Functional outcome after gamma knife surgery or microsurgery for vestibular schwannomas

Changes in patient-perceived balance and vestibular function after Gamma-knife stereotactic radiosurgery for vestibular schwannoma: 12-month outcomes in a single-centre pilot study

BACKGROUND

Hearing outcomes are well-documented for patients with vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (GK-SRS). However, how GK-SRS affects patient-perceived balance and vestibular function remains unclear. This study therefore evaluated changes in these parameters one-year post-treatment.

METHODS

A prospective, observational, before-and-after, pilot study was conducted on patients with unilateral VS treated with GK-SRS between June 2021 and July 2022. Balance-related handicap was assessed using the Dizziness Handicap Inventory (DHI). Objective vestibular function was evaluated through caloric tests and video head impulse tests (VHIT). Data were compared before treatment (0 M) and 12 months after treatment (12 M).

RESULTS

Thirty-eight patients were included (median age 69 years, 52.6% male). Median total DHI scores significantly deteriorated (14 [5; 24] at 0 M vs 18[8;40] at 12 M, p = 0.027), with an increase in cases classed with moderate handicap (12% to 29%, p = 0.025). We found a significant deterioration in median caloric deficit at low frequency (49 [29; 78]% vs 72 [40; 87]%; p = 0.012) and a significant deterioration in median vestibulo-ocular reflex (VOR) gain of the anterior semicircular canal (SSC) at high frequency (0.94[0.86;1.04] vs 0.9[0.72;0.98]; p = 0.012). Change in DHI score was only found weakly inversely correlated with change in VOR gain for the affected-side posterior SSC (r=-0.38; p = 0.04).

CONCLUSION

GK-SRS for VS can result in modest deterioration in subjective balance after one year. Changes in DHI were not strongly correlated with objective vestibular function deficits thus suggesting other factors can contribute to dizziness and balance outcomes.

Hypofractionated Versus Single-Session Radiosurgery to Preserve Hearing in Patients Affected by Sporadic Vestibular Schwannoma: The ACOUNEU Randomized Clinical Trial

PURPOSE

During the last decades, in addition to tumor control, hearing preservation has become an important priority in the treatment of vestibular schwannoma (VS). Given that the potential advantages of hypofractionated radiosurgery (hRS) over single-session radiosurgery (RS) in terms of improved hearing outcomes remain unclear, this randomized trial aims to provide a robust answer to this question.

METHODS AND MATERIALS

The present is a double-arm randomized clinical trial. The study started in 2011 and the last patient was enrolled in 2020. The minimum follow-up was 36 months. The trial involved patients with a diagnosis of sporadic VS with preserved hearing. One hundred and eight patients were enrolled. Participants were randomized to receive either hRS (18 Gy/3 consecutive fractions) or RS (most commonly 12 Gy/1 fraction). At each follow-up, clinical assessment, volumetric magnetic resonance imaging, and audiometry were evaluated. The primary endpoint was hearing sparing 36 months after RS or hRS. The maintenance of a serviceable hearing was defined according to the American Academy of Otorhinolaryngology Head and Neck Surgery classification.

RESULTS

Of the 108 randomized patients, 100 (47 RS and 53 hRS) were included in the analysis (mean age, 55 years; 56% female). No significant differences between hRS and RS were found in terms of hearing preservation (hazard ratio, 1.083; [95% CI, 0.603-1.946], and P = .789), with pretreatment hearing status, age, and dose to cochlea being the only significant predictors. No other parameters, including tumor volume, were associated with hearing preservation. At a median follow-up of 62 months, local control was 92% (95% CI, 84.8%-96.5%). Treatment-related toxicity was mild or moderate, in general not exceeding National Cancer Institute Common Terminology Criteria for Adverse Events grade 2.

CONCLUSIONS

To our knowledge, this is the first randomized clinical trial comparing 2 different radiosurgical regimens while focusing on hearing preservation. The study failed to demonstrate the potential advantages of hRS over RS with respect to hearing preservation. The volumetric analysis confirmed an excellent postradiosurgery tumor control rate for both RS and hRS groups. These results may guide the clinicians in the treatment schedule choice to preserve hearing in patients with VS.

Tinnitus after treatment of vestibular schwannoma: a systematic review and comparative analysis of microsurgery and stereotactic radiosurgery

PURPOSE

The purpose of this systematic review and meta-analysis was to compare tinnitus outcomes following microsurgery and stereotactic radiosurgery for vestibular schwannoma.

METHODS

The databases MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Ovid), SCOPUS, CINAHL (EBSCO), and Web of Science were searched for studies comparing microsurgery and radiosurgery treatment, and reporting tinnitus outcomes. Longitudinal tinnitus assessment with pre-treatment evaluation was required for inclusion. Fractionated radiotherapy treatment was excluded. Newcastle-Ottawa scale was used to assess the quality of the included studies. A separate random-effects meta-analysis was performed for the continuous, binary and ordinal tinnitus outcomes, with pooled effects described as a standardised mean difference or a log odds ratio as appropriate.

RESULTS

Thirteen studies involving 5814 patients were included in the review; 4 were prospective studies, and the rest were retrospective cohort studies. The median follow-up duration in the microsurgery and radiosurgery groups was 39.5 months and 41.1 months, respectively. Studies were diverse with respect to inclusion criteria and method of tinnitus outcome assessment. Only 4 studies reported tinnitus scores using tinnitus questionnaires, while others used Likert scale, visual analogue scale, binary (present or absent) scale or ordinal (improved, same or worse) scale. Four studies reported better tinnitus outcomes after microsurgery than radiosurgery. However, the overall quality of the studies was low, and most did not control for important confounders, such as age, tumour characteristics, and hearing impairment. Meta-analysis of continuous and binary tinnitus outcomes showed no difference between the interventions (standardised mean difference = -0.04, 95% CI -0.37 to 0.28, p = 0.80; log odds ratio = 0.32, 95% CI -1.11 to 1.74, p = 0.66). Meta-analysis of tinnitus outcomes on an ordinal scale showed microsurgery increased the odds of reporting improved tinnitus compared to radiosurgery (log odds ratio = 0.83, 95% CI 0.01 to 1.64, p = 0.045). Heterogeneity between the studies was high for all outcome measures (I2 > 56%).

CONCLUSION

Meta-analyses of tinnitus outcomes were largely inconclusive, except when tinnitus was reported as an ordinal outcome, which favoured microsurgery. However, due to the low quality of studies and high heterogeneity, no definitive conclusions could be drawn favouring either treatment.

Dynamics of tumor evolution after Gamma Knife radiosurgery for sporadic vestibular schwannoma: Defining volumetric patterns characterizing individual trajectory

BACKGROUND

The definition of tumor control and treatment failure after Gamma Knife radiosurgery (GKRS) for vestibular schwannoma (VS) is still debated. The lack of knowledge on the dynamics of tumor evolution can lead to misinterpretation and subsequent inappropriate second treatment. The aim of this study was to evaluate the post-GKRS dynamics of the evolution of tumor volume and characterize volumetric patterns.

METHODS

We included patients with sporadic VS treated by GKRS with an MRI follow-up of a minimum of 3 years. A clustering was performed in 2 steps: Definition of the patterns of evolution based on a subset of patients with the most comprehensive follow-up, and then the assignment of the remaining patients on a best-fit basis. The minimum length of follow-up was assessed by measuring the consistency of the clusters over time (adjusted rand index and normalized mutual information). An analysis of the discriminant variables was finally performed.

RESULTS

A total of 1607 patients were included (median follow-up: 67 months). Five patterns were defined with 1 pattern gathering almost all cases of treatment failure. The clustering at 5 years afforded the highest consistency with long-term follow-up. Discriminant variables for clusters were as follows: sex, initial symptoms, delay of diagnosis, Koos grading, fundus invasion, and number of isocenters.

CONCLUSIONS

The definition of these robust distinct patterns is likely to help the physicians tremendously to distinguish tumor control from potential failure. We advocate for no retreatment decision before 5 years post-GKRS. Further investigations are required to decide if the dynamics of evolution can be predicted at GKRS on an individual basis.

Outcomes in Vestibular Schwannoma Surgery: insights from our last 100 cases

Vestibular schwannoma (VS) is a benign tumor that varies in size and presentation. Surgery is the preferred treatment for large or symptomatic VS. Facial nerve (FN) preservation is a priority because of its impact on well-being. Despite advances in surgical technics and experience, 6% to 20% of patients still experience poor facial function post-surgery. Balancing FN preservation with tumor resection is challenging because residual tumors > 0.6 cm3 may grow further. Our center has refined its approach to prioritize FN function. This retrospective study evaluated outcomes of our last 100 consecutive cases of VS resection and outlines our current therapeutic indications. We included the last 100 consecutive cases of VS undergoing surgery from January 2022 to December 2023. Exclusion criteria included neurofibromatosis type 2-related schwannomatosis, recurrent VS surgery and radiosurgery, or pre-operative FN palsy. The mean tumor volume was 8.8 ± 0.6 cm3, corresponding to 1 case of KOOS grade 2, 19 cases of KOOS grade 3, and 80 cases of KOOS grade 4. Overall, 85 patients underwent surgery with a retrosigmoid approach; 33 cases exhibited a complex FN course that was challenging during tumor removal. Resection quality was assessed as gross total resection in 17 patients (no tumor remaining, not visible on MRI), near total resection in 22 (few tumor remaining, not visible on MRI), subtotal resection in 52 (residual tumor ≤ 0.5 cm3 on MRI), and partial resection in 9 (residual tumor ≥ 0.6 cm3 on MRI). In total, 94 patients had good FN function (grade I or II) immediately after surgery and 98 patients at last follow-up. Our experience with the last 100 consecutive VS surgeries highlights our revised policy to prioritize FN function, despite some minor residual tumor remaining of which only a few grow and will be treated by radiosurgery.

