Early-onset adverse events after stereotactic radiosurgery for jugular foramen schwannoma: a mid-term follow-up single-center review of 46 cases

Stereotactic Radiosurgery and Surgical Resection for Jugular Foramen Schwannomas: A Retrospective Comparative Study of Outcomes

BACKGROUND AND OBJECTIVES

Jugular foramen schwannomas (JFS) are rare benign tumors arising from lower cranial nerves. In this study, we aim to compare the outcomes of surgical resection (SR) and stereotactic radiosurgery (SRS) in the treatment of JFS.

METHODS

We conducted a retrospective analysis of 31 patients with JFS who underwent SRS (13 patients [41.9%]) or surgical resection (18 patients [58.1%]) as their primary management modality over a two-decade period. Outcomes included progression-free survival, post-treatment adverse events based on Common Terminology Criteria for Adverse Events, symptom improvement, overall survival, and the necessity for secondary interventions. Local tumor control was also evaluated in all patients who received SRS.

RESULTS

Significant differences were observed in baseline characteristics between the SRS and SR groups, including median age (58 vs 48 years, P = .001), largest tumor diameter (32.0 vs 47.5 mm, P = .02), and total tumor volume (6.50 vs 20.5 mm3, P = .01). There were no significant differences in sex or lesion morphology (dumbbell vs nondumbbell shaped). After adjusting for baseline characteristics, no significant differences were noted in progression-free survival (90.9 vs 86.2%), overall survival (92.3 vs 100%), symptom improvement (61.5 vs 55.5%), or median Common Terminology Criteria for Adverse Events grade (1 in both groups) between the SRS and SR groups, respectively. SRS patients had significantly lower odds of requiring secondary treatment procedures after their primary intervention as compared with those who underwent SR (odds ratio = 0.02, 95% CI: 0.001-0.88, P-value = .04). Local tumor control in all SRS patients (19 patients) was 93.7% and 79.1% at six-month and five-year time points, respectively.

CONCLUSION

SRS and SR demonstrate comparable effectiveness in treating JFS. However, SRS may be a more favorable option because of a reduced need for secondary interventions. Future controlled prospective studies are needed to draw more definitive conclusions.

Gamma knife radiosurgery for patients with jugular foramen schwannomas: systematic review and meta-analysis

Resection has traditionally been the gold standard for treating jugular foramen schwannomas (JFSs). However, given the high risk of neurological deficits associated with surgical intervention, stereotactic radiosurgery (SRS) has emerged as a promising alternative. Despite its growing popularity for other brain tumors, there remains a paucity of data on the outcomes of SRS for JFSs. This study aims to assess the safety and efficacy of SRS as a treatment option for patients with JFSs. We searched Medline, Embase, and Web of Science databases following PRISMA guidelines. Eligible studies included randomized controlled trials and observational studies reporting ≥ 4 JFS patients treated with gamma knife radiosurgery. Comparative analysis with 95% confidence intervals (CI) under a random-effects model was utilized to pool the data. A single-arm meta-analysis evaluated tumor control, neurological deficits, and complications. The analysis included 16 studies with 348 patients and a median follow-up of 33 months. Results demonstrated a 98% (CI: 95 - 100%) rate of tumor control, a 39% (CI: 23-54%) rate of tumor shrinking, and a 19% (CI: 13-26%) rate of neurological deficits. New cranial nerve deficits occurred in 34% of patients (CI: 27-41%). SRS demonstrated a high tumor control rate for jugular foramen schwannomas. However, complications remain significant, with neurological deficits and new cranial nerve deficits post Gamma Knife radiosurgery (GKRS). These findings underscore the need for further studies, including comparative analyses between SRS and surgical resection, to better delineate the risk-benefit profile of these treatment modalities.

Gamma-knife radiosurgery for jugular foramen schwannomas. A systematic review and meta-analysis

Introduction

Jugular Foramen Schwannomas (JFS) have been traditionally treated with surgical resection with an associated significant post-operative morbidity. Stereotactic radiosurgery has been investigated as potentially minimally invasive alternative to microsurgery. The aim of this study was to provide a systematic review and meta-analysis of the available literature regarding the outcomes of cases of JFS treated with radiosurgery.

