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Yagi K, Ikeda R, Suzuki J, Sunose H, Kawase T, Katori Y. Long-term tumor growth and hearing after conservative management of vestibular schwannomas. Acta Otolaryngol 2023; 143:37-42. [PMID: 36694965 DOI: 10.1080/00016489.2023.2168747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND There has been no report of a detailed long-term study of hearing at defined frequencies. AIMS/OBJECTIVES This study aimed to evaluate long-term vestibular shwannoma (VS) growth and long-term changes in hearing thresholds at defined frequencies. METHODS We retrospectively retrieved the medical records of 67 VS patients. Cases that were followed up for more than 5 years were analyzed. RESULTS Tumor growth was observed in 15 cases (22.4%) and 6 cases underwent gamma knife treatment (9.0%). The longest case of tumor growth and gamma knife treatment was observed 11 years after the initial diagnosis. Hearing thresholds at 500-2000 Hz was significantly different between the no growth and growth group (p < .05). Particularly at 1000 Hz, there was a significant difference between the two groups from an early time-point. CONCLUSIONS AND SIGNIFICANCE Even a 10-year or longer follow-up of VS may show an increase in tumor growth. Moreover, hearing thresholds, particularly at 1000 kHz, may predict tumor growth when following-up VS patients.
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Affiliation(s)
- Kazutake Yagi
- Department of Otolaryngology and Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryoukichi Ikeda
- Department of Otolaryngology and Head and Neck Surgery, Iwate Medical University School of Medicine, Iwate, Japan
| | - Jun Suzuki
- Department of Otolaryngology and Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroki Sunose
- Department of Otolaryngology and Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tetsuaki Kawase
- Department of Otolaryngology and Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yukio Katori
- Department of Otolaryngology and Head and Neck Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Brown A, Early S, Vasilijic S, Stankovic KM. Sporadic Vestibular Schwannoma Size and Location Do not Correlate With the Severity of Hearing Loss at Initial Presentation. Front Oncol 2022; 12:836504. [PMID: 35372070 PMCID: PMC8965062 DOI: 10.3389/fonc.2022.836504] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/14/2022] [Indexed: 11/24/2022] Open
Abstract
Vestibular schwannoma (VS) is a non-malignant intracranial neoplasm arising from the vestibular branch of the 8th cranial nerve; sensorineural hearing loss (SNHL) is the most common associated symptom. Understanding whether VS imaging characteristics at the time of VS diagnosis can be associated with severity of VS-induced SNHL can impact patient counseling and define promising areas for future research. Patients diagnosed with VS at Massachusetts Eye and Ear (MEE) from 1994 through 2018 were analyzed if magnetic resonance imaging at VS presentation and sequential audiometry were available. Results were compared with original studies available in PubMed, written in English, on VS imaging characteristics and their impact on hearing in patients. A total of 477 patients with unilateral VS from the MEE database demonstrated no significant correlation between any features of tumor imaging at the time of VS diagnosis, such as VS size, impaction or location, and any hearing loss metric. Twenty-three published studies on the impact of VS imaging characteristics on patient hearing met inclusion criteria, with six solely involving NF2 patients and three including both sporadic and NF2-related VS patients. Fifteen studies reported a significant relationship between SNHL and at least one VS imaging characteristic; however, these trends were universally limited to NF2 patients or involved small patient populations, and were not reproduced in larger studies. Taken together, SNHL in sporadic VS patients is not readily associated solely with any tumor imaging characteristics. This finding motivates future studies to define how VS microenvironment and secreted molecules influence VS-induced SNHL.
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Affiliation(s)
- Alyssa Brown
- Department of Otolaryngology-Head and Neck Surgery and Eaton-Peabody Laboratories, Massachusetts Eye and Ear, Boston, MA, United States
| | - Samuel Early
- Department of Otolaryngology-Head and Neck Surgery and Eaton-Peabody Laboratories, Massachusetts Eye and Ear, Boston, MA, United States.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA, United States.,Department of Otolaryngology Head and Neck Surgery, University of California, San Diego, San Diego Medical Center, San Diego, CA, United States
| | - Sasa Vasilijic
- Department of Otolaryngology-Head and Neck Surgery and Eaton-Peabody Laboratories, Massachusetts Eye and Ear, Boston, MA, United States.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA, United States.,Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Konstantina M Stankovic
- Department of Otolaryngology-Head and Neck Surgery and Eaton-Peabody Laboratories, Massachusetts Eye and Ear, Boston, MA, United States.,Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA, United States.,Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
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3
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Fink KR, Nobles SE, Zeitler DM. Comparing the Precision and Reliability Between Three Radiographic Techniques for Measuring Sporadic Vestibular Schwannomas. Acad Radiol 2022; 29:69-76. [PMID: 33158707 DOI: 10.1016/j.acra.2020.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/03/2020] [Accepted: 09/29/2020] [Indexed: 11/24/2022]
Abstract
RATIONALE AND OBJECTIVES Several methods exist for measuring vestibular schwannoma (VS) size radiographically. Our aim was to compare the precision and reproducibility of three different radiographic measurement techniques for assessing VS tumor size. MATERIAL AND METHODS Twenty patients with unilateral, sporadic VS previously untreated were identified. All patients had thin-slice T1 weighted, postcontrasted magnetization prepared rapid acquisition gradient echo images. Three measurement techniques were performed using within-subject and between-subject comparison. Experimental comparison of interobserver agreement between techniques was calculated. Interobserver intraclass correlation coefficients, repeatability coefficients, and relative smallest detectable difference were calculated and compared. RESULTS Mean tumor measurements were: 10.3 mm (maximum linear dimension, [MLD]), 495.9 mm3 (orthogonal volumetric analysis, [OVA]), and 572.1 mm3 (segmented volumetric analysis, [SVA]). Interobserver correlation coefficient was excellent for all measurement techniques, but highest for segmented volumetric analysis. Repeatability coefficient was 1.44 mm for MLD, 298.9 mm3 for OVA, and 174.8 mm3 for SVA. The smallest detectable difference was 13.9% for MLD, 60.2% for OVA, and 30.6% for SVA. A subgroup analysis was performed for small tumors (<14 mm) and large tumors (>14 mm) and demonstrated increased precision of segmented volumetric analysis for larger tumors. CONCLUSION Semi-automated segmented volumetric analysis appears more precise than either linear measurement or orthogonal volumetric analysis for reporting VS tumor size, and becomes increasingly precise for larger tumors. Tumor volume and tumor volume change over time using SVA may be more sensitive in surveilling VS than current measurement techniques.
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Gurewitz J, Schnurman Z, Nakamura A, Navarro RE, Patel DN, McMenomey SO, Roland JT, Golfinos JG, Kondziolka D. Hearing loss and volumetric growth rate in untreated vestibular schwannoma. J Neurosurg 2021; 136:768-775. [PMID: 34416729 DOI: 10.3171/2021.2.jns203609] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 02/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this study, the authors aimed to clarify the relationship between hearing loss and tumor volumetric growth rates in patients with untreated vestibular schwannoma (VS). METHODS Records of 128 treatment-naive patients diagnosed with unilateral VS between 2012 and 2018 with serial audiometric assessment and MRI were reviewed. Tumor growth rates were determined from initial and final tumor volumes, with a median follow-up of 24.3 months (IQR 8.5-48.8 months). Hearing changes were based on pure tone averages, speech discrimination scores, and American Academy of Otolaryngology-Head and Neck Surgery hearing class. Primary outcomes were the loss of class A hearing and loss of serviceable hearing, estimated using the Kaplan-Meier method and with associations estimated from Cox proportional hazards models and reported as hazard ratios. RESULTS Larger initial tumor size was associated with an increased risk of losing class A (HR 1.5 for a 1-cm3 increase; p = 0.047) and serviceable (HR 1.3; p < 0.001) hearing. Additionally, increasing volumetric tumor growth rate was associated with elevated risk of loss of class A hearing (HR 1.2 for increase of 100% per year; p = 0.031) and serviceable hearing (HR 1.2; p = 0.014). Hazard ratios increased linearly with increasing growth rates, without any evident threshold growth rate that resulted in a large, sudden increased risk of hearing loss. CONCLUSIONS Larger initial tumor size and faster tumor growth rates were associated with an elevated risk of loss of class A and serviceable hearing.
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Affiliation(s)
| | | | | | | | | | - Sean O McMenomey
- 2Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, New York
| | - J Thomas Roland
- 2Otolaryngology-Head and Neck Surgery, NYU Langone Health, New York, New York
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Kim JS, Cho YS. Growth of vestibular schwannoma: long-term follow-up study using survival analysis. Acta Neurochir (Wien) 2021; 163:2237-2245. [PMID: 34003365 DOI: 10.1007/s00701-021-04870-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND A vestibular schwannoma (VS) is a benign nerve sheath tumor derived from the vestibular nerves. The growth rate of VS during long-term follow-up has not yet been fully evaluated. We aimed to investigate the growth rate of newly diagnosed VS and the related predictive factors for tumor growth. METHODS A retrospective review was performed using VS patients who underwent at least two magnetic resonance imaging (MRI) scans before tumor growth was observed. Tumor growth was defined as a size increase of more than 2 mm in the longest diameter of the tumor. To assess the growth rate of VS and related factors, we assessed tumor growth using survival analysis. Survival analysis to assess the growth rate and Cox regression analysis were performed to find related factors. RESULTS The study included 118 patients. The mean age of patients was 57.0 ± 12.9 years. During the observation period, the 5-year cumulative growth incidence rate was 41.3% by survival analysis. Extrameatal tumor location and hearing loss were found to be associated with an increased hazard ratio (HR) for tumor growth. CONCLUSION After long-term observation of VS, 41.3% of VS patients presented cumulative growth incidence rate in the first 5 years after diagnosis. Extrameatal tumor location and hearing changes were related to subsequent tumor growth.
