1
|
Dhayalan D, Tveiten ØV, Finnkirk M, Storstein A, Hufthammer KO, Goplen FK, Lund-Johansen M. Upfront Radiosurgery vs a Wait-and-Scan Approach for Small- or Medium-Sized Vestibular Schwannoma: The V-REX Randomized Clinical Trial. JAMA 2023; 330:421-431. [PMID: 37526718 PMCID: PMC10394573 DOI: 10.1001/jama.2023.12222] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/15/2023] [Indexed: 08/02/2023]
Abstract
Importance Current guidelines for treating small- to medium-sized vestibular schwannoma recommend either upfront radiosurgery or waiting to treat until tumor growth has been detected radiographically. Objective To determine whether upfront radiosurgery provides superior tumor volume reduction to a wait-and-scan approach for small- to medium-sized vestibular schwannoma. Design, Setting, and Participants Randomized clinical trial of 100 patients with a newly diagnosed (<6 months) unilateral vestibular schwannoma and a maximal tumor diameter of less than 2 cm in the cerebellopontine angle as measured on magnetic resonance imaging. Participants were enrolled at the Norwegian National Unit for Vestibular Schwannoma from October 28, 2014, through October 3, 2017; 4-year follow-up ended on October 20, 2021. Interventions Participants were randomized to receive either upfront radiosurgery (n = 50) or to undergo a wait-and-scan protocol, for which treatment was given only upon radiographically documented tumor growth (n = 50). Participants underwent 5 annual study visits consisting of clinical assessment, radiological examination, audiovestibular tests, and questionnaires. Main Outcomes and Measures The primary outcome was the ratio between tumor volume at the trial end at 4 years and baseline (V4:V0). There were 26 prespecified secondary outcomes, including patient-reported symptoms, clinical examinations, audiovestibular tests, and quality-of-life outcomes. Safety outcomes were the risk of salvage microsurgery and radiation-associated complications. Results Of the 100 randomized patients, 98 completed the trial and were included in the primary analysis (mean age, 54 years; 42% female). In the upfront radiosurgery group, 1 participant (2%) received repeated radiosurgery upon tumor growth, 2 (4%) needed salvage microsurgery, and 45 (94%) had no additional treatment. In the wait-and-scan group, 21 patients (42%) received radiosurgery upon tumor growth, 1 (2%) underwent salvage microsurgery, and 28 (56%) remained untreated. For the primary outcome of the ratio of tumor volume at the trial end to baseline, the geometric mean V4:V0 was 0.87 (95% CI, 0.66-1.15) in the upfront radiosurgery group and 1.51 (95% CI, 1.23-1.84) in the wait-and-scan group, showing a significantly greater tumor volume reduction in patients treated with upfront radiosurgery (wait-and-scan to upfront radiosurgery ratio, 1.73; 95% CI, 1.23-2.44; P = .002). Of 26 secondary outcomes, 25 showed no significant difference. No radiation-associated complications were observed. Conclusion and relevance Among patients with newly diagnosed small- and medium-sized vestibular schwannoma, upfront radiosurgery demonstrated a significantly greater tumor volume reduction at 4 years than a wait-and-scan approach with treatment upon tumor growth. These findings may help inform treatment decisions for patients with vestibular schwannoma, and further investigation of long-term clinical outcomes is needed. Trial Registration ClinicalTrials.gov Identifier: NCT02249572.
Collapse
Affiliation(s)
- Dhanushan Dhayalan
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian National Unit for Vestibular Schwannoma, Haukeland University Hospital, Bergen, Norway
| | - Øystein Vesterli Tveiten
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- The Norwegian National Unit for Vestibular Schwannoma, Haukeland University Hospital, Bergen, Norway
- The Norwegian National Unit for Stereotactic Radiosurgery, Haukeland University Hospital, Bergen. Norway
| | - Monica Finnkirk
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- The Norwegian National Unit for Vestibular Schwannoma, Haukeland University Hospital, Bergen, Norway
| | - Anette Storstein
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Frederik Kragerud Goplen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian National Unit for Vestibular Schwannoma, Haukeland University Hospital, Bergen, Norway
- Department of Otorhinolaryngology & Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- The Norwegian National Advisory Unit on Vestibular Disorders, Haukeland University Hospital, Bergen, Norway
| | - Morten Lund-Johansen
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian National Unit for Vestibular Schwannoma, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
2
|
Balossier A, Tuleasca C, Delsanti C, Troude L, Thomassin JM, Roche PH, Régis J. Long-Term Hearing Outcome After Radiosurgery for Vestibular Schwannoma: A Systematic Review and Meta-Analysis. Neurosurgery 2023; 92:1130-1141. [PMID: 36735500 PMCID: PMC10150847 DOI: 10.1227/neu.0000000000002354] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/08/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is one of the main treatment options in the management of small to medium size vestibular schwannomas (VSs), because of high tumor control rate and low cranial nerves morbidity. Series reporting long-term hearing outcome (>3 years) are scarce. OBJECTIVE To perform a systematic review of the literature and meta-analysis, with the aim of focusing on long-term hearing preservation after SRS. METHODS Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we reviewed articles published between January 1990 and October 2020 and referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical study or case series of VSs treated with SRS (single dose), reporting hearing outcome after SRS with a median or mean audiometric follow-up of at least 5 years. Hearing preservation, cranial nerves outcomes, and tumor control were evaluated. RESULTS Twenty-three studies were included. Hearing preservation was found in 59.4% of cases (median follow-up 6.7 years, 1409 patients). Main favorable prognostic factors were young age, good hearing status, early treatment after diagnosis, small tumor volume, low marginal irradiation dose, and maximal dose to the cochlea. Tumor control was achieved in 96.1%. Facial nerve deficit and trigeminal neuropathy were found in 1.3% and 3.2% of patients, respectively, both significantly higher in Linear Accelerator series than Gamma Knife series ( P < .05). CONCLUSION Long-term hearing preservation remains one of the main issues after SRS, with a major impact on health-related quality of life. Our meta-analysis suggests that hearing preservation can be achieved in almost 60% of patients after a median follow-up of 6.7 years, irrespective of the technique.
Collapse
Affiliation(s)
- Anne Balossier
- AP-HM, Timone Hospital, Functional and Stereotactic Neurosurgery, Marseille, France;
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France;
| | - Constantin Tuleasca
- Centre Hospitalier Universitaire Vaudois (CHUV), Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland;
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland;
| | - Christine Delsanti
- AP-HM, Timone Hospital, Functional and Stereotactic Neurosurgery, Marseille, France;
| | - Lucas Troude
- AP-HM, North University Hospital, Department of Neurosurgery, Marseille, France;
| | - Jean-Marc Thomassin
- Department of Head and Neck Surgery, AP-HM, Timone Hospital, Marseille, France
| | - Pierre-Hugues Roche
- AP-HM, North University Hospital, Department of Neurosurgery, Marseille, France;
| | - Jean Régis
- AP-HM, Timone Hospital, Functional and Stereotactic Neurosurgery, Marseille, France;
- Aix Marseille Univ, INSERM, INS, Inst Neurosci Syst, Marseille, France;
| |
Collapse
|
3
|
Pisani D, Gioacchini FM, Chiarella G, Astorina A, Ricciardiello F, Scarpa A, Re M, Viola P. Vestibular Impairment in Patients with Vestibular Schwannoma: A Journey through the Pitfalls of Current Literature. Audiol Res 2023; 13:285-303. [PMID: 37102775 PMCID: PMC10135541 DOI: 10.3390/audiolres13020025] [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: 02/27/2023] [Revised: 03/17/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023] Open
Abstract
Vestibular Schwannoma is the most common tumour of Ponto Cerebellar Angle and is capable of strongly impacting the patient's quality of life. In recent decades, the proposals for the management of the disease have multiplied, just as the diagnostic capacity has improved. While in the past, the primary objective was the preservation of the facial function, and subsequently also of the auditory function, the attention to the vestibular symptomatology, which appears to be one of the main indicators of deterioration of quality of life, is still unsatisfactory. Many authors have tried to provide guidance on the best possible management strategy, but a universally recognized guideline is still lacking. This article offers an overview of the disease and the proposals which have advanced in the last twenty years, evaluating their qualities and defects in a critical reading.
Collapse
Affiliation(s)
- Davide Pisani
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Federico Maria Gioacchini
- Ear, Nose, and Throat Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Via Conca 71, 60020 Ancona, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Alessia Astorina
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | | | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, 84084 Salerno, Italy
| | - Massimo Re
- Ear, Nose, and Throat Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Via Conca 71, 60020 Ancona, Italy
| | - Pasquale Viola
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| |
Collapse
|
4
|
Bojrab DI, Fritz CG, Lin KF, Schutt CA, Hong RS, Babu SC, Chen PY, Maitz A, Bojrab DI. Pre-existing Vestibular Symptoms Are Associated With Acute Vestibular Symptoms After Gamma Knife Therapy for Vestibular Schwannoma. Otol Neurotol 2021; 42:912-917. [PMID: 33591068 DOI: 10.1097/mao.0000000000003064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To identify pretreatment variables associated with the development of acute vestibular symptoms after Gamma Knife (GK) treatment for Vestibular Schwannoma (VS). STUDY DESIGN Retrospective case series. SETTING Tertiary neurotology referral center. PATIENTS Patients treated with GK radiosurgery for VS between March 2007 and March 2017 were considered for this study. Patients with neurofibromatosis type II, previous VS surgery, follow-up less than 6 months, or the lack of T2 magnetic resonance imaging (MRI) sequences from the day of treatment were excluded. MAIN OUTCOME MEASURES The presence of acute vestibular symptoms arising within 6 months after GK was the main outcome variable. Tumor, patient, and treatment characteristics were gathered from the medical record. RESULTS In total, 98 patients met inclusion criteria. The incidence of acute vestibular symptoms occurring within 6 months after GK treatment was 46.9%. Post-GK vestibular symptoms were reported at a significantly higher frequency among subjects who had reported vestibular symptoms before their treatment (p = 0.001). Tumor size was not associated with a propensity to develop acute vestibular symptoms (p = 0.397). The likelihood of receiving a referral to vestibular rehabilitation services was not significantly different among patients with larger versus smaller tumor size, as defined by 1.6 cm and 1.4 cm thresholds (p = 0.896, p = 0.654). CONCLUSIONS Inquiries aimed at revealing a history of vestibular complaints may prove useful in counseling patients on the likelihood of experiencing acute vestibular symptoms after treatment of Vestibular Schwannoma with Gamma Knife therapy.
