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Abstract
OBJECTIVE This study aimed to assess the durability of audiological outcomes after radiation and surgery in the management of vestibular schwannoma. STUDY DESIGN Retrospective review. SETTING Tertiary academic center. PATIENTS Adults with sporadic vestibular schwannoma and serviceable hearing at the time of intervention. INTERVENTIONS Gamma Knife, middle cranial fossa, or retrosigmoid approaches. MAIN OUTCOME MEASURES Pure-tone audiometry and speech discrimination scores. RESULTS Postintervention serviceable hearing (class A/B) was preserved in 70.4% (n = 130; mean follow-up, 3.31 yr; range, 0-15.25 yr). Of the 49 patients treated with radiation, 19 (39.6%) had serviceable hearing at last follow-up, compared with 38 (46.9% of 81) who underwent retrosigmoid (n = 36 [44.4%]) and middle cranial fossa (n = 45 [55.6%]) approaches (odds ratio [OR], 1.40; 95% confidence interval [CI], 0.67-2.82; p = 0.47). A matched analysis by age, tumor volume, and preintervention hearing (n = 38) also found no difference in hearing preservation (HP) likelihood between surgery and radiation (OR, 2.33; 95% CI, 0.24-35.91; p = 0.59). After initial HP, 4 (9.5%) surgical versus 10 (37.0%) radiated patients subsequently lost residual serviceable (A/B) hearing (OR, 0.18; 95% CI, 0.06-0.69; p = 0.01) at a mean 3.74 ± 3.58 and 4.73 ± 3.83 years after surgery and radiation, respectively. Overall, 5- and 10-year HP rates (A/B) after initially successful HP surgery were 84.4 and 63.0%, respectively. However, survival estimates declined to 48.9% at 5 years and 32.7% at 10 years when patients with immediate postoperative serviceable hearing loss were also included, which were comparable to radiation-HP rates at 5 and 10 years of 28.0 and 14.2%, respectively ( p = 0.75). CONCLUSIONS After vestibular schwannoma intervention, overall HP was similar between radiated and surgical cohorts. However, when successful, surgical approaches offered more durable hearing outcomes at long-term follow-up.
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Ismail O, Sobhy O, Assal S, Sanghera P, Begg P, Irving R. Comparing Hearing Outcomes in Irradiated and Conservatively Managed Vestibular Schwannoma. Otol Neurotol 2022; 43:e374-e381. [PMID: 35061638 DOI: 10.1097/mao.0000000000003457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Compare hearing outcome for vestibular schwannoma patients following stereotactic radiosurgery (SRS) or conservative management. STUDY DESIGN Retrospective review. SETTING University Hospital. PATIENTS Patients with small- or medium-sized sporadic vestibular schwannoma (intracanalicular or with CPA component <2 cm) who were managed conservatively or underwent SRS with available clinical, radiological, and audiometric data from the time of presentation (or just before radiotherapy for the SRS group) and most recent follow-up; with the two sets of data to be compared being at least 3 years apart (minimum follow-up period). INTERVENTIONS SRS or observation. MAIN OUTCOME MEASURE Pure-tone averages, speech discrimination scores, and corresponding hearing classifications. RESULTS Two hundred forty-seven patients met our inclusion criteria; 140 were managed conservatively with a mean follow-up period of 5.9 ± 1.6 years and 107 underwent SRS with a mean follow-up period of 7.1 ± 1.9 years. There was significant deterioration of hearing measures for both groups; with the SRS group displaying consistently worse measures. SRS patients showed worse mean pure-tone averages and speech discrimination scores decline rates by 2.72 dB/yr and 2.98 %/yr, respectively, when compared with conservatively managed patients. Stratifying patients according to Tokyo's hearing classification revealed that 68.75% of conservatively managed patients who had baseline serviceable hearing preserved their hearing throughout the studied period compared with only 15.38% of the SRS patients. CONCLUSION Based on our data we conclude that patients with small- and medium-sized tumors will have a better hearing outcome if managed via an initial conservative approach with radiotherapy reserved for those demonstrating disease progression.