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Affiliation(s)
- Jong Sei Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Yang-Sun Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Reznitsky M, Petersen MMBS, West N, Stangerup SE, Cayé-Thomasen P. The natural history of vestibular schwannoma growth-prospective 40-year data from an unselected national cohort. Neuro Oncol 2021; 23:827-836. [PMID: 33068429 DOI: 10.1093/neuonc/noaa230] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Optimal management of vestibular schwannoma (VS) is still debated and thus international consensus has not been achieved. Treatment options are observation, radiotherapy, and surgery. Knowledge on the natural history of tumor growth is essential for choice of treatment modality. The aim is to present intra-/extrameatal tumor growth and management data from a prospective, unselected national cohort of patients diagnosed with VS during the period 1976-2015. METHODS Since 1976, all data from patients diagnosed with sporadic VS in Denmark have been referred to our national treatment center, where they have been entered prospectively into the national database. Data on tumor localization, growth, and treatment were retrieved. Growth definition: >2 mm by linear measurement, in accordance with the Tokyo 2001 consensus-meeting recommendations. RESULTS 3637 cases of VS were diagnosed, in which 1304 patients had surgery and 21 received radiotherapy post diagnosis. 2312 patients were observed with mean follow-up of 7.33 years. Of these, 434(19%; 102 intra-and 332 extrameatal tumors) changed to active treatment during the observation period due to tumor growth. 5 years after diagnosis, 21% of the intrameatal tumors exhibited growth during observation, whereas 37% of extrameatal tumors had grown, increasing to 25% intrameatal and 42% extrameatal after 10 years. Following growth, the intrameatal tumors were mostly observed further and the extrameatal mostly underwent surgery. Tumor growth occurred mainly within the first 5 years post diagnosis. CONCLUSION This natural history study documents the growth occurrence of both intra-and extrameatal VS during the first 12 years after diagnosis and should be used in patient counseling, management, and treatment decision making.
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Affiliation(s)
- Martin Reznitsky
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Niels West
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sven-Eric Stangerup
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Cayé-Thomasen
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Neves Cavada M, Fook-Ho Lee M, Jufas NE, Harvey RJ, Patel NP. Intracanalicular Vestibular Schwannoma: A Systematic Review and Meta-analysis of Therapeutics Outcomes. Otol Neurotol 2021; 42:351-362. [PMID: 33555742 DOI: 10.1097/mao.0000000000002979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis summarizing the current evidence on the management of intracanalicular vestibular schwannoma. DATA SOURCES Embase (1947-), Medline (1946-), Cochrane library (1947-), Scopus (2010-), and CINAHL (1961-) were searched from 1969 to October 5, 2019 (50 years). STUDY SELECTION A search strategy was performed to identify patients with vestibular schwannoma confined to the internal auditory canal without extension to the cerebellopontine angle. Studies with patients aged less than 18, Neurofibromatosis type 2, revision cases, and non-English language were excluded. DATA EXTRACTION A standardized collection sheet was used for the extracted data and a quality assessment was performed using the Newcastle-Ottawa Scale with the comparability criterion omitted. DATA SYNTHESIS Seventy-one studies were included with 24 on observation, 14 on radiotherapy, and 34 on surgery. The primary outcome was serviceable hearing preservation. Secondary outcomes were preservation of facial nerve function, growth, involution, and dizziness. Sub-analysis on the type of surgery and type of radiotherapy were performed. Excel 2016 with MIX 2.0 Pro add-on package was used to analyze the data and create forest plots. Data were presented in proportion with a 95% confidence interval. CONCLUSIONS Serviceable hearing was observed in 31% of patients after observation, 56% after radiotherapy, and 51% after surgical treatment with mean follow-up time of 4.04 years, 4.92 years, and 2.23 years, respectively. Facial nerve function was found to be best preserved in both observation and radiotherapy groups. Vestibular schwannoma growth occurred in 33% of patients under observation. Involution occurred in 2% of patients under observation and in 38% after radiotherapy.
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Affiliation(s)
- Marina Neves Cavada
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Sydney Adventist Hospital
| | | | - Nicholas Emmanuel Jufas
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Kolling Deafness Research Centre, University of Sydney & Macquarie University
- Department of Otolaryngology, Head and Neck Surgery, Royal North Shore Hospital
- Discipline of Surgery, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Richard John Harvey
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales
| | - Nirmal P Patel
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine and Health Sciences, Macquarie University
- Kolling Deafness Research Centre, University of Sydney & Macquarie University
- Department of Otolaryngology, Head and Neck Surgery, Royal North Shore Hospital
- Discipline of Surgery, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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8
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Strowd RE, Plotkin SR. Familial Nervous System Tumor Syndromes. ACTA ACUST UNITED AC 2020; 26:1523-1552. [PMID: 33273171 DOI: 10.1212/con.0000000000000950] [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: 11/15/2022]
Abstract
PURPOSE OF REVIEW Although sporadic primary neoplasms account for the majority of nervous system tumors, familial nervous system tumor syndromes are important and clinically relevant conditions for the neurologist to understand. This article reviews common inherited nervous system tumor syndromes including neurofibromatosis type 1, neurofibromatosis type 2, schwannomatosis, tuberous sclerosis complex, and von Hippel-Lindau syndrome. The epidemiology, genetics, approach to diagnosis, neurologic and nonneurologic manifestations, and management options are reviewed. RECENT FINDINGS Awareness of the more common and clinically relevant familial nervous system tumor syndromes is important. These conditions teach us about the underlying biology that drives tumor development in the central and peripheral nervous systems including peripheral nerve sheath tumors (eg, neurofibroma, schwannoma), meningioma, vestibular schwannoma, subependymal giant cell astrocytoma, and hemangioblastoma. Knowledge of the clinical manifestations ensures that the neurologist will be able to diagnose these conditions, recommend appropriate surveillance, refer to specialists, and support optimal management. Important discoveries in the role of the underlying genetics have contributed to the launch of several novel drug trials for these tumors, which are changing therapeutic options for patients. SUMMARY Familial nervous system tumor syndromes are uncommon conditions that require specialized surveillance and management strategies. Coordination across a multidisciplinary team that includes neurologists, neuro-oncologists, radiologists, neurosurgeons, radiation oncologists, otolaryngologists, pathologists, neuropsychologists, physical medicine and rehabilitation specialists, and geneticists is necessary for the optimal treatment of these patients.
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9
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Strowd RE. Available Therapies for Patients with Neurofibromatosis-Related Nervous System Tumors. Curr Treat Options Oncol 2020; 21:81. [DOI: 10.1007/s11864-020-00779-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Hearing and Quality of Life Over Time in Vestibular Schwannoma Patients: Observation Compared to Stereotactic Radiosurgery. Otol Neurotol 2020; 40:1094-1100. [PMID: 31335799 DOI: 10.1097/mao.0000000000002334] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine quality of life changes for patients with vestibular schwannoma (VS) undergoing observation or stereotactic radiosurgery (SRS). STUDY DESIGN Retrospective review. SETTING Academic medical center. PATIENTS Patients with VS who underwent observation or SRS and had at least two audiograms and Penn Acoustic Neuroma Quality of Life (PANQOL) surveys, a quality of life survey for patients with VS. INTERVENTIONS SRS or observation. MAIN OUTCOME MEASURES Pure-tone average (PTA), speech discrimination score (SDS), PANQOL score; controlling for tumor size, baseline hearing, and other factors. RESULTS One hundred twenty-three patients met inclusion criteria: 89 underwent observation and 34 SRS. There was no significant difference in the rate of decline measured by PTA (PTA worsened at a rate of 0.25 dB/yr more in the observation group compared with the SRS group, p = 0.77) and SDS (SDS worsened at a rate of 2.1%/yr more in the SRS group compared with the observation group, p = 0.82). Kaplan-Meier analysis demonstrated the SRS group had a higher probability to progress to class D hearing over observation (hazard ratio 7.1, p = 0.005). The rate of change of the SRS PANQOL scores was significantly improved in the total (p = 0.005) and hearing (p = 0.04) domain score compared with observation. However, both groups regress to a similar PANQOL total and hearing domain score over time. CONCLUSION PANQOL scores were higher at baseline in the observation group than in the SRS group. However, over time, PANQOL scores in the observation group decreased while PANQOL scores in the SRS group increased, resulting in PANQOL scores that were equivalent by the end of follow-up.
