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Huang CY, Peng SJ, Yang HC, Wu HM, Chen CJ, Wang MC, Hu YS, Lin CJ, Shiau CY, Guo WY, Chung WY, Pan DHC, Lee CC. Association Between Pseudoprogression of Vestibular Schwannoma After Radiosurgery and Radiological Features of Solid and Cystic Components. Neurosurgery 2023; 93:1383-1392. [PMID: 37432016 DOI: 10.1227/neu.0000000000002599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pathophysiology of vestibular schwannoma (VS) pseudoprogression after Gamma Knife radiosurgery (GKRS) remains unclear. Radiological features in pretreatment magnetic resonance images may help predict VS pseudoprogression. This study used VS radiological features quantified using an automated segmentation algorithm to predict pseudoprogression after GKRS treatment. METHODS This is a retrospective study comprising 330 patients with VS who received GKRS. After image preprocessing and T2W/contrast-enhanced T1-weighted image (CET1W) image generation, with fuzzy C-means clustering, VSs were segmented into solid and cystic components and classified as solid and cystic. Relevant radiological features were then extracted. The response to GKRS was classified into "nonpseudoprogression" and "pseudoprogression/fluctuation". The Z test for two proportions was used to compare solid and cystic VS for the likelihood of pseudoprogression/fluctuation. Logistic regression was used to assess the correlation between clinical variables and radiological features and response to GKRS. RESULTS The likelihood of pseudoprogression/fluctuation after GKRS was significantly higher for solid VS compared with cystic VS (55% vs 31%, P < .001). For the entire VS cohort, multivariable logistic regression revealed that a lower mean tumor signal intensity (SI) in T2W/CET1W images was associated with pseudoprogression/fluctuation after GKRS ( P = .001). For the solid VS subgroup, a lower mean tumor SI in T2W/CET1W images ( P = .035) was associated with pseudoprogression/fluctuation after GKRS. For the cystic VS subgroup, a lower mean SI of the cystic component in T2W/CET1W images ( P = .040) was associated with pseudoprogression/fluctuation after GKRS. CONCLUSION Pseudoprogression is more likely to occur in solid VS compared with cystic VS. Quantitative radiological features in pretreatment magnetic resonance images were associated with pseudoprogression after GKRS. In T2W/CET1W images, solid VS with a lower mean tumor SI and cystic VS with a lower mean SI of cystic component were more likely to have pseudoprogression after GKRS. These radiological features can help predict the likelihood of pseudoprogression after GKRS.
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Affiliation(s)
- Chih-Ying Huang
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Syu-Jyun Peng
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei , Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston , Texas , USA
| | - Mao-Che Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Cheng-Ying Shiau
- Cancer Center, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei , Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei , Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei , Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei , Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
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Dhayalan D, Perry A, Graffeo CS, Tveiten ØV, Muñoz Casabella A, Pollock BE, Driscoll CLW, Carlson ML, Link MJ, Lund-Johansen M. Salvage radiosurgery following subtotal resection of vestibular schwannomas: does timing influence tumor control? J Neurosurg 2023; 138:420-429. [PMID: 35907189 DOI: 10.3171/2022.5.jns22249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The goal of microsurgical resection of vestibular schwannoma (VS) is gross-total resection (GTR) to provide oncological cure. However, a popular strategy is to halt the resection if the surgical team feels the risk of cranial nerve injury is imminent, achieving a maximally safe subtotal resection (STR) instead. The tumor remnant can then be treated with stereotactic radiosurgery (SRS) once the patient has recovered from the immediate postoperative period, or it can be followed with serial