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Maldonado J, Porto E, Revuelta Barbero JM, Tello I, Rodas A, Vivas EX, Mattox DE, Solares CA, Garzon Muvdi T, Pradilla G. Thermal Analysis of an Ultrasonic Aspirator Micro Claw Tool Compared With Standard High-Speed Drilling During Internal Auditory Canal Opening in a Cadaveric Model. Oper Neurosurg (Hagerstown) 2023; 25:183-189. [PMID: 37083749 DOI: 10.1227/ons.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/16/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND The ultrasonic aspirator micro claw tool (UAmCT) can be used to remove the bone of the internal auditory canal (IAC) during vestibular schwannoma resection via the retrosigmoid approach (RSA) without the risk of a spinning drill shaft. However, the thermal profile of the UAmCT during IAC removal has not been reported. OBJECTIVE To compare the thermal profile of the UAmCT during access of the IAC to that of a conventional high-speed drill (HSD) and to present an illustrative case of this application. METHODS IAC opening via RSA was performed in 5 embalmed cadaveric specimens using the UAmCT with 3, 8, and 15 mL/min irrigation on the left and the HSD at 75 000 revolutions per minute and 0%, 14%, and 22% irrigation on the right. Peak bone surface temperatures were measured 4 times in 20-second intervals, and statistical analyses were performed using SPSS software. An illustrative case of a vestibular schwannoma resected via an RSA using the UAmCT to access the IAC is presented. RESULTS The IAC was opened in all 5 specimens using both the UAmCT and HSD without complication. The mean peak bone surface temperatures were significantly lower with the UAmCT compared with the HSD ( P < .001). The UAmCT did not meaningfully prolong the operating time in the illustrative case, and the IAC was accessed without complication. CONCLUSION The UAmCT may be a safe and effective alternative to HSD for IAC opening during vestibular schwannoma resection via the RSA. Larger studies under clinical conditions are required to further validate these findings.
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Affiliation(s)
- Justin Maldonado
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Edoardo Porto
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - J Manuel Revuelta Barbero
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Isaac Tello
- Department of Neurosurgery, Instituto Nacional de Neurología y Neurocirugía Manuel V. Suárez, Mexico City, Mexico
| | - Alejandra Rodas
- Department of Otolaryngology, Emory University, Atlanta, Georgia, USA
| | - Esther X Vivas
- Department of Otolaryngology, Emory University, Atlanta, Georgia, USA
| | - Douglas E Mattox
- Department of Otolaryngology, Emory University, Atlanta, Georgia, USA
| | - C Arturo Solares
- Department of Otolaryngology, Emory University, Atlanta, Georgia, USA
| | | | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
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Treatment for vestibular schwannoma: Systematic review and single arm meta-analysis. Am J Otolaryngol 2022; 43:103337. [PMID: 34973662 DOI: 10.1016/j.amjoto.2021.103337] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 11/13/2021] [Accepted: 12/09/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Vestibular schwannoma is a benign tumor in the schwannoma cells of the 8th cranial nerve. It causes symptoms like tinnitus, vertigo and end up with loss of hearing so the appropriate treatment is very important. There are many treatment techniques including conservative, surgery and radiosurgery. We aimed to systematically review and single arm meta-analysis the different treatment techniques of vestibular schwannoma. METHODS A comprehensive literature search using thirteen databases including PubMed, Scopus, and Web of Science was performed. All clinical trials about treatment vestibular schwannoma were included and single arm meta-analyzed. We assessed the risk of bias using ROBIN-I's tool and scale of Council Australia's Cancer Guidelines Wiki. The protocol was registered in PROSPERO (CRD42018089784) and has been updated on 17 April 2019. RESULTS A total of 35 clinical trials studies were included in the final analysis. The pooled proportion of stable hearing capability in patients receiving gamma knife radiosurgery (GKRS) was 64% (95% CI: 52%-74%). GKRS favored increased hearing capability 10% (95% CI: 7%-16%). Regarding tumor size, GKRS is the most protective method 53% (95% CI: 37%-69%). Complications occurred most commonly in single fractional linac stereotactic radiosurgery (SFSRT) 37% (95% CI: 12%-72%). CONCLUSION Our analysis suggested gamma knife radiosurgery could be the most ideal treatment for vestibular schwannoma based on stabilizing hearing capability, increasing hearing capability, decreasing tumor size and complications.
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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: 10] [Impact Index Per Article: 2.5] [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.
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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
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Przybylowski CJ, Baranoski JF, Paisan GM, Chapple KM, Meeusen AJ, Sorensen S, Almefty KK, Porter RW. CyberKnife radiosurgery for acoustic neuromas: Tumor control and clinical outcomes. J Clin Neurosci 2019; 63:72-76. [DOI: 10.1016/j.jocn.2019.01.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
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Nguyen T, Duong C, Sheppard JP, Lee SJ, Kishan AU, Lee P, Tenn S, Chin R, Kaprealian TB, Yang I. Hypo-fractionated stereotactic radiotherapy of five fractions with linear accelerator for vestibular schwannomas: A systematic review and meta-analysis. Clin Neurol Neurosurg 2018; 166:116-123. [PMID: 29414150 DOI: 10.1016/j.clineuro.2018.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/31/2017] [Accepted: 01/07/2018] [Indexed: 10/18/2022]
Abstract
Vestibular schwannomas (VS) are benign tumors stemming from the eighth cranial nerve. Treatment options for VS include conservative management, microsurgery, stereotactic radiosurgery, and fractionated radiotherapy. Though microsurgery has been the standard of care for larger lesions, hypo-fractionated stereotactic radiotherapy (hypo-FSRT) is an emerging modality. However, its clinical efficacy and safety have yet to be established. We conducted a systematic review and meta-analysis of manuscripts indexed in PubMed, Scopus, Web of Science, Embase, and Cochrane databases reporting outcomes of VS cases treated with hypo-FSRT. Five studies representing a total of 228 patients were identified. Across studies, the pooled rates of tumor control, hearing, facial nerve, and trigeminal nerve preservation were 95%, 37%, 97%, and 98%. No instances of malignant induction were observed at median follow-up of 34.8 months. Complications included trigeminal neuropathy (n = 3), maxillary paresthesia (n = 1), neuralgia (n = 1), vestibular dysfunction (n = 1), radionecrosis (n = 1), and hydrocephalus (n = 1). Hypo-FSRT may be another useful approach to manage VS, but studies with extended follow-up times are required to establish long-term safety.