Collapse
Affiliation(s)
| | - Christian G Fritz
- Michigan Ear Institute, Farmington Hills
- Oakland University William Beaumont School of Medicine, Rochester
| | | | | | | | | | - Peter Y Chen
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Ann Maitz
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | | |
Collapse
|
5
|
Long-term Outcomes of Gamma Knife Radiosurgery for Treating Vestibular Schwannoma With a Lower Prescription Dose of 12 Gy Compared With Higher Dose Treatment. Otol Neurotol 2021; 41:e1314-e1320. [PMID: 33492807 DOI: 10.1097/mao.0000000000002885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Gamma knife radiosurgery (GKRS) is commonly used to treat vestibular schwannomas (VSs). The risk of complications from GKRS decreases at lower doses, but it is unknown if long-term tumor control is negatively affected by dose reduction. STUDY DESIGN This was a retrospective case review and analysis of patient data. SETTING Tertiary referral center. PATIENTS Patients with VSs who underwent GKRS between 1990 and 2007 at the authors' institution. INTERVENTION(S) The subjects were divided into two cohorts based on the prescribed doses of radiation received: a 12 Gy cohort (96 patients) with a follow-up period of 124 months and a >12 Gy cohort (118 patients) with a follow-up period of 143 months. MAIN OUTCOME MEASURES Tumor control rates at 10 to 15 years, frequency of facial and trigeminal nerve complications, and hearing function. RESULTS The 10 to 15-year tumor control rates were 95% in the 12 Gy cohort and 88% in the > 12 Gy cohort, but the differences were not significant. Compared with the >12 Gy cohort, facial and trigeminal nerve deficits occurred significantly less frequently in the 12 Gy cohort, with the 10-year cumulative, permanent deficit-free rates being 2% and 0%, respectively. Multivariate analyses revealed that treatment doses exceeding 12 Gy were associated with a significantly higher risk for cranial nerve deficits. The percentage of subjects retaining pure-tone average ≤ 50 dB at the final follow-up did not significantly differ between the cohorts (12 Gy cohort, 30% and >12 Gy cohort, 33%; p = 0.823). CONCLUSIONS Dose reduction to 12 Gy for GKRS to treat VSs decreased facial and trigeminal nerve complications without worsening tumor control rates.
Collapse
|
6
|
Evolving Role of Non-Total Resection in Management of Acoustic Neuroma in the Gamma Knife Era. Otol Neurotol 2021; 41:e1354-e1359. [PMID: 33492813 DOI: 10.1097/mao.0000000000002904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine patients with residual tumor after vestibular schwannoma (VS) resection with focus on need for further therapy, including stereotactic radiosurgery (SRS) and revision surgery. STUDY DESIGN AND SETTING Retrospective review at two tertiary otology referral centers. PATIENTS AND INTERVENTION Patients undergoing primary surgery for VS from 2007 to 2017. MAIN OUTCOME MEASURE Degree of resection and need for further treatment. RESULTS Of 289 patients undergoing surgery, 38 (13.1%) underwent subtotal resections (<95% of tumor resected) and 77 (26.6%) underwent near-total resections (≥95% but <100%). Patients with any residual tumor had larger tumors preoperatively (mean estimated volume 6.3 cm versus 2.1 cm, p < 0.0005) but were otherwise clinically and demographically similar to the population as a whole. Further treatment (surgery or SRS) was needed in 4.6, 14.3, and 50.0% of patients after gross total, near-total, and subtotal resections, respectively (p < 0.0005). Patients undergoing additional therapy had larger residual tumors (median post- to preoperative estimated volume ratio 0.09 versus 0.01, p < 0.0005). Patients undergoing subtotal and near-total resections had poorer facial function at ultimate follow up than those undergoing gross total resections (p = 0.001), likely due to larger tumors and more difficult resections. Literature review revealed higher rates of gross total resection as well as facial palsy in the pre-SRS era. CONCLUSION Residual tumor following VS resection is more common today than in the pre-SRS era. Availability of SRS may encourage leaving residual tumor intraoperatively to preserve neural structures. Current surgical strategies decrease surgical morbidity but necessitate further treatment in over 10% of cases.
Collapse
|
7
|
Ermiş E, Anschuetz L, Leiser D, Poel R, Raabe A, Manser P, Aebersold DM, Caversaccio M, Mantokoudis G, Abu-Isa J, Wagner F, Herrmann E. Vestibular dose correlates with dizziness after radiosurgery for the treatment of vestibular schwannoma. Radiat Oncol 2021; 16:61. [PMID: 33771181 PMCID: PMC7995572 DOI: 10.1186/s13014-021-01793-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/18/2021] [Indexed: 11/20/2022] Open
Abstract
Background Stereotactic radiosurgery (SRS) has been recognized as a first-line treatment option for small to moderate sized vestibular schwannoma (VS). Our aim is to evaluate the impact of SRS doses and other patient and disease characteristics on vestibular function in patients with VS. Methods Data on VS patients treated with single-fraction SRS to 12 Gy were retrospectively reviewed. No dose constraints were given to the vestibule during optimization in treatment planning. Patient and tumor characteristics, pre- and post-SRS vestibular examination results and patient-reported dizziness were assessed from patient records. Results Fifty-three patients were analyzed. Median follow-up was 32 months (range, 6–79). The median minimum, mean and maximum vestibular doses were 2.6 ± 1.6 Gy, 6.7 ± 2.8 Gy, and 11 ± 3.6 Gy, respectively. On univariate analysis, Koos grade (p = 0.04; OR: 3.45; 95% CI 1.01–11.81), tumor volume (median 6.1 cm3; range, 0.8–38; p = 0.01; OR: 4.85; 95% CI 1.43–16.49), presence of pre-SRS dizziness (p = 0.02; OR: 3.98; 95% CI 1.19–13.24) and minimum vestibular dose (p = 0.033; OR: 1.55; 95% CI 1.03–2.32) showed a significant association with patient-reported dizziness. On multivariate analysis, minimum vestibular dose remained significant (p = 0.02; OR: 1.75; 95% CI 1.05–2.89). Patients with improved caloric function had received significantly lower mean (1.5 ± 0.7 Gy, p = 0.01) and maximum doses (4 ± 1.5 Gy, p = 0.01) to the vestibule. Conclusions Our results reveal that 5 Gy and above minimum vestibular doses significantly worsened dizziness. Additionally, mean and maximum doses received by the vestibule were significantly lower in patients who had improved caloric function. Further investigations are needed to determine dose-volume parameters and their effects on vestibular toxicity.
Collapse
Affiliation(s)
- Ekin Ermiş
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Lukas Anschuetz
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominic Leiser
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.,Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
| | - Robert Poel
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics, Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Janine Abu-Isa
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Evelyn Herrmann
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland. .,Department of Radiation Oncology, Hôpital Riviera-Chablais, Rennaz, Switzerland.
| |
Collapse
|
8
|
Teyateeti A, Graffeo CS, Perry A, Tryggestad EJ, Brown PD, Pollock BE, Link MJ. The Effect of Prescription Isodose Variation on Tumor Control and Toxicities in Stereotactic Radiosurgery for Sporadic Vestibular Schwannoma: Propensity Score-Matched Case–Control Study. Skull Base Surg 2021; 83:193-202. [DOI: 10.1055/s-0040-1718908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 09/03/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objective Vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (SRS) was typically performed at 50% isodose line (IDL50); however, the impact of IDL variation on outcomes is poorly understood. This study aimed to compare tumor control (TC) and toxicities between treatment at 40% (IDL40) and 50% (IDL50).
Methods Sporadic/unilateral VS patients treated with SRS dose 12 to 14 Gy and prescription isodose volume ≤10cm3 were included. Propensity score matching was applied to IDL40 cohort to generate an IDL50 companion cohort, adjusting for age and prescription isodose volume. After exclusion of patients with follow-up <24 months, there were 30 and 28 patients in IDL40 and IDL50 cohorts, respectively.
Results Median follow-up time was 96 months (24–225 months). Actuarial and radiographic TC rates were 91.8% and clinical TC was 96.2% both at 5 and 10 years. TC was higher in IDL40 cohort but not significant (96.4 vs. 86.7%; p = 0.243). Hearing preservation (HP) rates were 71.9 and 39.2% at 5- and 10-year intervals, with significantly higher rates of HP noted in IDL40 cohort (83.3 vs. 57.1% at 5-year interval; 62.5 vs. 11.4% at 10-year interval; p = 0.017). Permanent facial neuropathy occurred in two patients, both from the IDL50 cohort (3.5%). Rates of post-SRS steroid treatment or shunt placement for hydrocephalus were slightly higher in IDL50 patients (6.9 vs. 17.9%; p = 0.208 and 3.3 vs. 7.1%; p = 0.532).
Conclusion For treatment of VS with SRS, dose prescription at IDL40 or IDL50 provides excellent long-term TC and toxicity profiles. IDL40 may be associated with improved long-term HP.