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Affiliation(s)
- Omneya Ismail
- Otolaryngology Department-Head and Neck Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Otolaryngology Department-Audiovestibular Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ossama Sobhy
- Otolaryngology Department-Audiovestibular Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Samir Assal
- Otolaryngology Department-Audiovestibular Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Paul Sanghera
- Clinical Oncology Department, Queen Elizabeth Hospital Birmingham
| | - Philip Begg
- Otolaryngology Department-Head and Neck Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- The Royal Orthopaedic Hospital NHS Foundation Trust
- College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Richard Irving
- Otolaryngology Department-Head and Neck Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Baker S, Logie N, Paulson K, Duimering A, Murtha A. Radiotherapy for Brain Tumors: Current Practice and Future Directions. CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666181129105542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Radiotherapy is an important component of the treatment for primary and metastatic
brain tumors. Due to the close proximity of critical structures and normal brain parenchyma, Central
Nervous System (CNS) radiotherapy is associated with adverse effects such as neurocognitive
deficits, which must be weighed against the benefit of improved tumor control. Advanced radiotherapy
technology may help to mitigate toxicity risks, although there is a paucity of high-level
evidence to support its use. Recent advances have been made in the treatment for gliomas, meningiomas,
benign tumors, and metastases, although outcomes remain poor for many high grade
tumors. This review highlights recent developments in CNS radiotherapy, discusses common
treatment toxicities, critically reviews advanced radiotherapy technologies, and highlights promising
treatment strategies to improve clinical outcomes in the future.
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Affiliation(s)
- Sarah Baker
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Natalie Logie
- University of Florida Proton Therapy Institute, Jacksonville, FL, United States
| | - Kim Paulson
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Adele Duimering
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Albert Murtha
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
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Factors Associated With Facial Nerve Paresis Following Gamma Knife for Vestibular Schwannoma. Otol Neurotol 2020; 41:e83-e88. [DOI: 10.1097/mao.0000000000002401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To determine the long-term hearing preservation rate for spontaneous vestibular schwannoma treated by primary radiotherapy. DATA SOURCES The MEDLINE/PubMed, Web of Science, Cochrane Reviews, and EMBASE databases were searched using a comprehensive Boolean keyword search developed in conjunction with a scientific librarian. English language papers published from 2000 to 2016 were evaluated. STUDY SELECTION Inclusion criteria: full articles, pretreatment and posttreatment audiograms or audiogram based scoring system, vestibular schwannoma only tumor type, reported time to follow-up, published after 1999, use of either Gamma Knife or linear accelerator radiotherapy. EXCLUSION CRITERIA case report or series with fewer than five cases, inadequate audiometric data, inadequate time to follow-up, neurofibromatosis type 2 exceeding 10% of study population, previous treatment exceeding 10% of study population, repeat datasets, use of proton beam therapy, and non-English language. DATA EXTRACTION Two reviewers independently analyzed papers for inclusion. Class A/B, 1/2 hearing was defined as either pure tone average less than or equal to 50 db with speech discrimination score more than or equal to 50%, American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) Hearing Class A or B, or Gardner-Robertson Grade I or II. Aggregate data were used when individual data were not specified. DATA SYNTHESIS Means were compared with student t test. CONCLUSIONS Forty seven articles containing a total of 2,195 patients with preserved Class A/B, 1/2 hearing were identified for analysis. The aggregate crude hearing preservation rate was 58% at an average reporting time of 46.6 months after radiotherapy treatment. Analysis of time-based reporting shows a clear trend of decreased hearing preservation extending to 10-year follow-up. This data encourages a future long-term controlled trial.