imaging and treated with SRS in a delayed fashion if residual tumor growth is seen. In this study, the authors evaluated the efficacy of this multimodality approach, particularly the influence of timing and dose of SRS on radiological tumor control, need for salvage treatment, and cranial nerve function. METHODS VS patients treated with initial microsurgery and subsequent radiosurgery were retrospectively included from two tertiary treatment centers and dichotomized depending on whether SRS was given upfront (defined as before 12 months) or later. Radiological tumor control was defined as less than 20% tumor volume expansion and oncological tumor control as an absence of salvage treatment. Facial and cochlear nerve functions were assessed after surgery, at the time of SRS, and at last follow-up. Finally, a systematic literature review was conducted according to PRISMA guidelines. RESULTS A total of 110 VS patients underwent SRS following microsurgical resection, with a mean preradiosurgical tumor volume of 2.2 cm3 (SD 2.5 cm3) and mean post-SRS follow-up time of 5.8 years (SD 4.1 years). The overall radiological tumor control and oncological tumor control were 77.3% and 90.9%, respectively. Thirty-five patients (31.8%) received upfront SRS, while 75 patients (68.2%) were observed for a minimum of 12 months prior to SRS. The timing of SRS did not influence the radiological tumor control (p = 0.869), the oncological tumor control (p = 0.560), or facial nerve (p = 0.413) or cochlear nerve (p = 0.954) function. An escalated marginal dose (> 12 Gy) was associated with greater tumor shrinkage (p = 0.020) and superior radiological tumor control (p = 0.020), but it did not influence the risk of salvage treatment (p = 0.904) or facial (p = 0.351) or cochlear (p = 0.601) nerve deterioration. CONCLUSIONS Delayed SRS after close observation of residuals following STR is a safe alternative to upfront SRS regarding tumor control and cranial nerve preservation in selected patients.
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Affiliation(s)
- Dhanushan Dhayalan
- 1Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,3Department of Clinical Medicine, University of Bergen, Norway; and
| | - Avital Perry
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Bruce E Pollock
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Colin L W Driscoll
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew L Carlson
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,4Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Morten Lund-Johansen
- 1Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.,3Department of Clinical Medicine, University of Bergen, Norway; and
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Sergi B, Settimi S, Federici G, Galloni C, Cantaffa C, De Corso E, Lucidi D. Factors Influencing Personalized Management of Vestibular Schwannoma: A Systematic Review. J Pers Med 2022; 12:jpm12101616. [PMID: 36294756 PMCID: PMC9605318 DOI: 10.3390/jpm12101616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
Management of vestibular schwannoma (VS) is a complex process aimed at identifying a clinical indication for fractionated stereotactic radiotherapy (sRT) or microsurgical resection or wait and scan (WS). The aim of the review was to clarify which patient and tumor parameters may lead to different therapeutic choices, with a view to a personalized VS approach. A systematic review according to Preferred Reporting Items for Systematic Review and Meta-Analysis criteria was conducted between February and March 2022. The authors defined six parameters that seemed to influence decision-making in VS management: 1-incidental VS; 2-tumor size; 3-tumor regrowth after sRT; 4-subtotal resection; 5-patients' age; 6-symptoms. The initial search yielded 3532 articles, and finally, 812 articles were included. Through a qualitative synthesis of the included studies, management strategies were evaluated and discussed. An individualized proposal of procedures is preferable as compared to a single gold-standard approach in VS decision-making. The most significant factors that need to be considered when dealing with a VS diagnosis are age, tumor size and hearing preservation issues.