Collapse
Affiliation(s)
- Achiraya Teyateeti
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States
- Department of Radiology, Division of Radiation Oncology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J. Tryggestad
- Department of Radiation Physics, Mayo Clinic, Rochester, Minnesota, United States
| | - Paul D. Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, United States
| | - Bruce E. Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| |
Collapse
|
9
|
Soltys SG, Milano MT, Xue J, Tomé WA, Yorke E, Sheehan J, Ding GX, Kirkpatrick JP, Ma L, Sahgal A, Solberg T, Adler J, Grimm J, El Naqa I. Stereotactic Radiosurgery for Vestibular Schwannomas: Tumor Control Probability Analyses and Recommended Reporting Standards. Int J Radiat Oncol Biol Phys 2020; 110:100-111. [PMID: 33375955 DOI: 10.1016/j.ijrobp.2020.11.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/02/2020] [Accepted: 11/05/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE We sought to investigate the tumor control probability (TCP) of vestibular schwannomas after single-fraction stereotactic radiosurgery (SRS) or hypofractionated SRS over 2 to 5 fractions (fSRS). METHODS AND MATERIALS Studies (PubMed indexed from 1993-2017) were eligible for data extraction if they contained dosimetric details of SRS/fSRS correlated with local tumor control. The rate of tumor control at 5 years (or at 3 years if 5-year data were not available) were collated. Poisson modeling estimated the TCP per equivalent dose in 2 Gy per fraction (EQD2) and in 1, 3, and 5 fractions. RESULTS Data were extracted from 35 publications containing a total of 5162 patients. TCP modeling was limited by the absence of analyzable data of <11 Gy in a single-fraction, variability in definition of "tumor control," and by lack of significant increase in TCP for doses >12 Gy. Using linear-quadratic-based dose conversion, the 3- to 5-year TCP was estimated at 95% at an EQD2 of 25 Gy, corresponding to 1-, 3-, and 5-fraction doses of 13.8 Gy, 19.2 Gy, and 21.5 Gy, respectively. Single-fraction doses of 10 Gy, 11 Gy, 12 Gy, and 13 Gy predicted a TCP of 85.0%, 88.4%, 91.2%, and 93.5%, respectively. For fSRS, 18 Gy in 3 fractions (EQD2 of 23.0 Gy) and 25 Gy in 5 fractions (EQD2 of 30.2 Gy) corresponded to TCP of 93.6% and 97.2%. Overall, the quality of dosimetric reporting was poor; recommended reporting guidelines are presented. CONCLUSIONS With current typical SRS doses of 12 Gy in 1 fraction, 18 Gy in 3 fractions, and 25 Gy in 5 fractions, 3- to 5-year TCP exceeds 91%. To improve pooled data analyses to optimize treatment outcomes for patients with vestibular schwannoma, future reports of SRS should include complete dosimetric details with well-defined tumor control and toxicity endpoints.
Collapse
Affiliation(s)
- Scott G Soltys
- Department of Radiation Oncology, Stanford University, Stanford, California.
| | - Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - Jinyu Xue
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jason Sheehan
- Department of Neurologic Surgery, University of Virginia, Charlottesville, Virginia
| | - George X Ding
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - John P Kirkpatrick
- Departments of Radiation Oncology and Neurosurgery, Duke Cancer Institute, Durham, North Carolina
| | - Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Timothy Solberg
- Office of the Commissioner, US Food and Drug Administration, Silver Spring, Maryland
| | - John Adler
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Jimm Grimm
- Department of Radiation Oncology, Geisinger Health System, Danville, Pennsylvania; Department of Medical Imaging and Radiation Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Issam El Naqa
- Machine Learning Department, Moffitt Cancer Center, Tampa, Florida
| |
Collapse
|
10
|
Vestibular Schwannoma Tumor Size Is Associated With Acute Vestibular Symptoms After Gamma Knife Therapy. Otol Neurotol 2020; 40:1088-1093. [PMID: 31335798 DOI: 10.1097/mao.0000000000002312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess how pretreatment vestibular schwannoma (VS) tumor characteristics are associated with vestibular symptoms after gamma knife (GK) surgery. STUDY DESIGN Retrospective chart review of patients undergoing GK treatment for VS at our institution from 2005 to 2018. SETTING Academic tertiary referral center. PATIENTS Patients receiving primary GK surgery for vestibular schwannomas with at least 6 months of follow up. Patients with neurofibromatosis 2 or previous surgery were excluded. MAIN OUTCOME MEASURES The presence of posttreatment vestibular symptoms within 6 months after GK. Clinical records were assessed for pretreatment tumor, patient, and treatment characteristics that impacted posttreatment symptoms. RESULTS All patients received radiation doses between 12 and 13 Gy. Of 115 patients, the average age was 60. Thirty-seven (32%) patients developed vestibular symptoms within 6 months post-GK, and 18 patients were referred for vestibular rehabilitation. Ten of 13 patients undergoing vestibular rehabilitation reported improvement. Overall, 112 patients had tumor measurements. Pretreatment tumors were significantly smaller for patients with acute vestibular symptoms (mean 1.43 cm versus 1.71 cm, p = 0.007). On multivariate analysis, smaller tumor size (p = 0.009, odds ratio [OR] = 0.29, 95% confidence interval [CI] [0.12-0.73]) was significantly associated with vestibular symptoms within 6 months of GK. Patients with tumors less than 1.6 cm were more likely to receive referrals for vestibular rehabilitation within 6 months posttreatment (25% versus 9.4%, p = 0.026, OR = 3.22, 95% CI [1.00, 11.32]). CONCLUSIONS Smaller vestibular schwannomas were significantly associated with higher rates of post-GK vestibular symptoms. Pretreatment tumor size may be used to counsel patients on the likelihood of post-GK vestibular symptoms and vestibular rehabilitation.
Collapse
|
11
|
Khattab MH, Sherry AD, Manzoor N, Totten DJ, Luo G, Chambless LB, Rivas A, Haynes DS, Cmelak AJ, Attia A. Progressive Vestibular Schwannoma following Subtotal or Near-Total Resection: Dose-Escalated versus Standard-Dose Salvage Stereotactic Radiosurgery. J Neurol Surg B Skull Base 2020; 82:e9-e14. [PMID: 34306912 DOI: 10.1055/s-0040-1712462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 03/19/2020] [Indexed: 10/24/2022] Open
Abstract
Objective Local failure of incompletely resected vestibular schwannoma (VS) following salvage stereotactic radiosurgery (SRS) using standard doses of 12 to 13 Gy is common. We hypothesized that dose-escalated SRS, corrected for biologically effective dose, would have superior local control of high-grade VS progressing after subtotal or near-total resection compared with standard-dose SRS. Design Retrospective cohort study. Setting Tertiary academic referral center. Participants Adult patients treated with linear accelerator-based SRS for progressive VS following subtotal or near-total resection. Main Outcome Measures Dose-escalated SRS was defined by a biologically effective dose exceeding a single-fraction 13-Gy regimen. Study outcomes were local control and neurologic sequelae of SRS. Binary logistic regression was used to evaluate predictors of study outcomes. Results A total of 18 patients with progressive disease following subtotal (71%) and near-total (39%) resection of Koos grade IV disease (94%) were enrolled. Of the 18 patients, 7 were treated with dose-escalated SRS and 11 with standard-dose SRS. Over a median follow-up of 32 months after SRS, local control was 100% in the dose-escalated cohort and 91% in the standard-dose cohort ( p = 0.95). Neurologic sequelae occurred in 28% of patients, including 60% of dose-escalated cohort and 40% of the standard-dose cohort ( p = 0.12), although permanent neurologic sequelae were low at 6%. Conclusions Dose-escalated SRS has similar local control of recurrent VS following progression after subtotal or near-total resection and does not appear to have higher neurologic sequalae. Larger studies are needed.
Collapse
Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Nauman Manzoor
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Douglas J Totten
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alejandro Rivas
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - David S Haynes
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| |
Collapse
|
12
|
Udawatta M, Kwan I, Preet K, Nguyen T, Ong V, Sheppard JP, Duong C, Romiyo P, Lee P, Tenn S, Kaprealian T, Gopen Q, Yang I. Hearing Preservation for Vestibular Schwannomas Treated with Stereotactic Radiosurgery or Fractionated Stereotactic Radiotherapy. World Neurosurg 2019; 129:e303-e310. [PMID: 31132496 DOI: 10.1016/j.wneu.2019.05.133] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/17/2019] [Accepted: 05/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Vestibular schwannomas (VS) are benign intracranial neoplasms arising from the eighth cranial nerve for which targeted radiation therapy (RT) has proved increasingly successful. However, long-term hearing and related cranial nerve outcomes have been disputed for the 3 current RT modalities. OBJECTIVE To determine differences in hearing preservation for patients treated with stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), or hypofractionated stereotactic radiotherapy (hypoFSRT) for VS. METHODS A retrospective electronic chart review was conducted for all patients with unilateral VS treated with primary RT at a single academic medical center between 2000 and 2017. The primary outcome measure was preservation of serviceable hearing status in the affected ear at last follow-up. Secondary outcomes included tinnitus, vertigo, and imbalance. RESULTS A total of 33 FSRT cases, 21 SRS cases, and 6 hypoFSRT cases were identified. Postoperative deterioration in serviceable hearing and tinnitus showed significant differences across cohorts. The SRS cohort had a higher baseline incidence of nonserviceable hearing and disequilibrium compared with other cohorts before RT (P = 0.001 and 0.022, respectively); no differences in baseline morbidity were observed for vertigo and tinnitus. The 5-year tumor control rate was 95.2%, 93.9%, and 100% with SRS, FSRT, and hypoFSRT, respectively. CONCLUSIONS Our series indicated an excellent tumor control rate in all the modalities. Our SRS cohort showed increased incidence and shorter time to hearing deterioration compared with the FSRT and hypoFSRT cohorts. The FSRT and hypoFSRT cohorts have shown comparable overall outcomes. Onset of post-RT tinnitus was observed only with FSRT.