Methods

A literature review until 28th of March 2023 was performed. All studies looking at the outcomes of radiosurgery for the treatment of JFS were included. Studies including non-vestibular schwannomas without clear distinction of the tumour type were excluded. Risk of bias was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) scale.

Results

Eight (8) studies with a total of 375 patients met the inclusion and exclusion criteria and were included in the analysis. Pooled overall tumour control rate was 93.2 % (95 % CI 89.8-96.6) after a weighted mean follow-up of 54.07 months (95 % CI 46.8-61.3). Patient free survival was reported only in 4 studies and ranged from 87 % to 97 % and 76.9-93.8 % in 5 and 10 years respectively. The radiation induced cranial nerve deficits rates after GKRS were 3.6 % (95%CI 1.7, 5.5 %).

Conclusion

According to our findings, radiosurgery for JFS has favourable clinical outcomes with a high rate of long-term tumour control and low complication rates.

Outcomes after Surgical Resection of Jugular Foramen Schwannomas: Systematic Review and Meta-Analysis

Objectives  We sought to perform a systematic review and meta-analysis of outcomes after surgical resection of jugular foramen schwannomas (JFSs). Design  A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Setting  PubMed, Scopus, and Embase databases were searched. Participants  Case series of at least five patients undergoing surgical resection of JFSs were included. Main Outcome Measures  Primary outcomes included gross total resection (GTR) and near total resection (NTR) rates, as well as a composite of the two (GTR + NTR). Additional outcomes included new or worsening cranial nerve (CN) palsies and cerebrospinal fluid (CSF) leak. Random effects models were used to generate pooled outcomes. Results  A total of 25 studies comprising 567 patients were included in the study. The proportions of each tumor grade were the following: grade A (33.1%), grade B (16.1%), grade C (9.2%), and grade D (41.6%). The pooled rate of GTR was 81% (95% confidence interval [CI]: 70-88; I 2  = 78.9%) and the composite GTR + NTR rate was 88% (95% CI: 81-93; I 2  = 66.4%). Rates of new or worsening CN palsies were the following: 12% hearing loss (95% CI: 7-20; I 2  = 69.4%), 27% dysphagia (95% CI: 20-36; I 2  = 66%), 20% hoarseness (95% CI: 14-28; I 2  = 62.6%), and 19% facial palsy (95% CI: 13-28; I 2  = 64.6%). The pooled rate of CSF leak was 9% (95% CI: 6-15; I 2  = 43.9%). Conclusion  The literature suggests high GTR rates of JFSs can be achieved. However, new CN deficits are not uncommon.

Stereotactic radio-neurosurgery for jugular foramen schwannomas

BACKGROUND

Stereotactic radiosurgery (SRS) represents a minimally invasive and valuable alternative for jugular foramen schwannomas (JFS), both as upfront and/or adjuvant treatment (in hybrid approaches).

METHODS

We conducted a retrospective review of our cases treated at the Lausanne University Hospital (CHUV) from June 2010 to October 2023. Eleven patients underwent SRS, among whom three had prior surgery, two in our center in the frame of a planned combined approach and one in another center. Two patients received "volume-staged" SRS. The mean age at SRS was 60 years (median 68; range 29-83). Cranial nerve (CN) symptoms were present in six patients, while five were asymptomatic. The mean tumor volume at SRS was 2.1 cc (median 1.2; range 0.068-7.3 cc), with a 12 Gy marginal dose prescribed in all cases.

RESULTS

The mean follow-up period was 3.9 years (median 2, range 1-7). Cranial nerve function improved after SRS in six patients, while five remained stable. At the last follow-up, all tumors showed a decrease in volume, except for one patient, who underwent surgery at 18 months after SRS, for volumetric increase at 6 and 12 months, with further XII-th CN palsy and medulla oblongata compression. Although tumor decreased at 18 months, such patient needed microsurgical resection for symptom persistence and was further controlled. The mean tumor volume at 1 year post-SRS was 1.6 cc (median 0.55; range 0.028-7.77 cc), at 2 years was 1.31 cc (median 0.76; range 0.19-5), and at 3 years was 1.32 cc (median 0.59; range 0.23-4.8). No adverse radiation events were observed.