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Affiliation(s)
- Bruno Sergi
- Department of Head, Neck and Sensory Organs, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Unit of Otorhinolaryngology-Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Stefano Settimi
- Department of Head, Neck and Sensory Organs, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Unit of Otorhinolaryngology-Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-0630154439
| | - Gaia Federici
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Costanza Galloni
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Carla Cantaffa
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Eugenio De Corso
- Unit of Otorhinolaryngology-Head and Neck Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Daniela Lucidi
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
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Huang CY, Peng SJ, Wu HM, Yang HC, Chen CJ, Wang MC, Hu YS, Chen YW, Lin CJ, Guo WY, Pan DHC, Chung WY, Lee CC. Quantification of tumor response of cystic vestibular schwannoma to Gamma Knife radiosurgery by using artificial intelligence. J Neurosurg 2021:1-9. [PMID: 34598136 DOI: 10.3171/2021.4.jns203700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is a common treatment modality for vestibular schwannoma (VS). The ability to predict treatment response is important in patient counseling and decision-making. The authors developed an algorithm that can automatically segment and differentiate cystic and solid tumor components of VS. They also investigated associations between the quantified radiological features of each component and tumor response after GKRS. METHODS This is a retrospective study comprising 323 patients with VS treated with GKRS. After preprocessing and generation of pretreatment T2-weighted (T2W)/T1-weighted with contrast (T1WC) images, the authors segmented VSs into cystic and solid components by using fuzzy C-means clustering. Quantitative radiological features of the entire tumor and its cystic and solid components were extracted. Linear regression models were implemented to correlate clinical variables and radiological features with the specific growth rate (SGR) of VS after GKRS. RESULTS A multivariable linear regression model of radiological features of the entire tumor demonstrated that a higher tumor mean signal intensity (SI) on T2W/T1WC images (p < 0.001) was associated with a lower SGR after GKRS. Similarly, a multivariable linear regression model using radiological features of cystic and solid tumor components demonstrated that a higher solid component mean SI (p = 0.039) and a higher cystic component mean SI (p = 0.004) on T2W/T1WC images were associated with a lower SGR after GKRS. A larger cystic component proportion (p = 0.085) was associated with a trend toward a lower SGR after GKRS. CONCLUSIONS Radiological features of VSs on pretreatment MRI that were quantified using fuzzy C-means were associated with tumor response after GKRS. Tumors with a higher tumor mean SI, a higher solid component mean SI, and a higher cystic component mean SI on T2W/T1WC images were more likely to regress in volume after GKRS. Those with a larger cystic component proportion also trended toward regression after GKRS. Further refinement of the algorithm may allow direct prediction of tumor response.
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Affiliation(s)
- Chih-Ying Huang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
| | - Syu-Jyun Peng
- 2Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University
| | - Hsiu-Mei Wu
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ching-Jen Chen
- 5Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mao-Che Wang
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 6Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital
| | - Yong-Sin Hu
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 4Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 7Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University; and
| | - Wen-Yuh Chung
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Cheng-Chia Lee
- 1Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang Ming Chiao Tung University, Taipei
- 8Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Santa Maria PL, Shi Y, Aaron KA, Gurgel RK, Corrales CE, Soltys SG, Santa Maria C, Chang SD, Blevins NH, Jackler RK, Gibbs IC. Tumor Control Following Stereotactic Radiosurgery in Patients with Vestibular Schwannomas - A Retrospective Cohort Study. Otol Neurotol 2021. [PMID: 34353978 DOI: 10.1097/MAO.0000000000003285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To better counsel vestibular schwannoma patients, it is necessary to understand the tumor control rates of stereotactic radiosurgery (SRS). OBJECTIVES To determine tumor control rates, factors determining control and complication rates following SRS. METHODS Tertiary hospital retrospective cohort. RESULTS 579 tumors (576 patients) were treated with SRS. 477 tumors (474 patients, 82%) had ≥1 year follow up and 60% (344) ≥3 years follow up. 88% of tumors had primary SRS and 6.7% salvage SRS. Median follow up time was 4.6 years. At 3 years, the tumor control rate of primary SRS was 89% (258 of 290) in sporadic tumors compared to 43% in Neurofibromatosis type II (3 of 17) (p < 0.01). Our bivariable survival data analysis showed that Neurofibromatosis type II, documented pre-SRS growth, tumor measured by maximum dimension, SRS given as nonprimary treatment increased hazard of failure to control. There was one case of malignancy and another of rapid change following intra-tumoral hemorrhage. For tumors undergoing surgical salvage (25 of 59), 56% had a total or near-total resection, 16% had postoperative CSF leak, with 12% new facial paralysis (House-Brackmann grade VI) and worsening of facial nerve outcomes (House-Brackmann grade worse in 59% at 12 mo). CONCLUSIONS Control of vestibular schwannoma after primary SRS occurs in the large majority. Salvage surgical treatment was notable for higher rates of postoperative complications compared to primary surgery reported in the literature.