New-onset facial spasm is associated with treatment failure after radiosurgery in vestibular schwannoma

Background

New-onset facial spasm (NOFS) has been reported to be a post-therapeutic side effect, when treating vestibular schwannoma (VS) with radiosurgery (SRS) and has been linked to post-treatment pseudoprogression. The aim of this study was to identify risk factors for developing NOFS after SRS treatment and to investigate NOFS as a clinical parameter for radiographic tumor response in VS.

Methods

This study included all consecutive patients of N = 1,998 between 2004 and 2020, which were treated with SRS identified by a prospective registry. Patient and tumor characteristics (ie, sex, age, tumor extension and size, and intracanalicular extension) were analyzed retrospectively. Statistical testing was performed with R Studio.

Results

The incidence of NOFS was 5% overall. In total, 62% were permanent NOFS, whereas 39% recovered spontaneously between 4 and 34 months, postinterventionally. The incidence of NOFS was unrelated to tumor volume-however, previous SRS increased the incidence of NOFS to 20%. In primary SRS therapy, facial spasm was associated with a higher recurrence rate compared to non-NOFS patients in the Kaplan-Meier analysis (P < 0.001). Tumor control decreased with increasing tumor size. The rate of pseudoprogression was higher in the group of transient NOFS at 39% compared to permanent NOFS at 18% (P = 0.032).

Conclusions

The risk of NOFS was significantly higher in recurrent compared to primary treatment (20% vs 5%) and the majority of NOFS was permanent. The incidence of permanent NOFS was significantly associated with treatment failure. Temporary NOFS was associated with pseudoprogression. Future analysis comparing the risk profile of either treatment option should include facial spasm as a significant VS-related postinterventional symptom. Patients with postinterventional NOFS should be followed-up long-term for higher risk of treatment failure.

Treatment options for unilateral vestibular schwannoma: a network meta-analysis

This study aimed to explore the effect of observation, microsurgery, and radiotherapy for patients with vestibular schwannoma (VS). We searched PubMed, Medline, Embase, Web of Science, and Cochrane library from their establishment to July 31, 2024. 34 non-RCTs and 1 RCT that included 6 interventions were analyzed. We found the MS, and different SRS all had better tumor local control rates. Regarding preserved hearing, the order from the highest to the lowest was FSRT 5 fractions, FSRT 3 fractions, SRS, ConFSRT, Observation, and MS. Regarding improvement in the rate of tinnitus, the order from the highest to the lowest was ConFSRT, FSRT 3 fractions, SRS, Observation, MS, and FSRT 5 fractions. In terms of improving the rate of disequilibrium/vertigo, the order from the highest to the lowest was SRS, Observation, FSRT 3 fractions, FSRT 5 fractions, MS, and ConFSRT. In terms of protection of the trigeminal nerve, the order from the highest to lowest was observation, SRS, ConFSRT, FSRT 3 fractions, FSRT 5 fractions, and MS. Lastly, in terms of protection of the facial nerve, the order from the highest to lowest was SRS, ConFSRT, Observation, FSRT 3 fractions, FSRT 5 fractions, and MS. In patients with VS, MS and radiosurgery showed better local tumor control rates; however, compared with MS, different SRS all provided better protection of nerve function and improved the symptoms of vestibular function and tinnitus, among which the best was SRS. Therefore, in these patients, SRS may be a promising alternative treatment.

Understanding Permeability Changes in Vestibular Schwannomas as Part of the Dynamic Response to Radiosurgery Using Golden-Angle Radial Sparse Parallel Imaging: A Retrospective Study

BACKGROUND AND OBJECTIVES

Vestibular schwannomas demonstrate different responses after stereotactic radiosurgery (SRS), commonly including a transient loss of internal enhancement on postcontrast T1-weighted MRI thought to be due to an early reduction in tumor vascularity. We used dynamic contrast-enhanced based golden-angle radial sparse parallel (GRASP) MRI to characterize the vascular permeability changes underlying this phenomenon, with correlations to long-term tumor regression.

METHODS

Consecutive patients with vestibular schwannoma who underwent SRS between 2017 and 2019, had a transient loss of enhancement after SRS, and had long-term longitudinal GRASP studies (6, 18, and 30 months) were included in this retrospective cohort analysis (n = 19). Using GRAVIS ( https://gravis-imaging.org/gravis/ ), an analysis pipeline for GRASP studies, we extracted the key parameters normalized to the venous sinus from a region of interest within the tumor.

RESULTS

The peak, area under the curve (AUC), and wash-in phase slope were significantly reduced at 6, 18, and 30 months after SRS (corrected P < .05), even while the internal enhancement returned in the tumors. Larger pre-SRS tumors were more likely to have a greater reduction in peak ( P = .013) and AUC ( P = .029) at 6 months. In a subset of patients (N = 13) with long-term follow-up, the median percentage reduction in tumor volume was 58% at a median of 62 months. These patients showed a strong correlation between peak, AUC, and wash-in phase slope changes at 6 months and tumor volume at the last follow-up.

CONCLUSION

After SRS and loss of internal contrast uptake within vestibular schwannomas, a slow vascular permeability dynamic persisted, suggesting the presence of postradiation processes such as fibrosis. We show for the first time, using GRASP, a quantitative assessment of the vascular radiobiological effect.

Innovative minimally invasive options to treat drug-resistant epilepsies

Despite the regular discovery of new molecules, one-third of epileptic patients are resistant to antiepileptic drugs. Only a few can benefit from resective surgery, the current gold standard. Although effective in 50-70% of cases, this therapy remains risky, costly, and can be associated with long-term cognitive or neurological side effects. In addition, patients are increasingly reluctant to have a craniotomy, emphasizing the need for new less invasive therapies for focal drug-resistant epilepsies. Here, we review different minimally invasive approaches already in use in the clinic or under preclinical development to treat drug-resistant epilepsies. Localized thermolesion of the epileptogenic zone has been developed in the clinic using high-frequency thermo-coagulations or magnetic resonance imaging-guided laser or ultrasounds. Although less invasive, they have not yet significantly improved the outcomes when compared with resective surgery. Radiosurgery techniques have been used in the clinic for the last 20years and have proven efficiency. However, their efficacy is not better than resective surgery, and various side effects have been reported as well as the potential risk of sudden unexpected death associated with epilepsy. Recently, a new strategy of radiosurgery has emerged using synchrotron-generated X-ray microbeams: microbeam radiation therapy (MRT). The low divergence and high-flux of the synchrotron beams and the unique tolerance to MRT by healthy brain tissues, allows a precise targeting of specific brain regions with minimal invasiveness and limited behavioral or functional consequences in animals. Antiepileptic effects over several months have been recorded in animal models, and histological and synaptic tracing analysis suggest a reduction of neuronal connectivity as a mechanism of action. The possibility of transferring this approach to epileptic patients is discussed in this review.

Management of sporadic intracanalicular vestibular schwannomas: A critical review and International Stereotactic Radiosurgery Society (ISRS) practice guidelines

BACKGROUND

The choice of an appropriate strategy for intracanalicular vestibular schwannoma (ICVS) is still debated. We conducted a systematic review and meta-analysis with the aim to compare treatment outcomes amongst management strategies (conservative surveillance (CS), microsurgical resection (MR), or stereotactic radiosurgery (SRS)) aiming to inform guideline recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS).

METHODS

Using PRISMA guidelines, we reviewed manuscripts published between January 1990 and October 2021 referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical studies or case series reporting a cohort of ICVS managed with CS, MR, or SRS. Primary outcome measures included tumor control, the need for additional treatment, hearing outcomes, and posttreatment neurological deficits. These were pooled using meta-analytical techniques and compared using meta-regression with random effect.

RESULTS

Forty studies were included (2371 patients). The weighted pooled estimates for tumor control were 96% and 65% in SRS and CS series, respectively (P < .001). Need for further treatment was reported in 1%, 2%, and 25% for SRS, MR, and CS, respectively (P = .001). Hearing preservation was reported in 67%, 68%, and 55% for SRS, MR, and CS, respectively (P = .21). Persistent facial nerve deficit was reported in 0.1% and 10% for SRS and MR series, respectively (P = .01).

CONCLUSIONS

SRS is a noninvasive treatment with at least equivalent rates of tumor control and hearing preservation as compared to MR, with the caveat of better facial nerve preservation. As compared to CS, upfront SRS is an effective treatment in achieving tumor control with similar rates of hearing preservation.

[Vestibular Schwannoma: Factors in Therapy Decision-Making]

The treatment of vestibular schwannomas (VS) has always posed a challenge for physicians. Three essential treatment principles are available: wait-and-scan, surgery, and stereotactic radiotherapy. In addition to the type of treatment, decisions must be made regarding the optimal timing of therapy, the combination of different treatment modalities, the potential surgical approach, and the type and intensity of radiation. Factors influencing the therapy decision include tumor location and size or stage, patient age, comorbidities, symptoms, postoperative hearing rehabilitation options, patient preferences, and, not least, the experience of the surgeons and the personnel and technical capabilities of the clinical site. This article begins with a brief overview of vestibular schwannomas, then outlines the fundamental interdisciplinary treatment options, and finally discusses the ENT (ear, nose, and throat)-relevant factors in the therapy decision.

