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Tosi U, Maayan O, An A, Lavieri MET, Guadix SW, DeRosa AP, Christos PJ, Pannullo S, Stieg PE, Brandmaier A, Knisely JPS, Ramakrishna R. Stereotactic radiosurgery for vestibular schwannomas in neurofibromatosis type 2 patients: a systematic review and meta-analysis. J Neurooncol 2022; 156:431-441. [PMID: 35040021 DOI: 10.1007/s11060-021-03910-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/22/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Neurofibromatosis type 2 (NF2) is characterized by often bilateral vestibular schwannomas (VS) that result in progressive hearing loss and compression of nearby brainstem structures causing cranial nerve palsies. Treatment of these tumors remains challenging, as both surgical removal and expectant management can result in symptom progression. Stereotactic radiosurgery (SRS) has been investigated for the management of NF2-associated VS; however, the role, promises, and pitfalls of this treatment modality remain unclear. METHODS Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Reviews were searched for studies assessing SRS outcome in NF2-associated VS only. Primary endpoints included tumor control, serviceable hearing, presence of tinnitus, and cranial nerve V and VII symptoms. RESULTS A total of 16 studies (589 patients harboring 750 tumors) were analyzed. Clinical tumor control was achieved in 88% of cases (95% CI 80-95%); salvage surgery was needed in 8% (95% CI 4-13%) of cases. Treatment resulted in a worsening of pre-treatment serviceable hearing (OR = 0.26, p < 0.01), increased facial nerve (OR = 1.62, p < 0.01) and trigeminal nerve (OR = 1.42, p = 0.07) impairment. The incidence of vestibular symptoms and hydrocephalus were not consistently reported and thus could not be assessed. CONCLUSIONS The treatment of NF2-associated VS continues to pose a challenge, as current SRS regimens result in impaired hearing and worse cranial nerve comorbidities, despite achieving high tumor control. It remains unclear if these findings have to be regarded as treatment complications or, rather, continued disease progression.
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Affiliation(s)
- Umberto Tosi
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Omri Maayan
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Anjile An
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Miguel E Tusa Lavieri
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Sergio W Guadix
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Antonio P DeRosa
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | - Paul J Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Susan Pannullo
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA
| | - Andrew Brandmaier
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | | | - Rohan Ramakrishna
- Department of Neurological Surgery, Weill Cornell Medicine, 525 E. 68th St.10065, Box 99, New York, NY, USA.
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Farschtschi S, Mautner VF, McLean ACL, Schulz A, Friedrich RE, Rosahl SK. The Neurofibromatoses. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:354-360. [PMID: 32657748 DOI: 10.3238/arztebl.2020.0354] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 04/18/2019] [Accepted: 03/20/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Neurofibromatosis of types 1 and 2 (NF1, NF2) and schwannomatosis are the diseases that make up the neurofibromatosis spectrum. With respective incidences of 1 in 3000, 1 in 33 000, and 1 in 60 000 births, they form part of the group of rare tumor-suppressor syndromes. They give rise to a greater tumor burden for the nervous system than any other type of neoplastic disease. New approaches to symptomatic treatment are emerging. METHODS This review is based on articles retrieved by a selective literature search on the pathogenesis, diagnosis, and treatment of the neurofibromatoses. RESULTS NF1 and NF2 are monogenic diseases, while the genetics of schwannomatosis is complex. The three entities are clinically and pathophysiologically distinct. An important aspect of their tumor biology is the alternation of growth phases and growth pauses. Correlations between genotypes and phenotypes are variable, while new mutations and genetic mosaics are common. Ninety-nine percent of patients with NF1 have six or more café-au-lait spots by the age of 12 months; 90-95% of patients with NF2 develop bilateral vestibular schwannomas. In schwannomatosis, pain is the most prominent symptom; two-thirds of those affected develop spinal schwannomas. The severity and prognosis of these disorders are not closely correlated with the radiological findings; rather, neurologic deficits, malignant transformation, and psychosocial stress are of greater clinical importance. Advances in knowledge of pathophysiology have led to the development of targeted treatment approaches. Examples include the off-label treatment of vestibular schwannomas with bevacizumab and of plexiform neurofibromas with MEK inhibitors. CONCLUSION Patients with neurofibromatoses need individualized care. They should be treated in centers of expertise where interdisciplinary consultation is available and new types of pharmacotherapy can be provided.