CONCLUSIONS

Stereotactic radiosurgery is considered a safe and effective treatment for jugular foramen schwannomas, ensuring high rates of tumor control in all patients over the long term. The cranial nerve function improved after SRS in the 6 patients who had deficits and the other 5 patients who had no deficits remained asymptomatic. For larger tumors, combined/hybrid approaches can be a valuable alternative, to obtain tumor control and to preserve neurological function.

Lower Cranial Nerve Schwannomas: Cohort Study and Systematic Review

BACKGROUND AND OBJECTIVES

Schwannomas originating from the lower cranial nerves (LCNS) are rare and pose a significant surgical challenge. Resection is the mainstay treatment; however, risk of treatment morbidity is considerable, and the available literature regarding differential treatment outcomes in this vulnerable population is sparse.

METHODS

A single-institution cohort study and systematic literature review of LCNS were performed.

RESULTS

Fifty-eight patients were included: 34 underwent surgical resection and 24 underwent stereotactic radiosurgery (SRS). The median age at diagnosis was 48 years (range 17-74). Presenting symptoms were dysphagia (63%), dysarthria/hypophonia (47%), imbalance (33%), and hearing loss/tinnitus (30%). Tumor size was associated with surgical resection, as compared with initial SRS (4.1 cm vs 1.5 cm, P = .0001). Gross total resection was obtained in 52%, with tumor remnants predominantly localized to the jugular foramen (62%). Post-treatment worsening of symptoms occurred in 68% of surgical and 29% of SRS patients ( P = .003). Postoperative symptoms were mostly commonly hypophonia/hoarseness (63%) and dysphagia (59%). Seven patients (29%) had new neurological issues after SRS treatment, but symptoms were overall milder. The median follow-up was 60 months (range 12-252); 98% demonstrated meaningful clinical improvement. Eighteen surgical patients (53%) underwent adjuvant radiation at a median of 5 months after resection (range 2-32). At follow-up, tumor control was 97% in the surgical cohort and 96% among SRS patients.

CONCLUSION

Although LCNS resection is potentially morbid, most postoperative deficits are transient, and patients achieve excellent tumor control-particularly when paired with adjuvant SRS. For minimally symptomatic patients undergoing surgical intervention, we advise maximally safe resection with intracapsular dissection to preserve nerve integrity where possible. For residual or as a primary treatment modality, SRS is associated with low morbidity and high rates of long-term tumor control.

Diagnostic and Therapeutic Strategy for Vagal Schwannoma: Case Series and Literature Review

Background and Objectives: Clinical management of vagal schwannoma is a real diagnostic and therapeutic challenge because the medical history and clinical examination are often non-specific and vagal nerve injury following surgical resection still represents an unsolved problem. The aim of this paper is to provide a case series along with a diagnostic and therapeutic algorithm for vagal schwannoma of the head and neck, combining our experience with clinical evidence available in the literature. Materials and Methods: We retrospectively analyzed a series of patients affected by vagal schwannoma who were treated between 2000 and 2020. In addition, a review of the literature on vagal schwannoma management was conducted. Based on the cases described and the literature review, we made a diagnostic and therapeutic algorithm for the management of vagal schwannoma. Results: We were able to identify 10 patients affected by vagal schwannoma and treated between 2000 and 2020. All patients presented with a painless, mobile, slow-growing lateral neck mass with onset varying from a few months to years. The preoperative diagnostic workup included ultrasound (US) in nine cases, computed tomography (CT) with contrast in six patients and magnetic resonance imaging (MRI) of the neck in seven cases. All patients included in this study were surgically treated. Conclusions: Vagal schwannoma management represents a true challenge for clinicians and surgery is currently the most effective therapeutic strategy. A multidisciplinary approach through the collaboration of otolaryngologist with other specialists is desirable to develop a tailored treatment plan for the patient.