Stereotactic radiosurgery for Koos grade IV vestibular schwannoma: a systematic review and meta-analysis

BACKGROUND

Stereotactic radiosurgery (SRS) is a well-established treatment option for Koos stage I-III vestibular schwannomas (VS), often used as the first line of treatment or after subtotal resection. However, the optimal treatment for Koos-IV VS remains unclear. Therefore, our study aimed to evaluate the effectiveness of SRS as a primary treatment for large VS classified as Koos-IV.

METHODS

A systematic search was performed on December 28th, 2022, based on PubMed, Web of Science, and Scopus according to the PRISMA statement. The review was updated on September 7th, 2023. The risk of bias was assessed using the NIH Quality Assessment Tool. The R software (ver. 4.3.2) was used for all quantitative analyses and preparation of the forest plots. Publication bias and sensitivity analysis were performed to evaluate the reliability of the obtained results.

RESULTS

Among 2941 screened records, ten studies (1398 patients) have been included in quantitative synthesis. The overall tumor control rate was 90.7% (95%CI 86.3-94.4). Kaplan-Meier estimates of tumor control at 2, 6, and 10 years were 96.0% (95% CI 92.9-97.6%), 88.8% (95% CI 86.9-89.8%), and 84.5% (95% CI, 81.2-85.8%), respectively. The overall hearing preservation rate was 56.5% (95%CI 37-75.1). Kaplan-Meier estimates of hearing preservation rate at 2, 6, and 10 years were 77.1% (95% CI 67.9-82.5%), 53.5% (95% CI 44.2-58.5%), and 38.1% (95% CI 23.4-40.7%), respectively. The overall facial nerve preservation rate was 100% (95%CI 99.9-100.0). The overall trigeminal neuropathy rate reached 5.7% (95%CI 2.9-9.2). The overall rate of new-onset hydrocephalus was 5.6% (95%CI 3-9). The overall rates of worsening or new-onset tinnitus and vertigo were 6.8% (95%CI 4.2-10.0) and 9.1% (95%CI 2.1-19.6) respectively. No publication bias was detected according to the used methods.

CONCLUSIONS

Our systematic review and meta-analysis demonstrated a high overall tumor control rate, excellent facial nerve preservation, and low incidence of new-onset or worsened tinnitus and vertigo. However, several drawbacks associated with SRS should be noted, such as the presence of post-SRS hydrocephalus risk, mediocre long-term hearing preservation, and the lack of immediate tumor decompression. Nevertheless, the use of SRS may be beneficial in appropriately selected cases of Koos-IV VS. Moreover, further prospective studies directly comparing SRS with surgery are necessary to determine the optimal treatment for large VS and verify our results on a higher level of evidence. Registration and protocol: CRD42023389856.

Impact of the Mean Cochlear Biologically Effective Dose on Hearing Preservation After Stereotactic Radiosurgery for Vestibular Schwannoma: A Retrospective Longitudinal Analysis

BACKGROUND AND OBJECTIVES

Stereotactic radiosurgery (SRS) is a useful alternative for small- to medium-sized vestibular schwannoma. To evaluate whether biologically effective dose (BED Gy2.47 ), calculated for mean (BED Gy2.47 mean) and maximal (BED Gy2.47 max) cochlear dose, is relevant for hearing preservation.

METHODS

This is a retrospective longitudinal single-center study. Were analyzed 213 patients with useful baseline hearing. Risk of hearing decline was assessed for Gardner-Robertson classes and pure tone average (PTA) loss. The mean follow-up period was 39 months (median 36, 6-84).

RESULTS

Hearing decline (Gardner-Robertson class) 3 years after SRS was associated with higher cochlear BED Gy2.47 mean (odds ratio [OR] 1.39, P = .009). Moreover, BED Gy2.47 mean was more relevant as compared with BED Gy2.47 max (OR 1.13, P = .04). Risk of PTA loss (continuous outcome, follow-up minus baseline) was significantly corelated with BED Gy2.47 mean at 24 (beta coefficient 1.55, P = .002) and 36 (beta coefficient 2.01, P = .004) months after SRS. Risk of PTA loss (>20 dB vs ≤) was associated with higher BED Gy2.47 mean at 6 (OR 1.36, P = .002), 12 (OR 1.36, P = .007), and 36 (OR 1.37, P = .02) months. Risk of hearing decline at 36 months for the BED Gy2.47 mean of 7-8, 10, and 12 Gy 2.47 was 28%, 57%, and 85%, respectively.

CONCLUSION

Cochlear BED Gy2.47 mean is relevant for hearing decline after SRS and more relevant as compared with BED Gy2.47 max. Three years after SRS, this was sustained for all hearing decline evaluation modalities. Our data suggest the BED Gy2.47 mean cut-off of ≤8 Gy 2.47 for better hearing preservation rates .

Brazilian Society of Otology task force - Vestibular Schwannoma ‒ evaluation and treatment

OBJECTIVE

To review the literature on the diagnosis and treatment of vestibular schwannoma.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on vestibular schwannoma were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: (1) Diagnosis - audiologic, electrophysiologic tests, and imaging; (2) Treatment - wait and scan protocols, surgery, radiosurgery/radiotherapy, and systemic therapy.

CONCLUSIONS

Decision making in VS treatment has become more challenging. MRI can diagnose increasingly smaller tumors, which has disastrous consequences for the patients and their families. It is important to develop an individualized approach for each case, which highly depends on the experience of each surgical team.

COX inhibitor use during definitive radiotherapy is associated with worse hearing preservation in patients with vestibular schwannoma

PURPOSE

Patients with vestibular schwannoma undergoing definitive radiotherapy commonly experience hearing loss due to tumor and treatment effects; however, there is limited data evaluating concurrent medication use and other clinicopathologic factors associated with hearing preservation during and after radiotherapy. We performed a retrospective cohort study reviewing consecutive patients from 2004 to 2019 treated with radiotherapy for vestibular schwannoma at our institution.

METHODS

Ninety four patients with concurrent medications, baseline audiograms, and post-radiotherapy audiograms available were evaluable. We performed chi-squared analyses of the frequency of various clinicopathologic factors and t-tests evaluating the degree of hearing loss based on audiograms.

RESULTS

At a median follow-up of 35.7 months (mean: 46.5 months), the baseline pure-tone average (PTA) of the ipsilateral ear worsened from 38.4 to 59.5 dB following completion of radiotherapy (difference: 21.1, 95% CI 17.8-24.4 dB, p < 0.001). 36 patients (38.3%) reported regular use of cyclooxygenase (COX) inhibitors (including acetaminophen and NSAIDs) during radiotherapy. The mean increase in PTA was significantly higher for patients taking COX inhibitors (25.8 dB vs 18.1 dB, p = 0.024) in the ipsilateral ear but not for the contralateral side. COX inhibitor use remained independently associated with worse PTA in the multivariate analysis.

CONCLUSION

COX inhibitor use during definitive radiotherapy is associated with worse hearing loss in the affected ear but not for the contralateral side. This suggests the ototoxic effects of COX inhibitors may influence the effects of radiotherapy. These results could have clinical implications and warrant further investigation.

Long-Term Hearing Outcome After Radiosurgery for Vestibular Schwannoma: A Systematic Review and Meta-Analysis

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.

Dosimetric predictive factors for facial nerve paralysis after cyberknife® stereotactic radiotherapy for vestibular schwannomas: A single institution experience of 88 patients

PURPOSE

To identify dosimetric predictive factors of facial nerve paralysis for patients with vestibular schwannomas (VS) treated in a single institution with Cyberknife® (CK) hypofractionated stereotactic radiotherapy (SRT).

METHODS AND MATERIALS

Eighty-eight patients were treated from 2010 to 2020. Different treatment schedules were used over that period, some prescribed to the 80% isodose line (4 × 5 Gy, 3 × 7 Gy, 3 × 8 Gy and 5 × 5 Gy) and one to the 70% isodose line (3 × 7.7 Gy). Local control tumor and facial nerve toxicity were recorded, as well as various dosimetric indicators.

RESULTS

Median follow-up 37 months (range, 7-96). Of the 88 stereotactic treatments, 20 patients (23%) developed objectively diagnosed radiation-induced facial nerve paralysis. The 2-year and 5-year local tumor control were respectively 95% and 88%, and the overall 2-year facial nerve preservation was 76%. Prescriptions with a maximum dose point (Dmax) of 33 Gy were at a substantially higher risk of facial paralysis than prescriptions with a Dmax less than or equal to 30 Gy (HR = 4.51, 95% CI = [1.04;19.6], p = 0.045). The 2-years cumulative incidences of facial paralysis were 32% [20%;44%] in the case of a 33 Gy Dmax, against 7% [1%;21%] otherwise. We identified four significative dosimetric predictive factors for radiation-induced facial nerve dysfunction: a GTV minimal dose over 22 Gy (EQD2 = 45.5 Gy, p = 0.019), a GTV mean dose over 29 Gy (EQD2 = 73.5 Gy, HR = 2.84, 95% CI = [1.10;7.36], p = 0.024), a PTV mean dose over 27 Gy (EQD2 = 64.8 Gy, HR = 10.52, 95% CI = [1.39;79.76], p = 0.002) and a PTV maximal dose of 32 Gy (EQD2 = 87.5 Gy,HR = 5.09, 95% CI = [1.17;22.15], p = 0.013).

CONCLUSION

We identified four dosimetric predictive factors for post-treatment facial paralysis. Increasing the doses of hypofractionated stereotactic radiotherapy for vestibular schwannomas leads to higher facial nerve toxicity and may lead to lower local control rates than other published series. Our three-hypofractionated regimens may have also played a role in these results.