Collapse
Affiliation(s)
- Methma Udawatta
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Isabelle Kwan
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Komal Preet
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Thien Nguyen
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Vera Ong
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - John P Sheppard
- Department of Neurosurgery, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Courtney Duong
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Prasanth Romiyo
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Stephen Tenn
- Department of Radiation Oncology, University of California, Los Angeles, California, USA
| | - Tania Kaprealian
- Department of Neurosurgery, University of California, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, USA
| | - Quinton Gopen
- Department of Head and Neck Surgery, University of California, Los Angeles, California, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, California, USA; Department of Radiation Oncology, University of California, Los Angeles, California, USA; Department of Head and Neck Surgery, University of California, Los Angeles, California, USA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California, USA; Los Angeles Biomedical Research Institute, University of California, Los Angeles, California, USA; Harbor-UCLA Medical Center, University of California, Los Angeles, California, USA; David Geffen School of Medicine, University of California, Los Angeles, California, USA.
| |
Collapse
|
13
|
Chow KKH, Ajlan A, Ho AL, Li G, Soltys SG. Facial Nerve Paralysis Occurring 4 Days following Stereotactic Radiosurgery for a Vestibular Schwannoma. Asian J Neurosurg 2019; 14:262-265. [PMID: 30937049 PMCID: PMC6417297 DOI: 10.4103/ajns.ajns_53_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is commonly used for the treatment of vestibular schwannomas given its high rate of tumor control and low rate of complications. Facial nerve palsy has been reported several months after treatment as a rare late complication of SRS. Here, we report a case of facial weakness occurring only 4 days after treatment and discuss potential etiology and management considerations.
Collapse
Affiliation(s)
| | - Abdulrazag Ajlan
- Department of Neurosurgery, Stanford University, California, USA.,Stanford Cancer Institute, Stanford University, California, USA
| | - Allen Lin Ho
- Department of Neurosurgery, Stanford University, California, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University, California, USA.,Stanford Cancer Institute, Stanford University, California, USA
| | - Scott Gerard Soltys
- Stanford Cancer Institute, Stanford University, California, USA.,Department of Radiation Oncology, Stanford University, California, USA
| |
Collapse
|
14
|
Galloway L, Palaniappan N, Shone G, Hayhurst C. Trigeminal neuropathy in vestibular schwannoma: a treatment algorithm to avoid long-term morbidity. Acta Neurochir (Wien) 2018; 160:681-688. [PMID: 29344779 DOI: 10.1007/s00701-017-3452-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/22/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Trigeminal neuropathy (TGN) can occur as a presenting feature of vestibular schwannoma (VS) or as an adverse effect of radiosurgery. This study was designed to evaluate a treatment algorithm for presenting symptoms of TGN in patients with VS, and a new radiosurgery dosimetric tolerance to avoid TGN after treatment. Outcome was measured after microsurgery (MS), stereotactic radiosurgery (SRS), hypofractionated stereotactic radiotherapy (HSRT), and fractionated radiotherapy (FRT). METHODS A prospectively held VS database was retrospectively analysed from 2011 to 2016 at a tertiary university hospital. All patients who underwent MS from 2011 and all patients who underwent radiotherapy (SRS, HSRT, FRT) from 2015 were studied. Patients on surveillance and neurofibromatosis type 2 patients were not included. Patient demographic data, tumour characteristics, presenting symptoms, and post-treatment outcomes were analysed. RESULTS Eighty-eight patients were included in the study (43 microsurgery, 45 radiotherapy). Twenty-seven (31%) patients presented with TGN symptoms. The median age of patients included was 56.5 (range 6-72 years), with a median follow-up for MS and SRS of 38 and 20 months, respectively (range 10-80 months). All 27 patients with TGN were offered MS as per protocol. Three patients declined, or were not fit for surgery, and received FRT. Complete resolution of TGN symptoms was achieved in all 24 patients who underwent MS and 33% (1/3) of patients with FRT. Eleven patients experienced transient post-operative complications (pseudomeningocele (6), meningitis (3), venous sinus thrombosis, cerebellar haemorrhagic contusion, and posterior fossa haematoma). Of the 45 patients in the radiotherapy cohort, 36 were suitable for SRS, of which 30 patients who met the dose-volume constraints for trigeminal nerve underwent single-fraction SRS and 6 patients who did not meet the constraints received HSRT. Nine patients (20%) received FRT including three patients with pre-treatment TGN. None of the patients developed new TGN symptoms following SRS or HSRT. CONCLUSIONS Our algorithm to select the optimal treatment modality appears to achieve comparable or better long-term outcome. Microsurgical resection in our cohort resulted in complete resolution of symptoms in all patients. None of our SRS- or HSRT-treated patients developed TGN during the follow-up period. The adherence to strict trigeminal nerve dose-volume constraints for SRS remains critical to minimise TGN post treatment. Fractionated radiotherapy is an alternative for patients who refuse surgery or those who are unfit for surgery.
Collapse
Affiliation(s)
- Luke Galloway
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK.
- Department of Neurosurgery, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK.
| | - Nachi Palaniappan
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK
| | - Geoffrey Shone
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK
| | - Caroline Hayhurst
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK
| |
Collapse
|
15
|
Neff BA, Carlson ML, O'Byrne MM, Van Gompel JJ, Driscoll CLW, Link MJ. Trigeminal neuralgia and neuropathy in large sporadic vestibular schwannomas. J Neurosurg 2017; 127:992-999. [DOI: 10.3171/2016.9.jns16515] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe aim of this study was to evaluate the incidence, presentation, and treatment outcomes of trigeminal nerve–mediated symptoms secondary to large vestibular schwannomas (VSs) with trigeminal nerve contact. Specifically, the symptomatic results of pain, paresthesias, and numbness after microsurgical resection or stereotactic radiosurgery (SRS) were examined.METHODSThe authors conducted a retrospective review of a database for concomitant diagnosis of trigeminal neuralgia (TN) or trigeminal neuropathy and VS between 1994 and 2014 at a tertiary academic center. All patients with VS with TN or neuropathy were included, with the exception of those patients with neurofibromatosis Type 2 and patients who elected observation. Patient demographic data, symptom evolution, and treatment outcomes were collected. Population data were summarized, and outcome comparisons between microsurgery and SRS were analyzed at last follow-up.RESULTSSixty (2.2%) of 2771 total patients who had large VSs and either TN or neuropathy symptoms met inclusion criteria. The average age of trigeminal symptom onset was 53.6 years (range 24–79 years), the average age at VS diagnosis was 54.4 years (range 25–79 years), and the average follow-up for the microsurgery and SRS groups was 30 and 59 months, respectively (range 3–132 months). Of these patients, 50 (83%) had facial numbness, 16 (27%) had TN pain, and 13 (22%) had paresthesias (i.e., burning or tingling). Subsequently, 50 (83%) patients underwent resection and 10 (17%) patients received SRS.Treatment of VS with SRS did not improve trigeminal symptoms in any patient. This included 2 subjects with unimproved facial numbness and 4 patients with worsened numbness. Similarly, SRS worsened TN pain and paresthesias in 5 patients and failed to improve pain in 2 additional patients. The Barrow Neurological Institute neuralgia and hypesthesia scale scores were significantly worse for patients undergoing SRS compared with microsurgery.Resection alleviated facial numbness in 22 (50%) patients, paresthesias in 5 (42%) patients, and TN in 7 (70%) patients. In several patients, surgery was not successful in relieving facial numbness, which failed to improve in 17 (39%) cases and became worse in 5 (11%) cases. Also, surgery did not change the intensity of facial paresthesias or neuralgia in 6 (50%) and 3 (25%) patients, respectively. Microsurgery exacerbated facial paresthesias in 1 (8%) patient but, notably, did not aggravate TN in any patient.CONCLUSIONSOverall, resection of large VSs provided improved outcomes for patients with concomitant TN, facial paresthesia, and numbness compared with SRS. However, caution should be used when counseling surgical candidates because a number of patients did not experience improvement. This was especially true in patients with preoperative facial numbness and paresthesias, who frequently reported that these symptoms were unchanged following surgery.
Collapse
Affiliation(s)
| | | | - Megan M. O'Byrne
- 3Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | |
Collapse
|
16
|
Kim JH, Jung HH, Chang JH, Chang JW, Park YG, Chang WS. Predictive Factors of Unfavorable Events After Gamma Knife Radiosurgery for Vestibular Schwannoma. World Neurosurg 2017; 107:175-184. [PMID: 28826715 DOI: 10.1016/j.wneu.2017.07.139] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKS) for the treatment of vestibular schwannoma (VS) introduces risks to the facial nerve and auditory perception and may involve post-treatment complications such as pseudoprogression, hydrocephalus, and other cranial neuropathies. This study of patients with VS who underwent GKS investigated radiosurgical results, focusing on post-treatment complications and identifying the factors that predict such complications. METHODS We undertook a retrospective review of all VS patients treated with the Perfexion Leksell Gamma Knife between November 2007 and October 2010 at our institution. Patients who underwent at least 12 months of clinical and radiologic assessments before and after GKS were included. RESULTS All 235 patients were included in the analyses reported here. The 5-year serviceable hearing and facial nerve preservation values were 73.9% and 94.3%, respectively. Following GKS, 43 patients (18.30%) showed pseudoprogression, 15 (6.38%) exhibited hydrocephalus, 22 (9.36%) showed trigeminal neuropathy, 14 (5.96%) showed vertigo, and 25 (10.64%) showed facial myokymia. According to multivariate analysis, solid tumor nature was significantly associated with pseudoprogression and patient age was significantly associated with hydrocephalus. Patients receiving margin doses ≥13 Gy had a significantly higher probability of loss of serviceable hearing. Patients with smaller tumors had a trigeminal nerve preservation rate comparable with patients harboring larger tumors. Patients receiving margin doses <13 Gy or older patients had a significantly higher probability of vestibular nerve dysfunction. CONCLUSIONS Further prospective studies should be designed to provide further insight into the exact relationship between the predictive factors we investigated and post-treatment complications.
