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Whitmeyer M, Brahimaj BC, Beer-Furlan A, Alvi S, Epsten MJ, Crawford F, Byrne RW, Wiet RM. Resection of vestibular schwannomas after stereotactic radiosurgery: a systematic review. J Neurosurg 2021; 135:881-889. [PMID: 34331121 DOI: 10.3171/2020.7.jns2044] [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: 01/05/2020] [Accepted: 07/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Multiple short series have evaluated the efficacy of salvage microsurgery (MS) after stereotactic radiosurgery (SRS) for treatment of vestibular schwannomas (VSs); however, there is a lack of a large volume of patient data available for interpretation and clinical adaptation. The goal of this study was to provide a comprehensive review of tumor characteristics, management, and surgical outcomes of salvage of MS after SRS for VS. METHODS The Medline/PubMed, Scopus, CINAHL, Cochrane Library, and Google Scholar databases were queried according to PRISMA guidelines. All English-language and translated publications were included. Studies lacking adequate study characteristics and outcomes were excluded. Cases involving neurofibromatosis type 2, previous MS, or malignant transformation were excluded when possible. RESULTS Twenty studies containing 297 cases met inclusion criteria. Three additional cases from Rush University Medical Center were added for 300 total cases. Tumor growth with or without symptoms was the primary indication for salvage surgery (92.3% of cases), followed by worsening of symptoms without growth (4.6%) and cystic enlargement (3.1%). The average time to MS after SRS was 39.4 months. The average size and volume of tumor at surgery were 2.44 cm and 5.92 cm3, respectively. The surgical approach was retrosigmoid (42.8%) and translabyrinthine (57.2%); 59.5% of patients had a House-Brackmann (HB) grade of I or II. The facial nerve was preserved in 91.5% of cases. Facial nerve preservation and HB grades were lower for the translabyrinthine versus retrosigmoid approach (p = 0.31 and p = 0.18, respectively); however, fewer complications were noted in the translabyrinthine approach (p = 0.29). Gross-total resection (GTR) was completed in 55.7% of surgeries. Studies that predominantly used subtotal resection (STR) were associated with a lower rate of facial nerve injury (5.3% vs 11.3%, p = 0.07) and higher rate of HB grade I or II (72.9% vs 48.0%, p = 0.00003) versus those using predominantly GTR. However, majority STR was associated with a recurrence rate of 3.6% as compared to 1.4% for majority GTR (p = 0.29). CONCLUSIONS This study showed that the leading cause of MS after SRS was tumor growth at an average of 39.4 months after radiation. There were no significant differences in outcomes of facial nerve preservation, postoperative HB grade, or complication rate based on surgical approach. Patients who underwent STR showed statistically significant better HB outcomes compared with GTR. MS after SRS was considered by most authors to be more difficult than primary MS. These data support the notion that the surgical goals of salvage surgery are debulking of tumor mass, decreasing compression of the brainstem, and not necessarily pursuing GTR.
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Affiliation(s)
- Max Whitmeyer
- 1Ohio State University College of Medicine, Columbus, Ohio
| | - Bledi C Brahimaj
- 2Department of Neurological Surgery, Rush University Medical Center, Chicago
| | - André Beer-Furlan
- 2Department of Neurological Surgery, Rush University Medical Center, Chicago
| | | | | | | | - Richard W Byrne
- 2Department of Neurological Surgery, Rush University Medical Center, Chicago
| | - R Mark Wiet
- 2Department of Neurological Surgery, Rush University Medical Center, Chicago
- 5Department of Otolaryngology, Rush University Medical Center, Chicago, Illinois
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Starnoni D, Giammattei L, Cossu G, Link MJ, Roche PH, Chacko AG, Ohata K, Samii M, Suri A, Bruneau M, Cornelius JF, Cavallo L, Meling TR, Froelich S, Tatagiba M, Sufianov A, Paraskevopoulos D, Zazpe I, Berhouma M, Jouanneau E, Verheul JB, Tuleasca C, George M, Levivier M, Messerer M, Daniel RT. Surgical management for large vestibular schwannomas: a systematic review, meta-analysis, and consensus statement on behalf of the EANS skull base section. Acta Neurochir (Wien) 2020; 162:2595-2617. [PMID: 32728903 PMCID: PMC7550309 DOI: 10.1007/s00701-020-04491-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/10/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The optimal management of large vestibular schwannomas continues to be debated. We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of this problem from a European perspective. MATERIAL AND METHODS A systematic review of MEDLINE database, in compliance with the PRISMA guidelines, was performed. A subgroup analysis screening all surgical series published within the last 20 years (January 2000 to March 2020) was performed. Weighted summary rates for tumor resection, oncological control, and facial nerve preservation were determined using meta-analysis models. This data along with contemporary practice patterns were discussed within the task force to generate consensual recommendations regarding preoperative evaluations, optimal surgical strategy, and follow-up management. RESULTS Tumor classification grades should be systematically used in the perioperative management of patients, with large vestibular schwannomas (VS) defined as > 30 mm in the largest extrameatal diameter. Grading scales for pre- and postoperative hearing (AAO-HNS or GR) and facial nerve function (HB) are to be used for reporting functional outcome. There is a lack of consensus to support the superiority of any surgical strategy with respect to extent of resection and use of adjuvant radiosurgery. Intraoperative neuromonitoring needs to be routinely used to preserve neural function. Recommendations for postoperative clinico-radiological evaluations have been elucidated based on the surgical strategy employed. CONCLUSION The main goal of management of large vestibular schwannomas should focus on maintaining/improving quality of life (QoL), making every attempt at facial/cochlear nerve functional preservation while ensuring optimal oncological control, thereby allowing to meet patient expectations. Despite the fact that this analysis yielded only a few Class B evidences and mostly expert opinions, it will guide practitioners to manage these patients and form the basis for future clinical trials.