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Audiological Outcomes in Growing Vestibular Schwannomas Managed Either Conservatively, or With Stereotactic Radiosurgery. Otol Neurotol 2019; 39:e143-e150. [PMID: 29315190 DOI: 10.1097/mao.0000000000001677] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Recent studies have suggested good hearing preservation following stereotactic radiosurgery (STRS) in patients with vestibular schwannomas (VS). This study aims to assess audiological outcomes in patients with growing VS treated either with STRS, or managed conservatively. STUDY DESIGN Retrospective cohort study. SETTING Tertiary referral center. PATIENTS Out of 540 patients with VS, 69 patients with growing VS fulfilled the inclusion criteria; 24 treated conservatively and 45 with STRS. VS were considered growing if demonstrating more than 15% tumor volume increase during 1 year of watchful waiting. INTERVENTION American Association of Otolaryngology-Head and Neck Surgery (AAOHNS) hearing threshold (dB averaged over 500-3000 Hz) deterioration and Gardner-Robertson class deterioration over time were used as the primary outcome measures. Rate of progression to loss of functional hearing (Gardner-Robertson class I-II) was also determined between cohorts. RESULTS Mean follow-up was similar between treatment cohorts (STRS = 69.6 mo, conservative management = 71.7 mo). There was no significant difference in AAOHNS deterioration (t = 1.05, df = 53, p = 0.301) or Gardner-Robertson deterioration (χ = 0.47, df = 1, p = 0.492) between cohorts. Furthermore, rate of progression to loss of functional hearing was similar between cohorts (Hazard ratio = 0.704, 95% CI 0.287-1.728, p = 0.44). In STRS patients, AAOHNS deterioration was greater in those with lower AAOHNS thresholds at diagnosis (t = -2.683, df = 28, p = 0.0121). Similarly, Gardner-Robertson deterioration was significantly more likely in STRS patients with functional hearing (Gardner-Robertson class I-II) (Adjusted odds ratio = 32.14, 95% CI 3.15-328, p = 0.0034). CONCLUSIONS STRS results in similar audiological outcomes compared with patients managed conservatively; Consequently, STRS given to patients with VS to preserve hearing is not justified. In contrast to recent studies, patients with preserved hearing at diagnosis have significantly greater audiological deterioration when undergoing STRS.
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Twelve-year results of LINAC-based radiosurgery for vestibular schwannomas. Strahlenther Onkol 2019; 196:40-47. [DOI: 10.1007/s00066-019-01498-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
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Ros-Sanjuán Á, Iglesias-Moroño S, Troya-Castilla M, Márquez-Márquez B, Herruzo-Cabrera I, Arráez-Sánchez MÁ. LINAC radiosurgery treatment for vestibular schwannoma. Neurocirugia (Astur) 2019; 30:179-187. [PMID: 30770322 DOI: 10.1016/j.neucir.2018.12.005] [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: 11/18/2018] [Revised: 12/15/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aims of our study were to evaluate tumour response in a series of patients with vestibular schwannoma (VS) treated with linear accelerator stereotactic radiosurgery (LINAC-RS), to describe the complications and to analyze the variables associated with the response to treatment. MATERIAL AND METHODS This retrospective descriptive study included 64 patients treated from 2010 to 2016 with a minimum follow-up of one year, excluding patients with neurofibromatosis. Clinical-radiological parameters were evaluated. The treatment was performed using LINAC-RS. The prescribed dose was 12Gy at 90% isodose. RESULTS The mean age at treatment was 53 years, 56% were women. Ninety-eight percent of the patients had hearing loss, 71% with grade III according to the Gardner-Robertson Classification. The mean volume at treatment was 2.92cc and the mean follow-up, 40.95 months. The overall therapeutic success was 90%, reaching 100% at 12 and 24 months, and 86% after 36 months of follow-up. The radiological result was significantly related to the initial tumour volume (p<0.037). In 20 patients there was evidence of transient tumour growth compatible with pseudoprogression. Acute complications were present in 37.5%, and transitory complications in 50%. Chronic complications were found in 20%, with 84% being permanent. The rate of acute complications was lower in patients with regression (p<0.016). Chronic complications were more frequent in the 41-60 year old age group (p<0.040). CONCLUSIONS In our study, the overall tumour control was in accordance with other published series. The radiological result significantly related to the tumour volume at the commencement of treatment. The rate of acute complications was lower in patients with regression.
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Affiliation(s)
- Ángela Ros-Sanjuán
- Department of Neurosurgery, Regional University Hospital of Malaga, Malaga, Spain.