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Patel NS, Huang AE, Dowling EM, Lees KA, Tombers NM, Lohse CM, Marinelli JP, Van Gompel JJ, Neff BA, Driscoll CLW, Link MJ, Carlson ML. The Influence of Vestibular Schwannoma Tumor Volume and Growth on Hearing Loss. Otolaryngol Head Neck Surg 2020; 162:530-537. [PMID: 31986971 DOI: 10.1177/0194599819900396] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To ascertain the relationship among vestibular schwannoma (VS) tumor volume, growth, and hearing loss. STUDY DESIGN Retrospective cohort study. SETTING Single tertiary center. SUBJECTS AND METHODS Adults with observed VS and serviceable hearing at diagnosis were included. The primary outcome was the development of nonserviceable hearing as estimated using the Kaplan-Meier method. Associations of tumor volume with baseline hearing were assessed using Spearman rank correlation coefficients. Associations of volume and growth with the development of nonserviceable hearing over time were assessed using Cox proportional hazards models and summarized with hazard ratios (HRs). RESULTS Of 230 patients with VS and serviceable hearing at diagnosis, 213 had serial volumetric tumor data for analysis. Larger tumor volume at diagnosis was associated with increased pure-tone average (PTA) (P < .001) and decreased word recognition score (WRS) (P = .014). Estimated rates of maintaining serviceable hearing at 6 and 10 years following diagnosis were 67% and 49%, respectively. Larger initial tumor volume was associated with development of nonserviceable hearing in a univariable setting (HR for 1-cm3 increase: 1.36, P = .040) but not after adjusting for PTA and WRS. Tumor growth was not significantly associated with time to nonserviceable hearing (HR, 1.57; P = .14), although estimated rates of maintaining serviceable hearing during observation were poorer in the group that experienced growth. CONCLUSION Larger initial VS tumor volume was associated with poorer hearing at baseline. Larger initial tumor volume was also associated with the development of nonserviceable hearing during observation in a univariable setting; however, this association was not statistically significant after adjusting for baseline hearing status.
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Affiliation(s)
- Neil S Patel
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alice E Huang
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric M Dowling
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine A Lees
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicole M Tombers
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine M Lohse
- Department of Health Science Research, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian A Neff
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Colin L W Driscoll
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Link
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew L Carlson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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12
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Vellutini EDAS, Teles Gomes MDQ, Brock RS, Oliveira MFD, Salomone R, Godoy LFDS, Ruschel LG. Radiologic Features of Spontaneous Regression of Vestibular Schwannomas. World Neurosurg 2019; 135:e488-e493. [PMID: 31843724 DOI: 10.1016/j.wneu.2019.12.034] [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: 10/23/2019] [Revised: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Vestibular schwannoma (VS) is the most common benign tumor originating in the cerebellopontine angle. In most cases, tumors tend to grow and deserve proper treatment. Sometimes they stabilize, and rarely they decrease in size spontaneously. METHODS We evaluated retrospectively the images of patients with spontaneous tumor regression. We describe the common neuroimage findings of patients with spontaneous tumoral regression. RESULTS Four patients with diagnosis of VS were followed with magnetic resonance imaging (MRI). There were some relevant features in MRI: a heterogeneous contrast enhancement in the outer layer of the tumor and presence of a cerebrospinal fluid column between the tumor and the entrance of the internal auditory canal. The percentage of tumor diameter reduction ranged from 20% to 40%. CONCLUSIONS Some MRI features may demonstrate a spontaneous involution of VS and may be closely followed in asymptomatic or oligosymptomatic patients.
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Affiliation(s)
| | - Marcos de Queiroz Teles Gomes
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Roger Schmidt Brock
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Matheus Fernandes de Oliveira
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil.
| | - Raquel Salomone
- Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Leonardo Gilmone Ruschel
- DFV Neuro, São Paulo, Brazil; Hospital Sírio Libanês, São Paulo, Brazil; Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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13
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Letter to the Editor Regarding "Spontaneous Regression of a Hypoglossal Neurinoma: Case Report and Review of the Literature". World Neurosurg 2019; 130:578-579. [PMID: 31581401 DOI: 10.1016/j.wneu.2019.06.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/20/2022]
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14
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Prasad SC, Patnaik U, Grinblat G, Giannuzzi A, Piccirillo E, Taibah A, Sanna M. Decision Making in the Wait-and-Scan Approach for Vestibular Schwannomas: Is There a Price to Pay in Terms of Hearing, Facial Nerve, and Overall Outcomes? Neurosurgery 2019; 83:858-870. [PMID: 29281097 DOI: 10.1093/neuros/nyx568] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 10/10/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The wait-and-scan modality has emerged as an important strategy in the management of vestibular schwannoma (VS) as it has been demonstrated that many tumors grow slowly or do not show any growth over long periods. OBJECTIVE To analyze long-term outcomes of wait-and-scan in the treatment of patients with VS, discuss the factors contributing to the decision making, determine the inherent risks of the policy, and compare our results with literature. METHODS In total, 576 patients with sporadic unilateral VS who were managed with wait-and-scan were reviewed retrospectively. Of these, a subset of 154 patients with 5-yr follow-up was separately analyzed. The tumor characteristics including patterns of growth, rate of growth, hearing outcomes, and likely factors affecting the above parameters were analyzed. RESULTS The mean period of follow-up was 36.9 ± 30.2 mo. The mean age was 59.2 ± 11.6 yr. Thirteen different patterns of tumor growth were observed. Eighty-four (54.5%) of 154 tumors with 5-yr follow-up showed no growth throughout 5 yr. Fifty-six (36.4%) tumors showed mixed growth rates. Only 57 (37%) patients had serviceable hearing at the start of follow-up, but 32 (56.1%) maintained it at the end of follow-up. One hundred fifty (26%) of the 576 patients who failed wait-and-scan had to be taken up for surgery. CONCLUSION While there may be no price to pay in wait-and-scan as far as hearing is concerned, this may not be the case for facial nerve outcomes, wherein the results may be better if the patients are taken earlier for surgery.
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Affiliation(s)
- Sampath Chandra Prasad
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza-Rome, Italy
| | - Uma Patnaik
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza-Rome, Italy.,Department of Otolaryngology-Head and Neck Surgery, Military Hospital, Hisar, India
| | - Golda Grinblat
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza-Rome, Italy
| | - Annalisa Giannuzzi
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza-Rome, Italy
| | - Enrico Piccirillo
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza-Rome, Italy
| | - Abdelkader Taibah
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza-Rome, Italy
| | - Mario Sanna
- Department of Neurotology and Skull Base Surgery, Gruppo Otologico, Piacenza-Rome, Italy
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15
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Carlson ML, Vivas EX, McCracken DJ, Sweeney AD, Neff BA, Shepard NT, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Hearing Preservation Outcomes in Patients With Sporadic Vestibular Schwannomas. Neurosurgery 2019; 82:E35-E39. [PMID: 29309683 DOI: 10.1093/neuros/nyx511] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/02/2017] [Indexed: 11/14/2022] Open
Abstract
Question 1 What is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery utilizing modern dose planning, at 2, 5, and 10 yr following treatment? Recommendation Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 2 Among patients with AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery hearing classification) class A or GR (Gardner-Robertson hearing classification) grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery, utilizing modern dose planning, at 2, 5, and 10 yr following treatment? Recommendation Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 3 What patient- and tumor-related factors influence progression to nonserviceable hearing following stereotactic radiosurgery using ≤13 Gy to the tumor margin? Recommendation Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size, marginal tumor dose ≤12 Gy, and cochlear dose ≤4 Gy. Age and sex are not strong predictors of hearing preservation outcome. Question 4 What is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment? Recommendation Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately low probability (>25%-50%) of hearing preservation immediately following surgery, moderately low probability (>25%-50%) of hearing preservation at 2 yr, moderately low probability (>25%-50%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 5 Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment? Recommendation Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately high probability (>50%-75%) of hearing preservation immediately following surgery, moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 6 What patient- and tumor-related factors influence progression to nonserviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas? Recommendation Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size commonly less than 1 cm, and presence of a distal internal auditory canal cerebrospinal fluid fundal cap. Age and sex are not strong predictors of hearing preservation outcome. Question 7 What is the overall probability of maintaining serviceable hearing with conservative observation of vestibular schwannomas at 2, 5, and 10 yr following diagnosis? Recommendation Level 3: Individuals who meet these criteria and are considering observation should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr. Question 8 Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing with conservative observation at 2 and 5 yr following diagnosis? Recommendation Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, and moderately high probability (>50%-75%) of hearing preservation at 5 yr. Insufficient data were available to determine the probability of hearing preservation at 10 yr for this population subset. Question 9 What patient and tumor-related factors influence progression to nonserviceable hearing during conservative observation? Recommendation Level 3: Individuals who meet these criteria and are considering observation should be counseled regarding probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, as well as nongrowth of the tumor. Tumor size at the time of diagnosis, age, and sex do not predict future development of nonserviceable hearing during observation. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-manage-ment-patients-vestibular-schwannoma/chapter_3.