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Affiliation(s)
- Daniele Starnoni
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | | | - Giulia Cossu
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Michael J Link
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Pierre-Hugues Roche
- Department of Neurosurgery, CHU North Hospital, Aix-Marseille University, Marseille, France
| | - Ari G Chacko
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Majid Samii
- Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Michael Bruneau
- Department of Neurosurgery, Erasme Hospital, Brussels, Belgium
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Luigi Cavallo
- Department of Neurosurgery, University Hospital of Naples Federico II, Naples, NA, Italy
| | - Torstein R Meling
- Department of Neurosurgery, University Hospital of Geneva, Geneva, Switzerland
| | | | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Albert Sufianov
- Federal Centre of Neurosurgery, Tyumen, Russian Federation; Department of Neurosurgery, The State Education Institution of Higher Professional Training, The First Sechenov Moscow State Medical University under Ministry of Health, Tyumen, Russian Federation
| | - Dimitrios Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK
| | - Idoya Zazpe
- Servicio de Neurocirugía, Complejo Hospitalario de Navarra, Pamplona, Spain
- Servicio de Cirugía Torácica, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Moncef Berhouma
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Lyon, France
| | - Emmanuel Jouanneau
- Department of Neurosurgery, Hopital Neurologique Pierre Wertheimer, Lyon, France
| | - Jeroen B Verheul
- Department of Neurosurgery and Gamma knife Centre, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Constantin Tuleasca
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5) Ecole Polytechnique Fédérale de Lausanne (EPFL) Lausanne, Lausanne, Switzerland
| | - Mercy George
- ENT Service, Centre Hospitalier Universitaire Vaudois (CHUV); Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Marc Levivier
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery Service and Gamma Knife Center, University hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
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Breshears JD, Chang J, Molinaro AM, Sneed PK, McDermott MW, Tward A, Theodosopoulos PV. Temporal Dynamics of Pseudoprogression After Gamma Knife Radiosurgery for Vestibular Schwannomas-A Retrospective Volumetric Study. Neurosurgery 2020. [PMID: 29518221 DOI: 10.1093/neuros/nyy019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The optimal observation interval after the radiosurgical treatment of a sporadic vestibular schwannoma, prior to salvage intervention, is unknown. OBJECTIVE To determine an optimal postradiosurgical treatment interval for differentiating between pseudoprogression and true tumor growth by analyzing serial volumetric data. METHODS This single-institution retrospective study included all sporadic vestibular schwannomas treated with Gamma Knife radiosurgery (Eketa AB, Stockholm, Sweden; 12-13 Gy) from 2002 to 2014. Volumetric analysis was performed on all available pre- and posttreatment magnetic resonance imaging scans. Tumors were classified as "stable/decreasing," "transient enlargement", or "persistent growth" after treatment, based on incrementally increasing follow-up durations. RESULTS A total of 118 patients included in the study had a median treatment tumor volume of 0.74 cm3 (interquartile range [IQR] = 0.34-1.77 cm3) and a median follow-up of 4.1 yr (IQR = 2.6-6.0 yr). Transient tumor enlargement was observed in 44% of patients, beginning at a median of 1 yr (IQR = 0.6-1.4 yr) posttreatment, with 90% reaching peak volume within 3.5 yr, posttreatment. Volumetric enlargement resolved at a median of 2.4 yr (IQR 1.9-3.6 yr), with 90% of cases resolved at 6.9 yr. Increasing follow-up revealed that many of the tumors initially enlarging 1 to 3 yr after stereotactic radiosurgery ultimately begin to shrink on longer follow-up (45% by 4 yr, 77% by 6 yr). CONCLUSION Tumor enlargement within ∼3.5 yr of treatment should not be used as a sole criterion for salvage treatment. Patient symptoms and tumor size must be considered, and giving tumors a chance to regress before opting for salvage treatment may be worthwhile.
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Affiliation(s)
- Jonathan D Breshears
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Joseph Chang
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Annette M Molinaro
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, Uni-versity of California, San Francisco, San Francisco, California
| | - Penny K Sneed
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron Tward
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California
| | - Philip V Theodosopoulos
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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