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Affiliation(s)
- Thien Nguyen
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Courtney Duong
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States
| | - John P Sheppard
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Seung Jin Lee
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Amar U Kishan
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Percy Lee
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Stephen Tenn
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Robert Chin
- Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Tania B Kaprealian
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States
| | - Isaac Yang
- Departments of Neurosurgery, Los Angeles (UCLA), Los Angeles, CA, United States; Radiation Oncology, Los Angeles (UCLA), Los Angeles, CA, United States; Head and Neck Surgery, Los Angeles (UCLA), Los Angeles, CA, United States; Jonsson Comprehensive Cancer Center, Los Angeles (UCLA), Los Angeles, CA, United States; Los Angeles Biomedical Research Institute, Los Angeles (UCLA), Los Angeles, CA, United States; Harbor-UCLA Medical Center, Los Angeles (UCLA), Los Angeles, CA, United States; David Geffen School of Medicine of the University of California, Los Angeles (UCLA), Los Angeles, CA, United States.
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Mahboubi H, Sahyouni R, Moshtaghi O, Tadokoro K, Ghavami Y, Ziai K, Lin HW, Djalilian HR. CyberKnife for Treatment of Vestibular Schwannoma: A Meta-analysis. Otolaryngol Head Neck Surg 2017; 157:7-15. [PMID: 28441508 DOI: 10.1177/0194599817695805] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives (1) Perform a meta-analysis of the available data on the outcomes of CyberKnife radiosurgery for treatment of vestibular schwannomas (VSs) in the published English-language literature and (2) evaluate the collective outcomes of CyberKnife treatment with respect to tumor control and hearing preservation. Data Sources A thorough literature search of published English-language articles was performed in the PubMed, Ovid, and Cochrane databases. Review Methods A database search was conducted with the keywords "CyberKnife" and "vestibular schwannoma" or "acoustic neuroma." A total of 25 papers were found and reviewed. Data were extracted for patient demographics, number of patients with neurofibromatosis type 2, pretreatment hearing status, tumor size, margin dose, and follow-up duration. The primary outcome variables evaluated were tumor control and hearing preservation. Results After careful review of the published articles, 11 papers reported data on outcomes of CyberKnife treatment for VS and were included in the analysis, comprising 800 patients studied during 1998 to 2012. The reported mean tumor volume ranged from 0.02 to 19.8 cm3, and the follow-up duration ranged from 6 to 120 months. Margin dose varied from 14 to 25 Gy. The collective mean tumor control rate was 96.3% (95% CI: 94.0%-98.5%). The collective hearing preservation rate was 79.1% (95% CI: 71.0%-87.3%) in 427 patients with measurable hearing. Conclusion Clinical data on outcomes of CyberKnife radiosurgery for treatment of VSs are sparse and primarily limited to single-institution analyses, with considerable variation in tumor volume and follow-up time. This meta-analysis not only provides an in-depth analysis of available data in the literature but also reviews reported outcomes and complications.
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Affiliation(s)
- Hossein Mahboubi
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Ronald Sahyouni
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA.,2 Department of Biomedical Engineering, University of California, Irvine, California, USA
| | - Omid Moshtaghi
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Kent Tadokoro
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Yaser Ghavami
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Kasra Ziai
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Harrison W Lin
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Hamid R Djalilian
- 1 Division of Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA.,2 Department of Biomedical Engineering, University of California, Irvine, California, USA
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Vestibular Schwannomas Treated with Cyberknife®: Clinical Outcomes. TUMORI JOURNAL 2016; 102:569-573. [DOI: 10.5301/tj.5000561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2016] [Indexed: 11/20/2022]
Abstract
Purpose Fractionated stereotactic radiotherapy (FSR) is a recognized treatment for vestibular schwannomas (VS). This study's aim is to present clinical outcomes and local control (LC) results for patients with VS treated with FSR using the Cyberknife® (CK) in 2 French cancer centers. Methods Patients treated with FSR for VS between 2007 and 2012 were retrospectively analyzed. Local control was determined using follow-up MRI. The hearing preservation (HP) rate was determined by analyzing pretreatment and posttreatment audiograms. Results Forty patients were treated for VS with the CK in both centers. The mean maximal VS dimension was 18.3 mm (range 3–30). The median follow-up was 36 months and the LC was 97% at 3 years of follow-up and 89% after 5 years. The HP rate was 83% and no facial nerve impairment was reported. Conclusions Our results in terms of LC and HP rate are congruent with similar studies that use the CK to treat VS. It appears that the CK is safe and efficient in VS management even for large lesions. Further studies with larger cohorts are warranted.
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Rashid A, Karam SD, Rashid B, Kim JH, Pang D, Jean W, Grimm J, Collins SP. Multisession Radiosurgery for Hearing Preservation. Semin Radiat Oncol 2015; 26:105-11. [PMID: 27000506 DOI: 10.1016/j.semradonc.2015.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Clinically relevant dose-tolerance limits with reliable estimates of risk in 1-5 fractions for cochlea are still unknown. Timmerman׳s limits from the October 2008 issue of Seminars in Radiation Oncology have served as the basis for clinical practice, augmented by updated constraints in TG-101 and QUANTEC, but the corresponding estimates of risk have not yet been well-reported. A total of 37 acoustic neuroma CyberKnife cases from Medstar Georgetown University Hospital treated in 3 or 5 fractions were combined with single-fraction Gamma Knife data from the 69 cases in Timmer 2009 to form an aggregate dataset of 106 cochlea cases treated in 1-5 fractions. Probit dose-response modeling was performed in the DVH Evaluator software to estimate normal tissue complication probability. QUANTEC recommends keeping single-fraction maximum dose to the cochlea less than 14Gy to maintain less than 25% risk of serviceable hearing loss, and our 17.9% risk estimate for 14Gy in 1 fraction is within their predicted range. In 5 fractions, our estimate of the Timmerman 27.5Gy maximum cochlea dose limit was 17.4%. For cases in which lower risk is required, the Timmerman 12Gy in 1 fraction and the TG-101 limit of 25Gy in 5 fractions had an estimated risk level of 11.8% and 13.8%, respectively. High-risk and low-risk dose tolerance with risk estimates in 1-5 fractions are all presented.