Collapse
Affiliation(s)
- Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Korea
| | - Hyun Ho Jung
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Hee Chang
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Woo Chang
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Gou Park
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea
| | - Won Seok Chang
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Yonsei Gamma Knife Center, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
17
|
Tuleasca C, George M, Faouzi M, Schiappacasse L, Leroy HA, Zeverino M, Daniel RT, Maire R, Levivier M. Acute clinical adverse radiation effects after Gamma Knife surgery for vestibular schwannomas. J Neurosurg 2016; 125:73-82. [DOI: 10.3171/2016.7.gks161496] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEVestibular schwannomas (VSs) represent a common indication of Gamma Knife surgery (GKS). While most studies focus on the long-term morbidity and adverse radiation effects (AREs), none describe the acute clinical AREs that might appear on a short-term basis. These types of events are investigated, and their incidence, type, and outcomes are reported in the present paper.METHODSThe included patients were treated between July 2010 and March 2016, underwent at least 6 months of follow-up, and presented with a disabling symptom during the first 6 months after GKS that affected their quality of life. The timing of appearance, as well as the type of main symptom and outcome, were noted. The prescribed dose was 12 Gy at the margin.RESULTSThirty-five (22%) of 159 patients who fulfilled the inclusion criteria had acute clinical AREs. The mean followup period was 30 months (range 6–49.2 months). The mean time of appearance was 37.9 days (median 31 days; range 3–110 days). In patients with de novo symptoms, the more frequent symptoms were vertigo (n = 4; 11.4%) and gait disturbance (n = 3; 8.6%). The exacerbation of a preexisting symptom was more frequently related to hearing loss (n = 10; 28.6%), followed by gait disturbance (n = 7; 20%) and vertigo (n = 3, 8.6%). In the univariate logistic regression analysis, the following factors were statistically significant: age (p = 0.002; odds ratio [OR] 0.96), hearing at baseline by Gardner-Robertson (GR) class (p = 0.006; OR 0.21), pure tone average at baseline (p = 0.006; OR 0.97), and Koos grade at baseline (with Koos Grade I used as a reference) (for Koos Grade II, OR 0.17 and p = 0.002; for Koos Grade III, OR 0.42 and p = 0.05). The following were not statistically significant but showed a tendency toward significance: the number of isocenters (p = 0.06; OR 0.94) and the maximal dose received by the cochlea (p = 0.07; OR 0.74). Fractional polynomial regression analysis showed a nonlinear relationship between the outcome and the radiation dose rate (minimum reached at a cutoff of 2.5 Gy/minute) and the maximal vestibular dose (maximum reached at a cutoff of 8 Gy), but the small sample size precludes a detailed analysis of the former. The clinical acute AREs disappeared in 32 (91.4%) patients during the first 6 months after appearance. Permanent and somewhat disabling morbidity was found in 3 cases (1.9% from the whole series): 1 each with complete hearing loss (GR Class I before and V after), hemifacial spasm (persistent but alleviated), and dysgeusia.CONCLUSIONSAcute effects after radiosurgery for VS are not rare. They concern predominantly de novo vertigo and gait disturbance and the exacerbation of preexistent hearing loss. In de novo vestibular symptoms, a vestibular dose of more than 8 Gy is thought to play a role. In most cases, none of these effects are permanent, and they will ultimately improve or disappear with steroid therapy. Permanent AREs remain very rare.
Collapse
Affiliation(s)
- Constantin Tuleasca
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 2Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL)
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Mercy George
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 4Department of ENT Surgery,
| | - Mohamed Faouzi
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 5Institute of Social and Preventive Medicine, and
| | - Luis Schiappacasse
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 6Radiation Oncology Service, Lausanne University Hospital (CHUV), Lausanne
| | - Henri-Arthur Leroy
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 7Division of Neurosurgery, Centre Hospitalier Régional Universitaire de Lille, France; and
| | | | - Roy Thomas Daniel
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | - Raphael Maire
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
- 4Department of ENT Surgery,
| | - Marc Levivier
- 1Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center,
- 3Faculty of Biology and Medicine, University of Lausanne, Switzerland
| |
Collapse
|
18
|
Gamma Knife Radiosurgery as Primary Treatment for Large Vestibular Schwannomas: Clinical Results at Long-Term Follow-Up in a Series of 59 Patients. World Neurosurg 2016; 95:487-501. [DOI: 10.1016/j.wneu.2016.07.117] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/27/2016] [Accepted: 07/30/2016] [Indexed: 12/19/2022]
|
19
|
Surgical management of vestibular schwannomas after failed radiation treatment. Neurosurg Rev 2016; 39:303-12; discussion 312. [DOI: 10.1007/s10143-015-0690-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/31/2015] [Indexed: 12/28/2022]
|
20
|
Senova S, Aggad M, Golmard JL, Hasboun D, Lamproglou I, Jenny C, Cornu P, Mazeron JJ, Valéry CA. Predictors of Trigeminal Neuropathy After Radiosurgery for Vestibular Schwannomas. Int J Radiat Oncol Biol Phys 2016; 95:721-8. [PMID: 26960748 DOI: 10.1016/j.ijrobp.2016.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 01/02/2016] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE To analyze the relationship between dosimetric characteristics and symptoms related to trigeminal neuropathy (TN) observed after radiosurgery (RS) for vestibular schwannomas (VS); to propose guidelines to optimize planification in VS RS regarding TN preservation; and to detail the mechanism of TN impairment after VS RS. METHODS AND MATERIALS One hundred seventy-nine patients treated between 2011 and 2013 for VS RS and without trigeminal impairment before RS were included in a retrospective study. Univariate and multivariate analyses were performed to determine predictors of TN among characteristics of the patients, the dosimetry, and the VS. RESULTS There were 20 Koos grade 1, 99 grade 2, 57 grade 3, and 3 grade 4. Fourteen patients (7.8%) presented a transitory or permanent TN. Between the patients with and without TN after VS RS, there was no significant difference regarding dosimetry or VS volume itself. Significant differences (univariate analysis P<.05, Mann-Whitney test) were found for parameters related to the cisternal portion of the trigeminal nerve: total integrated dose, maximum dose, mean dose, volume of the Vth nerve (Volv), and volume of the Vth nerve receiving at least 11 Gy (VolVcist>11Gy), but also for maximal dose to the Vth nerve nucleus and intra-axial portion (Dose maxVax). After multivariate analysis, the best model predicting TN included VolVcist>11Gy (P=.0045), Dose maxVax (P=.0006), and Volv (P=.0058). The negative predictive value of this model was 97%. CONCLUSIONS The parameters VolVcist>11Gy, Dose maxVax, and Volv should be checked when designing dosimetry for VS RS.
Collapse
Affiliation(s)
- Suhan Senova
- Unité de Radiochirurgie Gamma Knife, Region Ile De France, Paris, France; Service de Neurochirurgie, Centre Hospitalier Universitaire (CHU) La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France; Inserm, U955, Equipe 14, Université Paris Est, Faculté de médecine, Créteil, France
| | - Mourad Aggad
- Unité de Radiochirurgie Gamma Knife, Region Ile De France, Paris, France; Service de Neurochirurgie, Centre Hospitalier Universitaire (CHU) La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Jean-Louis Golmard
- Service de Biostatistiques, CHU La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Dominique Hasboun
- Service de Neuroanatomie, CHU La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Ioannis Lamproglou
- Unité de Radiochirurgie Gamma Knife, Region Ile De France, Paris, France
| | - Catherine Jenny
- Unité de Radiochirurgie Gamma Knife, Region Ile De France, Paris, France; Service de Radiothérapie, Unité de physique médicale, CHU La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, France
| | - Philippe Cornu
- Service de Neurochirurgie, Centre Hospitalier Universitaire (CHU) La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France
| | - Jean-Jacques Mazeron
- Service de Radiothérapie, Unité de physique médicale, CHU La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, France
| | - Charles A Valéry
- Unité de Radiochirurgie Gamma Knife, Region Ile De France, Paris, France; Service de Neurochirurgie, Centre Hospitalier Universitaire (CHU) La Pitié-Salpêtrière, Assistance Publique des Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France.
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Sughrue ME, Sayegh ET, Parsa AT. Towards a hypermodern theory of meningioma surgery. Clin Neurol Neurosurg 2014; 126:69-75. [PMID: 25215444 DOI: 10.1016/j.clineuro.2014.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/26/2014] [Accepted: 06/01/2014] [Indexed: 11/18/2022]
Abstract
In spite of significant improvements in patient outcomes, meningioma surgery continues to be associated with appreciable morbidity and variability in management schemes, suggesting an opportunity for improvement. In this article, we attempt to cross-pollinate our discipline with theoretical concepts and analytic frameworks from the field of cultural studies over the past several decades. We provide an overview of modernist, postmodernist, and hypermodernist thinking, the last of which emphasizes rapid progress, repeated recreation of dogmas, and data-driven decision-making. We subsequently demonstrate how the evolution of these schools of thought can be used to improve the analytic approach to comparative outcomes research in neurosurgery, with meningioma research as a principal example. We contend that with the renaissance of microsurgery and advent of improved technologies in meningioma management over recent years, modernist analytic methods are no longer adequate. Instead, we advocate for a new hypermodern paradigm that provides evidence-based answers to unresolved questions, minimizes unwarranted variability in clinical practice patterns, and provides a system for continuous assessment and reassessment of outcomes in the rapidly evolving environment of contemporary skull base neurosurgery. In particular, we discuss the relevance of historical case series from leading neurosurgeons for clinical decision-making, the value of seeking new data for longstanding clinical questions, the merits of radiosurgery versus open surgery, and the importance of recognizing tumor heterogeneity rather than simply stratifying them based on general characteristics such as tumor location. In turn, we lay a conceptual foundation for improving outcomes research in meningioma surgery.
