controlling for age, gender, and radiation dose.
Level of Evidence :This study indicates that the level of evidence is V.
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Affiliation(s)
- Daniel E. Killeen
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Anthony M. Tolisano
- Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Brandon Isaacson
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - J Walter Kutz
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Samuel Barnett
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Jacob B. Hunter
- Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, United States
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Dietz N, Sharma M, Ugiliweneza B, Wang D, Boakye M, Williams B, Andaluz N. Health Care Utilization in Patients Undergoing Repeat Stereotactic Radiosurgery for Vestibular Schwannoma with 5-Year Follow-up: A National Database Analysis. J Neurol Surg B Skull Base 2020; 83:19-27. [DOI: 10.1055/s-0040-1716672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 08/03/2020] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Stereotactic radiosurgery (SRS) has been used as an alternative to microsurgery in patients with small vestibular schwannoma (VS). We compare health care utilization metrics in patients undergoing repeat-SRS (re-SRS) and no repeat SRS (nr-SRS) at long-term follow-up.
Materials and Methods We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had diagnosis of VS and treatment with SRS with at least 5 years of continuous enrollment after the procedure. Outcomes were hospital admissions, outpatient services, and medication refills.
Results Of 1,047 patients, 5.1% (n = 53) had repeat SRS. Majority of re-SRS (74%, n = 39) were done within 2 years of index procedure and 51% were within 1-year of initial procedure. Patients who required re-SRS incurred higher hospital readmission rate, outpatient services, and had higher payments compared with those who did not require re-SRS at 6 months, 1 year, and 2 years following the initial procedures. Re-SRS received 3.0- and 3.1-times higher payments at 1 and 2 years compared with nr-SRS cohort. At 5 years following SRS, median combined payments for re-SRS cohort was $105286 (interquartile range [IQR] $70999, $156569) compared with $44172 (IQR $22956, $84840) for nr-SRS cohort.
Conclusion More than half of the re-SRS procedures were noted within first year of initial SRS for VS. Overall payments at 5 years for repeat SRS was more than double that for nr-SRS. Repeat SRS was also associated with more re-admissions and outpatient services at annual follow-up time points.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Brian Williams
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
| | - Norberto Andaluz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
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Touska P, Connor S. Imaging of the temporal bone. Clin Radiol 2020; 75:658-674. [DOI: 10.1016/j.crad.2020.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/22/2020] [Indexed: 12/20/2022]
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Nasi D, Zunarelli E, Puzzolante A, Moriconi E, Pavesi G. Early life-threating enlargement of a vestibular schwannoma after gamma knife radiosurgery. Acta Neurochir (Wien) 2020; 162:1977-1982. [PMID: 32504117 DOI: 10.1007/s00701-020-04434-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
Stereotactic gamma knife radiosurgery (GKS) may induce a transient enlargement of vestibular schwannomas (VS). This phenomenon, known as pseudoprogression or swelling, starts at about 3 months following GKS, peaks at about 6 months, and typically subsides thereafter, usually without significant neurological deterioration. We describe a 34-year-old female who developed an aggressive enlargement of a VS 1 month after GKS. The patient was treated with an immediate external ventricular drainage and surgical resection via retrosigmoid approach for an acute neurological deterioration due to hydrocephalus and brainstem compression. Histopathological examination revealed a VS with abundant intratumoral thrombosis and necrosis, suggesting that its rapid expansion could be related to massive radiation-induced tumor necrosis. The present case indicated that rapid life-threating enlargement of a VS may occur as an early complication following GKS.
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Vestibular Schwannoma Tumor Size Is Associated With Acute Vestibular Symptoms After Gamma Knife Therapy. Otol Neurotol 2020; 40:1088-1093. [PMID: 31335798 DOI: 10.1097/mao.0000000000002312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess how pretreatment vestibular schwannoma (VS) tumor characteristics are associated with vestibular symptoms after gamma knife (GK) surgery. STUDY DESIGN Retrospective chart review of patients undergoing GK treatment for VS at our institution from 2005 to 2018. SETTING Academic tertiary referral center. PATIENTS Patients receiving primary GK surgery for vestibular schwannomas with at least 6 months of follow up. Patients with neurofibromatosis 2 or previous surgery were excluded. MAIN OUTCOME MEASURES The presence of posttreatment vestibular symptoms within 6 months after GK. Clinical records were assessed for pretreatment tumor, patient, and treatment characteristics that impacted posttreatment symptoms. RESULTS All patients received radiation doses between 12 and 13 Gy. Of 115 patients, the average age was 60. Thirty-seven (32%) patients developed vestibular symptoms within 6 months post-GK, and 18 patients were referred for vestibular rehabilitation. Ten of 13 patients undergoing vestibular rehabilitation reported improvement. Overall, 112 patients had tumor measurements. Pretreatment tumors were significantly smaller for patients with acute vestibular symptoms (mean 1.43 cm versus 1.71 cm, p = 0.007). On multivariate analysis, smaller tumor size (p = 0.009, odds ratio [OR] = 0.29, 95% confidence interval [CI] [0.12-0.73]) was significantly associated with vestibular symptoms within 6 months of GK. Patients with tumors less than 1.6 cm were more likely to receive referrals for vestibular rehabilitation within 6 months posttreatment (25% versus 9.4%, p = 0.026, OR = 3.22, 95% CI [1.00, 11.32]). CONCLUSIONS Smaller vestibular schwannomas were significantly associated with higher rates of post-GK vestibular symptoms. Pretreatment tumor size may be used to counsel patients on the likelihood of post-GK vestibular symptoms and vestibular rehabilitation.
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Li LF, Yu CP, Tsang ACO, Taw BBT, Lui WM. Near-complete regression 19 years after Gamma Knife radiosurgery of vestibular schwannoma with massive pseudoprogression: case report. J Neurosurg 2020; 134:1455-1458. [PMID: 32384272 DOI: 10.3171/2020.3.jns20389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 03/17/2020] [Indexed: 11/06/2022]
Abstract
Gamma Knife radiosurgery (GKRS) is a frequent treatment choice for patients with small- to moderate-sized vestibular schwannoma (VS). However, pseudoprogression after GKRS is commonly observed, with a reported incidence ranging from 7% to 77%. The wide range of the reported incidence of pseudoprogression reflects the fact that there is no consensus on how it should be diagnosed. The authors present the case of a 66-year-old woman who had a 2.5-cm right-sided VS treated with GKRS in 1997. The first posttreatment MRI obtained 5 months later showed that the tumor volume had increased to 9.7 cm3. The tumor volume increased further and reached its peak 24 months after treatment at 20.9 cm3, which was a 161% increase from pretreatment volume. Thereafter, the tumor shrank gradually and mass effect on the brainstem reduced over time. By 229 months after treatment, the tumor volume was 1.0 cm3, equaling 12.5% of pretreatment tumor volume, or 4.8% of peak tumor volume after treatment. This case demonstrates that if a patient remains asymptomatic despite a dramatic increase in tumor volume after GKRS, observation remains an option, because even a very sizable tumor can shrink with near-complete resolution. Patients undergoing GKRS for VS should be counseled regarding the possibility of pseudoprogression, and followed carefully over time while avoiding premature decisions for surgical removal after treatment.
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Affiliation(s)
- Lai-Fung Li
- 1Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong; and
| | | | - Anderson Chun-On Tsang
- 1Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong; and
| | - Benedict Beng-Teck Taw
- 1Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong; and
| | - Wai-Man Lui
- 1Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong; and
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