Diagnosis and Treatment of Peripheral and Cranial Nerve Tumors with Expert Recommendations: An EUropean Network for RAre CANcers (EURACAN) Initiative

The 2021 WHO classification of the CNS Tumors identifies as "Peripheral nerve sheath tumors" (PNST) some entities with specific clinical and anatomical characteristics, histological and molecular markers, imaging findings, and aggressiveness. The Task Force has reviewed the evidence of diagnostic and therapeutic interventions, which is particularly low due to the rarity, and drawn recommendations accordingly. Tumor diagnosis is primarily based on hematoxylin and eosin-stained sections and immunohistochemistry. Molecular analysis is not essential to establish the histological nature of these tumors, although genetic analyses on DNA extracted from PNST (neurofibromas/schwannomas) is required to diagnose mosaic forms of NF1 and SPS. MRI is the gold-standard to delineate the extension with respect to adjacent structures. Gross-total resection is the first choice, and can be curative in benign lesions; however, the extent of resection must be balanced with preservation of nerve functioning. Radiotherapy can be omitted in benign tumors after complete resection and in NF-related tumors, due to the theoretic risk of secondary malignancies in a tumor-suppressor syndrome. Systemic therapy should be considered in incomplete resected plexiform neurofibromas/MPNSTs. MEK inhibitor selumetinib can be used in NF1 children ≥2 years with inoperable/symptomatic plexiform neurofibromas, while anthracycline-based treatment is the first choice for unresectable/locally advanced/metastatic MPNST. Clinical trials on other MEK1-2 inhibitors alone or in combination with mTOR inhibitors are under investigation in plexiform neurofibromas and MPNST, respectively.

Hearing Preservation, Facial Nerve Dysfunction, and Tumor Control in Small Vestibular Schwannoma: A Systematic Review of Gamma Knife Radiosurgery Versus Microsurgery

BACKGROUND AND PURPOSE

Vestibular schwannoma (VS) is the most common type of tumor found in the cerebellopontine angle that accounts for 8% of all intracranial tumors. VS management is currently a challenge due to the unpredictable nature of the tumor. Few studies have compared the results and complications of various therapeutic approaches to VS. Therefore, as a treatment option for VSs smaller than 25 mm, we conducted a systematic review to compare Gamma Knife radiosurgery (GKRS) with conventional surgery.

METHODS

Literature searches were conducted of four online databases (PubMed, Google Scholar, Cochrane, and ScienceDirect) using the following keyword search: ("vestibular schwannoma" OR "acoustic neuroma") AND ("gamma knife" OR "gamma knife radiosurgery") AND ("resection" OR "open surgery") AND ("hearing preservation" OR "facial nerve" OR "tumor growth").

RESULTS

We identified six retrospective cohort studies, five of which were of fair-to-good quality. All studies showed that GKRS was superior to surgery in hearing preservation. Two studies indicated that surgery was superior to GKRS in maintaining tumor control, one indicated that GKRS was superior, and the remainder indicated that there was no significant difference in maintaining tumor control between GKRS and microsurgery.

CONCLUSIONS

Based on the three outcomes chosen for this review, GKRS was superior to microsurgery in small VS.

A comparative study of microsurgery and gamma knife radiosurgery in vestibular schwannoma evaluating tumor control and functional outcome

Background

Both stereotactic radiosurgery (SRS) and microsurgical resection (SURGERY) are available as treatment options for sporadic vestibular schwannoma (VS). There are very few direct comparative studies comparing both treatment modalities in large cohorts allowing detailed subgroup analysis. This present study aimed to compare the nuances in the treatment of VS by SURGERY and SRS in 2 highly specialized neurosurgical centers.

Methods

This is a retrospective bicentric cohort study. Data from patients treated between 2005 and 2011 were collected retrospectively. Recurrence-free survival (RFS) was assessed radiographically by contrast-enhanced magnetic resonance imaging.

Results

The study population included N = 901 patients with a mean follow-up of 7 years. Overall, the incidence of recurrence was 7% after SURGERY, and 11% after SRS with superior tumor control in SURGERY in the Kaplan-Meier-analysis (P = 0.031). In small tumors (Koos I and II), tumor control was equivalent in both treatment arms. In large VS (Koos III and IV), however, RFS was superior in SURGERY. The extent of resection correlated with RFS (P < .001). Facial and hearing deterioration was similar in both treatment arms in small VS, but more pronounced in SURGERY of large VS. Tinnitus, vertigo, imbalance, and trigeminal symptoms were more often improved by SURGERY than SRS.

Conclusions

SRS can achieve similar tumor control compared to SURGERY in smaller VS (Koos I and II)-with similar postinterventional morbidities. In large VS (Koos III and IV), long-term tumor control of SRS is inferior to SURGERY. Based on these results, we suggest that if combination therapy is chosen, the residual tumor should not exceed the size of Koos II.

Modern Hearing Preservation Outcomes After Vestibular Schwannoma Stereotactic Radiosurgery

BACKGROUND

For patients with vestibular schwannoma (VS), stereotactic radiosurgery (SRS) has proven effective in controlling tumor growth while hearing preservation remains a key goal.

OBJECTIVE

To evaluate hearing outcomes in the modern era of cochlear dose restriction.

METHODS

During the years 2013 to 2018, 353 patients underwent Gamma knife surgery for VS at our institution. We followed 175 patients with pre-SRS serviceable hearing (Gardner-Robertson Score, GR 1 and 2). Volumetric and dosimetry data were collected, including biological effective dose, integral doses of total and intracanalicular tumor components, and hearing outcomes.

RESULTS

The mean age was 56 years, 74 patients (42%) had a baseline GR of 2, and the mean cochlear dose was 3.5 Gy. The time to serviceable hearing loss (GR 3-4) was 38 months (95% CI 26-46), with 77% and 62% hearing preservation in the first and second years, respectively. Patients optimal for best hearing outcomes were younger than 58 years with a baseline GR of 1, free canal space ≥0.041 cc (diameter of 4.5 mm), and mean cochlear dose <3.1 Gy. For such patients, hearing preservation rates were 92% by 12 months and 81% by 2 years, staying stable for >5 years post-SRS, significantly higher than the rest of the population.

CONCLUSION

Hearing preservation after SRS for patients with VS with serviceable hearing is correlated to the specific baseline GR score (1 or 2), age, cochlear dose, and biological effective dose. Increased tumor-free canal space correlates with better outcomes. The most durable hearing preservation correlates with factors commonly associated with smaller tumors away from the cochlea.

The longitudinal volumetric response of vestibular schwannomas after Gamma Knife radiosurgery

OBJECTIVE

Gamma Knife radiosurgery (GKRS) is an effective treatment for vestibular schwannomas (VSs) and has been used in > 100,000 cases worldwide. In the present study the authors sought to define the serial volumetric tumor response of Koos grade I-IV VS after radiosurgery.

METHODS

A total of 201 consecutive VS patients underwent GKRS at a single institution between 2015 and 2019. All patients had a minimum follow-up of 18 months and at least 2 interval postprocedure MRI scans. The contrast-enhanced tumor volumes were contoured manually and compared between pre- and post-GKRS imaging. The percentages of tumor volume change at 18 months (short-term follow-up) and up to 5 years after GKRS (long-term follow-up) were compared with the baseline tumor volume. An increase of 20% was considered a significant increase of tumor volume. Trends of tumor volume over time were assessed with linear models using time as a continuous variable. A test for linear trend was evaluated according to the initial Koos tumor classification.

RESULTS

Koos grade II VS was the most frequently occurring tumor (n = 74, 36.8%), followed by grade III (n = 57, 28.4%), grade I (n = 41, 20.4%), and grade IV (n = 29, 14.4%). The mean tumor volume at the time of GKRS was 2.12 ± 2.82 cm3 (range 0.12-18.77 cm3) and the median margin dose was 12 Gy. Short-term follow-up revealed that tumor volumes transiently increased in 34.2% and 28.4% of patients at 6 and 18 months, respectively, regardless of Koos grade. Linear regression analysis of Koos grade II, III, and IV tumors showed a significant longitudinal volume decrease on long-term follow-up. At last follow-up (median 30 months, range 18-54 months), 19 patients (9.4%) showed a persistent increase of tumor volume. Five patients received additional management after GKRS.

CONCLUSIONS

Although selected VS patients demonstrate an early and measurable transient volumetric increase after GKRS, > 90% have stable or reduced tumor volumes over an observed period of up to 5 years. Volumetric regression is most pronounced in Koos grade II, III, and IV tumors and may not be fully detectable until 3 years after GKRS.

Vestibular Schwannomas

Vestibular Schwannomas are well treated by GKNS. This can be used alone for tumors up to 20cm³. For larger tumors subtotal, intracapsular resection followed by GKNS a few months later would seem to give the best results. While there remain disagreements relating to optimal treatment for VSs among colleagues using different techniques, there are indications that these are becoming less confrontational. The evidence in this chapter suggests that early GKNS intervention results in better hearing preservation and tumor control in small tumors. The evidence in favor of "wait and see" depends on series reporting on changes in tumor size using suboptimal measurements. It is more important to record the fate of hearing, and this would seem to be better preserved following early GKNS. The results of GKNS for NF2 are by no means as good as could be wished but would seem to be superior to those of microsurgery. The importance of screening of family members cannot be over emphasized.

Radiotherapy of benign intracranial tumours

We present the updated recommendations of the French Society for Radiation Oncology on benign intracranial tumours. Most of them are meningiomas, vestibular schwannomas, pituitary adenomas, craniopharyngiomas, and glomus tumours. Some grow very slowly, and can be observed without specific treatment, especially if they are asymptomatic. Symptomatic or growing tumours are treated by surgery, which is the reference treatment. When surgery is not possible, due to the location of the lesion, or general conditions, radiotherapy can be applied, as it is if there is a postoperative growing residual tumour, or a local relapse. Indications have to be discussed at a multidisciplinary panel, with precise evaluation of the benefit and risks of the treatments. The techniques to be used are the most modern ones, as multimodal imaging and image-guided radiation therapy. Stereotactic treatments, using fractionated or single doses depending on the size or the location of the tumours, are commonly realized, to avoid as much a possible the occurrence of late side effects.