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Affiliation(s)
- Said Farschtschi
- International Center for Neurofibromatoses (ICNF), Department of Neurology, University MedicalCenter Hamburg-Eppendorf
| | - Victor-Felix Mautner
- International Center for Neurofibromatoses (ICNF), Department of Neurology, University MedicalCenter Hamburg-Eppendorf
| | | | | | - Reinhard E Friedrich
- Department of Oromaxillofacial Surgery, University Medical Center Hamburg-Eppendorf
| | - Steffen K Rosahl
- Neurofibromatosis Center, Department of Neurosurgery, Helios Hospital Erfurt
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Rosahl S, Bohr C, Lell M, Hamm K, Iro H. Diagnostics and therapy of vestibular schwannomas - an interdisciplinary challenge. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2017; 16:Doc03. [PMID: 29279723 PMCID: PMC5738934 DOI: 10.3205/cto000142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vestibular schwannomas (VS) expand slowly in the internal auditory canal, in the cerebellopontine angle, inside the cochlear and the labyrinth. Larger tumors can displace and compress the brainstem. With an annual incidence of 1:100,000 vestibular schwannoma represent 6-7% of all intracranial tumors. In the cerebellopontine angle they are by far the most neoplasm with 90% of all lesions located in this region. Magnetic resonance imaging (MRI), audiometry, and vestibular diagnostics are the mainstays of the clinical workup for patients harboring tumors. The first part of this paper delivers an overview of tumor stages, the most common grading scales for facial nerve function and hearing as well as a short introduction to the examination of vestibular function. Upholding or improving quality of life is the central concern in counseling and treating a patient with vestibular schwannoma. Preservation of neuronal function is essential and the management options - watchful waiting, microsurgery and stereotactic radiation - should be custom-tailored to the individual situation of the patient. Continuing interdisciplinary exchange is important to monitor treatment quality and to improve treatment results. Recently, several articles and reviews have been published on the topic of vestibular schwannoma. On the occasion of the 88th annual meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck surgery a special volume of the journal "HNO" will be printed. Hence this presentation has been designed to deviate from the traditional standard which commonly consists of a pure literature review. The current paper was conceptually woven around a series of interdisciplinary cases that outline examples for every stage of the disease that show characteristic results for management options to date. Systematic clinical decision pathways have been deduced from our experience and from results reported in the literature. These pathways are graphically outlined after the case presentations. Important criteria for decision making are size and growth rate of the tumor, hearing of the patient and the probability of total tumor resection with preservation of hearing and facial nerve function, age and comorbidity of the patient, best possible control of vertigo and tinnitus and last but not least the patient's preference and choice. In addition to this, the experience and the results of a given center with each treatment modality will figure in the decision making process. We will discuss findings that are reported in the literature regarding facial nerve function, hearing, vertigo, tinnitus, and headache and reflect on recent studies on their influence on the patient's quality of life. Vertigo plays an essential role in this framework since it is an independent predictor of quality of life and a patient's dependence on social welfare. Pathognomonic bilateral vestibular schwannomas that occur in patients suffering from neurofibromatosis typ-2 (NF2) differ from spontaneous unilateral tumors in their biologic behavior. Treatment of neurofibromatosis type-2 patients requires a multidisciplinary team, especially because of the multitude of separate intracranial and spinal lesions. Off-label chemotherapy with Bevacizumab can stabilize tumor size of vestibular schwannomas and even improve hearing over longer periods of time. Hearing rehabilitation in NF2 patients can be achieved with cochlear and auditory brainstem implants.
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Affiliation(s)
- Steffen Rosahl
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
| | - Christopher Bohr
- Department of Otolaryngology, University Hospital of Erlangen, Germany
| | - Michael Lell
- Institute for Radiology and Nuclear Medicine, Hospital of Nuremberg, Germany
| | - Klaus Hamm
- Cyberknife Center of Central Germany, Erfurt, Germany
| | - Heinrich Iro
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
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Chung LK, Nguyen TP, Sheppard JP, Lagman C, Tenn S, Lee P, Kaprealian T, Chin R, Gopen Q, Yang I. A Systematic Review of Radiosurgery Versus Surgery for Neurofibromatosis Type 2 Vestibular Schwannomas. World Neurosurg 2017; 109:47-58. [PMID: 28882713 DOI: 10.1016/j.wneu.2017.08.159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Neurofibromatosis type 2 (NF2) is an autosomal dominant disease characterized by bilateral vestibular schwannomas (VSs). NF2-associated VSs (NF2-VSs) are routinely treated with microsurgery; however, stereotactic radiosurgery (SRS) has emerged as an effective alternative in recent decades. To elucidate the role of SRS in NF2-VSs, a systematic review of the literature was conducted to compare outcomes of SRS versus surgery. METHODS PubMed, Web of Science, Scopus, Embase, and Cochrane databases were queried using relevant search terms. Retrospective studies investigating outcomes of NF2-VS patients treated with either SRS or surgery were included. Single-patient case reports were excluded. Outcome measures between the SRS and surgery groups were compared using χ2 2-sample tests for equality of proportions on the pooled patient data. RESULTS A total of 974 patients (485 SRS, 489 surgery) were identified. The mean 5-year local control rate for SRS was 75.1%, and the mean recurrence rate for surgery was 8.1%. The mean hearing and facial nerve preservation rates were 40.1% and 92.3%, respectively, for SRS and 52.0% and 75.7%, respectively, for surgery. Rates of hearing preservation were higher after surgery than after SRS (P = 0.006), whereas rates of facial nerve preservation were higher after SRS than after surgery (P < 0.001). CONCLUSIONS SRS appears to be a safe and effective alternative to surgery for NF2-VS. Although rates of hearing preservation were higher in the surgery cohorts, SRS demonstrated high rates of local control and significantly lower facial nerve complications. Certain patients may therefore benefit more from SRS than surgery.