Collapse
Affiliation(s)
- Michael E Sughrue
- Department of Neurological Surgery, University of Oklahoma, Oklahoma City, USA
| | - Eli T Sayegh
- Department of Neurological Surgery, Northwestern University, Chicago, USA
| | - Andrew T Parsa
- Department of Neurological Surgery, Northwestern University, Chicago, USA.
| |
Collapse
|
23
|
Gerganov VM, Giordano M, Elolf E, Osamah A, Amir S, Madjid S. Operative management of patients with radiosurgery-related trigeminal neuralgia: Analysis of the surgical morbidity and pain outcome. Clin Neurol Neurosurg 2014; 122:23-8. [DOI: 10.1016/j.clineuro.2014.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/02/2014] [Accepted: 04/13/2014] [Indexed: 11/25/2022]
|
24
|
Hebb ALO, Sawynok J, Bance M, Walling S, Chisholm K, Morris DP. Pharmacological management of neuropathic pain in patients with vestibular schwannomas: Experience of the Atlantic Lateral Skull Base Clinic. World J Pharmacol 2014; 3:24-32. [DOI: 10.5497/wjp.v3.i2.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 05/31/2014] [Accepted: 07/29/2014] [Indexed: 02/06/2023] Open
Abstract
Neuropathic pain is chronic pain generated by disorders of the peripheral and central nervous system, including skull base tumours. A skull base tumour can be any type of tumour that forms in the skull base, and this includes vestibular schwannomas which arise from the sheath of the inner ear vestibulocochlear nerve (eighth cranial nerve). Growth of the tumour, surgical resection, and/or stereotactic radiotherapy may result in compression and/or irritation of the fifth cranial nerve (trigeminal nerve) resulting in facial pain and/or numbness. Non-trigeminal afferent input may contribute to the wide constellation of symptoms seen in orofacial pain patients. The purpose of this report was to develop a decision tool to guide the recognition and treatment of neuropathic pain in this specialized population. Recommendations for treatment are based on evidence presented in Canadian and international neuropathic treatment guidelines. Algorithms are included for assessment and treatment of adult patients with agents that are recognized to have analgesic efficacy within the broad context of neuropathic pain.
Collapse
|
25
|
Abstract
OBJECT To review our institutional experience with Gamma Knife (GK) stereotactic radiosurgery in treating large vestibular schwannomas (VS) of 3 to 4 cm diameter. METHODS We conducted a retrospective cohort review of all patients treated with GK for VS at our institution between November 2003 and March 2012. Data on age, sex, VS volume, location and maximal diameter, House-Brackmann (HB) facial nerve scores pre and post-GK, Gardner-Robertson (GR) hearing score pre and post-GK, GK treatment parameters, VS response time, complications and clinical outcome was recorded RESULTS A total of 28 patients during the defined time period were identified. Three patients were lost to follow-up. Mean follow-up was 34.5 months. Tumor control occurred in 92%, and was maintained in 85.7% at two years. Facial nerve or hearing preservation occurred in all treated compared to pre-GK status, as per HB and GR grading. Transient complications occurred in 80%. Temporary vestibular dysfunction occurred in seven patients (28%). One patient (4%) had the permanent complication of worsening pre-GK hemifacial spasm. Four patients (16%) developed hydrocephalus post-GK. CONCLUSION GK stereotactic radiosurgery as a primary treatment modality for large VS can provide acceptable tumor control rates with good facial nerve and hearing preservation, and low complication rates.
Collapse
|
26
|
Fractionated radiation therapy for vestibular schwannoma. J Clin Neurosci 2013; 21:1083-8. [PMID: 24513160 DOI: 10.1016/j.jocn.2013.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 11/13/2013] [Indexed: 11/23/2022]
Abstract
Vestibular schwannomas are the most common tumors of the cerebellopontine angle. Multiple management paradigms exist for patients with these benign tumors, including observation, microsurgery, stereotactic radiosurgery, and fractionated radiation therapy, or some combination of these. While the proper course of management is controversial, the goals of therapy are to achieve excellent local tumor control and optimize functional outcomes with as little treatment-related morbidity as possible. Decision-making is tailored to patient-specific factors such as tumor size, clinical presentation, patient age, and goals of hearing preservation. We review the literature in order to summarize the application of fractionated radiation therapy to this tumor entity, where it is used as a primary treatment or, more commonly, as an adjunct therapy. We also provide an overview of the use of fractionated radiation therapy for the preservation of hearing and facial function, and dosing and other technical considerations, in light of the indolent natural history of vestibular schwannomas. We also discuss potential risks associated with this treatment modality, including its effects on temporal bone structures and cranial nerves among other possible complications. Lastly, we outline future directions in this rapidly evolving segment of vestibular schwannoma therapy, which has benefited from the advent of intensity-modulated radiation therapy coupled with stereotactic localization.
Collapse
|
27
|
Van Gompel JJ, Patel J, Danner C, Zhang AN, Samy Youssef AA, van Loveren HR, Agazzi S. Acoustic neuroma observation associated with an increase in symptomatic tinnitus: results of the 2007-2008 Acoustic Neuroma Association survey. J Neurosurg 2013; 119:864-8. [PMID: 23790115 DOI: 10.3171/2013.5.jns122301] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Tinnitus is a known presenting symptom of acoustic neuromas, but little is known about the impact of observation or treatment on tinnitus. Most patients experience improvement with treatment, while others may worsen. Therefore, this study was designed to assess the overall impact of observation and treatment on tinnitus outcome in patients with acoustic tumors. METHODS Data from the 2007-2008 Acoustic Neuroma Association survey were used. Tinnitus severity was graded both at presentation and at last follow-up for all patients questioned. This data set was analyzed using the Student t-test and a linear regression model adjusted for possible confounders. RESULTS Overall there were more patients receiving intervention (n = 1138) for their acoustic neuromas than observation (n = 289). Presenting tumor size positively correlated with tinnitus severity score. Regardless of treatment (microsurgery or stereotactic radiosurgery), tinnitus improved at last follow-up and worsened in those who were observed (p = 0.02). When comparing microsurgical options, retrosigmoid and translabyrinthine resection improved tinnitus symptoms (both p < 0.01). Stereotactic radiosurgery had a treatment effect similar to microsurgery. CONCLUSIONS Presenting tinnitus severity correlates strongly with tumor size. Furthermore, regardless of treatment, there appears to be an overall reduction in tinnitus severity for all forms of microsurgery and stereotactic radiosurgery. Importantly, observation leads to a worsening in symptomatic tinnitus and therefore should be weighed in the treatment recommendation.
Collapse
|
28
|
|
29
|
Han SJ, Sughrue ME. The rise and fall of "biopsy and radiate": a history of surgical nihilism in glioma treatment. Neurosurg Clin N Am 2012; 23:207-14, vii. [PMID: 22440864 DOI: 10.1016/j.nec.2012.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Many neurosurgeons take a nihilistic approach to surgical treatment of gliomas, stating the inability to achieve a cure. Where this idea comes from is somewhat nebulous to most neurosurgeons. A review of the scientific studies supporting the commonly held beliefs about gliomas shows that these ideas regarding the surgical treatment of gliomas are based on overgeneralizations of data from older studies. One should avoid the temptation to apply them to the greater concept of what gliomas are, how they behave, and what should be done, but rather we should continue to scientifically evaluate the role of surgical resection in glioma treatment.
Collapse
Affiliation(s)
- Seunggu J Han
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M779, San Francisco, CA 94117, USA
| | | |
Collapse
|
30
|
Jian BJ, Sughrue ME, Kaur R, Rutkowski MJ, Kane AJ, Kaur G, Yang I, Pitts LH, Parsa AT. Implications of cystic features in vestibular schwannomas of patients undergoing microsurgical resection. Neurosurgery 2012; 68:874-80; discussion 879-80. [PMID: 21221029 DOI: 10.1227/neu.0b013e318208f614] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cystic vestibular schwannomas (VSs) are described as being more aggressive than solid tumors. OBJECTIVE We examined 468 VS patients to evaluate whether the presence of cystic components in VSs may be an important feature for predicting postoperative outcome. METHODS We selected all VS patients from a prospectively collected database (1984-2009) who underwent microsurgical resection for VS. Hearing data were analyzed using American Association of Otolaryngology-Head and Neck Surgery. Facial nerve dysfunction was analyzed using the House-Brackmann scale. We used univariate comparisons to determine the clinical impact of cystic changes on preoperative and postsurgical hearing and facial nerve preservation. RESULTS We identified 58 patients (11%) with cystic changes and 410 patients with solid VSs. In this analysis, cystic VS patients tended to have larger tumors (78% of patients with >2.0 cm extrameatal extension) compared with the solid VS group, which consisted of many smaller and medium-sized tumors (P < .0001). Univariate analyses found that tumors with cystic changes did not lead to worse rates of preoperative hearing loss (χ(2), P = not significant) compared with solid VSs. Cystic changes conferred worse postoperative hearing in patients with medium-sized tumors (P = .035). Cystic changes also did not significantly affect facial nerve outcomes (χ(2), P = not significant). CONCLUSION Cystic tumors tend to be larger than noncystic tumors and affect outcomes by reducing the rate at which hearing preservation is attempted and by worsening hearing outcome in medium-sized tumors. Further, peripheral cysts cause lower rates of hearing preservation compared with centrally located cysts.
Collapse
Affiliation(s)
- Brian J Jian
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Roche PH, Noudel R, Régis J. Management of radiation/radiosurgical complications and failures. Otolaryngol Clin North Am 2012; 45:367-74, ix. [PMID: 22483822 DOI: 10.1016/j.otc.2011.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
To describe the incidence and the course of complications after the radiosurgical treatment of vestibular schwannomas, the authors reviewed their own experience and reviewed the literature. Failure is described in less than 3% of cases, and this had to be distinguished from transient enlargement of tumor volume. In case of failure, microsurgical resection or another radiosurgical procedure should be discussed. The risk of radio-induced tumorigenesis is not clearly established with single-dose radiosurgical technique. Incidence and management of potential complications should be explained at the time of decision making in the management of vestibular schwannomas.