Long-term outcomes of rotating gamma knife for vestibular schwannoma: A 4-year prospective longitudinal study of 89 consecutive patients in Vietnam

Background:

Microsurgical total removal of vestibular schwannoma (VS) is the definitive treatment but has a high incidence of postoperative neurological deficits. Rotating Gamma Knife (RGK) is a preferred option for a small tumor. This study aims to evaluate long-term neurological outcomes of RGK for VS.

Methods:

This prospective longitudinal study was conducted at the Nuclear Medicine and Oncology Center, Bach Mai Hospital, Hanoi, Vietnam. Eighty-nine consecutive patients were enrolled from October 2011 to October 2015 and followed up to June 2017. RGK was indicated for VS measuring <2.2 cm, while RGK for tumors measuring 2.2–3 cm was considered in patients with severe comorbidities, high-risk surgery, and who denied surgery. Concurrently, VS consisted of newly diagnosed, postoperative residual, and recurrent tumors. Patients with neurofibromatosis type 2 were excluded from the study. Primary outcomes were radiological tumor control rate, vestibulocochlear functions, facial and trigeminal nerve preservation. Stereotactic radiosurgery was performed by the Rotating Gamma System Gamma ART 6000.

Results:

The tumors were measured 20.7 ± 5.6 mm at pre treatment and 17.6 ± 4.1 mm at 3-year post treatment. The mean radiation dose was 13.5 ± 0.9 Gy. Mean follow-up was 40.6 ± 13.3 months. The radiological tumor control rate was achieved 95.5% at 5-year post treatment. The hearing and vestibular functions were preserved in 70.3% and 68.9%, respectively. The facial and trigeminal nerve preservation rates were 94.4% and 73.3%, respectively.

Conclusion:

RGK is an effective and safe treatment for VS measuring ≤3 cm with no significant complications during long-term follow-up.

Assessing the long-term safety and efficacy of gamma knife and linear accelerator radiosurgery for vestibular schwannoma: A systematic review and meta-analysis

Background

Differences in long-term outcomes of single-fraction stereotactic radiosurgery (SRS) between gamma knife (GK) and linear accelerator (LINAC) systems for vestibular schwannoma (VS) management remain unclear. To investigate differences in safety and efficacy between modalities, we conducted a meta-analysis of studies over the past decade.

Methods

MEDLINE, EMBASE, and Cochrane databases were queried for studies with the following inclusion criteria: English language, published between January 2010 and April 2020, cohort size ≥30, and mean/median follow-up ≥5 years. Odds ratios (OR) compared rates of tumor control, hearing preservation, and cranial nerve toxicities before and after SRS.

Results

Thirty-nine studies were included (29 GK, 10 LINAC) with 6516 total patients. Tumor control rates were 93% (95% CI 91-94%) and 94% (95% CI 91-97%) for GK and LINAC, respectively. Both GK (OR 0.06, 95% CI 0.02-0.13) and LINAC (OR 0.47, 95% CI 0.29-0.76) reduced odds of serviceable hearing. Neither GK (OR 0.71, 95% CI 0.41-1.22) nor LINAC (OR 1.13, 95% CI 0.64-2.00) impacted facial nerve function. GK decreased odds of trigeminal nerve (TN) impairment (OR 0.55, 95% CI 0.32-0.94) while LINAC did not impact TN function (OR 1.45, 95% CI 0.81-2.61). Lastly, LINAC offered decreased odds of tinnitus (OR 0.15, 95% CI 0.03-0.87) not observed with GK (OR 0.70, 95% CI 0.48-1.01).

Conclusions

VS tumor control and hearing preservation rates are comparable between GK and LINAC SRS. GK may better preserve TN function, while LINAC decreases tinnitus rates. Future studies are warranted to investigate the efficacy of GK and LINAC SRS more directly.

Stereotactic radiosurgery as the primary management for patients with Koos grade IV vestibular schwannomas

OBJECTIVE

While extensive long-term outcome studies support the role of stereotactic radiosurgery (SRS) for smaller-volume vestibular schwannomas (VSs), its role in the management for larger-volume tumors remains controversial.

METHODS

Between 1987 and 2017, the authors performed single-session SRS on 170 patients with previously untreated Koos grade IV VSs (volumes ranged from 5 to 20 cm3). The median tumor volume was 7.4 cm3. The median maximum extracanalicular tumor diameter was 27.5 mm. All tumors compressed the middle cerebellar peduncle and distorted the fourth ventricle. Ninety-three patients were male, 77 were female, and the median age was 61 years. Sixty-two patients had serviceable hearing (Gardner-Robertson [GR] grades I and II). The median margin dose was 12.5 Gy.

RESULTS

At a median follow-up of 5.1 years, the progression-free survival rates of VSs treated with a margin dose ≥ 12.0 Gy were 98.4% at 3 years, 95.3% at 5 years, and 90.7% at 10 years. In contrast, the tumor control rate after delivery of a margin dose < 12.0 Gy was 76.9% at 3, 5, and 10 years. The hearing preservation rates in patients with serviceable hearing at the time of SRS were 58.1% at 3 years, 50.3% at 5 years, and 35.9% at 7 years. Younger age (< 60 years, p = 0.036) and initial GR grade I (p = 0.006) were associated with improved serviceable hearing preservation rate. Seven patients (4%) developed facial neuropathy during the follow-up interval. A smaller tumor volume (< 10 cm3, p = 0.002) and a lower margin dose (≤ 13.0 Gy, p < 0.001) were associated with preservation of facial nerve function. The probability of delayed facial neuropathy when the margin dose was ≤ 13.0 Gy was 1.1% at 10 years. Nine patients (5%) required a ventriculoperitoneal shunt because of delayed symptomatic hydrocephalus. Fifteen patients (9%) developed detectable trigeminal neuropathy. Delayed resection was performed in 4% of patients.

CONCLUSIONS

Even for larger-volume VSs, single-session SRS prevented the need for delayed resection in almost 90% at 10 years. For patients with minimal symptoms of tumor mass effect, SRS should be considered an effective alternative to surgery in most patients, especially those with advanced age or medical comorbidities.

Tumor control and trigeminal dysfunction improvement after stereotactic radiosurgery for trigeminal schwannomas: a systematic review and meta-analysis

Trigeminal nerve schwannomas (TS) are uncommon intracranial tumors, frequently presenting with debilitating trigeminal and/or oculomotor nerve dysfunction. While surgical resection has been described, its morbidity and mortality rates are non-negligible. Stereotactic radiosurgery (SRS) has emerged with variable results as a valuable alternative. Here, we aimed at reviewing the medical literature on TS treated with SRS so as to investigate rates of tumor control and symptomatic improvement. We reviewed manuscripts published between January 1990 and December 2019 on PubMed. Tumor control and symptomatic improvement rates were evaluated with separate meta-analyses. This meta-analysis included 18 studies comprising a total of 564 patients. Among them, only one reported the outcomes of linear accelerators (Linac), while the others of GK. Tumor control rates after SRS were 92.3% (range 90.1-94.5; p < 0.001), and tumor decrease rates were 62.7% (range 54.3-71, p < 0.001). Tumor progression rates were 9.4% (range 6.8-11.9, p < 0.001). Clinical improvement rates of trigeminal neuralgia were 63.5% (52.9-74.1, p < 0.001) and of oculomotor nerves were 48.2% (range 36-60.5, p < 0.001). Clinical worsening rate was 10.7% (range 7.6-13.8, p < 0.001). Stereotactic radiosurgery for TS is associated with high tumor control rates and favorable clinical outcomes, especially for trigeminal neuralgia and oculomotor nerves. However, patients should be correctly advised about the risk of tumor progression and potential clinical worsening. Future clinical studies should focus on standard reporting of clinical outcomes.

Tufts Medical Center Experience With Long-Term Follow-Up of Vestibular Schwannoma Treated With Gamma Knife Stereotactic Radiosurgery: Novel Finding of Delayed Pseudoprogression

Purpose

Our purpose was to evaluate the long-term outcomes of patients with vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (GKSRS) with modern techniques, with attention to posttreatment tumor growth dynamics, dosimetric predictors, and late toxicities.

Methods and Materials

One hundred twelve patients with VS were treated with GKSRS with a median dose of 12.5 Gy to the 50% isodose line treated between 2004 and 2015, with patients followed up to 15 years. Target and organ-at-risk doses were recorded, and tumor diameter/volume, audiologic decline, and trigeminal/facial nerve preservation were tracked from treatment onward.

Results

GKSRS yielded local control of 5, 10, and 15 years at 96.9%, 90.0%, and 87.1% respectively. Pseudoprogression was found in 45%, with a novel pattern detected with peak swelling at 31 months. Pseudoprogression was associated with smaller tumor diameter at treatment and fewer treatment isocenters, but not with the development of any toxicity, nor was it predicted by any dosimetric factor. Median time to hearing loss was 3.4 years with actuarial hearing preservation at 2, 5, and 10 years of 66.5%, 43.1%, and 37.6%, with rate of hearing loss correlating with maximum cochlea and modiolus doses. Trigeminal and facial nerve preservation rates were 92.7% and 97.6%, respectively. Increasing maximum tumor dose was associated with facial paresthesia.