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Lee WJ, Lee JI, Choi JW, Kong DS, Nam DH, Cho YS, Shin HJ, Seol HJ. Optimal Volume of the Residual Tumor to Predict Long-term Tumor Control Using Stereotactic Radiosurgery after Facial Nerve-preserving Surgery for Vestibular Schwannomas. J Korean Med Sci 2021; 36:e102. [PMID: 33904259 PMCID: PMC8076845 DOI: 10.3346/jkms.2021.36.e102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/03/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Intended subtotal resection (STR) followed by adjuvant gamma knife radiosurgery (GKRS) has emerged as an effective treatment option for facial nerve (FN) preservation in vestibular schwannomas (VSs). This study aimed to identify the optimal cut-off volume of residual VS to predict favorable outcomes in terms of both tumor control and FN preservation. METHODS This retrospective study assessed the patients who underwent adjuvant GKRS for residual VS after microsurgery. A total of 68 patients who had been followed up for ≥ 24 months after GKRS were included. Tumor progression was defined as an increase in tumor volume (TV) of ≥ 20%. House-Brackmann grades I and II were considered to indicate good FN function. RESULTS The median residual TV was 2.5 cm³ (range: 0.3-27.4). The median follow-up period after the first adjuvant GKRS was 64 months (range: 25.7-152.4). Eight (12%) patients showed tumor progression. In multivariate analyses, residual TV was associated with tumor progression (P = 0.003; hazard ratio [HR], 1.229; 95% confidence interval [CI], 1.075-1.405). A residual TV of 6.4 cm³ was identified as the cut-off volume for showing the greatest difference in progression-free survival (PFS). The 5-year PFS rates in the group with residual TVs of < 6.4 cm³ (54 patients) and that with residual TVs of ≥ 6.4 cm³ (14 patients) were 93.3% and 69.3%, respectively (P = 0.014). A good FN outcome was achieved in 57 (84%) patients. Residual TV was not associated with good FN function during the immediate postoperative period (P = 0.695; odds ratio [OR], 1.024; 95% CI, 0.908-1.156) or at the last follow-up (P = 0.755; OR, 0.980; 95% CI, 0.866-1.110). CONCLUSION In this study, residual TV was associated with tumor progression in VS after adjuvant GKRS following STR. As preservation of FN function is not correlated with the extent of resection, optimal volume reduction is imperative to achieve long-term tumor control. Our findings will help surgeons predict the prognosis of residual VS after FN-preserving surgery.
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Affiliation(s)
- Won Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Doo Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Sun Cho
- Department of Otorhinolaryngology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Radwan H, Elserry T, Eisenberg MB, Knisely JPS, Ghaly MM, Schulder M. Subtotal Resection Followed by Adjuvant Radiosurgery for Large Vestibular Schwannomas: Outcomes with Regard to the Timing and Regimen of Irradiation. Acta Neurochir Suppl 2021; 128:1-5. [PMID: 34191056 DOI: 10.1007/978-3-030-69217-9_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the results of combined management of large vestibular schwannomas (VS) with initial subtotal resection (STR) followed by adjuvant stereotactic radiosurgery (SRS), with a particular emphasis on the timing and regimen of irradiation. METHODS Seventeen patients underwent STR of a VS followed by SRS, whereas five others were observed after STR. Early SRS (<6 months after surgery) and late SRS (>6 months after surgery) were done in 8 and 9 patients, respectively. Single- and multisession SRS treatments were administered in 10 and 7 patients, respectively. The mean follow-up durations after surgery and SRS were 40 and 28 months, respectively. RESULTS The rates of radiological and oncological tumor control after SRS were 82% and 100%, respectively. The tumor volume at the last follow-up and its relative changes after SRS did not differ significantly on the basis of the irradiation timing (early versus late) or on the basis of the irradiation regimen (single-session versus multisession). In no patient who was observed after STR of a VS was tumor regrowth noted during a mean follow-up period of 49 months. At 12 months after surgery, motor function of the ipsilateral facial nerve corresponded to House-Brackmann grades I, II, III, and IV in 16 patients (73%), 3 patients (14%), 1 patient (5%), and 2 patients (9%), respectively. Facial nerve function at the last follow-up did not differ significantly on the basis of the irradiation timing (early versus late) or on the basis of the irradiation regimen (single-session versus multisession). CONCLUSION The combination of initial STR followed by adjuvant SRS is an effective treatment strategy for patients with a large VS. Although the optimal timing and regimen of postoperative irradiation of the residual lesion should be defined further, our preliminary data suggest that either early or late SRS after surgery may provide good tumor control and optimal functional results.