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Affiliation(s)
- Abdul Rashid
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC.
| | - Sana D Karam
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Beenish Rashid
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Jeffrey H Kim
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Dalong Pang
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Walter Jean
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jimm Grimm
- Bott Cancer Center, Holy Redeemer Hospital, Meadowbrook, PA
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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Kondziolka D, Shin SM, Brunswick A, Kim I, Silverman JS. The biology of radiosurgery and its clinical applications for brain tumors. Neuro Oncol 2014; 17:29-44. [PMID: 25267803 DOI: 10.1093/neuonc/nou284] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Stereotactic radiosurgery (SRS) was developed decades ago but only began to impact brain tumor care when it was coupled with high-resolution brain imaging techniques such as computed tomography and magnetic resonance imaging. The technique has played a key role in the management of virtually all forms of brain tumor. We reviewed the radiobiological principles of SRS on tissue and how they pertain to different brain tumor disorders. We reviewed the clinical outcomes on the most common indications. This review found that outcomes are well documented for safety and efficacy and show increasing long-term outcomes for benign tumors. Brain metastases SRS is common, and its clinical utility remains in evolution. The role of SRS in brain tumor care is established. Together with surgical resection, conventional radiotherapy, and medical therapies, patients have an expanding list of options for their care. Clinicians should be familiar with radiosurgical principles and expected outcomes that may pertain to different brain tumor scenarios.
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Affiliation(s)
- Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Samuel M Shin
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Andrew Brunswick
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Irene Kim
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
| | - Joshua S Silverman
- Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.); Department of Radiation Oncology, NYU Langone Medical Center, New York University, New York, New York (D.K., S.M.S., A.B., I.K., J.S.S.)
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Kranzinger M, Zehentmayr F, Fastner G, Oberascher G, Merz F, Nairz O, Rahim H, Sedlmayer F. Hypofractionated stereotactic radiotherapy of acoustic neuroma: volume changes and hearing results after 89-month median follow-up. Strahlenther Onkol 2014; 190:798-805. [PMID: 24638268 DOI: 10.1007/s00066-014-0630-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The goal of this work was to evaluate toxicity and local control following hypofractionated stereotactic radiation treatment with special focus on changes in tumor volume and hearing capacity. PATIENTS AND METHODS In all, 29 patients with unilateral acoustic neuroma were treated between 2001 and 2007 within a prospective radiation protocol (7 × 4 Gy ICRU dose). Median tumor volume was 0.9 ml. Follow-up started at 6 months and was repeated annually with MRI volumetry and audiometry. Hearing preservation was defined as preservation of Class A/B hearing according to the guidelines of the American Academy of Otolaryngology (1995). RESULTS No patient had any intervention after a median imaging follow-up of 89.5 months, one patient showed radiological progression. Transient increase of tumor volume developed in 17/29 patients, whereas 22/29 patients (75.9%) presented with a volume reduction at last follow-up. A total of 21 patients were eligible for hearing evaluation. Mean pure tone average (PTA) deteriorated from 39.3 to 65.9 dB and mean speech discrimination score (SDS) dropped from 74.3 to 38.1%. The 5-year actuarial Class A/B hearing preservation rate was 50.0 ± 14.4%. CONCLUSION Radiation increases only minimally, if at all, the hearing deterioration which emerges by observation alone. Presbyacusis is not responsible for this deterioration. Transient tumor enlargement is common. Today radiation of small- and medium-sized acoustic neuroma can be performed with different highly conformal techniques as fractionated treatment or single low-dose radiosurgery with equal results regarding tumor control, hearing preservation, and side effects. Hypofractionation is more comfortable for the patient than conventional regimens and represents a serious alternative to frameless radiosurgery.
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Affiliation(s)
- Manfred Kranzinger
- University Clinic of Radiotherapy and Radio-Oncology, Salzburg County Hospital, Paracelsus Medical University Clinics (PMU), Müllner Hauptstraße 48, 5020, Salzburg, Austria,
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Clinical evaluation of CyberKnife in the treatment of vestibular schwannomas. BIOMED RESEARCH INTERNATIONAL 2013; 2013:297093. [PMID: 24312910 PMCID: PMC3842077 DOI: 10.1155/2013/297093] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 09/27/2013] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
Abstract
Objective. This study assessed the posttreatment tumor control and auditory function of vestibular schwannoma (VS) patients after CyberKnife (CK) and analyzed the possible prognostic factors of hearing loss. Methods. We retrospectively studied 117 VS patients, with Gardner-Robertson (GR) classification grades I to IV, who underwent CK between 2006 and 2012. Data including radiosurgery treatment parameters, pre- and postoperative tumor size, and auditory function were collected and examined. Results. With CK, 117 patients had excellent tumor control rates (99.1%), with a mean imaging followup of 61.1 months. Excluding 52 patients (GR III-IV pretreatment), 53 (81.5%) of the remaining 65 patients (initial GR I-II) maintained GR I or II hearing after CK, with a mean audiometric followup of 64.5 months. Twelve patients experienced hearing degradation (91.6% were GR II pretreatment); they appeared to have significantly larger tumor sizes, significantly smaller cochlear sizes, and higher prescribed cochlear doses, compared to the patients with preserved hearing. Conclusion. Our data showed that CK treatment provided an excellent tumor control rate and a comparable hearing preservation rate in VS patients. Patients with pretreatment GR II hearing levels, larger tumor volumes, smaller cochlear sizes, and higher prescribed cochlear doses may have poor hearing prognoses.