| | - Sara Iglesias-Moroño
- Department of Neurosurgery, Regional University Hospital of Malaga, Malaga, Spain
| | - Marta Troya-Castilla
- Department of Neurosurgery, Regional University Hospital of Malaga, Malaga, Spain
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Mahboubi H, Sahyouni R, Moshtaghi O, Tadokoro K, Ghavami Y, Ziai K, Lin HW, Djalilian HR. CyberKnife for Treatment of Vestibular Schwannoma: A Meta-analysis. Otolaryngol Head Neck Surg 2017; 157:7-15. [PMID: 28441508 DOI: 10.1177/0194599817695805] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives (1) Perform a meta-analysis of the available data on the outcomes of CyberKnife radiosurgery for treatment of vestibular schwannomas (VSs) in the published English-language literature and (2) evaluate the collective outcomes of CyberKnife treatment with respect to tumor control and hearing preservation. Data Sources A thorough literature search of published English-language articles was performed in the PubMed, Ovid, and Cochrane databases. Review Methods A database search was conducted with the keywords "CyberKnife" and "vestibular schwannoma" or "acoustic neuroma." A total of 25 papers were found and reviewed. Data were extracted for patient demographics, number of patients with neurofibromatosis type 2, pretreatment hearing status, tumor size, margin dose, and follow-up duration. The primary outcome variables evaluated were tumor control and hearing preservation. Results After careful review of the published articles, 11 papers reported data on outcomes of CyberKnife treatment for VS and were included in the analysis, comprising 800 patients studied during 1998 to 2012. The reported mean tumor volume ranged from 0.02 to 19.8 cm3, and the follow-up duration ranged from 6 to 120 months. Margin dose varied from 14 to 25 Gy. The collective mean tumor control rate was 96.3% (95% CI: 94.0%-98.5%). The collective hearing preservation rate was 79.1% (95% CI: 71.0%-87.3%) in 427 patients with measurable hearing. Conclusion Clinical data on outcomes of CyberKnife radiosurgery for treatment of VSs are sparse and primarily limited to single-institution analyses, with considerable variation in tumor volume and follow-up time. This meta-analysis not only provides an in-depth analysis of available data in the literature but also reviews reported outcomes and complications.
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Affiliation(s)
- Hossein Mahboubi
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Ronald Sahyouni
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA.,2 Department of Biomedical Engineering, University of California, Irvine, California, USA
| | - Omid Moshtaghi
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Kent Tadokoro
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Yaser Ghavami
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Kasra Ziai
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Harrison W Lin
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Hamid R Djalilian
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA.,2 Department of Biomedical Engineering, University of California, Irvine, California, USA
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Haidar YM, Bhatt JM, Ghavami Y, Moshtaghi O, Schwer A, Chenery S, Djalilian HR. Dosimetric Analysis of Neural and Vascular Structures in Skull Base Tumors Treated with Stereotactic Radiosurgery. Otolaryngol Head Neck Surg 2017; 156:857-862. [PMID: 28195750 DOI: 10.1177/0194599817691452] [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: 12/24/2022]
Abstract
Objective To examine the relationship between the prescribed target dose and the dose to healthy neurovascular structures in patients with vestibular schwannomas treated with stereotactic radiosurgery (SRS). Study Design Case series with chart review. Setting SRS center from 2011 to 2013. Subjects Twenty patients with vestibular schwannomas treated at the center from 2011 to 2013. Methods Twenty patients with vestibular schwannomas were included. The average radiation dose delivered to healthy neurovascular structures (eg, carotid artery, basilar artery, facial nerve, trigeminal nerve, and cochlea) was analyzed. Results Twenty patients with vestibular schwannomas who were treated with fused computed tomography/magnetic resonance imaging-guided SRS were included in the study. The prescribed dose ranged from 10.58 to 17.40 Gy over 1 to 3 hypofractions to cover 95% of the target tumor volume. The mean dose to the carotid artery was 5.66 Gy (95% confidence interval [CI], 4.53-6.80 Gy), anterior inferior cerebellar artery was 8.70 Gy (95% CI, 4.54-12.86 Gy), intratemporal facial nerve was 3.76 Gy (95% CI, 3.04-4.08 Gy), trigeminal nerve was 5.21 Gy (95% CI, 3.31-7.11 Gy), and the cochlea was 8.70 Gy (95% CI, 7.81-9.59 Gy). Conclusions SRS for certain vestibular schwannomas can expose the anterior inferior cerebellar artery (AICA) and carotid artery to radiation doses that can potentially initiate atherosclerotic processes. The higher doses to the AICA and carotid artery correlated with increasing tumor volume. The dose delivered to other structures such as the cochlea and intratemporal facial nerve appears to be lower and much less likely to cause immediate complications when shielded.