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Affiliation(s)
- Hesham Radwan
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Tarek Elserry
- Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Mark B Eisenberg
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | | | - Maged M Ghaly
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Michael Schulder
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA. .,Brain Tumor Center, Northwell Neurosciences Insitute, Lake Success, NY, USA.
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Iwai Y, Ishibashi K, Yamanaka K. Preplanned Partial Surgical Removal Followed by Low-Dose Gamma Knife Radiosurgery for Large Vestibular Schwannomas. Acta Neurochir Suppl 2021; 128:7-13. [PMID: 34191057 DOI: 10.1007/978-3-030-69217-9_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The present study evaluated outcomes after preplanned partial surgical removal of a large vestibular schwannoma (VS) followed by low-dose Gamma Knife surgery (GKS). METHODS Between January 2000 and May 2015, 47 patients with a unilateral VS (median maximum diameter 32 mm) underwent preplanned partial tumor removal at our clinic. GKS for a residual lesion was done within a median time interval of 3 months. The median prescription dose was 12 Gy. The median length of subsequent follow-up was 74 months. RESULTS The actuarial tumor growth control rates without a need for additional management at 3, 5, and 15 years after GKS were 92%, 86%, and 86%, respectively. At the time of the last follow-up, the function of the ipsilateral facial nerve corresponded to House-Brackmann grade I in 92% of patients. Significant improvement of ipsilateral hearing was noted in two patients after partial tumor removal and in one after GKS. Among 16 patients who presented with ipsilateral serviceable hearing, it was preserved immediately after surgery in 81% of cases and at the time of the last follow-up in 44%. Salvage surgical treatment was required in 9% of patients. CONCLUSION Preplanned partial surgical removal followed by low-dose GKS provides a high level of functional preservation in patients with a large VS.
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Affiliation(s)
- Yoshiyasu Iwai
- Department of Neurosurgery, Tominaga Hospital, Osaka, Japan.
| | - Kenichi Ishibashi
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
| | - Kazuhiro Yamanaka
- Department of Neurosurgery, Osaka City General Hospital, Osaka, Japan
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Massaad E, Hamidi N, Goetz J, Padmanaban V, Mau C, Tsang D, de Moraes FY, Chung C, Zacharia BE, Mansouri A. Equivalent Efficacy and Safety of Radiosurgery for Cystic and Solid Vestibular Schwannomas: A Systematic Review. World Neurosurg 2021; 146:322-331.e1. [PMID: 33212274 DOI: 10.1016/j.wneu.2020.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Cystic vestibular schwannomas (VS) are associated with unpredictable growth behavior and potentially worse surgical outcomes compared with their solid counterparts. Growth control and potential adverse effects of radiosurgery for cystic VS have created concerns surrounding this modality. We sought to compare the treatment efficacy and safety profile of radiosurgery between cystic and solid VS through a systematic review. METHODS PubMed, EMBASE, Web of Science, and Cochrane were searched for related terms and studies reporting radiosurgical outcomes of cystic and solid VS. A meta-analysis was performed to compare the rates of tumor control. Random-effect models with generic inverse variance method was used to calculate overall pooled estimates. Study quality was assessed with the Newcastle Ottawa Criteria. RESULTS In total, 2989 studies were retrieved, and 6 including 1358 VS (79.89% solid; 20.11% cystic, median follow-up range 31.8-150 months) were selected. The median maximal dose was 25 Gy (range, 13-36 Gy) and the median marginal tumor dose was 12 Gy (10-18 Gy). There was no difference between cystic and solid VS (risk ratio, 1.02; 95% confidence interval 0.94-1.10; P = 0.69; I2 = 78%). Transient enlargement of cystic tumors may be associated with trigeminal or facial neuropathy. CONCLUSIONS The evidence collected by this study suggests that radiosurgery for cystic VS exhibits effective tumor control probabilities similar to solid VS. Consensus definitions and standard criteria are needed in the future to better understand the patterns of tumor growth and response to treatment following radiosurgery for cystic VS, as well as long-term neurological and functional outcomes.