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Morimoto M, Yoshioka Y, Kotsuma T, Adachi K, Shiomi H, Suzuki O, Seo Y, Koizumi M, Kagawa N, Kinoshita M, Hashimoto N, Ogawa K. Hypofractionated stereotactic radiation therapy in three to five fractions for vestibular schwannoma. Jpn J Clin Oncol 2013; 43:805-12. [PMID: 23780990 DOI: 10.1093/jjco/hyt082] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To retrospectively examine the outcomes of hypofractionated stereotactic radiation therapy in three to five fractions for vestibular schwannomas. METHODS Twenty-five patients with 26 vestibular schwannomas were treated with hypofractionated stereotactic radiation therapy using a CyberKnife. The vestibular schwannomas of 5 patients were associated with type II neurofibromatosis. The median follow-up time was 80 months (range: 6-167); the median planning target volume was 2.6 cm(3) (0.3-15.4); and the median prescribed dose (≥D90) was 21 Gy in three fractions (18-25 Gy in three to five fractions). Progression was defined as ≥2 mm 3-dimensional post-treatment tumor enlargement excluding transient expansion. Progression or any death was counted as an event in progression-free survival rates, whereas only progression was counted in progression-free rates. RESULTS The 7-year progression-free survival and progression-free rates were 78 and 95%, respectively. Late adverse events (≥3 months) with grades based on Common Terminology Criteria for Adverse Events, v4.03 were observed in 6 patients: Grade 3 hydrocephalus in one patient, Grade 2 facial nerve disorders in two and Grade 1-2 tinnitus in three. In total, 12 out of 25 patients maintained pure tone averages ≤50 dB before hypofractionated stereotactic radiation therapy, and 6 of these 12 patients (50%) maintained pure tone averages at this level at the final audiometric follow-up after hypofractionated stereotactic radiation therapy. However, gradient deterioration of pure tone average was observed in 11 of these 12 patients. The mean pure tone averages before hypofractionated stereotactic radiation therapy and at the final follow-up for the aforementioned 12 patients were 29.8 and 57.1 dB, respectively. CONCLUSIONS Treating vestibular schwannomas with hypofractionated stereotactic radiation therapy in three to five fractions may prevent tumor progression with tolerable toxicity. However, gradient deterioration of pure tone average was observed.
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Affiliation(s)
- Masahiro Morimoto
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Japan
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Karam SD, Tai A, Strohl A, Steehler MK, Rashid A, Gagnon G, Harter KW, Jay AK, Collins SP, Kim JH, Jean W. Frameless fractionated stereotactic radiosurgery for vestibular schwannomas: a single-institution experience. Front Oncol 2013; 3:121. [PMID: 23730624 PMCID: PMC3656472 DOI: 10.3389/fonc.2013.00121] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 04/30/2013] [Indexed: 11/29/2022] Open
Abstract
Objective: To examine tumor control, hearing preservation, and complication rates after frameless fractionated stereotactic radiosurgery (SRS) in patients with vestibular schwannomas (VS). Methods: Thirty-seven patients treated with fractionated SRS from 2002 to 2011 were retrospectively analyzed. Ninety-five percent were treated with 25 Gy in five fractions, targeting a median tumor volume of 1.03 cc (range 0.14–7.60). Results: With a median follow-up of 4.25 years (range, 15 months–9 years), no tumors required an additional treatment resulting in 100% tumor control rate. Radiographic control rate was 91% in 32 patients at a median follow-up of 3 years. Of the 14 patients with serviceable hearing and with audiograms, the hearing preservation rate was 78% at a median follow-up of 18 months. Twenty-six patients with serviceable hearing pretreatment, were evaluated by a phone survey with a hearing preservation rate of 73% at a 5 year median follow-up. There were two cases that developed both new increased trigeminal parasthesias and facial spasms but there were no cases of facial weakness. Patient had 96% of good to excellent satisfaction rate with the treatment at a median follow-up of 5 years. Conclusion: Frameless fractionated SRS treatment of VS results in good rate of tumor control. Hearing preservation rate and rates of cranial nerve toxicity are comparable to what is reported in the literature. Patients choose this modality because of its non-invasive nature and are generally very satisfied with their long term outcome.
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Affiliation(s)
- Sana D Karam
- Department of Radiation Medicine, MedStar Georgetown University Hospital Washington, DC, USA
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Kondziolka D, Mousavi SH, Kano H, Flickinger JC, Lunsford LD. The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation? Neurosurg Focus 2013; 33:E8. [PMID: 22937859 DOI: 10.3171/2012.6.focus12192] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Management recommendations for patients with smaller-volume or newly diagnosed vestibular schwannomas (< 4 cm(3)) need to be based on an understanding of the anticipated natural history of the tumor and the side effects it produces. The natural history can then be compared with the risks and benefits of therapeutic intervention using a minimally invasive strategy such as stereotactic radiosurgery (SRS). METHODS The authors reviewed the emerging literature stemming from recent recommendations to "wait and scan" (observation) and compared this strategy with published outcomes after early intervention using SRS or results from matched cohort studies of resection and SRS. RESULTS Various retrospective studies indicate that vestibular schwannomas grow at a rate of 0-3.9 mm per year and double in volume between 1.65 and 4.4 years. Stereotactic radiosurgery arrests growth in up to 98% of patients when studied at intervals of 10-15 years. Most patients who select "wait and scan" note gradually decreasing hearing function leading to the loss of useful hearing by 5 years. In contrast, current studies indicate that 3-5 years after Gamma Knife surgery, 61%-80% of patients maintain useful hearing (speech discrimination score > 50%, pure tone average < 50). CONCLUSIONS Based on published data on both volume and hearing preservation for both strategies, the authors devised a management recommendation for patients with small vestibular schwannomas. When resection is not chosen by the patient, the authors believe that early SRS intervention, in contrast to observation, results in long-term tumor control and improved rates of hearing preservation.
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Affiliation(s)
- Douglas Kondziolka
- The Center for Image Guided Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA.
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Lin MC, Chen CM, Tseng HM, Xiao F, Young YH. A Proposed Method to Comprehensively Define Outcomes in Acoustic Tumor Patients Undergoing CyberKnife Management. Stereotact Funct Neurosurg 2013; 91:177-85. [DOI: 10.1159/000343215] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 09/01/2012] [Indexed: 11/19/2022]
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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.