Collapse
Affiliation(s)
- Pierre-Hugues Roche
- Service de neurochirurgie, CHU Nord, Chemin des Bourrely, 13915, Marseille Cedex 20, France.
| | | | | |
Collapse
|
32
|
Predicting Nonauditory Adverse Radiation Effects Following Radiosurgery for Vestibular Schwannoma: A Volume and Dosimetric Analysis. Int J Radiat Oncol Biol Phys 2012; 82:2041-6. [DOI: 10.1016/j.ijrobp.2011.02.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 01/29/2011] [Accepted: 02/02/2011] [Indexed: 11/22/2022]
|
33
|
Hansasuta A, Choi CYH, Gibbs IC, Soltys SG, Tse VCK, Lieberson RE, Hayden MG, Sakamoto GT, Harsh GR, Adler JR, Chang SD. Multisession stereotactic radiosurgery for vestibular schwannomas: single-institution experience with 383 cases. Neurosurgery 2012; 69:1200-9. [PMID: 21558974 DOI: 10.1227/neu.0b013e318222e451] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Single-session stereotactic radiosurgery (SRS) treatment of vestibular schwannomas results in excellent tumor control. It is not known whether functional outcomes can be improved by fractionating the treatment over multiple sessions. OBJECTIVE To examine tumor control and complication rates after multisession SRS. METHODS Three hundred eighty-three patients treated with SRS from 1999 to 2007 at Stanford University Medical Center were retrospectively reviewed. Ninety percent were treated with 18 Gy in 3 sessions, targeting a median tumor volume of 1.1 cm3 (range, 0.02-19.8 cm3). RESULTS During a median follow-up duration of 3.6 years (range, 1-10 years), 10 tumors required additional treatment, resulting in 3- and 5-year Kaplan-Meier tumor control rates of 99% and 96%, respectively. Five-year tumor control rate was 98% for tumors < 3.4 cm3. Neurofibromatosis type 2-associated tumors were associated with worse tumor control (P = .02). Of the 200 evaluable patients with pre-SRS serviceable hearing (Gardner-Robertson grade 1 and 2), the crude rate of serviceable hearing preservation was 76%. Smaller tumor volume was associated with hearing preservation (P = .001). There was no case of post-SRS facial weakness. Eight patients (2%) developed trigeminal dysfunction, half of which was transient. CONCLUSION Multisession SRS treatment of vestibular schwannomas results in an excellent rate of tumor control. The hearing, trigeminal nerve, and facial nerve function preservation rates reported here are promising.
Collapse
Affiliation(s)
- Ake Hansasuta
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Wagner JN, Glaser M, Wowra B, Muacevic A, Goldbrunner R, Cnyrim C, Tonn JC, Strupp M. Vestibular function and quality of life in vestibular schwannoma: does size matter? Front Neurol 2011; 2:55. [PMID: 21941519 PMCID: PMC3171060 DOI: 10.3389/fneur.2011.00055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 08/09/2011] [Indexed: 12/04/2022] Open
Abstract
Objectives: Patients with vestibular schwannoma (VS) frequently suffer from disabling vestibular symptoms. This prospective follow-up study evaluates vestibular and auditory function and impairment of quality of life due to vertigo, dizziness, and imbalance in patients with unilateral VS of different sizes before/after microsurgical or radiosurgical treatment. Methods: Thirty-eight patients with unilateral VS were included. Twenty-two received microsurgery, 16 CyberKnife radiosurgery. Two follow-ups took place after a median of 50 and 186.5 days. Patients received a standardized neuro-ophthalmological examination, electronystagmography with bithermal caloric testing, and pure-tone audiometry. Quality of life was evaluated with the Dizziness Handicap Inventory (DHI). Patient data was grouped and analyzed according to the size of the VS (group 1: <20 mm vs group 2: ≥20 mm). Results: In group 1, the median loss of vestibular function was +10.5% as calculated by Jongkees Formula (range −43 to +52; group 2: median +36%, range −56 to +90). The median change of DHI scores was −9 in group 1 (range −68 to 30) and +2 in group 2 (−54;+20). Median loss of hearing was 4 dB (−42; 93) in group 1 and 12 dB in group 2 (5; 42). Conclusion: Loss of vestibular function in VS clearly correlates with tumor size. However, loss of vestibular function was not strictly associated with a long-term deterioration of quality of life. This may be due to central compensation of vestibular deficits in long-standing large tumors. Loss of hearing before treatment was significantly influenced by the age of the patient but not by tumor size. At follow-up 1 and 2, hearing was significantly influenced by the size of the VS and the manner of treatment.
Collapse
|
35
|
Yang I, Han SJ, Sughrue ME, Tihan T, Parsa AT. Immune cell infiltrate differences in pilocytic astrocytoma and glioblastoma: evidence of distinct immunological microenvironments that reflect tumor biology. J Neurosurg 2011; 115:505-11. [PMID: 21663411 DOI: 10.3171/2011.4.jns101172] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECT The tumor microenvironment in astrocytomas is composed of a variety of cell types, including infiltrative inflammatory cells that are dynamic in nature, potentially reflecting tumor biology. In this paper the authors demonstrate that characterization of the intratumoral inflammatory infiltrate can distinguish high-grade glioblastoma from low-grade pilocytic astrocytoma. METHODS Tumor specimens from ninety-one patients with either glioblastoma or pilocytic astrocytoma were analyzed at the University of California, San Francisco. A systematic neuropathology analysis was performed. All tissue was collected at the time of the initial surgery prior to adjuvant treatment. Immune cell infiltrate not associated with necrosis or hemorrhage was analyzed on serial 4-μm sections. Analysis was performed for 10 consecutive hpfs and in 3 separate regions (total 30 × 0.237 mm(2)). Using immunohistochemistry for markers of infiltrating cytotoxic T cells (CD8), natural killer cells (CD56), and macrophages (CD68), the inflammatory infiltrates in these tumors were graded quantitatively and classified based on microanatomical location (perivascular vs intratumoral). Control markers included CD3, CD20, and human leukocyte antigen. RESULTS Glioblastomas exhibited significantly higher perivascular (CD8) T-cell infiltration than pilocytic astrocytomas (62% vs 29%, p = 0.0005). Perivascular (49%) and intratumoral (89%; p = 0.004) CD56-positive cells were more commonly associated with glioblastoma. The CD68-positive cells also were more prevalent in the perivascular and intratumoral space in glioblastoma. In the intratumoral space, all glioblastomas exhibited CD68-positive cells compared with 86% of pilocytic astrocytomas (p = 0.0014). Perivascularly, CD68-positive infiltrate was also more prevalent in glioblastoma when compared with pilocytic astrocytoma (97% vs 86%, respectively; p = 0.0003). The CD3-positive, CD20-positive, and human leukocyte antigen-positive infiltrates did not differ between glioblastoma and pilocytic astrocytoma. CONCLUSIONS This analysis suggests a significantly distinct immune profile in the microenvironment of high-grade glioblastoma versus low-grade pilocytic astrocytoma. This difference in tumor microenvironment may reflect an important difference in the tumor biology of glioblastoma.
Collapse
Affiliation(s)
- Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | | | | | | | | |
Collapse
|
36
|
Sughrue ME, Kaur R, Rutkowski MJ, Kane AJ, Yang I, Pitts LH, Parsa AT. A critical evaluation of vestibular schwannoma surgery for patients younger than 40 years of age. Neurosurgery 2011; 67:1646-53; discussion 1653-4. [PMID: 21107195 DOI: 10.1227/neu.0b013e3181f8d3d3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There are few published prospective data sets specifically focusing on patients younger than 40 years old undergoing microsurgery for vestibular schwannoma. OBJECTIVE We describe functional outcomes and long-term tumor control after surgery in patients younger than 40 years old enrolled in a prospectively collected database over a 25-year period. METHODS We selected all vestibular schwannoma patients from a prospectively collected database who were younger than 40 years old at the time of surgical resection for a vestibular schwannoma. Rates of tumor control and hearing preservation were analyzed using Kaplan-Meier analysis, and risk factors for facial nerve palsy, hearing loss, and trigeminal neuropathy were analyzed using multivariate logistic regression. RESULTS A total of 204 patients younger than 40 years of age met our inclusion criteria and were included in the analysis. Our data indicate that surgical resection leads to durable long-term freedom from tumor recurrence or progression in 89% of young patients at 15 years of follow-up. Consistent with other published series, hearing was preserved in 68% of patients with smaller tumors (<3 cm). Facial nerve function was preserved in 76% of patients with smaller tumors and 52% of patients with larger tumors (P<.001). On multivariate logistic regression, tumor size was a significant predictor of hearing loss, whereas gross total resection was nearly a significant predictor of hearing loss controlling for other variables (P=.06). CONCLUSION We present the largest prospectively studied cohort of young patients undergoing microsurgical resection of vestibular schwannoma. These data suggest that surgical resection provides excellent long-term tumor control in these patients.
Collapse
Affiliation(s)
- Michael E Sughrue
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California 94143, USA
| | | | | | | | | | | | | |
Collapse
|
37
|
Sughrue ME, Kaur R, Rutkowski MJ, Kane AJ, Kaur G, Yang I, Pitts LH, Parsa AT. Extent of resection and the long-term durability of vestibular schwannoma surgery. J Neurosurg 2011; 114:1218-23. [PMID: 21250800 DOI: 10.3171/2010.11.jns10257] [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 With limited studies available, the correlation between the extent of resection and tumor recurrence in vestibular schwannomas (VSs) has not been definitively established. In this prospective study, the authors evaluated 772 patients who underwent microsurgical resection of VSs to analyze the association between total tumor resection and the tumor recurrence rate. METHODS The authors selected all cases from a prospectively collected database of patients who underwent microsurgical resection as their initial treatment for a histopathologically confirmed VS. Recurrence-free survival was analyzed using Kaplan-Meier analysis. The authors studied the impact of possible confounders such as patient age and tumor size using stepwise Cox regression to calculate the proportional hazard ratio of recurrence while controlling for other cofounding variables. RESULTS The authors analyzed data obtained in 571, 89, and 112 patients in whom gross-total, near-total, and subtotal resections, respectively, were performed. A gross-total resection was achieved in 74% of the patients, and the overall recurrence rate in these patients 8.8%. There was no significant relation between the extent of resection and the rate of tumor recurrence (p = 0.58). As expected, the extent of resection was highly correlated with patient age, tumor size, and surgical approach (p < 0.0001). Using Cox regression, the authors found that the approach used did not significantly affect tumor control when the extent of resection was controlled for. CONCLUSIONS While complete tumor removal is ideal, the results presented here suggest that there is no significant relationship between the extent of resection and tumor recurrence.