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Affiliation(s)
- Matthew L Carlson
- Department of Otorhinolaryngology, Mayo Clinic, School of Medicine, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, School of Medicine, Rochester, Minnesota
| | - Esther X Vivas
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - D Jay McCracken
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Alex D Sweeney
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | - Brian A Neff
- Department of Otorhinolaryngology, Mayo Clinic, School of Medicine, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, School of Medicine, Rochester, Minnesota
| | - Neil T Shepard
- Department of Otorhinolaryngology, Mayo Clinic, School of Medicine, Rochester, Minnesota
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
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Extended Retrolabyrinthine Approach: Results of Hearing Preservation Surgery Using a New System for Continuous Near Real-time Neuromonitoring in Patients With Growing Vestibular Schwannomas. Otol Neurotol 2019; 40:S72-S79. [DOI: 10.1097/mao.0000000000002216] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Long-Term Tumor Control Rates Following Gamma Knife Radiosurgery for Acoustic Neuroma. World Neurosurg 2019; 122:366-371. [DOI: 10.1016/j.wneu.2018.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/31/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022]
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18
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Emmanouil B, Houston R, May A, Ramsden JD, Hanemann CO, Halliday D, Parry A, Mackeith S. Progression of hearing loss in neurofibromatosis type 2 according to genetic severity. Laryngoscope 2018; 129:974-980. [DOI: 10.1002/lary.27586] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2018] [Indexed: 11/12/2022]
Affiliation(s)
| | - Rory Houston
- Department of ENTOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | - Anne May
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
| | - James D. Ramsden
- Department of ENTOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | | | - Dorothy Halliday
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
- Oxford Centre for Genomic MedicineOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
| | - Allyson Parry
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
| | - Samuel Mackeith
- Oxford NF2 Unit, Neurosciences Oxford United Kingdom
- Department of ENTOxford University Hospitals NHS Foundation Trust Oxford United Kingdom
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19
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Hearing Outcomes in Conservatively Managed Vestibular Schwannoma Patients With Serviceable Hearing. Otol Neurotol 2018; 39:e704-e711. [DOI: 10.1097/mao.0000000000001914] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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West N, Møller MN, Hansen S, Cayé-Thomasen P. Audiovestibular Loss of Function Correlates in Vestibular Schwannomas. J Int Adv Otol 2018; 14:161-165. [PMID: 30100546 DOI: 10.5152/iao.2018.5500] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The aim of the present study was to investigate the relationships between tumor size, hearing, and vestibular outcomes in patients with vestibular schwannomas (VSs). MATERIALS AND METHODS Adult patients (n=124) with unilateral extrameatal VS prior to surgery were included in the study. This was a retrospective cohort study of preoperative audiovestibular investigations including audiometry, discrimination test, caloric test, cervical vestibular evoked myogenic potential (c-VEMP), and ocular vestibular evoked myogenic potential (o-VEMP). RESULTS The difference between lesioned and non-lesioned ear was significant for all audiovestibular outcomes. The mean caloric deficit was 74%. No tumor sided o-VEMPs were elicited. Caloric deficit correlated with hearing loss measured with pure tone average and discrimination score. c-VEMP deficit was significantly associated with severe hearing loss and larger tumors. CONCLUSION The presence of VS leads to a significant deterioration of audiovestibular function in all objective measures. Caloric test and o-VEMPS are sensitive though unspecific measures of VSs. Increasing tumor size is not directly associated with hearing loss and only somewhat to vestibular deficit. However, audiovestibular findings are correlated.
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Affiliation(s)
- Niels West
- Department of Otorhinolaryngology, Head and Neck Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Martin Nue Møller
- Department of Otorhinolaryngology, Head and Neck Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Søren Hansen
- Department of Otorhinolaryngology, Head and Neck Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Per Cayé-Thomasen
- University of Copenhagen, School of Health and Medical Sciences, Copenhagen, Denmark
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21
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Calculating the Tumor Volumes in Vestibular Schwannomas: Are the ABC/2 and Volumetric Methods Comparable? Otol Neurotol 2018; 38:889-894. [PMID: 28394785 DOI: 10.1097/mao.0000000000001423] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the efficacy of the ABC/2 method for calculating the volume of vestibular schwannomas as compared with 3-D planimetric method. STUDY DESIGN Retrospective. METHODS Fifty eight cases of pathologically confirmed sporadic vestibular schwannomas (VS) were analyzed. Tumors volumes were calculated for each tumor twice, once through semiautomated 3-D volumetric method and subsequently through ABC/2 (AP × ML × CC/2) methodology after calculating the maximal tumor dimensions in anteroposterior (AP), coronal (ML), and craniocaudal (CC) dimensions. Tumor volumes were initially correlated as a group and subsequently by dividing them into three groups using the Hannover classification. RESULTS The two methodologies were highly correlated when tumors were analyzed as a group (rho = 0.913, p < 0.0001). In the sub-group analysis, tumor volumes were again strongly correlated for larger tumors (rho = 0.918, p < 0.0001) but the correlation progressively reduced as tumor volumes decreased. CONCLUSION Given the ease and universal accessibility of linear measurement applications, the ABC/2 methodology is a robust substitute for calculating tumor volumes, especially for larger tumors.
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22
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Nguyen T, Duong C, Sheppard JP, Lee SJ, Kishan AU, Lee P, Tenn S, Chin R, Kaprealian TB, Yang I. Hypo-fractionated stereotactic radiotherapy of five fractions with linear accelerator for vestibular schwannomas: A systematic review and meta-analysis. Clin Neurol Neurosurg 2018; 166:116-123. [PMID: 29414150 DOI: 10.1016/j.clineuro.2018.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/31/2017] [Accepted: 01/07/2018] [Indexed: 10/18/2022]
Abstract
Vestibular schwannomas (VS) are benign tumors stemming from the eighth cranial nerve. Treatment options for VS include conservative management, microsurgery, stereotactic radiosurgery, and fractionated radiotherapy. Though microsurgery has been the standard of care for larger lesions, hypo-fractionated stereotactic radiotherapy (hypo-FSRT) is an emerging modality. However, its clinical efficacy and safety have yet to be established. We conducted a systematic review and meta-analysis of manuscripts indexed in PubMed, Scopus, Web of Science, Embase, and Cochrane databases reporting outcomes of VS cases treated with hypo-FSRT. Five studies representing a total of 228 patients were identified. Across studies, the pooled rates of tumor control, hearing, facial nerve, and trigeminal nerve preservation were 95%, 37%, 97%, and 98%. No instances of malignant induction were observed at median follow-up of 34.8 months. Complications included trigeminal neuropathy (n = 3), maxillary paresthesia (n = 1), neuralgia (n = 1), vestibular dysfunction (n = 1), radionecrosis (n = 1), and hydrocephalus (n = 1). Hypo-FSRT may be another useful approach to manage VS, but studies with extended follow-up times are required to establish long-term safety.
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Affiliation(s)
- Thien Nguyen
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Courtney Duong
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States
| | - John P Sheppard
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Seung Jin Lee
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Amar U Kishan
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Percy Lee
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Stephen Tenn
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Robert Chin
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Tania B Kaprealian
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Isaac Yang
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Head and Neck Surgery, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States; Los Angeles Biomedical Research Institute, Los Angeles (UCLA), Los Angeles, CA, United States; Harbor-UCLA Medical Center, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States.
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23
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Single Institutional Experience With Observing 564 Vestibular Schwannomas: Factors Associated With Tumor Growth. Otol Neurotol 2017; 37:1630-1636. [PMID: 27668793 DOI: 10.1097/mao.0000000000001219] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the risk and predictors of growth during observation of vestibular schwannomas (VS). STUDY DESIGN Retrospective case series. SETTING Single academic, tertiary care center. PATIENTS Five hundred sixty-four consecutive VS patients who underwent at least two magnetic resonance imaging (MRI) studies before intervention. INTERVENTION(S) Serial MRI studies. MAIN OUTCOME MEASURE(S) Tumor growth, defined as a ≥2 mm increase in the maximum tumor diameter between consecutive MRI studies, or between the first and last study. RESULTS A total of 1296 patients (1995-2015) with VS were identified. Of those, 564 patients (median age 59.2 years; 53.5% female) were initially observed and underwent multiple MRI studies (median follow-up 22.9 months, interquartile range [IQR] 11.7-42.7). The median maximum tumor diameter at presentation was 1.00 cm (IQR 0.6-1.51 cm). In all, 40.8% of tumors demonstrated growth and 32.1% underwent intervention (21.5% microsurgery, 10.5% radiation) during the surveillance period. Multivariable Cox regression analysis showed that for each tumor, the risk of growth or intervention was significantly increased for larger initial VS diameters (HR = 2.22; 95% CI: 1.90-2.61) and when disequilibrium was a presenting symptom (HR = 1.70; 95% CI: 1.30-2.23). Patient age, sex, aspirin use, and presenting symptoms of asymmetric hearing loss, tinnitus, and vertigo were not associated with tumor growth. CONCLUSION To date, this is the largest series of observed VS reported in the literature. Risk of VS growth is significantly increased among patients who present with larger tumors and who have concomitant disequilibrium.IRB:: 151481. DEFINE PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED No cohort with this sample size has assessed vestibular schwannoma growth rates in conjunction with this number of variables. LEARNING OBJECTIVE To characterize vestibular schwannoma growth rates and predictors of growth.
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Vestibular Schwannomas: Do Linear and Volumetric Parameters on MRI Correlate With Hearing Loss? Otol Neurotol 2017; 37:1168-73. [PMID: 27466888 DOI: 10.1097/mao.0000000000001150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine if two-dimensional and volumetric imaging parameters in vestibular schwannomas (VS) correlate with hearing loss at presentation. STUDY DESIGN Retrospective. METHODS Forty-one cases of pathologically confirmed sporadic VS were analyzed. Maximal tumor dimensions in anteroposterior (AP), coronal (ML), and craniocaudal (CC) dimensions were obtained along with tumor-fundus distance and internal auditory canal (IAC) porus diameters. Volumetric analysis was done on 37 cases. Tumors volumes were calculated through both 3-D volumetric and ABC/2 [AP × ML × CC/2] methodology. With the 3-D method, total tumor volume (TTV), and cerebellopontine angle (CPA) tumor volume were separately calculated and IAC volumes obtained by subtracting CPA tumor volumes from TTV. Pure tone average (PTA) and speech discrimination scores (SDS) were correlated with tumor dimensions. RESULTS Non-volumetric analysis was performed on 41 tumors. The AP and ML dimensions correlated with both PTA and SDS (p < 0.05). No significant correlations were seen between hearing loss and tumor-fundus distance or porus diameters. The tumor volume calculated through ABC/2 methodology correlated with PTA and SDS (p < 0.05). The 3-D TTV and CPA volumes only correlated with PTA. IAC tumor volumes did not correlate with hearing loss. CONCLUSION Maximal AP and ML dimensions are the only non-volumetric variables, which significantly correlate with hearing loss. Tumor volume calculated through ABC/2 method significantly correlates with hearing impairment while the 3-D TTV and CPA tumor volumes only correlated significantly with PTA scores but not SDS scores.