Conclusions

Modern GKSRS is a safe and effective treatment for VS on long-term follow-up, with high levels of facial and trigeminal nerve preservation. A novel pattern of pseudoprogression has been identified suggesting longer imaging follow-up may be needed before initiating salvage in those without symptomatic progression. Several tumor and dosimetric predictors have been suggested for the development of different toxicities, requiring further evaluation.

Depression and ability to work after vestibular schwannoma surgery: a nationwide registry-based matched cohort study on antidepressants, sedatives, and sick leave

BACKGROUND

In patients with vestibular schwannomas (VS), tumor control is often achieved, and life expectancy is relatively good. The main risks of surgical treatment are hearing loss and facial nerve function. The occurrence of mood and sleeping disorders in relation to surgery is an important aspect of health that has rarely been studied. Similarly, only limited data exist on the rate of sick leave for patients with VS. In this nationwide registry-based study, we define the use of antidepressants and sedatives and the sick leave pattern before and after VS surgery.

METHODS

Adult patients with histopathologically verified VS were identified in the Swedish Brain Tumor Registry (SBTR) and clinical data were linked to relevant national registries after assigning five matched controls to each patient. We studied patterns of dispensed antidepressants and sedative drugs as well as patterns of sick leave compared to respective controls at 2 years before and 2 years following surgery.

RESULTS

We identified 333 patients and 1662 matched controls. The rate of antidepressant use was similar between patients and controls 2 years before surgery (6.0% vs 6.3%) and 2 years after surgery (10.1% vs 7.5%). The rate of sedative use was also similar 2 years before surgery (3.9% vs 4.3%) and 2 years after surgery (4.8% vs 5.3%). The rate of sick leave was similar at baseline between patients and controls, but at 2 years after surgery, 75% of patients vs 88% of controls (p < 0.01) had no registered sick leave. Long-term sick leave after surgery was predicted by use of sedatives (OR 0.60, 95% CI 0.38-0.94, p = 0.03), more preoperative sick leave (OR 0.91, 95% CI 0.89-0.93, p < 0.001), and new-onset neurological deficits after surgery (OR 0.42, 95% CI 0.24-0.76, p = 0.004).

CONCLUSION

This nationwide study shows no significant differences in the use of antidepressants and sedatives between patients and controls, while the rate of postoperative sick leave was higher in patients than in controls after VS surgery. Our findings underpin the importance of avoiding surgical sequelae and facilitating return to normal professional life.

Repeat stereotactic radiosurgery for progressive vestibular schwannomas after previous radiosurgery: a systematic review and meta-analysis

Vestibular schwannomas (VS) are slow-growing intracranial extraaxial benign tumors, developing from the vestibular part of the eight cranial nerves. Stereotactic radiosurgery (SRS) has now a long-term scientific track record as first intention treatment for small- to medium-sized VS. Though its success rate is very high, SRS for VS might fail to control tumor growth in some cases. However, the literature on repeat SRS after previously failed SRS remains scarce and reported in a low number of series with a limited number of cases. Here, we aimed at performing a systematic review and meta-analysis of the literature on repeat SRS for VS. Using PRISMA guidelines, we reviewed manuscripts published between January 1990 and October 2020 and referenced in PubMed. Tumor control and cranial nerve outcomes were evaluated with separate meta-analyses. Eight studies comprising 194 patients were included. The overall rate of patients treated in repeat SRS series as per overall series with first SRS was 2.2% (range 1.2–3.2%, p < 0.001). The mean time between first and second SRS was 50.7 months (median 51, range 44–64). The median marginal dose prescribed at first SRS was 12 Gy (range 8–24) and at second SRS was 12 Gy (range 9.8–19). After repeat SRS, tumor stability was reported in 61/194 patients, i.e., a rate of 29.6% (range 20.2–39%, I² = 49.1%, p < 0.001). Tumor decrease was reported in 83/194 patients, i.e., a rate of 54.4% (range 33.7–75.1%, I² = 89.1%, p < 0.001). Tumor progression was reported in 50/188 patients, i.e., a rate of 16.1% (range 2.5–29.7%, I² = 87.1%, p = 0.02), rarely managed surgically. New trigeminal numbness was reported in 27/170 patients, i.e., a rate of 9.9% (range 1.4–18.3%, p < 0.02). New facial nerve palsy of worsened of previous was reported in 8/183 patients, i.e., a rate of 4.3% (range 1.4–7.2%, p = 0.004). Hearing loss was reported in 12/22 patients, i.e., a rate of 54.3% (range 24.8–83.8%, I² = 70.7%, p < 0.001). Repeat SRS after previously failed SRS for VS is associated with high tumor control rates. Cranial nerve outcomes remain favorable, particularly for facial nerve. The rate of hearing loss appears similar to the one related to first SRS.

EANO guideline on the diagnosis and treatment of vestibular schwannoma

The level of evidence to provide treatment recommendations for vestibular schwannoma is low compared with other intracranial neoplasms. Therefore, the vestibular schwannoma task force of the European Association of Neuro-Oncology assessed the data available in the literature and composed a set of recommendations for health care professionals. The radiological diagnosis of vestibular schwannoma is made by magnetic resonance imaging. Histological verification of the diagnosis is not always required. Current treatment options include observation, surgical resection, fractionated radiotherapy, and radiosurgery. The choice of treatment depends on clinical presentation, tumor size, and expertise of the treating center. In small tumors, observation has to be weighed against radiosurgery, in large tumors surgical decompression is mandatory, potentially followed by fractionated radiotherapy or radiosurgery. Except for bevacizumab in neurofibromatosis type 2, there is no role for pharmacotherapy.

Proton and Heavy Particle Intracranial Radiosurgery

Stereotactic radiosurgery (SRS) involves the delivery of a highly conformal ablative dose of radiation to both benign and malignant targets. This has traditionally been accomplished in a single fraction; however, fractionated approaches involving five or fewer treatments have been delivered for larger lesions, as well as lesions in close proximity to radiosensitive structures. The clinical utilization of SRS has overwhelmingly involved photon-based sources via dedicated radiosurgery platforms (e.g., Gamma Knife® and Cyberknife®) or specialized linear accelerators. While photon-based methods have been shown to be highly effective, advancements are sought for improved dose precision, treatment duration, and radiobiologic effect, among others, particularly in the setting of repeat irradiation. Particle-based techniques (e.g., protons and carbon ions) may improve many of these shortcomings. Specifically, the presence of a Bragg Peak with particle therapy at target depth allows for marked minimization of distal dose delivery, thus mitigating the risk of toxicity to organs at risk. Carbon ions also exhibit a higher linear energy transfer than photons and protons, allowing for greater relative biological effectiveness. While the data are limited, utilization of proton radiosurgery in the setting of brain metastases has been shown to demonstrate 1-year local control rates >90%, which are comparable to that of photon-based radiosurgery. Prospective studies are needed to further validate the safety and efficacy of this treatment modality. We aim to provide a comprehensive overview of clinical evidence in the use of particle therapy-based radiosurgery.

Surgical management for large vestibular schwannomas: a systematic review, meta-analysis, and consensus statement on behalf of the EANS skull base section

BACKGROUND AND OBJECTIVE

The optimal management of large vestibular schwannomas continues to be debated. We constituted a task force comprising the members of the EANS skull base committee along with international experts to derive recommendations for the management of this problem from a European perspective.

MATERIAL AND METHODS

A systematic review of MEDLINE database, in compliance with the PRISMA guidelines, was performed. A subgroup analysis screening all surgical series published within the last 20 years (January 2000 to March 2020) was performed. Weighted summary rates for tumor resection, oncological control, and facial nerve preservation were determined using meta-analysis models. This data along with contemporary practice patterns were discussed within the task force to generate consensual recommendations regarding preoperative evaluations, optimal surgical strategy, and follow-up management.

RESULTS

Tumor classification grades should be systematically used in the perioperative management of patients, with large vestibular schwannomas (VS) defined as > 30 mm in the largest extrameatal diameter. Grading scales for pre- and postoperative hearing (AAO-HNS or GR) and facial nerve function (HB) are to be used for reporting functional outcome. There is a lack of consensus to support the superiority of any surgical strategy with respect to extent of resection and use of adjuvant radiosurgery. Intraoperative neuromonitoring needs to be routinely used to preserve neural function. Recommendations for postoperative clinico-radiological evaluations have been elucidated based on the surgical strategy employed.

CONCLUSION

The main goal of management of large vestibular schwannomas should focus on maintaining/improving quality of life (QoL), making every attempt at facial/cochlear nerve functional preservation while ensuring optimal oncological control, thereby allowing to meet patient expectations. Despite the fact that this analysis yielded only a few Class B evidences and mostly expert opinions, it will guide practitioners to manage these patients and form the basis for future clinical trials.

Outcome and toxicity analysis of single dose stereotactic radiosurgery in vestibular schwannoma based on the Koos grading system

Stereotactic radiosurgery (SRS) has evolved as widely accepted treatment option for small-sized (Koos I up to II) vestibular schwannoma (VS). For larger tumors (prevalent Koos VI), microsurgery or combined treatment strategies are mostly recommended. However, in patients not suited for microsurgery, SRS might also be an alternative to balance tumor control, hearing preservation and adverse effects. The purpose of this analysis was to evaluate the efficacy and toxicity of SRS for VS with regard to different Koos grades. All patients with untreated VS who received SRS at our center were included. Outcome analysis included tumor control, preservation of serviceable hearing based on median pure tone averages (PTA), and procedure-related adverse events rated by the Common Terminology Criteria for Adverse Events (CTCAE; v4.03) classification. In total, 258 patients (median age 58 years, range 21-84) were identified with a mean follow-up of 52 months (range 3-228 months). Mean tumor volume was 1.8 ml (range 0.1-18.5). The mean marginal dose was 12.3 Gy ± 0.6 (range 11-13.5). The cohort was divided into two groups: A (Koos grades I and II, n = 186) and B (Koos grades III and IV, n = 72). The actuarial tumor control rate was 98% after 2 years and 90% after 5 and 10 years. Koos grading did not show a significant impact on tumor control (p = 0.632) or hearing preservation (p = 0.231). After SRS, 18 patients (7%) had new transient or permanent symptoms classified by the CTCAE. The actuarial rate of CTCAE-free survival was not related to Koos grading (p = 0.093). Based on this selected population of Koos grade III and IV VS without or with only mild symptoms from brainstem compression, SRS can be recommended as the primary therapy with the advantage of low morbidity and satisfactory tumor control. The overall hearing preservation rate and toxicity of SRS was influenced by age and cannot be predicted by tumor volume or Koos grading alone.