Collapse
Affiliation(s)
- Michael E Sughrue
- Department of Neurological Surgery, University of California, San Francisco, California 94143, USA
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Stereotactic radiation treatment of vestibular schwannoma: indications, limitations, and outcomes. Curr Opin Otolaryngol Head Neck Surg 2011; 18:351-6. [PMID: 20613529 DOI: 10.1097/moo.0b013e32833c71a2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Stereotactic radiation treatment is an increasingly performed procedure for patients with vestibular schwannoma and other benign skull base tumors. During the past 30 years, advancements in stereotactic imaging, radiation delivery techniques, and dose planning have improved overall patient outcomes. The specific role of radiation in current management strategies for vestibular schwannoma continues to evolve as long-term outcome data are analyzed and standardized studies are performed. The recent literature regarding the indications, limitations, and outcomes for stereotactic radiation treatment is reviewed. RECENT FINDINGS Systematic reviews of the Gamma Knife literature demonstrate improved overall outcomes with radiation doses below 13 Gy. Observation of small vestibular schwannomas is recommended over early radiation or microsurgical intervention. Radiation may be used as adjunctive therapy for large tumors and in certain postradiation treatment failures. Stereotactic radiosurgery and fractionated radiotherapy are equally effective treatment modalities. SUMMARY Long-term outcome data will ultimately define future indications and limitations for the use of stereotactic radiation with benign skull base lesions. Current evidence supports its use for small to medium sized primary and recurrent vestibular schwannomas with optimal dosing below 13 Gy. It is also recommended for adjunctive therapy, recurrent tumors, in poor surgical candidates, and for those who do not desire observation or surgery.
Collapse
|
39
|
Transmastoid Labyrinthectomy for Disabling Vertigo in a Patient With Internal Auditory Canal Pathology. Otol Neurotol 2011; 32:122-4. [DOI: 10.1097/mao.0b013e318200a0ad] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
40
|
|
41
|
Current Opinion in Otolaryngology & Head and Neck Surgery. Current world literature. Curr Opin Otolaryngol Head Neck Surg 2010; 18:466-74. [PMID: 20827086 DOI: 10.1097/moo.0b013e32833f3865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
42
|
Factors associated with preservation of facial nerve function after surgical resection of vestibular schwannoma. J Neurooncol 2010; 102:281-6. [PMID: 20694574 PMCID: PMC3052445 DOI: 10.1007/s11060-010-0315-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 07/12/2010] [Indexed: 11/09/2022]
Abstract
Avoidance of facial nerve palsy is one of the major goals of vestibular schwannoma (VS) microsurgery. In this study, we examined the significance of previously implicated prognostic factors (age, tumor size, the extent of resection and the surgical approach) on post-operative facial nerve function. We selected all VS patients from prospectively collected database (1984–2009) who underwent microsurgical resection as their initial treatment for histopathologically confirmed VS. The effect of variables such as surgical approach, tumor size, patient age and extent of resection on rates facial nerve dysfunction after surgery, were analyzed using multivariate logistic regression. Patients with preoperative facial nerve dysfunction (House-Brackman [HB] score 3 or higher) were excluded, and HB grade of 1 or 2 at the last follow-up visit was defined as “facial nerve preservation.” A total of 624 VS patients were included in this study. Multivariate logistic regression analysis found that only pre-operative tumor size significantly predicted poorer facial nerve outcome for patients followed-up for ≥6 and ≥12 months (OR 1.27, 95% CI 1.09–1.49, p < 0.01; OR 1.35, 95% CI 1.10–1.67, P < 0.01, respectively). We found no significant relationship between facial nerve function and age, extent of resection, surgical approach, or tumor size (when extent of resection and surgical approach were included in the regression analysis). Because facial nerve palsy is a debilitating and psychologically devastating condition for the patient, we suggest altering surgical aggressiveness in patients with unfavorable tumor anatomy, particularly in cases with large tumors where overaggressive resection might subject the patient to unwarranted risk. Residual disease can be followed and controlled with radiosurgery if interval growth is noted.
Collapse
|
43
|
The value of intraoperative facial nerve electromyography in predicting facial nerve function after vestibular schwannoma surgery. J Clin Neurosci 2010; 17:849-52. [DOI: 10.1016/j.jocn.2010.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 02/23/2010] [Indexed: 11/20/2022]
|
44
|
Sughrue ME, Kaur R, Kane AJ, Rutkowski MJ, Yang I, Pitts LH, Tihan T, Parsa AT. Intratumoral hemorrhage and fibrosis in vestibular schwannoma: a possible mechanism for hearing loss. J Neurosurg 2010; 114:386-93. [PMID: 20560722 DOI: 10.3171/2010.5.jns10256] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Vestibular schwannomas (VSs) are benign lesions with an unpredictable natural history. Perhaps the greatest barrier to predicting which patients need treatment is our poor understanding of how these tumors cause hearing loss in the first place. In this case-control study, the authors investigated the relationship between preoperative hearing loss and histological changes such as intratumoral microhemorrhage and extensive fibrosis. METHODS From a prospectively collected database, the authors selected all patients with VS who had undergone microsurgical resection as their initial treatment for histopathologically confirmed VS. Histological specimens obtained in 274 of these patients were systematically reviewed by a blinded neuropathologist who graded the extent of microhemorrhage and fibrosis in these tumors. The effect of these variables on preoperative hearing loss was studied using binary logistic regression. RESULTS On univariate analysis, patients with extensive intratumoral microhemorrhage or fibrosis (p < 0.0001), patients with larger tumors (p < 0.05), and patients 65 years of age or older (p < 0.05) were significantly more likely to have unserviceable hearing at the time of surgery. On multivariate analysis, only patients with extensive intratumoral microhemorrhage or fibrosis had an increased risk of having unserviceable hearing at the time of surgery (OR 3.72, 95% CI 1.3-10; p = 0.01). Older age and tumor size greater than 3 cm were not statistically significant risk factors for hearing loss, controlling for the effect of microhemorrhage and fibrosis. CONCLUSIONS In this study, the authors have demonstrated a correlation between the extent of nonneoplastic histological changes, such as microhemorrhage and fibrosis, and hearing loss. This alternate hypothesis has the potential to explain many of the exceptions to previously described mechanisms of hearing loss in patients with VS. The advent of high-resolution MR imaging technology to identify microhemorrhages may provide a method to screen for patients with VS at risk for hearing loss.
Collapse
Affiliation(s)
- Michael E Sughrue
- Department of Neurological Surgery, University of California, San Francisco, 94143, USA
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Sughrue ME, Kane AJ, Kaur R, Barry JJ, Rutkowski MJ, Pitts LH, Cheung SW, Parsa AT. A prospective study of hearing preservation in untreated vestibular schwannomas. J Neurosurg 2010; 114:381-5. [PMID: 20486891 DOI: 10.3171/2010.4.jns091962] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors previously published a systematic review of the English language literature regarding the natural history of untreated vestibular schwannomas (VSs). This analysis found that the best predictor of future hearing loss was tumor growth > 2.5 mm/year on serial imaging, a factor that doubled the rate of hearing loss. In this paper the authors present an analysis of prospectively collected outcomes in patients with untreated VS from their institution that confirms their previous findings. METHODS Clinical, radiographic, and audiometric data for all patients evaluated for VS at the authors' institution over a 22-year period were prospectively collected in a database. All patients in this database who had serviceable hearing (American Academy of Otolaryngology-Head and Neck Surgery Grade A or B) on initial presentation were selected, and underwent serial observation. Magnetic resonance imaging and audiometric data were analyzed, and the time from presentation until hearing loss was analyzed using Kaplan-Meier analysis. RESULTS Fifty-nine patients with VS who initially presented with serviceable hearing were treated conservatively over this period. Consistent with the authors' previous findings, patients with a tumor growth rate > 2.5 mm/year at any point during follow-up lost their hearing at a much faster rate than those who had slower growing tumors. The median time to hearing loss was 7.0 years in those patients with tumor growth rate > 2.5 mm/year compared to 14.8 years in the other patients (p < 0.0001). The estimated median time to hearing loss in the 3 initial tumor size groups was 11.6 years in the intracanalicular group, 10.3 years in the group with 0.1-1 cm extension into the CPA cistern, and 9.3 years in the group with > 1 cm extension into the CPA cistern (p value nonsignificant). Initial tumor size, age at diagnosis, and neurofibromatosis Type 2 status did not affect the time to loss of serviceable hearing. Interestingly, many patients who were followed up for more than a decade eventually lost their hearing, regardless of whether the tumor displayed any documented interval growth. CONCLUSION The authors confirmed the findings of their systematic review of the literature using a prospectively followed group of patients with untreated VS. Collectively, these data suggest that the expectation for more rapid hearing loss should be communicated to patients, and the decision for surgical or other intervention should be made in the context of the known risk of continued observation of fast growing tumors.
Collapse
Affiliation(s)
- Michael E Sughrue
- Department of Neurological Surgery, University of California, San Francisco, 94143, USA
| | | | | | | | | | | | | | | |
Collapse
|