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Stereotactic radiosurgery vs. fractionated radiotherapy for tumor control in vestibular schwannoma patients: a systematic review. Acta Neurochir (Wien) 2017; 159:1013-1021. [PMID: 28409393 PMCID: PMC5425507 DOI: 10.1007/s00701-017-3164-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/27/2017] [Indexed: 12/14/2022]
Abstract
Objective Repeated controlled studies have revealed that stereotactic radiosurgery is better than microsurgery for patients with vestibular schwannoma (VS) <3 cm in need of intervention. In this systematic review we aimed to compare results from single-fraction stereotactic radiosurgery (SRS) to fractionated stereotactic radiotherapy (FSRT) for patients with VS. Data sources and eligibility criteria We systematically searched MEDLINE, Web of Science, Embase and Cochrane and screened relevant articles for references. Publications from 1995 through 2014 with a minimum of 50 adult (>18 years) patients with unilateral VS, followed for a median of >5 years, were eligible for inclusion. After screening titles and abstracts of the 1094 identified articles and systematically reviewing 98 of these articles, 19 were included. Intervention Patients with unilateral VS treated with radiosurgery were compared to patients treated with fractionated stereotactic radiotherapy. Results No randomized controlled trial (RCT) was identified. None of the identified controlled studies comparing SRS with FSRT were eligible according to the inclusion criteria. Nineteen case series on SRS (n = 17) and FSRT (n = 2) were included in the systematic review. Loss of tumor control necessitating a new VS-targeted intervention was found in an average of 5.0% of the patients treated with SRS and in 4.8% treated with FSRT. Mean deterioration ratio for patients with serviceable hearing before treatment was 49% for SRS and 45% for FSRT, respectively. The risk for facial nerve deterioration was 3.6% for SRS and 11.2% for FSRT and for trigeminal nerve deterioration 6.0% for SRS and 8.4% for FSRT. Since these results were obtained from case series, a regular meta-analysis was not attempted. Conclusion SRS and FSRT are both noninvasive treatment alternatives for patients with VS with low rates of treatment failure in need of rescue therapy. In this selection of patients, the progression-free survival rates were on the order of 92–100% for both treatment options. There is a lack of high-quality studies comparing radiation therapy alternatives for patients with VS. Finally, 19 articles reported long-term tumor control after SRS, while only 2 articles reported long-term FSRT results, making effect estimates more uncertain for FSRT. Electronic supplementary material The online version of this article (doi:10.1007/s00701-017-3164-6) contains supplementary material, which is available to authorized users.
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26
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Diagnostic Criteria for Detection of Vestibular Schwannomas in the VA Population. Otol Neurotol 2016; 37:1510-1515. [DOI: 10.1097/mao.0000000000001251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Neutrophil to Lymphocyte Ratio as a Predictive Marker of Vestibular Schwannoma Growth. Otol Neurotol 2016; 37:580-5. [DOI: 10.1097/mao.0000000000001026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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28
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Bernardeschi D, Peyre M, Collin M, Smail M, Sterkers O, Kalamarides M. Internal Auditory Canal Decompression for Hearing Maintenance in Neurofibromatosis Type 2 Patients. Neurosurgery 2015; 79:370-7. [DOI: 10.1227/neu.0000000000001125] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
In neurofibromatosis type 2 (NF2), multiple therapeutic options are available to prevent bilateral hearing loss that significantly affects the quality of life of patients.
OBJECTIVE:
To evaluate the morbidity and functional results of internal auditory canal (IAC) decompression in NF2 patients with an only hearing ear.
METHODS:
Twenty-one NF2 patients operated on for IAC decompression in a 3-year period with a minimum follow-up of 1 year were included in this retrospective study. They presented unilateral deafness due to previous contralateral vestibular schwannoma removal in 16 patients or contralateral hearing loss due to the tumor in 5 patients. Hearing level was of class A (American Academy of Otolaryngology-Head and Neck Surgery classification) in 7 patients, B in 8 patients, C in 1 patient, and D in 5 patients. Pure-tone average and speech discrimination score evaluations were performed at 6 days, 1 year, and during the follow-up. Eight patients had postoperative chemotherapy.
RESULTS:
No case of facial nerve palsy was observed. In the early postoperative period; all patients maintained the hearing class of the preoperative period. At 1-year follow-up, all but 3 patients maintained their hearing scores; at last follow-up (mean follow-up, 23 + 8 months; range, 12-44 months), hearing classes remained stable with only 1 patient worsening from class B to C and 1 patient improving from class D to B.
CONCLUSION:
Decompression of IAC seems to be a useful procedure for hearing maintenance in NF2 patients, with very low morbidity. Ideal timing and association with chemotherapy should be evaluated in the future.
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Affiliation(s)
- Daniele Bernardeschi
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- INSERM UMR-S 1159, Réhabilitation Chirurgicale Mini-invasive et Robotisée de l'audition, Paris, France
| | - Matthieu Peyre
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Neurosurgery Department, Paris, France
| | - Michael Collin
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
| | - Mustapha Smail
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
| | - Olivier Sterkers
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Otology, Auditory Implants and Skull Base Surgery Department, Paris, France
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- INSERM UMR-S 1159, Réhabilitation Chirurgicale Mini-invasive et Robotisée de l'audition, Paris, France
| | - Michel Kalamarides
- Sorbonne Universités, UPMC Université Paris VI, Paris, France
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Neurosurgery Department, Paris, France
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Boari N, Bailo M, Gagliardi F, Franzin A, Gemma M, Vecchio AD, Bolognesi A, Picozzi P, Mortini P. Gamma Knife radiosurgery for vestibular schwannoma: clinical results at long-term follow-up in a series of 379 patients. J Neurosurg 2014; 121 Suppl:123-42. [DOI: 10.3171/2014.8.gks141506] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectSince the 1990s, Gamma Knife radiosurgery (GKRS) has become the first-line treatment option for small- to medium-size vestibular schwannomas (VSs), especially in patients without mass effect–related symptoms and with functional hearing. The aim of this study was to assess the safety and efficacy of GKRS, in terms of tumor control, hearing preservation, and complications, in a series of 379 consecutive patients treated for VS.MethodsOf 523 patients treated at the authors' institution for VS between 2001 and 2010, the authors included 379 who underwent GKRS as the primary treatment. These patients were not affected by Type 2 neurofibromatosis and had clinical follow-up of at least 36 months. Clinical follow-up (mean and median 75.7 and 69.5 months, respectively) was performed for all patients, whereas audiometric and quantitative radiological follow-up examinations were obtained for only 153 and 219 patients, respectively. The patients' ages ranged from 23 to 85 years (mean 59 years). The mean tumor volume was 1.94 ± 2.2 cm3 (median 1.2 cm3, range 0.013–14.3 cm3), and the median margin dose was 13 Gy (range 11–15 Gy). Parameters considered as determinants of the clinical outcome were long-term tumor control, hearing preservation, and complications. A statistical analysis was performed to correlate clinical outcomes with the radiological features of the tumor, dose-planning parameters, and patient characteristics.ResultsControl of the tumor with GKRS was achieved in 97.1% of the patients. In 82.7% of the patients, the tumor volume had decreased at the last follow-up, with a mean relative reduction of 34.1%. The rate of complications was very low, with most consisting of a transient worsening of preexisting symptoms. Patients who had vertigo, balance disorders, or facial or trigeminal impairment usually experienced a complete or at least significant symptom relief after treatment. However, no significant improvement was observed in patients previously reporting tinnitus. The overall rate of preservation of functional hearing at the long-term follow-up was 49%; in patients with hearing classified as Gardner-Robertson (GR) Class I, this value was 71% and reached 93% among cases of GR Class I hearing in patients younger than 55 years.ConclusionsGamma Knife radiosurgery is a safe and effective treatment for VS, achieving tumor control in 97.1% of cases and resulting in a very low morbidity rate. Younger GR Class I patients had a significantly higher probability of retaining functional hearing even at the 10-year follow-up; for this reason, the time between symptom onset, diagnosis, and treatment should be shortened to achieve better outcomes in functional hearing preservation.