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Affiliation(s)
- Yarah M Haidar
- 1 University of California, Irvine Medical Center, Department of Otolaryngology-Head and Neck Surgery, Irvine, California, USA
| | - Jay M Bhatt
- 1 University of California, Irvine Medical Center, Department of Otolaryngology-Head and Neck Surgery, Irvine, California, USA
| | - Yaser Ghavami
- 1 University of California, Irvine Medical Center, Department of Otolaryngology-Head and Neck Surgery, Irvine, California, USA
| | - Omid Moshtaghi
- 1 University of California, Irvine Medical Center, Department of Otolaryngology-Head and Neck Surgery, Irvine, California, USA
| | - Amanda Schwer
- 2 Newport Diagnostic Cyberknife Center, Newport Beach, California, USA
| | - Stafford Chenery
- 2 Newport Diagnostic Cyberknife Center, Newport Beach, California, USA
| | - Hamid R Djalilian
- 1 University of California, Irvine Medical Center, Department of Otolaryngology-Head and Neck Surgery, Irvine, California, USA
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Zygourakis CC, Oh T, Sun MZ, Barani I, Kahn JG, Parsa AT. Surgery is cost-effective treatment for young patients with vestibular schwannomas: decision tree modeling of surgery, radiation, and observation. Neurosurg Focus 2016. [PMID: 26218621 DOI: 10.3171/2014.8.focus14435] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Vestibular schwannomas (VSs) are managed in 3 ways: observation ("wait and scan"); Gamma Knife surgery (GKS); or microsurgery. Whereas there is considerable literature regarding which management approach is superior, there are only a few studies addressing the cost of treating VSs, and there are no cost-utility analyses in the US to date. METHODS In this study, the authors used the University of California at San Francisco medical record and hospital accounting databases to determine total hospital charges and costs for 33 patients who underwent open surgery, 42 patients who had GKS, and 12 patients who were observed between 2010 and 2013. The authors then performed decision-tree analysis to determine which treatment paradigm produces the highest quality-adjusted life years and to calculate the incremental cost-effectiveness ratio, depending on the patient's age at VS diagnosis. RESULTS The average total hospital cost over a 3-year period for surgically treated patients was $80,074 (± $49,678) versus $9737 (± $5522) for patients receiving radiosurgery and $1746 (± $2792) for patients who were observed. When modeling the most debilitating symptoms and worst outcomes of VSs (vertigo and death) at different ages at diagnosis, radiation is dominant to observation at all ages up to 70 years. Surgery is cost-effective when compared with radiation (incremental cost-effectiveness ratio < $150,000) at younger ages at diagnosis (< 45 years old). CONCLUSIONS In this model, surgery is a cost-effective alternative to radiation when VS is diagnosed in patients at < 45 years. For patients ≥ 45 years, radiation is the most cost-effective treatment option.
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Affiliation(s)
| | - Taemin Oh
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | | | - Igor Barani
- Radiation Oncology, University of California at San Francisco
| | - James G Kahn
- Department of Epidemiology and Biostatistics, Philip R Lee Institute for Health Policy Studies, University of California at San Francisco, California; and
| | - Andrew T Parsa
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
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Han JH, Kim DG, Chung HT, Paek SH, Jung HW. Hearing Outcomes After Stereotactic Radiosurgery for Vestibular Schwannomas : Mechanism of Hearing Loss and How to Preserve Hearing. Adv Tech Stand Neurosurg 2016:3-36. [PMID: 26508404 DOI: 10.1007/978-3-319-21359-0_1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The use of stereotactic radiosurgery (SRS) expanded to include the treatment of vestibular schwannomas (VSs) in 1969; since then, efforts to increase tumour control and to reduce cranial neuropathy have continued. Using the currently recommended marginal dose of 12-13 Gy, long-term reported outcomes after SRS include not only excellent tumour control rates of 92-100 % but also outstanding functional preservation of the trigeminal and facial nerves, with values of 92-100 % and 94-100 %, respectively. Nonetheless, hearing preservation remains in the range of 32-81 %. Previous studies have suggested possible prognostic factors of hearing preservation such as the Gardner-Robertson grade, radiation dose to the cochlea, transient volume expansion (TVE) after SRS, length of irradiated cochlear nerve, marginal dose to the tumour, and age. However, we still do not clearly understand why patients lose their hearing after SRS for VS.Relevant to these considerations, one study recently reported that the auditory brainstem response (ABR) wave V latency and waves I and V interval (IL_I-V) correlated well with intracanalicular pressure values and even with hearing level. The demonstration that ABR values, especially wave V latency and IL_I-V, correlate well with intracanalicular pressure suggests that patients with previously elevated intracanalicular pressure might have an increased chance of hearing loss on development of TVE, which has been recognised as a common phenomenon after SRS or stereotactic radiotherapy (SRT) for intracranial schwannomas.In our experience, the ABR IL_I-V increased during the first 12 months after SRS for VSs in patients who lost their serviceable hearing. The effect of increased ABR IL_I-V on hearing outcome also became significant over time, especially at 12 months after SRS, and was more prominent in patients with poor initial pure-tone average (PTA) and/or ABR values. We hypothesise that patients with considerable intracanalicular pressure at the time of SRS are prone to lose their serviceable hearing due to the added intracanalicular pressure induced by TVE, which usually occurs within the first 12 months after SRS for VSs. Using these findings, we suggested a classification system for the prediction of hearing outcomes after SRS for VSs. This classification system could be useful in the proper selection of management modalities for hearing preservation, especially in patients with only hearing ear schwannoma or neurofibromatosis type 2.Advances in diagnostic tools, treatment modalities, and optimisation of radiosurgical dose have improved clinical outcomes, including tumour control and cranial neuropathies, in patients with VSs. However, the preservation of hearing function still falls short of our expectation. A prediction model for hearing preservation after each treatment modality will guide the proper selection of treatment modalities and permit the appropriate timing of active treatment, which will lead to the preservation of hearing function in patients with VSs.