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Affiliation(s)
- Ake Hansasuta
- Division of Neurological Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Milano MT, Usuki KY, Walter KA, Clark D, Schell MC. Stereotactic radiosurgery and hypofractionated stereotactic radiotherapy: Normal tissue dose constraints of the central nervous system. Cancer Treat Rev 2011; 37:567-78. [PMID: 21571440 DOI: 10.1016/j.ctrv.2011.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 03/31/2011] [Accepted: 04/16/2011] [Indexed: 12/31/2022]
Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Whitmore RG, Urban C, Church E, Ruckenstein M, Stein SC, Lee JYK. Decision analysis of treatment options for vestibular schwannoma. J Neurosurg 2011; 114:400-13. [DOI: 10.3171/2010.3.jns091802] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Widespread use of MR imaging has contributed to the more frequent diagnosis of vestibular schwannomas (VSs). These tumors represent 10% of primary adult intracranial neoplasms, and if they are symptomatic, they usually present with hearing loss and tinnitus. Currently, there are 3 treatment options for quality of life (QOL): wait and scan, microsurgery, and radiosurgery. In this paper, the authors' purpose is to determine which treatment modality yields the highest QOL at 5- and 10-year follow-up, considering the likelihood of recurrence and various complications.
Methods
The MEDLINE, Embase, and Cochrane online databases were searched for English-language articles published between 1990 and June 2008, containing key words relating to VS. Data were pooled to calculate the prevalence of treatment complications, tumor recurrence, and QOL with various complications. For parameters in which incidence varied with time of follow-up, the authors used meta-regression to determine the mean prevalence rates at a specified length of follow-up. A decision-analytical model was constructed to compare 5- and 10-year outcomes for a patient with a unilateral tumor and partially intact hearing. The 3 treatment options, wait and scan, microsurgery, and radiosurgery, were compared.
Results
After screening more than 2500 abstracts, the authors ultimately included 113 articles in this analysis. Recurrence, complication rates, and onset of complication varied with the treatment chosen. The relative QOL at the 5-year follow-up was 0.898 of normal for wait and scan, 0.953 for microsurgery, and 0.97 for radiosurgery. These differences are significant (p < 0.0052). Data were too scarce at the 10-year follow-up to calculate significant differences between the microsurgery and radiosurgery strategies.
Conclusions
At 5 years, patients treated with radiosurgery have an overall better QOL than those treated with either microsurgery or those investigated further with serial imaging. The authors found that the complications associated with wait-and-scan and microsurgery treatment strategies negatively impacted patient lives more than the complications from radiosurgery. One limitation of this study is that the 10-year follow-up data were too limited to analyze, and more studies are needed to determine if the authors' results are still consistent at 10 years.
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Affiliation(s)
| | | | | | - Michael Ruckenstein
- 2Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Vernimmen FJAI, Slabbert JP. Assessment of the alpha/beta ratios for arteriovenous malformations, meningiomas, acoustic neuromas, and the optic chiasma. Int J Radiat Biol 2010; 86:486-98. [PMID: 20470198 DOI: 10.3109/09553001003667982] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To determine alpha/beta (alpha/beta) values of arteriovenous malformations (AVM), meningiomas, acoustic neuromas (AN), and the optic chiasma using clinical data. METHODS AND MATERIALS Data of dose/fractionation schedules form the literature, iso-effective for a specific clinical outcome, were analysed using the Fraction Equivalent plot (FE) method and the Tucker method. Established safe dose/fractionation schedules for the optic chiasma were used to determine its alpha/beta value. RESULTS With the FE plot method, an alpha/beta value of 3.76 Gray (Gy) (95% confidence level [CL]: 2.8-4.6 Gy) for meningiomas, 2.4 Gy (95% CL: 0.8-3.9 Gy) for acoustic neuroma, and 14.7 Gy (95% CL: 3.8-25.7 Gy) for arteriovenous malformations were determined. The respective alpha/beta values using the Tucker method were 3.3 Gy (95%CL: 2.2-6.8 Gy), 1.77 Gy (95%CL: 1.3-3.0 Gy) and -57 Gy (95%CL: -79.6 to -35.2 Gy). No meaningful alpha/beta values could be determined for the optic chiasma. CONCLUSION Acoustic neuromas with a low alpha/beta value would show no lesion intrinsic benefit from fractionation. Meningiomas probably benefit from a hypofractionated schedule. The high alpha/beta value for AVM can be explained but needs further research. Fractionation versus radiosurgery can be considered when the primary objective is to avoid normal tissue damage.
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Abstract
Radiosurgery involves the precise delivery of sharply collimated high-energy beams of radiation to a distinct target volume along selected trajectories. Historically, accurate targeting required the application of a stereotactic frame, thus limiting the use of this procedure to single treatments of selected intracranial lesions. However, the scope of radiosurgery has undergone a remarkable broadening since the introduction of image-guided robotic radiosurgery. Recent developments in real-time image guidance provide an effective frameless alternative to conventional radiosurgery and allow both the treatment of lesions outside the skull and the possibility of performing hypofractionation. As a consequence, targets in the spine, chest and abdomen can now also be radiosurgically ablated with submillimetric precision. Meanwhile, the combination of image guidance, robotic beam delivery, and non-isocentric inverse planning can greatly enhance the conformality and homogeneity of radiosurgery. The aim of this article is to describe the technological basis of image-guided radiosurgery and provide a perspective on future developments. The current clinical usage of robotic radiosurgery will be reviewed with an emphasis on those applications that may represent a major shift in the therapeutic paradigm.