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Affiliation(s)
| | | | | | | | | | | | - Angelo Bolognesi
- 4Service of Radiation Oncology, I.R.C.C.S. San Raffaele Hospital; and
| | | | - Pietro Mortini
- 1Department of Neurosurgery,
- 5Department of Neurosurgery, Vita-Salute San Raffaele University, Milan, Italy
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Progress of hearing loss in neurofibromatosis type 2: implications for future management. Eur Arch Otorhinolaryngol 2014; 272:3143-50. [DOI: 10.1007/s00405-014-3317-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
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González-Orús Álvarez-Morujo RJ, Álvarez-Palacios I, Martin-Oviedo C, Scola-Yurrita B, Arístegui-Ruiz MÁ. Conservative Management of Vestibular Schwannoma. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.otoeng.2014.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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González-Orús Álvarez-Morujo RJ, Alvarez-Palacios I, Martin-Oviedo C, Scola-Yurrita B, Arístegui-Ruiz MÁ. Conservative management of vestibular schwannoma. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2014; 65:275-82. [PMID: 24930856 DOI: 10.1016/j.otorri.2014.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/13/2014] [Accepted: 01/22/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Vestibular schwannoma (VS) is a benign, slow-growing tumour originating in the 8th cranial nerve. The treatment includes microsurgery, stereotactic radiotherapy and conservative management of tumours with periodic radiological tests. METHODS This was a retrospective study of patients with VS following conservative management in a tertiary hospital between 1993 and 2013. A total of 73 patients were enrolled in our protocol. The mean age at diagnosis was 59.7 years. The average size was 11.9mm (4-27mm); 58.9% of the tumours were intracanalicular and 41.1%, extracanalicular. The mean follow-up period was 35.75 months. RESULTS In 87.7% of patients there was no evidence of tumour growth. A total of 9 tumours (12.3%) increased in size. The average growth rate was 0.62mm/year. The percentage of extracanalicular tumours that grew (20%) was higher than that of intracanalicular tumours (7%). Seven patients (9.5%) experienced significant changes in their symptoms and 6 of these (8.2%) experienced a loss of useful hearing. Six patients (8.2%) left follow-up and underwent surgery. CONCLUSIONS Periodic monitoring of vestibular schwannomas with magnetic resonance imaging represents an option for management, because most small tumours experience little or no growth over time.
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Affiliation(s)
| | | | - Carlos Martin-Oviedo
- Servicio de ORL, Hospital General Universitario Gregorio Marañón, Madrid, España
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Yu YL, Lee MS, Juan CJ, Hueng DY. Calculating the tumor volume of acoustic neuromas: Comparison of ABC/2 formula with planimetry method. Clin Neurol Neurosurg 2013; 115:1371-4. [DOI: 10.1016/j.clineuro.2012.12.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 12/12/2012] [Accepted: 12/26/2012] [Indexed: 10/27/2022]
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Di Lella F, Merkus P, Di Trapani G, Taibah A, Guida M, Sanna M. Vestibular Schwannoma in the Only Hearing Ear: Role of Cochlear Implants. Ann Otol Rhinol Laryngol 2013; 122:91-9. [DOI: 10.1177/000348941312200204] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We sought to delineate the role of cochlear implantation in the management of vestibular schwannoma or other cerebellopontine angle tumors in the only hearing ear. Methods: We performed a retrospective analysis in a quaternary referral skull base center of all patients who were affected by vestibular schwannoma (or other lesions of the cerebellopontine angle) in the only hearing ear and received a cochlear implant before or after tumor treatment (surgery or radiotherapy) or during the wait-and-scan follow-up. We also performed a systematic review of the English-language literature. Results: The clinical and audiological results of 10 patients are reported. All patients were managed with contralateral cochlear implantation. In 7 patients, cochlear implantation was performed before tumor removal, while hearing in the ear with the tumor was still present. In 3 patients, the implant was placed after curative surgery. Nine of the 10 patients routinely use their implant with subjective benefit and fairly good auditory performance (median disyllabic word recognition, 90%; median sentence comprehension, 75%). The literature search retrieved no major series with assessment of the long-term efficacy of cochlear implantation in this rare clinical scenario. Conclusions: Patients affected by vestibular schwannoma in their only hearing ear may significantly benefit from a cochlear implant on the contralateral side prior to tumor removal. Recent and significant hearing deterioration and tumor growth represent the main indications for cochlear implantation.
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Thakur JD, Banerjee AD, Khan IS, Sonig A, Shorter CD, Gardner GL, Nanda A, Guthikonda B. An update on unilateral sporadic small vestibular schwannoma. Neurosurg Focus 2013; 33:E1. [PMID: 22937843 DOI: 10.3171/2012.6.focus12144] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Advances in neuroimaging have increased the detection rate of small vestibular schwannomas (VSs, maximum diameter < 25 mm). Current management modalities include observation with serial imaging, stereotactic radiosurgery, and microsurgical resection. Selecting one approach over another invites speculation, and no standard management consensus has been established. Moreover, there is a distinct clinical heterogeneity among patients harboring small VSs, making standardization of management difficult. The aim of this article is to guide treating physicians toward the most plausible therapeutic option based on etiopathogenesis and the highest level of existing evidence specific to the different cohorts of hypothetical case scenarios. Hypothetical cases were created to represent 5 commonly encountered scenarios involving patients with sporadic unilateral small VSs, and the literature was reviewed with a focus on small VS. The authors extrapolated from the data to the hypothetical case scenarios, and based on the level of evidence, they discuss the most suitable patient-specific treatment strategies. They conclude that observation and imaging, stereotactic radiosurgery, and microsurgery are all important components of the management strategy. Each has unique advantages and disadvantages best suited to certain clinical scenarios. The treatment of small VS should always be tailored to the clinical, personal, and social requirements of an individual patient, and a rigid treatment protocol is not practical.
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Affiliation(s)
- Jai Deep Thakur
- Department of Neurosurgery, Louisiana State University Health Sciences Center–Shreveport, Louisiana 71103, USA
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Yomo S, Carron R, Thomassin JM, Roche PH, Régis J. Longitudinal analysis of hearing before and after radiosurgery for vestibular schwannoma. J Neurosurg 2012; 117:877-85. [PMID: 22937934 DOI: 10.3171/2012.7.jns10672] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to perform an accurate analysis of changes in hearing in patients with vestibular schwannoma (VS) who have undergone Gamma Knife surgery (GKS) and distinguish the impact of radiosurgery from the natural course of hearing deterioration due to the tumor itself. METHODS This study was a retrospective review of prospectively collected patient data. A group of 154 patients with unilateral nonsurgically treated VS was conservatively monitored for more than 6 months and then treated with GKS between July 1997 and September 2005. They were followed up with serial clinical examination, MRI, and audiometry. The annual hearing decrease rate (AHDR) was measured before and after radiosurgery, and the possible prognostic factors for hearing preservation were investigated. RESULTS The mean dose prescribed to the tumor margins was 12.1 Gy. The mean radiological follow-up period after GKS was 60 months (range 7-123 months). The tumor control rate was 94.8%, and 8 patients underwent subsequent intervention due to tumor progression. The mean audiological follow-up times before and after GKS were 22 and 52 months, respectively. The mean AHDRs before and after GKS were 5.39 dB/year (95% CI 3.31-7.47 dB/year) and 3.77 dB/year (95% CI 3.13-4.40 dB/year), respectively (p > 0.05). The mean pre- and post-GKS AHDRs in patients who initially had Gardner-Robertson (GR) Class I hearing were -0.57 dB/year (95% CI -2.95 to 1.81 dB/year) and 3.59 dB/year (95% CI 2.52-4.65 dB/year), respectively (p = 0.007). The mean pre- and post-GKS AHDRs in patients who initially had GR Class II hearing were 5.09 dB/year (95% CI 1.36-8.82 dB/year) and 4.98 dB/year (95% CI 3.86-6.10 dB/year), respectively (p > 0.05). A subgroup of 80 patients had both early and late post-intervention AHDR assessment (with early referring to the period from GKS to the assessment closest to the 2-year follow-up point and late referring to the period from that assessment to the most recent one); in these patients, the mean early post-GKS AHDR was 5.86 dB/year (95% CI 4.25-7.50 dB/year) and the mean late post-GKS AHDR was 1.86 dB/year (95% CI 0.77-2.96 dB/year) (p < 0.001). A maximum cochlear dose of less than 4 Gy was found to be the sole prognostic factor for hearing preservation. CONCLUSIONS The present study demonstrated the absence of an increase in AHDR after radiosurgery as compared with the preoperative AHDR. There was even a trend indicating a reduction in the annual hearing loss after radiosurgery over the long term. To fully elucidate a possible protective effect of radiosurgery, longer-term follow-up with a larger group of patients will be required.
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Affiliation(s)
- Shoji Yomo
- Department of Functional Neurosurgery, CHU Timone, APHM, Marseille, France
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Outcome on hearing and facial nerve function in microsurgical treatment of small vestibular schwannoma via the middle cranial fossa approach. Eur Arch Otorhinolaryngol 2012; 270:1209-16. [DOI: 10.1007/s00405-012-2074-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Accepted: 05/31/2012] [Indexed: 11/25/2022]
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Walz PC, Bush ML, Robinett Z, Kirsch CFE, Welling DB. Three-Dimensional Segmented Volumetric Analysis of Sporadic Vestibular Schwannomas. Otolaryngol Head Neck Surg 2012; 147:737-43. [DOI: 10.1177/0194599812447766] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To compare 3-D segmented volumetric analysis of vestibular schwannomas (VS) with traditional linear tumor measurement on serial magnetic resonance imaging (MRI) studies to assess volume and growth rates. Study Design Case series with retrospective chart review. Setting Tertiary care medical center. Methods This analysis identified 24 VS patients clinically followed with serial gadolinium enhanced images. Maximum linear dimensions (MLD) were obtained from gadolinium-contrasted T1 sequences from 3 serial MRI scans per RECIST guidelines. MLD was cubed (MLD3) and orthogonal analysis (OA) was carried out to provide volumetric estimates for comparison with segmented data. Segmented volumetric analysis (SVA) was performed with semi-automated 3-D conformal procedure. Tumor volume, percentage change in volume, and interval percentage change were compared using paired 2-tailed t tests. Results The average interval between MRIs was 2.6 years. Volume estimates differed significantly between SVA and OA and MLD3 at all intervals. Linear growth measurements averaged 0.5 mm/y (5.4%). Volumetric growth was 50 mm3/y (22.8%) with SVA, 110 mm3/y (19.6%) with OA, and 210 mm3/y (14.4%) with MLD3 estimates. Differences between MLD and both MLD3 and SVA were significant, but significance between MLD3 and SVA was only identified in interval analysis. Progression was identified in 75% more patients with SVA than OA, MLD3, or MLD. Conclusions VS assume complex configurations. Linear measurements inaccurately estimate tumor volume and growth compared with segmented analysis. SVA is a useful clinical tool that accurately assesses tumor volume. Use of outcomes such as tumor volume and percentage of volume change may be more sensitive in assessing tumor progression compared with linear measurements.