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Affiliation(s)
- Jung Ho Han
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea.
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.
| | - Hyun-Tai Chung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Hee-Won Jung
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
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Ikonomidis C, Pica A, Bloch J, Maire R. Vestibular Schwannoma: The Evolution of Hearing and Tumor Size in Natural Course and after Treatment by LINAC Stereotactic Radiosurgery. Audiol Neurootol 2015; 20:406-15. [PMID: 26571111 DOI: 10.1159/000441119] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 09/17/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To review the natural course of tumor size and hearing during conservative management of 151 patients with unilateral vestibular schwannoma (VS), and to evaluate the same parameters for the part of the group (n = 84) who were treated by LINAC stereotactic radiosurgery (SRS). METHODS In prospectively collected data, patients underwent MRI and complete audiovestibular tests at inclusion, during the conservative management period and after SRS. Hearing was graded according to the Gardner-Robertson (GR) scale and tumor size according to Koos. Statistics were performed using Kaplan-Meier survival analysis and multivariate analyses including linear and logistic regression. Specific insight was given to patients with serviceable hearing. RESULTS During the conservative management period (mean follow-up time: 24 months, range: 6-96), the annual risk of GR class degradation was 6% for GRI and 15% for GR II patients. Hearing loss as an initial symptom was highly predictive of further hearing loss (p = 0.003). Tumor growth reached 25%. For SRS patients, functional hearing preservation was 51% at 1 year and 36% at 3 years. Tumor control was 94 and 91%, respectively. CONCLUSION In VS patients, hearing loss at the time of diagnosis is a predictor of poorer hearing outcome. LINAC SRS is efficient for tumor control. Patients who preserved their pretreatment hearing presented less hearing loss per year after SRS than before treatment, suggesting a protective effect of SRS when cochlear function can be preserved.
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Affiliation(s)
- Christos Ikonomidis
- Departments of Otolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Basura GJ, Budenz C, Arts HA. Vestibular Schwannomas: Surgical and Nonsurgical Management. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0082-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Neurofibromatosis type 2 vestibular schwannoma treatment: a review of the literature, trends, and outcomes. Otol Neurotol 2015; 35:889-94. [PMID: 24675066 DOI: 10.1097/mao.0000000000000272] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Review the useful hearing preservation and tumor control outcomes of microsurgery (MS), stereotactic radiation (SR), conservative management (CM), and chemotherapy (ChT) for Neurofibromatosis type 2 vestibular schwannomas. DATA SOURCES Ovid MEDLINE was used to conduct a thorough search of English-language publications dating from 1948 to February 2013. STUDY SELECTION Patients must have had useful hearing at diagnosis and treated with one of the 4 treatments as their primary therapy. All sporadic vestibular schwannoma cases were excluded. DATA EXTRACTION A total of 19 articles were reviewed. Hearing preservation was defined as unchanged or improved useful hearing. Tumor control was defined as no change in size or tumor regression for SR, CM, and ChT-treated cases, and as no recurrence for MS treated cases. CONCLUSION Microsurgery seems to have the worse overall results, while SR has very good tumor control with poor useful hearing preservation. If a patient qualifies for CM, he is likely to show the most satisfactory results with the least treatment available. A close follow-up on ChT clinical trials and possible side-effects is warranted as preliminary short-term results are quite favorable. Additional long-term studies are required for a better understanding of this disease.