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Nonvestibular schwannomas: an evaluation of functional outcome after radiosurgical and microsurgical management. Acta Neurochir (Wien) 2010; 152:35-46. [PMID: 19499174 DOI: 10.1007/s00701-009-0403-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 05/05/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Nonvestibular cranial nerve schwannomas (NVCNS) are relatively rare tumors. We evaluated our experience with radiosurgical and microsurgical treatment alone and in combination for the management of NVCNS. METHODS The charts of 62 patients with NVCNS who were treated between 1993 and 2005 at our institution were reviewed. Patients diagnosed with neurofibromatosis type 2 were excluded. The patients underwent microsurgery and/or radiosurgery treatment. RESULTS Trigeminal and jugular foramen schwannomas were the most common NVCNS tumors (n = 47), and the only two groups with sufficient numbers of patients to allow comparison of the three treatment approaches. In these two groups, the mean tumor volume was significantly higher in those who received combined therapy (8.59 +/- 2.29 cc), compared with radiosurgery (4.94 +/- 3.02 cc; p = 0.05) or microsurgery alone (5.38 +/- 3.23; p = 0.027). Patients who underwent radiosurgery alone were significantly older (67.7 +/- 13.3 years; p = 0.019) than those treated with microsurgery (55.3 +/- 13.7 years) or with both modalities (48.7 +/- 12.8 years). The Karnofsky Performance Scale scores were significantly higher (p < or = 0.05) at follow-up compared with baseline for all three treatment approaches. There was no significant change in the Glasgow Outcome scores before and after treatment. CONCLUSIONS Microsurgery and radiosurgery can both be used to manage NVCNS tumors with excellent results. When treatment with either modality alone is not reasonable, tumors can be managed effectively with combined micro- and radiosurgery treatment.
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Franzin A, Spatola G, Serra C, Picozzi P, Medone M, Milani D, Castellazzi P, Mortini P. Evaluation of hearing function after Gamma Knife surgery of vestibular schwannomas. Neurosurg Focus 2009; 27:E3. [DOI: 10.3171/2009.9.focus09196] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Due to technological advances in neuroradiology in recent years, incidental diagnoses of vestibular schwannomas (VSs) have increased. The aim of this study was to evaluate the hearing function after treatment with Gamma Knife surgery (GKS) for VSs in patients adequately selected with “good” or “useful” hearing before treatment and to assess the possible predictive factors for hearing function preservation.
Methods
Of all patients treated in the authors' hospital between 2001 and 2007, they retrospectively studied 50 patients with a unilateral VS in whom there was serviceable hearing (Gardner-Robertson [GR] Class I or II). Additional inclusion criteria were: no Type 2 neurofibromatosis, no previous treatment, and at least 6 months' follow-up of neuroradiological and audiological data. The median patient age was 54 years (range 24–78 years). The median tumor volume was 0.73 ml (range 0.03–6.6 ml), and the median radiation dose to the tumor margin was 13 Gy (range 12–16 Gy) with an isodose of 50%.
Results
Patient age, tumor volume, and presenting symptoms were found to correlate with hearing function. At a median of 36 months after radiosurgery, tumor growth control was 96% and no patient required any other additional treatment. Serviceable hearing was preserved in 34 patients (68%): 21 (62%) with GR Class I hearing and 13 (38%) with GR Class II hearing. The remaining 16 patients had poor hearing function:15 with GR Class III and 1 with GR Class IV hearing function. In 19 (58%) of 33 patients with GR Class I function before GKS the same class was maintained posttreatment; 29 (88%) maintained functional hearing (GR Class I or II). In all patients with an intracanalicular lesion, functional hearing was maintained. Significant prognostic factors for maintaining serviceable hearing were GR Class I function before treatment, symptoms at presentation, patient age younger than 54 years, and Koos Stage T1 disease.
Conclusions
The results of the study show that the probability of preserving functional hearing in patients undergoing GKS treatment for unilateral VSs is very high. Patients with GR Class I, age younger than 54 years, with presenting symptoms other than hearing loss, and a Koos Stage T1 tumor have better prognosis. The prescribed dose of 13 Gy appears to represent an excellent compromise between controlling the disease and preserving auditory function.
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Sahgal A, Ma L, Chang E, Shiu A, Larson DA, Laperriere N, Yin FF, Tsao M, Menard C, Basran PS, Létourneau D, Heydarian M, Beachey D, Shukla V, Cusimano M, Hodaie M, Zadeh G, Bernstein M, Schwartz M. Advances in technology for intracranial stereotactic radiosurgery. Technol Cancer Res Treat 2009; 8:271-80. [PMID: 19645520 DOI: 10.1177/153303460900800404] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Stereotactic radiosurgery (SRS) refers to a single radiation treatment delivering a high dose to an intra-cranial target localized in three-dimensions by CT and/or MRI imaging. Traditionally, immobilization of the patient's head has been achieved using a rigid stereotactic head frame as the key step in allowing for accurate dose delivery. SRS has been delivered by both Cobalt-60 (Gamma Knife) and linear accelerator (linac) technologies for many decades. The focus of this review is to highlight recent advances and major innovations in SRS technologies relevant to clinical practice and developments allowing for non-invasive frame SRS.
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Affiliation(s)
- Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, the Princess Margaret Hospital, and the Joey Toby Tanenbaum family Gamma Knife Center, University of Toronto, Toronto, Ontario, Canada.