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Affiliation(s)
- Patrick C. Walz
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Matthew L. Bush
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology Head and Neck Surgery; Dr Bush recently relocated to the University of Kentucky, Lexington, Kentucky, USA
| | - Zachary Robinett
- School of Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - D. Bradley Welling
- Department of Otolaryngology–Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
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Breivik CN, Varughese JK, Wentzel-Larsen T, Vassbotn F, Lund-Johansen M. Conservative Management of Vestibular Schwannoma—A Prospective Cohort Study: Treatment, Symptoms, and Quality of Life. Neurosurgery 2011; 70:1072-80; discussion 1080. [DOI: 10.1227/neu.0b013e31823f5afa] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
One hundred ninety-three patients with sporadic unilateral vestibular schwannoma given conservative management were enrolled in a prospective study.
OBJECTIVE:
To evaluate the efficacy of conservative management and to determine the effect of an initial conservative management on the quality of life (QOL) and severity of audio vestibular symptoms.
METHODS:
The patients underwent magnetic resonance imaging scans, clinical examination, and QOL assessment by 2 validated questionnaires, the Short Form-36 (SF-36) and Glasgow Benefit Inventory (GBI). Using regression analysis of clustered data, we analyzed possible associations between tumor growth and symptoms and tested whether our earlier finding that vertigo is associated with reduced QOL could be verified.
RESULTS:
The median follow-up time was 43 months (range, 9–115 months; SD, 21.48 months). Results are based on 703 clinical controls and 642 (SF-36) and 638 (GBI) questionnaires. Seven patients were lost to follow-up. Approximately 40% of patients were in need of treatment during follow-up. We found a statistically significant association between tinnitus and vertigo and tumor growth. Vertigo was found to significantly reduce QOL. There was a significant drop in the Social Function subscales of both SF-36 and GBI, possibly attributable to progressive hearing loss. Otherwise, there was no overall trend toward any change in QOL during the observation period. In addition, QOL seemed to be little affected by treatment.
CONCLUSION:
There was a small but statistically significant improvement in vestibular complaints and no change in the occurrence of tinnitus. Except for hearing loss caused by surgery, treatment did not affect symptoms or QOL significantly. Growth was associated with the occurrence of tinnitus and balance problems.
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Affiliation(s)
| | | | | | - Flemming Vassbotn
- Institute of Surgical Science, University of Bergen, Bergen, Norway
- Department of ENT, Haukeland University Hospital, Bergen Norway
| | - Morten Lund-Johansen
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Institute of Surgical Science, University of Bergen, Bergen, Norway
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Quaranta N, Baguley DM, Moffat DA. Change in hearing and tinnitus in conservatively managed vestibular schwannomas. Skull Base 2011; 17:223-8. [PMID: 18174921 DOI: 10.1055/s-2007-984491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the change of hearing and tinnitus in a group of conservatively managed unilateral vestibular schwannomas (VS). DESIGN Retrospective case series review. SETTING Tertiary referral otoneurological and skull base surgery department. PARTICIPANTS Seventy patients affected by unilateral VS with at least two audiograms available were retrospectively evaluated. MAIN OUTCOME MEASURES Changes in pure tone average (PTA), speech discrimination score (SDS), and tinnitus were analyzed. RESULTS At diagnosis 16 patients (22.9%) had a PTA of 0 to 30 dB and 38 (54.4%) a PTA of 0 to 50 dB. At the end of the follow-up period, 9 patients (12.9%) had a PTA of 0 to 30 dB and 27 (38.7%) had a PTA of 0 to 50 dB, representing a hearing preservation rate of 56% and 70%, respectively. Of patients with both tonal and speech audiometry, 71.4% with class A hearing (PTA < 30 dB/SDS > 70%) maintained their initial hearing and 60% with class A or B hearing (PTA < 50 dB/SDS > 50%) maintained this useful hearing. Forty-two patients (60%) did not show a significant growth in their tumor over the period of observation. In this group of patients the mean PTA after a mean follow-up time of 40 months decreased from 44 dB HL to 50.8 dB HL, with a yearly rate of 2.47 dB HL. The chance of maintaining a PTA of 0 to 30 dB in this group of patients was 57.1% and a PTA of 0 to 50 dB was 81.4%. CONCLUSIONS In this group of patients affected by VS and managed conservatively with a mean follow-up of 33.3 months, the risk of losing eligibility for hearing preservation surgery was lower than 30%.
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Affiliation(s)
- Nicola Quaranta
- Otolaryngology Clinic "G. Lugli," Department of Ophthalmology and Otolaryngology, University of Bari, Bari, Italy
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Humphriss RL, Baguley DM, Axon PR, Moffat DA. Preoperative audiovestibular handicap in patients with vestibular schwannoma. Skull Base 2011; 16:193-9. [PMID: 17471318 PMCID: PMC1766462 DOI: 10.1055/s-2006-950388] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate preoperative hearing, dizziness, and tinnitus handicap in patients with unilateral vestibular schwannoma (VS). DESIGN Prospective administration of the Hearing Handicap Inventory (HHI), Dizziness Handicap Inventory (DHI), and Tinnitus Handicap Inventory (THI), prior to surgical intervention. SETTING A tertiary referral neuro-otology clinic. PARTICIPANTS A total of 145 consecutive patients who were admitted for excision of their vestibular schwannomas between May 1998 and July 2002. MAIN OUTCOME MEASURES HHI, THI, and DHI scores. RESULTS HHI, THI, and DHI scores were all found to be significantly correlated. There was no significant association between tumor size and any of the questionnaire scores. When data were categorized to give a measure of handicap severity, 68% had mild to significant hearing handicap, 30% had mild to severe tinnitus handicap, and 75% had mild to severe dizziness handicap. Eighty-eight percent of patients had some handicap in at least one domain, and 23% had some handicap in all three domains. Seven percent of patients had severe or significant handicap in all three domains. CONCLUSIONS A considerable proportion of patients with unilateral VS have hearing, tinnitus, and dizziness handicap. These patients should optimally be offered appropriate rehabilitation, something that is especially important as conservative management by "watch, wait, and rescan" becomes more common.
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Affiliation(s)
- Rachel L. Humphriss
- Department of Audiology, Addenbrooke's National Health Service (NHS) Trust, Cambridge, United Kingdom
| | - David M. Baguley
- Department of Audiology, Addenbrooke's National Health Service (NHS) Trust, Cambridge, United Kingdom
| | - Patrick R. Axon
- Department of Otolaryngology, Addenbrooke's National Health Service (NHS) Trust, Cambridge, United Kingdom
| | - David A. Moffat
- Department of Otolaryngology, Addenbrooke's National Health Service (NHS) Trust, Cambridge, United Kingdom
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Predictors of volumetric growth and auditory deterioration in vestibular schwannomas followed in a wait and scan policy. Otol Neurotol 2011; 32:338-44. [PMID: 21150682 DOI: 10.1097/mao.0b013e3182040d9f] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to identify factors predicting growth and audiologic deterioration during follow-up (FU) in a wait and scan (W&S) policy of vestibular schwannomas (VSs) using a novel volumetric measuring tool. So far, only consecutive magnetic resonance imaging (MRI) is able to show growth objectively, and growth, combined with hearing function, generally dictates further intervention. Other factors predicting growth or hearing deterioration would be invaluable and might ease clinical decision making. STUDY DESIGN Retrospective case study. SETTING Tertiary referral center. PATIENTS Sixty-three patients diagnosed with VS at Maastricht University Medical Center between 2003 and 2008, with FU data available from 36 patients. INTERVENTION(S) A W&S policy for unilateral VS with sequential contrast-enhanced T1- and T2-weighted MRI and audiograms during FU. MAIN OUTCOME MEASURE(S) 1. Patient and radiologic VS features potentially related to growth and auditory function during a W&S policy. 2. The correlation between increase in VS volume and audiologic deterioration during FU. RESULTS Labyrinthine hypointensity on T2-weighted magnetic resonance images and complaints of hearing loss at presentation are predictive of a faster deterioration of hearing (p < 0.05). Growth during the first FU year predicts further growth. Vestibular schwannoma volume does not correlate with audiologic deterioration significantly. CONCLUSION Hypointensity on T2-weighted image of the affected labyrinth will result in a significant faster deterioration of hearing. Hearing loss was more profound, and hearing will deteriorate significantly faster in patients presenting with complaints of hearing loss. Significant growth during the first year of FU predicts further growth during FU. Sequential MRI cannot be substituted by audiologic examinations solely because increase in VS volume does not correlate with audiologic deterioration significantly.