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Affiliation(s)
- Lawrance K Chung
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Thien P Nguyen
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - John P Sheppard
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Carlito Lagman
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Stephen Tenn
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA
| | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California, USA
| | - Tania Kaprealian
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California, USA
| | - Robert Chin
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA
| | - Quinton Gopen
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California, USA; Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California, USA.
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McCabe MG, Evans DG. Pathogenesis and management of type 2 neurofibromatosis. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1014800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lustgarten L. The impact of stereotactic radiosurgery in the management of neurofibromatosis type 2-related vestibular schwannomas. Surg Neurol Int 2013; 4:S151-5. [PMID: 23682341 PMCID: PMC3654776 DOI: 10.4103/2152-7806.110663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 02/25/2013] [Indexed: 11/14/2022] Open
Abstract
Although there is an ongoing debate about the ideal management of vestibular schwannomas, radiosurgical treatment has become popular in the past decade with good to excellent results reported. Given the young age at presentation, the bilateral nature of vestibular schwanomas, the presence of other associated central nervous system tumors, patients with neurofibromatosis Type 2 (NF2) are very complex and present significant management challenges. Although results do not seem to be as good as for patients with sporadic unilateral tumors, stereotactic radiosurgery has proven a safe, attractive, and effective management modality for NF2 vestibular schwannomas. An overview of the impact stereotactic radiosurgery has had in the management of these tumors is discussed.
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Affiliation(s)
- Leonardo Lustgarten
- Department of Neurosurgery Hospital Clinicas Caracas, Venezuela/Department of Radiation Oncology Hospital Clinicas Caracas, Venezuela/Gammaknife Unit, CDD Las Mercedes, Caracas, Venezuela
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Lloyd SKW, Evans DGR. Neurofibromatosis type 2 (NF2): diagnosis and management. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:957-67. [PMID: 23931824 DOI: 10.1016/b978-0-444-52902-2.00054-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Neurofibromatosis type 2 (NF2) is an autosomal dominant inherited tumor predisposition syndrome caused by mutations in the NF2 gene on chromosome 22. Affected individuals develop schwannomas typically involving both vestibular nerves leading to hearing loss and eventual deafness. Rehabilitation with brainstem implants and in some cases cochlear implants is improving this outcome. Schwannomas also occur on other cranial nerves, on spinal nerve roots and peripheral nerves, and intracutaneously as plaques. Cranial and spinal meningiomas and spinal ependymomas are other common tumors. Fifty to sixty percent of patients represent de novo mutations and as many as 33% of these are mosaic for the underlying disease causing mutation. Truncating mutations (nonsense, frameshift insertions/deletions) are the most frequent germline events and cause the most severe disease, whilst single and multiple exon deletions are common and are usually associated with milder NF2. Neurological deficits are a major feature of the condition and neurologists have a pivotal role in assigning symptoms to lesions and in managing neuropathies. NF2 represents a difficult management problem with most patients facing substantial morbidity and reduced life expectancy. Surgery remains the focus of current management although watchful waiting and occasionally radiation treatment have a role. We are seeing the advent of tailored drug therapies aimed at the genetic level and these are likely to provide huge improvements for this devastating, life-limiting condition.
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Affiliation(s)
- Simon K W Lloyd
- Salford Royal NHS Foundation Trust, Salford, and Department of Otolaryngology, Manchester Academic Health Science Centre, Central Manchester NHS Foundation Trust, Manchester Royal Infirmary, Manchester, UK
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Maier W, Grauvogel T, Laszig R, Ridder G. Wertigkeit unterschiedlicher Methoden zur Behandlung von Akustikusneurinomen. HNO 2011; 59:425-36. [DOI: 10.1007/s00106-011-2302-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Stereotactic radiosurgery: a meta-analysis of current therapeutic applications in neuro-oncologic disease. J Neurooncol 2010; 103:1-17. [DOI: 10.1007/s11060-010-0360-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 08/09/2010] [Indexed: 10/18/2022]
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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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