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Yang I, Aranda D, Han SJ, Chennupati S, Sughrue ME, Cheung SW, Pitts LH, Parsa AT. Hearing preservation after stereotactic radiosurgery for vestibular schwannoma: A systematic review. J Clin Neurosci 2009; 16:742-7. [DOI: 10.1016/j.jocn.2008.09.023] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2008] [Revised: 09/17/2008] [Accepted: 09/18/2008] [Indexed: 11/16/2022]
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Hudgins WR, Antes KJ, Herbert MA, Weiner RL, DeSaloms JM, Stamos D, Barker JL, Echt GA, Nichols TD, Schwarz DE. Control of growth of vestibular schwannomas with low-dose Gamma Knife surgery. J Neurosurg 2009; 105 Suppl:154-60. [PMID: 18503350 DOI: 10.3171/sup.2006.105.7.154] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The treatment of solitary vestibular schwannomas by performing Gamma Knife surgery is well established. It has been reported that decreasing the surface dose reduces patient morbidity, especially facial weakness and numbness. The authors of this retrospective study examine patient data from a single center to determine if low-dose (< or = 14 Gy) GKS controls tumor growth as effectively as higher doses (> 14 Gy). METHODS Based on the formula for ellipsoid volumes, the tumor volumes were calculated using measurements from MR images obtained at follow up in patients treated at the authors' center. Follow-up data were available in 159 patients with a mean age of 59.5 +/- 14.2 years at treatment. Fifty-six percent of the patients were women and 53.5% of the tumors were located on the right side of the brain. The mean tumor volume was 3.3 +/- 4.3 cm3 with 10% of the tumors having volumes larger than 8 cm3. After GKS, smaller tumors (> or = 40% decrease in volume) were observed in 44.8% of patients treated with a low dose and in 48.8% treated with a high dose. Enlarged tumors (> or = 40% increase in volume) were seen in 5.2% of the patients receiving a low dose and 2.3% of those receiving a high dose. These differences were not statistically significant. Patients who had been followed up for longer than 5 years after treatment had median residual volumes of only 28.2% of the starting volume in the low-dose group and 26% in the high-dose group. This difference was statistically not significant. CONCLUSIONS No statistically significant differences were observed between tumors given low-dose radiation treatment and those given high-dose radiation treatment.
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Affiliation(s)
- W Robert Hudgins
- Gamma Knife Department, Presbyterian Hospital of Dallas, Dallas, Texas, USA.
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Calcerrada Díaz-Santos N, Blasco Amaro JA, Cardiel GA, Andradas Aragonés E. The safety and efficacy of robotic image-guided radiosurgery system treatment for intra- and extracranial lesions: A systematic review of the literature. Radiother Oncol 2008; 89:245-53. [DOI: 10.1016/j.radonc.2008.07.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 07/18/2008] [Accepted: 07/20/2008] [Indexed: 10/21/2022]
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Guiding patients through the choices for treating vestibular schwannomas: balancing options and ensuring informed consent. 2007. Neurosurg Clin N Am 2008; 19:379-92, viii. [PMID: 18534346 DOI: 10.1016/j.nec.2008.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Counseling patients who are diagnosed with vestibular schwannomas, formerly known as acoustic neuromas, can be challenging. The health care provider has the responsibility to explain, in understandable language, to the patient or legal representative the proposed treatment options, risks and complications associated with each form of treatment, and alternatives to treatment, including no therapy. Patients should be encouraged to gather information before making a treatment decision. For the physicians managing these patients, information should be delivered in a balanced way to ensure patient understanding of their options leading to adequate informed consent.
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Gagnon GJ, Henderson FC, Gehan EA, Sanford D, Collins BT, Moulds JC, Dritschilo A. Cyberknife radiosurgery for breast cancer spine metastases: a matched-pair analysis. Cancer 2007; 110:1796-802. [PMID: 17786939 DOI: 10.1002/cncr.22977] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are few options for breast cancer patients with spinal metastases recurrent within a previous radiation treatment field. CyberKnife radiosurgery has been used in our institution to treat such patients. To evaluate their outcomes, as there are no comparable radiation treatment options, the outcomes were compared between 18 patients with spinal metastases from breast cancer treated with CyberKnife stereotactic radiosurgery, 17 of which had prior radiotherapy to the involved spinal region and were progressing, and 18 matched patients who received conventional external beam radiotherapy (CRT) up-front for spinal metastases. METHODS Radiosurgery was delivered in 3 to 5 fractions to doses ranging from 2100 to 2800 cGy. Women were matched to patients in a CRT group with respect to time from original diagnosis to diagnosis of metastases, estrogen receptor / progesterone receptor (ER/PR) status, presence or absence of visceral metastases, prior radiotherapy, and prior chemotherapy. Survival and complications were compared between treatment groups. Surviving patients were followed out to 24 months. RESULTS The CyberKnife and CRT groups were comparable along all matching dimensions and in performance status before treatment. Outcomes of treatment were similar for patients in both groups; ambulation, performance status, and pain worsened similarly across groups posttreatment. Survival and the number of complications appeared to favor the CyberKnife group, but the differences did not reach statistical significance. CONCLUSIONS The statistical comparability of the CyberKnife and CRT groups reflects the small sample size and stringent requirements for significance of the matched-pair analysis. Nevertheless, comparability in these difficult cases shows that salvage CyberKnife treatment is as efficacious as initial CRT without added toxicity.
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Affiliation(s)
- Gregory J Gagnon
- Department of Radiation Oncology, Georgetown University Medical Center, Washington, DC 20007-2113, USA.
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Backous DD, Pham HT. Guiding patients through the choices for treating vestibular schwannomas: balancing options and ensuring informed consent. Otolaryngol Clin North Am 2007; 40:521-40, viii-ix. [PMID: 17544694 DOI: 10.1016/j.otc.2007.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Counseling patients who are diagnosed with vestibular schwannomas, formerly known as acoustic neuromas, can be challenging. The health care provider has the responsibility to explain, in understandable language, to the patient or legal representative the proposed treatment options, risks and complications associated with each form of treatment, and alternatives to treatment, including no therapy. Patients should be encouraged to gather information before making a treatment decision. For the physicians managing these patients, information should be delivered in a balanced way to ensure patient understanding of their options leading to adequate informed consent.
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Affiliation(s)
- Douglas D Backous
- Otology, Neurotology and Skull Base Surgery, Section of Otolaryngology-Head and Neck Surgery, Virginia Mason Medical Center, 1100 Ninth Avenue, X10-0N, Seattle, WA 98111-0900, USA.