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Whitmore RG, Urban C, Church E, Ruckenstein M, Stein SC, Lee JYK. Decision analysis of treatment options for vestibular schwannoma. J Neurosurg 2011; 114:400-13. [DOI: 10.3171/2010.3.jns091802] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Widespread use of MR imaging has contributed to the more frequent diagnosis of vestibular schwannomas (VSs). These tumors represent 10% of primary adult intracranial neoplasms, and if they are symptomatic, they usually present with hearing loss and tinnitus. Currently, there are 3 treatment options for quality of life (QOL): wait and scan, microsurgery, and radiosurgery. In this paper, the authors' purpose is to determine which treatment modality yields the highest QOL at 5- and 10-year follow-up, considering the likelihood of recurrence and various complications.
Methods
The MEDLINE, Embase, and Cochrane online databases were searched for English-language articles published between 1990 and June 2008, containing key words relating to VS. Data were pooled to calculate the prevalence of treatment complications, tumor recurrence, and QOL with various complications. For parameters in which incidence varied with time of follow-up, the authors used meta-regression to determine the mean prevalence rates at a specified length of follow-up. A decision-analytical model was constructed to compare 5- and 10-year outcomes for a patient with a unilateral tumor and partially intact hearing. The 3 treatment options, wait and scan, microsurgery, and radiosurgery, were compared.
Results
After screening more than 2500 abstracts, the authors ultimately included 113 articles in this analysis. Recurrence, complication rates, and onset of complication varied with the treatment chosen. The relative QOL at the 5-year follow-up was 0.898 of normal for wait and scan, 0.953 for microsurgery, and 0.97 for radiosurgery. These differences are significant (p < 0.0052). Data were too scarce at the 10-year follow-up to calculate significant differences between the microsurgery and radiosurgery strategies.
Conclusions
At 5 years, patients treated with radiosurgery have an overall better QOL than those treated with either microsurgery or those investigated further with serial imaging. The authors found that the complications associated with wait-and-scan and microsurgery treatment strategies negatively impacted patient lives more than the complications from radiosurgery. One limitation of this study is that the 10-year follow-up data were too limited to analyze, and more studies are needed to determine if the authors' results are still consistent at 10 years.
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Affiliation(s)
| | | | | | - Michael Ruckenstein
- 2Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Kapoor S, Batra S, Carson K, Shuck J, Kharkar S, Gandhi R, Jackson J, Wemmer J, Terezakis S, Shokek O, Kleinberg L, Rigamonti D. Long-term outcomes of vestibular schwannomas treated with fractionated stereotactic radiotherapy: an institutional experience. Int J Radiat Oncol Biol Phys 2010; 81:647-53. [PMID: 20884130 DOI: 10.1016/j.ijrobp.2010.06.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 04/20/2010] [Accepted: 06/07/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE We assessed clinical outcome and long-term tumor control after fractionated stereotactic radiotherapy (FSRT) for unilateral schwannoma. METHODS AND MATERIALS Between 1995 and 2007, 496 patients were treated with fractionated stereotactic radiotherapy at Johns Hopkins Hospital (Baltimore, MD); 385 patients had radiologic follow-up that met the inclusion criteria. The primary endpoint was treatment failure. Secondary endpoints were radiologic progression and clinical outcome. Logistic regression analysis assessed the association of age, race, tumor side, sex, and pretreatment symptoms. RESULTS In 11 patients (3%) treatment failed, and they required salvage (microsurgical) treatment. Radiologic progression was observed in 116 patients (30.0%), including 35 patients (9%) in whom the treatment volume more than doubled during the follow-up period, although none required surgical resection. Tumors with baseline volumes of less than 1 cm(3) were 18.02 times more likely to progress than those with tumor volumes of 1 cm(3) or greater (odds ratio, 18.02; 95% confidence interval, 4.25-76.32). Treatment-induced neurologic morbidity included 8 patients (1.6%) with new facial weakness, 12 patients (2.8%) with new trigeminal paresthesias, 4 patients (0.9%) with hydrocephalus (1 communicating and 3 obstructive), and 2 patients (0.5%) with possibly radiation-induced neoplasia. CONCLUSIONS Although the rate of treatment failure is low (3%), careful follow-up shows that radiologic progression occurs frequently. When reporting outcome, the "no salvage surgery needed" and "no additional treatment needed" criteria for treatment success need to be complemented by the radiologic data.
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Affiliation(s)
- Sumit Kapoor
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
AIM To undertake a systematic review of the literature on acoustic neuroma growth. Predictors of growth were also explored. MATERIALS AND METHODS A comprehensive search was conducted to identify the relevant literature. The search yielded 2,455 papers. All titles were reviewed by 2 of the authors, and finally, 41 papers were found reporting data pertinent to growth. RESULTS The percentage of acoustic neuromas exhibiting growth ranges widely from 18 to 73%. The percentage of tumors reported not to grow for some years after diagnosis ranges from 9 to 75%. Some (usually less than 10%, but up to 22%) may get smaller. No reliable predictors of growth have been identified. The mean growth rate for all tumors varies between 1 and 2 mm/yr, and for only those that grow, between 2 and 4 mm/yr. However, there are cases with significant regression or exceptional growth (exceeding 18 mm/yr). There are various patterns of growth, and a tumor that shows growth may stop doing so and vice versa. Finally, some tumors that have been stable for many years can exhibit tumor growth. CONCLUSION The growth pattern of acoustic neuromas is variable and incompletely understood. As much as 75% of tumors have been reported to show no growth, supporting a "wait and rescan" policy in many patients, although there are no reliable predictors of tumor behavior, and some tumors may grow rapidly. Primary longitudinal studies are needed to better define the natural history and limit unnecessary interventions.
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von Eckardstein KL, Beatty CW, Driscoll CLW, Link MJ. Spontaneous regression of vestibular schwannomas after resection of contralateral tumor in neurofibromatosis Type 2. J Neurosurg 2010; 112:158-62. [DOI: 10.3171/2009.5.jns09240] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report on 2 patients with bilateral vestibular schwannomas (VSs) who underwent unilateral surgical tumor removal. One patient was followed up for 4 years, the other for 9; in both cases, the contralateral VS regressed markedly without any additional treatment during the follow-up period. Serial MR imaging was performed to monitor the untreated tumor, which in both cases involved the only hearing ear. The tumors were assessed volumetrically. The contralateral tumors appeared to enlarge mildly at initial follow-up and then, with no treatment, regressed (to 23% of the original maximum volume in Case 1 and to 15% of the original maximum in Case 2). The largest posterior fossa diameter decreased from 30.1 mm to 18.6 mm in Case 1 over 4 years and from 27 mm to 16 mm over 8 years in Case 2. Hearing declined only mildly during follow-up in both patients.These cases demonstrate the first well-documented, long-term, spontaneous VS regressions in patients with neurofibromatosis Type 2. They underline the importance of careful observation of VS involving the only hearing ear in the management of bilateral VS to determine the natural growth pattern of the tumors. The mechanism of the dramatic spontaneous tumor regression is uncertain.
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Affiliation(s)
| | | | - Colin L. W. Driscoll
- 1Departments of Neurologic Surgery and
- 2Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - Michael J. Link
- 1Departments of Neurologic Surgery and
- 2Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
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Ipsilateral and Contralateral Acoustic Brainstem Response Abnormalities in Patients With Vestibular Schwannoma. Otolaryngol Head Neck Surg 2009; 141:695-700. [DOI: 10.1016/j.otohns.2009.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Revised: 09/16/2009] [Accepted: 09/21/2009] [Indexed: 11/18/2022]
Abstract
OBJECTIVE: To analyze auditory brainstem response (ABR) data in patients with vestibular schwannomas (VS) in an effort to identify correlations between abnormal ABR parameters and tumor size. STUDY DESIGN: Cross-sectional study with chart review. SETTING: Tertiary referral hospital. SUBJECTS AND METHODS: Retrospective chart review and analysis of bilateral ABR records in patients with VS. Interaural latency differences of interpeak I-V (ILD-I-V) and ILD-V longer than 0.2 ms were used as abnormal criteria. RESULTS: Thirty patients with a mean age of 50 ± 14 years were included in this study. The most frequent changes in ABR parameters included those of ILD-I-V (100%), wave V latency (96.7%), ILD-V (93.3%), and interpeak I-V latency (90%). Average VS tumor size was 2.48 ± 1.31 cm. For patients with VS greater than or equal to 2 cm, the prevalences of abnormal ipsilateral interpeak III-V latency, contralateral wave V latency, and interpeak III-V latency showed statically significant differences ( P = 0.0035, P = 0.0267, and P = 0.0273, respectively) compared to those in patients with VS less than 2 cm. Tumor size was positively correlated with pure-tone average ( P = 0.0106) and with the total number of bilateral abnormal ABR parameters ( P = 0.004). CONCLUSIONS: We identified a correlation between ABR parameters and VS tumor size. An ipsilateral ILD-I-V greater than 0.2 ms was sensitive for detecting VS. Abnormal contralateral wave V and interpeak III-V latency indicated a tumor size potentially larger than 2 cm. Further studies are needed to confirm these findings.
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