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Abstract
BACKGROUND Vestibular schwannomas (acoustic neuromas) are common benign tumours that arise from the Schwann cells of the vestibular nerve. Management options include observation with neuroradiological follow-up, microsurgical resection and stereotactic radiotherapy. OBJECTIVES To assess the effect of stereotactic radiotherapy compared to observation, microsurgical resection, any other treatment modality, or a combination of two or more of the above approaches for vestibular schwannoma. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials; PubMed; EMBASE; CINAHL; Web of Science; CAB Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the search was 24 July 2014. SELECTION CRITERIA Randomised controlled trials (RCTs) exploring the efficacy of stereotactic radiotherapy compared with observation alone, microsurgical resection or any other possible treatment or combination of treatments in patients with a cerebellopontine angle tumour up to 3 cm in diameter, presumed to be a vestibular schwannoma. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS No studies met the inclusion criteria for this review. AUTHORS' CONCLUSIONS There is no high quality evidence in the literature from RCTs to determine whether stereotactic radiotherapy is better than microsurgical resection or observation alone for patients with a vestibular schwannoma. In the absence of such evidence, the treatment method should be chosen on an individual basis, taking into consideration the patient's preferences, clinician experience and the availability of radiotherapeutic equipment. With the growing availability of radiotherapeutic equipment, randomised controlled trials should be undertaken to evaluate the role of stereotactic radiotherapy in comparison with other treatment options.
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Affiliation(s)
- Dario Muzevic
- Department of Neurosurgery, School ofMedicine, Josip Juraj Strossmayer University of Osijek, Josipa Huttlera 4, Osijek, 31 000, Croatia.
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Lim SHS, Ardern-Holmes S, McCowage G, de Souza P. Systemic therapy in neurofibromatosis type 2. Cancer Treat Rev 2014; 40:857-61. [PMID: 24877986 DOI: 10.1016/j.ctrv.2014.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 05/09/2014] [Indexed: 01/06/2023]
Abstract
The systemic treatment of patients with neurofibromatosis type 2 associated tumours is challenging, as these patients often have prolonged survival but with the inevitable propensity for their disease to cause symptoms, and no effective therapies other than local treatments such as surgery. Understanding the molecular mechanisms driving NF-2 pathogenesis holds promise for the potential use of targeted therapy. Initial studies of agents such as bevacizumab (angiogenesis inhibitor) and lapatinib (epidermal growth factor and ErbB2 inhibitor) have indicated benefit for selected patients. As the biology of NF-2 is dependent on multiple interlinked downstream signalling pathways, targeting multiple pathways may be more effective than single agents. Phase zero trials, adaptive phase II or small multi-arm trials, are likely the way forward in this rare disease. Ideally, well-tolerated targeted therapy would appear to be the most promising approach for patients with NF-2, given the natural history of this disease.
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Affiliation(s)
- Stephanie Hui-Su Lim
- Department of Medical Oncology and Ingham Research Institute, Liverpool, NSW, Australia.
| | - Simone Ardern-Holmes
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia.
| | - Geoffrey McCowage
- Oncology Research Unit, The Children's Hospital at Westmead, Westmead, NSW, Australia.
| | - Paul de Souza
- Department of Medical Oncology and Ingham Research Institute, Liverpool, NSW, Australia; University of Western Sydney, School of Medicine, Molecular Medicine Research Group, NSW, Australia.
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Long-term quality of life and tumour control following gamma knife radiosurgery for vestibular schwannoma. Acta Neurochir (Wien) 2014; 156:389-96. [PMID: 24193890 DOI: 10.1007/s00701-013-1924-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 10/15/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Gamma knife radiosurgery (GKRS) has for the last decades been an established treatment option for patients with small- or medium-sized vestibular schwannomas (VS), although little data is reported on long-term outcome regarding quality of life (QOL) and tumour control in this patient category. The objective of this study was to investigate long-term QOL and tumour control in GKRS-treated VS patients at our institution. METHODS Data was reviewed from a consecutive cohort of 128 patients, 62 men and 66 women, diagnosed with VS and treated with GKRS at Karolinska University Hospital between 1997 and 2003. Patients previously treated for VS, patients from abroad, and patients with neurofibromatosis were excluded from the study. Median age at the time of treatment was 66 years (range 23-89), with a median follow-up time of 104 months (range 11-165) and radiological median follow-up of 86 months (range 5-170). Five patients were lost to follow-up. RESULTS Data on QOL (EQ-5D score) was obtained in 90 % (98/109) of all cases at the end of follow-up, showing low morbidity and a high QOL with median index of 0.91 (max. score 1.0) in these patients. Tumour control was achieved in 92 % (118/128) of patients after a single GKRS treatment. Ten patients had loss of tumour control, either radiologically seen as growth progression, or due to the need for salvage treatment. Neither pre-treatment growth of the vestibular schwannoma, or a large tumour size (Koos grade 3 & 4) was correlated with a higher degree of treatment failure (p = 0.695 and p = 0.647, respectively). There was no difference in tumour control in young (<60 y/o) vs. elderly (≥60 y/o) patients (p = 0.167). CONCLUSION We report a high QOL and low morbidity at long-term follow-up after GKRS treatment in VS patients. Furthermore, a high tumour control rate was achieved independent of tumour size, patient age or pre-treatment evidence of tumour growth.