Delayed pseudoprogression of a vestibular schwannoma postradiosurgery

Radiosurgery (RS) can offer excellent local control in the management of both benign and malignant tumors measuring less than 3 cm in size. A known late complication of radiosurgery is radiation necrosis which generally occurs within 6-18 months following treatment and has an increased risk of occurrence with higher radiation doses. The lower dose used to treat vestibular schwannomas (VS) makes this complication less frequent. Tumors that do not respond to radiosurgery and continue to grow may require surgical intervention. We report a case of a young male who received radiosurgery (18 Gy in 3 fractions) in February 2016 for a recurrent VS following initial debulking surgery in 2008. Follow-up imaging revealed an interval decrease in size by May 2017; however, by April 2018, there was significant interval increase in the cisternal components of the tumor. By September 2018, the lesion had increased by >50% (to a size of 29 mm) compared to May 2017. The patient agreed to undergo repeat surgical debulking. Upon review of the preoperative MRI, the cisternal component of the tumor had substantially decreased in size. Although uncommon, this reflects delayed, pseudoprogression which, in our case, was self-limiting. This raises a question regarding when to proceed with surgical intervention of growing VS following radiosurgery given the potential for delayed resolution of radiation necrosis and demonstrates a gap in our current literature involving surgery of VS following radiosurgery.

Middle-ear cholesteatoma co-existing with labyrinthine fistula and vestibular schwannoma

BACKGROUND

Many conditions, among them vestibular schwannoma and middle ear cholesteatoma with lateral semicircular canal destruction, may be associated with asymmetrical sensorineural hearing loss (SNHL) and vertigo. However, the probability that these two distinct disease entities causing the same symptoms occur in a single patient is very low, approximately 1 per 28 billion per 1 year.

METHODS

We present the case of a 40-year-old male admitted to our clinic because of chronic middle ear inflammation with concomitant tinnitus vertigo, and deafness in the right ear. The patient was diagnosed with lateral semicircular canal fistula caused by middle-ear cholesteatoma and concomitant vestibular schwannoma. Canal wall-down surgery was carried out to remove the cholesteatoma, followed by gamma knife radiosurgery for the vestibular schwannoma.

RESULTS

Vertigo and tinnitus resolved within 3 days after the ear surgery, and gamma knife treatment resulted in the complete involution of the vestibular schwannoma. The patient presented with completely dry middle-ear cavity and no recurrence of the cholesteatoma was observed during a 3-year follow-up.

CONCLUSION

As the hereby reported condition is very rare, the results cannot be compared with any similar report published previously. Nevertheless, based on the outcome, the treatment strategy seems to be both reasonable and effective.

Comparing costs of microsurgical resection and stereotactic radiosurgery for vestibular schwannoma

OBJECTIVE

Given rising scrutiny of healthcare expenditures, understanding intervention costs is increasingly important. This study aimed to compare and characterize costs for vestibular schwannoma (VS) management with microsurgery and radiosurgery to inform practice decisions and appraise cost reduction strategies.

METHODS

In conjunction with medical records, internal hospital financial data were used to evaluate costs. Total cost was divided into index costs (costs from arrival through discharge for initial intervention) and follow-up costs (through 36 months) for 317 patients with unilateral VSs undergoing initial management between June 2011 and December 2015. A retrospective matched cohort based on tumor size with 176 patients (88 undergoing each intervention) was created to objectively compare costs between microsurgery and radiosurgery. The full sample of 203 patients treated with resection and 114 patients who underwent radiosurgery was used to evaluate a broad range of outcomes and identify cost contributors within each intervention group.

RESULTS

Within the matched cohort, average index costs were significantly higher for microsurgery (100% by definition, because costs are presented as a percentage of the average index cost for the matched microsurgery group; 95% CI 93-107) compared to radiosurgery (38%, 95% CI 38-39). Microsurgery had higher average follow-up costs (1.6% per month, 95% CI 0.8%-2.4%) compared to radiosurgery (0.5% per month, 95% CI 0.4%-0.7%), largely due to costs incurred in the initial months after resection. A major contributor to total cost and cost variability for both resection and radiosurgery was the need for additional interventions in the follow-up period, which were necessary due to complications or persistent functional deficits. Although tumor size was not associated with increased total costs for radiosurgery, linear regression analysis demonstrated that, for patients who underwent microsurgery, each centimeter increase in tumor maximum diameter resulted in an estimated increase in total cost of 50.2% of the average index cost of microsurgery (95% CI 34.6%-65.7%) (p < 0.001, R2 = 0.17). There were no cost differences associated with the proportion of inpatient days in the ICU or with specific surgical approach for patients who underwent resection.

CONCLUSIONS

This study is the largest assessment to date based on internal cost data comparing VS management with microsurgery and radiosurgery. Both index and follow-up costs are significantly higher when tumors were managed with resection compared to radiosurgery. Larger tumors were associated with increased resection costs, highlighting the incremental costs associated with observation as the initial management.

Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes

OBJECTIVE There are numerous treatment strategies in the management for large vestibular schwannomas, including resection only, staged resections, resections followed by radiosurgery, and radiosurgery only. Recent evidence has pointed toward maximal resection as being the optimum strategy to prevent tumor recurrence; however, durable tumor control through aggressive resection has been shown to occur at the expense of facial nerve function and to risk other approach-related complications. Through a retrospective analysis of their single-institution series of keyhole neurosurgical approaches for large vestibular schwannomas, the authors aim to report and justify key techniques to maximize tumor resection and reduce surgical morbidity. METHODS A retrospective chart review was performed at the Centre for Minimally Invasive Neurosurgery. All patients who had undergone a keyhole retrosigmoid approach for the resection of large vestibular schwannomas, defined as having a tumor diameter of ≥ 3.0 cm, were included in this review. Patient demographics, preoperative cranial nerve status, perioperative data, and postoperative follow-up were obtained. A review of the literature for resections of large vestibular schwannomas was also performed. The authors' institutional data were compared with the historical data from the literature. RESULTS Between 2004 and 2017, 45 patients met the inclusion criteria for this retrospective chart review. When compared with findings in a historical cohort in the literature, the authors' minimally invasive, keyhole retrosigmoid technique for the resection of large vestibular schwannomas achieved higher rates of gross-total or near-total resection (100% vs 83%). Moreover, these results compare favorably with the literature in facial nerve preservation (House-Brackmann I-II) at follow-up after gross-total resections (81% vs 47%, p < 0.001) and near-total resections (88% vs 75%, p = 0.028). There were no approach-related complications in this series. CONCLUSIONS It is the experience of the senior author that complete or near-complete resection of large vestibular schwannomas can be successfully achieved via a keyhole approach. In this series of 45 large vestibular schwannomas, a greater extent of resection was achieved while demonstrating high rates of facial nerve preservation and low approach-related and postoperative complications compared with the literature.

Systematic Review of Hearing Preservation After Radiotherapy for Vestibular Schwannoma

OBJECTIVE

To determine the long-term hearing preservation rate for spontaneous vestibular schwannoma treated by primary radiotherapy.

DATA SOURCES

The MEDLINE/PubMed, Web of Science, Cochrane Reviews, and EMBASE databases were searched using a comprehensive Boolean keyword search developed in conjunction with a scientific librarian. English language papers published from 2000 to 2016 were evaluated.

STUDY SELECTION

Inclusion criteria: full articles, pretreatment and posttreatment audiograms or audiogram based scoring system, vestibular schwannoma only tumor type, reported time to follow-up, published after 1999, use of either Gamma Knife or linear accelerator radiotherapy.

EXCLUSION CRITERIA

case report or series with fewer than five cases, inadequate audiometric data, inadequate time to follow-up, neurofibromatosis type 2 exceeding 10% of study population, previous treatment exceeding 10% of study population, repeat datasets, use of proton beam therapy, and non-English language.

DATA EXTRACTION

Two reviewers independently analyzed papers for inclusion. Class A/B, 1/2 hearing was defined as either pure tone average less than or equal to 50 db with speech discrimination score more than or equal to 50%, American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) Hearing Class A or B, or Gardner-Robertson Grade I or II. Aggregate data were used when individual data were not specified.

DATA SYNTHESIS

Means were compared with student t test.

CONCLUSIONS

Forty seven articles containing a total of 2,195 patients with preserved Class A/B, 1/2 hearing were identified for analysis. The aggregate crude hearing preservation rate was 58% at an average reporting time of 46.6 months after radiotherapy treatment. Analysis of time-based reporting shows a clear trend of decreased hearing preservation extending to 10-year follow-up. This data encourages a future long-term controlled trial.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Hearing Preservation Outcomes in Patients With Sporadic Vestibular Schwannomas

Question 1

What is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery utilizing modern dose planning, at 2, 5, and 10 yr following treatment?