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Martin JJ, Kondziolka D, Flickinger JC, Mathieu D, Niranjan A, Lunsford LD. Cranial nerve preservation and outcomes after stereotactic radiosurgery for jugular foramen schwannomas. Neurosurgery 2007; 61:76-81; discussion 81. [PMID: 17621021 DOI: 10.1227/01.neu.0000279726.90650.6d] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Jugular foramen region schwannomas are rare intracranial tumors that usually present with multiple lower cranial nerve deficits. For some patients, complete surgical resection is possible but may be associated with significant morbidity. Stereotactic radiosurgery is a minimally invasive alternative or adjunct to microsurgery for such tumors. We reviewed our clinical and imaging outcomes after patients underwent gamma knife radiosurgery for management of jugular foramen schwannomas. METHODS Thirty-four patients with 35 tumors (one patient had bilateral tumors) underwent radiosurgery between May 1990 and December 2005. Twenty-two patients had previous microsurgical resection and all patients experienced various cranial neuropathies. A median of six isocenters were used. Median marginal and maximum doses were 14 and 28 Gy, respectively. RESULTS None of the patients were lost to evaluation and the mean duration of follow-up was 83 months. Tumors regressed in 17 patients, remained stable in 16, and progressed in two. Five- and 10-year actuarial control rates were 97 and 94%, respectively. Preexisting cranial neuropathies improved in 20% and remained stable in 77% after radiosurgery. One patient worsened. The function of all previous intact nerves was preserved after radiosurgery. CONCLUSION Stereotactic radiosurgery proved to be a safe and effective management for newly diagnosed or residual jugular foramen schwannomas. Long-term tumor control rates and stability or improvement in cranial nerve function was confirmed.
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Affiliation(s)
- Juan J Martin
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Sahu RN, Mehrotra N, Tyagi I, Banerji D, Jain VK, Behari S. Management strategies for bilateral vestibular schwannomas. J Clin Neurosci 2007; 14:715-22. [PMID: 17577524 DOI: 10.1016/j.jocn.2006.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Revised: 05/17/2006] [Accepted: 05/17/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bilateral vestibular schwannomas (VS) are rare. Most patients in India present late in the course of illness with large tumors and disabling deafness. Clinical presentation and management goals are different from that of unilateral VS. AIMS To highlight the differences in clinical presentations and surgical results of bilateral VS compared to unilateral VS; and, to propose a management strategy for these tumors with reference to tumor size, extent of growth and the presence or absence of hearing impairment. METHOD This is a retrospective study of 16 patients with bilateral VS treated over 10 years in a tertiary referral hospital. Assessment of VIIth and VIIIth cranial nerve function, tumor size, volume and extent of growth was performed in all patients. The management strategy was based on Samii's classification of tumor extent. All patients were operated using a retromastoid suboccipital approach. Postoperative results were analyzed and compared with those of unilateral VS. RESULTS The mean age of presentation was 25.7 years. Hearing impairment was the commonest symptom. Headache with features of raised intracranial pressure were present in 10 (62.5%) patients. Giant tumors were present in seven (43.7%) patients; large tumors in eight (50%) and a medium-sized tumor in one (6.3%). Total tumor resection was achieved in 13 patients and subtotal resection in two. One patient was managed conservatively and followed up with serial CT scans. On the contralateral side, one large tumor required total excision. One medium sized tumor underwent sub-capsular excision in an attempt to preserve hearing. The facial nerve was anatomically preserved in seven (46.7%) patients and in one, the cochlear nerve was anatomically preserved. There was no peri-operative mortality. CONCLUSIONS Patients with bilateral schwannomas are younger, have larger lesions, poorer preoperative hearing and are more likely to lose either auditory and/or facial nerve function during attempted total resection of the tumor. Classifying the tumors into two groups by extent, that is, tumors extending to the cerebellopontine angle cistern (T1-T3a) and, tumors extending to or compressing the brainstem (T3b to T4b), allows the surgical strategy to be defined.
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Affiliation(s)
- Rabi N Sahu
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226014, India
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Romanelli P, Schaal DW, Adler JR. Image-guided radiosurgical ablation of intra- and extra-cranial lesions. Technol Cancer Res Treat 2007; 5:421-8. [PMID: 16866572 DOI: 10.1177/153303460600500410] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
For decades since its introduction, stereotactic radiosurgery (SRS) was used only to treat intracranial lesions because intracranial targets could be immobilized and located relative to a rigid metal frame affixed to the patient's head. Lesions outside the head were generally not treated with SRS because it is difficult to immobilize extracranial lesions and to attach stereotactic frames elsewhere on the body. Advances in computerized image guidance and robotics allowed the development of systems, such as the CyberKnife SRS System (Accuray, Inc, Sunnyvale, CA), that could target intracranial lesions without the stereotactic frame. Enhancements have resulted in a radiation delivery system that can accurately deliver high-dose, focal radiation to lesions in the spine, chest, and abdomen, even if they move during respiration. In this review we will describe the technical features of frameless SRS systems and briefly review their application to treating intracranial and extracranial lesions, focusing in particular on spinal lesions.
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Abstract
PURPOSE OF REVIEW The intention of the authors is to provide the reader with an overview of the recent advances in the diagnosis and treatment of nerve sheath tumors. Vestibular schwannomas, neurogenetic syndromes such as schwannomatosis and multiple isolated neurofibromas, and malignant peripheral nerve sheath tumors are covered in this review. RECENT FINDINGS Over the last year, literature focusing on different management strategies for patients with vestibular schwannomas dominated the field. Surgical options for this group of patients are changing. Stereotactic radiation is also employed more frequently with promising results. New insights into the biology of peripheral nerve tumor development and growth, including expression of vascular endothelial growth factor by vestibular schwannomas and the role of Notch signaling in malignant transformation of benign neurofibromas have been described. Diagnostic criteria for schwannomatosis, a recently described condition, are being developed. Several cases of multiple isolated neurofibromas and spinal neurofibromas were reported. SUMMARY Peripheral nerve tumors are classified according to the specific features of cellular differentiation. The most common types include schwannoma and neurofibroma. These tumors can occur sporadically or as manifestations of genetic syndromes such as neurofibromatosis types 1 and 2 or schwannomatosis. The majority of peripheral nerve tumors are benign but malignant transformation does occur. Metastatic tumors can also affect peripheral nerves. The diagnostic modality of choice is magnetic resonance imaging. Positron emission tomography is a useful technique in the presurgical differentiation between benign and malignant peripheral nerve sheath tumors. Treatment is directed towards symptomatic control. Surgery, radiation and, in rare instances, chemotherapy are the major treatment modalities employed.
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Affiliation(s)
- Maciej M Mrugala
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.
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