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Karam SD, Tai A, Strohl A, Steehler MK, Rashid A, Gagnon G, Harter KW, Jay AK, Collins SP, Kim JH, Jean W. Frameless fractionated stereotactic radiosurgery for vestibular schwannomas: a single-institution experience. Front Oncol 2013; 3:121. [PMID: 23730624 PMCID: PMC3656472 DOI: 10.3389/fonc.2013.00121] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 04/30/2013] [Indexed: 11/29/2022] Open
Abstract
Objective: To examine tumor control, hearing preservation, and complication rates after frameless fractionated stereotactic radiosurgery (SRS) in patients with vestibular schwannomas (VS). Methods: Thirty-seven patients treated with fractionated SRS from 2002 to 2011 were retrospectively analyzed. Ninety-five percent were treated with 25 Gy in five fractions, targeting a median tumor volume of 1.03 cc (range 0.14–7.60). Results: With a median follow-up of 4.25 years (range, 15 months–9 years), no tumors required an additional treatment resulting in 100% tumor control rate. Radiographic control rate was 91% in 32 patients at a median follow-up of 3 years. Of the 14 patients with serviceable hearing and with audiograms, the hearing preservation rate was 78% at a median follow-up of 18 months. Twenty-six patients with serviceable hearing pretreatment, were evaluated by a phone survey with a hearing preservation rate of 73% at a 5 year median follow-up. There were two cases that developed both new increased trigeminal parasthesias and facial spasms but there were no cases of facial weakness. Patient had 96% of good to excellent satisfaction rate with the treatment at a median follow-up of 5 years. Conclusion: Frameless fractionated SRS treatment of VS results in good rate of tumor control. Hearing preservation rate and rates of cranial nerve toxicity are comparable to what is reported in the literature. Patients choose this modality because of its non-invasive nature and are generally very satisfied with their long term outcome.
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Affiliation(s)
- Sana D Karam
- Department of Radiation Medicine, MedStar Georgetown University Hospital Washington, DC, USA
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Microsurgery versus stereotactic radiation for small vestibular schwannomas: a meta-analysis of patients with more than 5 years' follow-up. Otol Neurotol 2013; 33:1611-20. [PMID: 22996165 DOI: 10.1097/mao.0b013e31826dbd02] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the long-term outcome of hearing and tumor outcome of small vestibular schwannomas treated with stereotactic radiation and microsurgery. DATA SOURCES A thorough search for English-language publications and "in process" articles dating from 1948 to December 2011 was conducted using Ovid MEDLINE. STUDY SELECTION The principal criteria were patients having had microsurgery or radiation therapy as their sole treatment, with a follow-up of at least 5 years, and a useful hearing level at diagnosis. DATA EXTRACTION Sixteen studies met our criteria. Hearing preservation outcome (worse or preserved) and tumor outcome (failure, control) data, as well as all other significant observations, were collected from the articles. Stereotactic radiation was the only radiation therapy analyzed. DATA SYNTHESIS The Pearson χ test was our primary statistical analysis. CONCLUSION Stereotactic radiation showed significantly better long-term hearing preservation outcome rates than microsurgery (p < 0.001). However, long-term tumor outcome was not significantly different in stereotactic radiation as compared with microsurgery (p = 0.122). Although stereotactic radiation demonstrates a more favorable long-term hearing preservation outcome as compared with microsurgery, additional studies are required to provide the medical field with a better understanding of vestibular schwannoma treatment.
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