Recommendation

Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr.

Question 2

Among patients with AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery hearing classification) class A or GR (Gardner-Robertson hearing classification) grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following stereotactic radiosurgery, utilizing modern dose planning, at 2, 5, and 10 yr following treatment?

Recommendation

Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr.

Question 3

What patient- and tumor-related factors influence progression to nonserviceable hearing following stereotactic radiosurgery using ≤13 Gy to the tumor margin?

Recommendation

Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size, marginal tumor dose ≤12 Gy, and cochlear dose ≤4 Gy. Age and sex are not strong predictors of hearing preservation outcome.

Question 4

What is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment?

Recommendation

Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately low probability (>25%-50%) of hearing preservation immediately following surgery, moderately low probability (>25%-50%) of hearing preservation at 2 yr, moderately low probability (>25%-50%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr.

Question 5

Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas early after surgery, at 2, 5, and 10 yr following treatment?

Recommendation

Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled that there is a moderately high probability (>50%-75%) of hearing preservation immediately following surgery, moderately high probability (>50%-75%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr.

Question 6

What patient- and tumor-related factors influence progression to nonserviceable hearing following microsurgical resection of small to medium-sized sporadic vestibular schwannomas?

Recommendation

Level 3: Individuals who meet these criteria and are considering microsurgical resection should be counseled regarding the probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, smaller tumor size commonly less than 1 cm, and presence of a distal internal auditory canal cerebrospinal fluid fundal cap. Age and sex are not strong predictors of hearing preservation outcome.

Question 7

What is the overall probability of maintaining serviceable hearing with conservative observation of vestibular schwannomas at 2, 5, and 10 yr following diagnosis?

Recommendation

Level 3: Individuals who meet these criteria and are considering observation should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, moderately high probability (>50%-75%) of hearing preservation at 5 yr, and moderately low probability (>25%-50%) of hearing preservation at 10 yr.

Question 8

Among patients with AAO-HNS class A or GR grade I hearing at baseline, what is the overall probability of maintaining serviceable hearing with conservative observation at 2 and 5 yr following diagnosis?

Recommendation

Level 3: Individuals who meet these criteria and are considering stereotactic radiosurgery should be counseled that there is a high probability (>75%-100%) of hearing preservation at 2 yr, and moderately high probability (>50%-75%) of hearing preservation at 5 yr. Insufficient data were available to determine the probability of hearing preservation at 10 yr for this population subset.

Question 9

What patient and tumor-related factors influence progression to nonserviceable hearing during conservative observation?

Recommendation

Level 3: Individuals who meet these criteria and are considering observation should be counseled regarding probability of successful hearing preservation based on the following prognostic data: the most consistent prognostic features associated with maintenance of serviceable hearing are good preoperative word recognition and/or pure tone thresholds with variable cut-points reported, as well as nongrowth of the tumor. Tumor size at the time of diagnosis, age, and sex do not predict future development of nonserviceable hearing during observation.  The full guideline can be found at: https://www.cns.org/guidelines/guidelines-manage-ment-patients-vestibular-schwannoma/chapter_3.

Hydrocephalus after Gamma Knife Radiosurgery for Schwannoma

Objective:

Gamma Knife radiosurgery (GKRS) has been established as an effective and safe treatment for intracranial Schwannoma. However, communicating hydrocephalus can occur after GKRS. The risk factors of this disorder are not yet fully understood. The objective of the study was to assess potential risk factors for hydrocephalus after GKRS.

Methods:

We retrospectively reviewed the medical radiosurgical records of 92 patients who underwent GKRS to treat intracranial Schwannoma and developed communicating hydrocephalus. The following parameters were analyzed as potential risk factors for hydrocephalus after GKRS: age, sex, target volume, irradiation dose, prior tumor resection, treatment technique, tumor enhancement pattern, and protein level of cerebrospinal fluid (CSF) after GKRS.

Results:

Of the 92 patients, eight of them developed communicating hydrocephalus. Target volume and tumor enhancement pattern, and protein level of CSF ware associated with the development of hydrocephalus.

Conclusion:

In particular, patients with intracranial Schwannomas with large tumor size, ring enhancement patterns, and high protein level of CSF should be carefully observed.

Long-term outcome after Gamma Knife radiosurgery for acoustic neuroma of all Koos grades: a single-center study

OBJECTIVE

The authors present long-term follow-up data on patients treated with Gamma Knife radiosurgery (GKRS) for acoustic neuroma.

METHODS

Six hundred eighteen patients were radiosurgically treated for acoustic neuroma between 1992 and 2016 at the Department of Neurosurgery, Medical University Vienna. Patients with neurofibromatosis and patients treated too recently to attain 1 year of follow-up were excluded from this retrospective study. Thus, data on 557 patients with spontaneous acoustic neuroma of any Koos grade are presented, as are long-term follow-up data on 426 patients with a minimum follow-up of 2 years. Patients were assessed according to the Gardner-Robertson (GR) hearing scale and the House-Brackmann facial nerve function scale, both prior to GKRS and at the times of follow-up.

RESULTS

Four hundred fifty-two patients (81%) were treated with radiosurgery alone and 105 patients (19%) with combined microsurgery-radiosurgery. While the combined treatment was especially favored before 2002, the percentage of cases treated with radiosurgery alone has significantly increased since then. The overall complication rate after GKRS was low and has declined significantly in the last decade. The risk of developing hydrocephalus after GKRS increased with tumor size. One case (0.2%) of malignant transformation after GKRS was diagnosed. Radiological tumor control rates of 92%, 91%, and 91% at 5, 10, and 15 years after GKRS, regardless of the Koos grade or pretreatment, were observed. The overall tumor control rate without the need for additional treatment was even higher at 98%. At the last follow-up, functional hearing was preserved in 55% of patients who had been classified with GR hearing class I or II prior to GKRS. Hearing preservation rates of 53%, 34%, and 34% at 5, 10, and 15 years after GKRS were observed. The multivariate regression model revealed that the GR hearing class prior to GKRS and the median dose to the cochlea were independent predictors of the GR class at follow-up.

CONCLUSIONS

In small to medium-sized spontaneous acoustic neuromas, radiosurgery should be recognized as the primary treatment at an early stage. Although minimizing the cochlear dose seems beneficial for hearing preservation, the authors, like others before, do not recommend undertreating intracanalicular tumors in favor of low cochlear doses. For larger acoustic neuromas, radiosurgery remains a reliable management option with tumor control rates similar to those for smaller acoustic neuromas; however, careful patient selection and counseling are recommended given the higher risk of side effects. Microsurgery must be considered in acoustic neuromas with significant brainstem compression or hydrocephalus.

Impact of pretreatment growth on Tumor control for vestibular schwannomas following gamma knife

OBJECTIVES/HYPOTHESIS

To determine if volumetric growth prior to gamma knife (GK) radiosurgery predicts long-term tumor control.

STUDY DESIGN

Retrospective cohort study.

METHODS

Sporadic vestibular schwannomas (VS) treated with GK between 2002 and 2014 at a single tertiary care center were identified. Patients were included if they had over 6 months of pretreatment observation and over 1.5 years of posttreatment follow-up. Volumetric tumor analysis was performed on T1 postcontrast imaging. Pretreatment and posttreatment volume change was calculated. Tumors with over 20% volume increase were classified as growing.

RESULTS

There were 62 patients included in this study; 48 had pretreatment growth and 14 had no pretreatment growth. Median tumor volume was 0.58 ± 1.8 cm³ and median follow-up was 3.3 ± 2.0 years. For tumors with and without pretreatment growth, salvage treatment rates were 2% and 7% (P = .35), and posttreatment radiologic stability rates were 73% and 86%, respectively (P = .33). Median pretreatment growth was 27 ± 33% per year for tumors with posttreatment radiographic growth and 18 ± 26% per year for tumors without posttreatment radiographic growth (P = .99).

CONCLUSIONS

Pretreatment growth was not associated with increased salvage treatment or posttreatment radiographic progression rates in VS following GK.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:743-747, 2019.

Local experience with radiosurgery for vestibular schwannomas and recommendations for management

INTRODUCTION

There are many treatment options for vestibular schwannomas (VSs), including radiosurgery. Previous studies have shown good outcomes for smaller tumours. We report the results of a seven-year cohort of patients with VS who were treated at our centre using a linear accelerator-based stereotactic radiosurgery system.

METHODS

We retrospectively reviewed the case notes and magnetic resonance (MR) images of patients with VS treated with radiosurgery. Treatment was administered as either a single 13 Gy session or 25 Gy in five sessions. At our centre, only larger or higher Koos grade VSs, were routinely treated with hypofractionated radiosurgery. Tumour response and hearing were assessed using RECIST criteria and Gardner-Robertson scale, respectively. Other toxicities were assessed using physical examination and history-taking. Freedom from radiological progression was estimated with the Kaplan-Meier method.

RESULTS

46 patients received single-fraction radiosurgery and 31 received hypofractionated radiosurgery. Median follow-up duration was 40.6 months. 29 patients had prior surgery to remove the tumour (median size 1.68 cm3). One patient who had symptomatic increase in tumour size (> 20% in largest diameter) was treated conservatively and subsequently showed stable disease on MR imaging. Progression-free survival was 98.7%. Another patient had symptomatic oedema requiring ventriculoperitoneal shunt insertion. 11 patients had serviceable hearing before radiotherapy and 72.7% of them retained useful hearing (20.1 dB mean decline in pure tone average). Facial and trigeminal nerve functions and sense of equilibrium were preserved in > 90% of patients.

CONCLUSION

Radiosurgery is effective and safe for small VSs or as an adjunct therapy after microsurgery.