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10
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Yang HC, Wu CC, Lee CC, Huang HE, Lee WK, Chung WY, Wu HM, Guo WY, Wu YT, Lu CF. Prediction of pseudoprogression and long-term outcome of vestibular schwannoma after Gamma Knife radiosurgery based on preradiosurgical MR radiomics. Radiother Oncol 2020; 155:123-130. [PMID: 33161011 DOI: 10.1016/j.radonc.2020.10.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Gamma Knife radiosurgery (GKRS) is a safe and effective treatment modality with a long-term tumor control rate over 90% for vestibular schwannoma (VS). However, numerous tumors may undergo a transient pseudoprogression during 6-18 months after GKRS followed by a long-term volume reduction. The aim of this study is to determine whether the radiomics analysis based on preradiosurgical MRI data could predict the pseudoprogression and long-term outcome of VS after GKRS. MATERIALS AND METHODS A longitudinal dataset of patients with VS treated by single GKRS were retrospectively collected. Overall 336 patients with no previous craniotomy for tumor removal and a median of 65-month follow-up period after radiosurgery were finally included in this study. In total 1763 radiomic features were extracted from the multiparameteric MRI data before GKRS followed by the machine-learning classification. RESULTS We constructed a two-level machine-learning model to predict the long-term outcome and the occurrence of transient pseudoprogression after GKRS separately. The prediction of long-term outcome achieved an accuracy of 88.4% based on five radiomic features describing the variation of T2-weighted intensity and inhomogeneity of contrast enhancement in tumor. The prediction of transient pseudoprogression achieved an accuracy of 85.0% based on another five radiomic features associated with the inhomogeneous hypointensity pattern of contrast enhancement and the variation of T2-weighted intensity. CONCLUSION The proposed machine-learning model based on the preradiosurgical MR radiomics provides a potential to predict the pseudoprogression and long-term outcome of VS after GKRS, which can benefit the treatment strategy in clinical practice.
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Affiliation(s)
- Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Chun Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Huai-En Huang
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Department of Medical Imaging, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Wei-Kai Lee
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taiwan
| | - Yu-Te Wu
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan; Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan; Institute of Biophotonics, National Yang-Ming University, Taipei, Taiwan.
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11
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Starnoni D, Giammattei L, Cossu G, Link MJ, Roche PH, Chacko AG, Ohata K, Samii M, Suri A, Bruneau M, Cornelius JF, Cavallo L, Meling TR, Froelich S, Tatagiba M, Sufianov A, Paraskevopoulos D, Zazpe I, Berhouma M, Jouanneau E, Verheul JB, Tuleasca C, George M, Levivier M, Messerer M, Daniel RT. Surgical management for large vestibular schwannomas: a systematic review, meta-analysis, and consensus statement on behalf of the EANS skull base section. Acta Neurochir (Wien) 2020; 162:2595-617. [PMID: 32728903 DOI: 10.1007/s00701-020-04491-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/10/2020] [Indexed: 12/24/2022]
Abstract
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.
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12
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Ng IB, Heller RS, Heilman CB, Wu JK. Facial nerve outcomes following gamma knife radiosurgery for subtotally resected vestibular schwannomas: Early versus delayed timing of therapy. Clin Neurol Neurosurg 2020; 198:106148. [PMID: 32823189 DOI: 10.1016/j.clineuro.2020.106148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/12/2020] [Accepted: 08/09/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Initially treating vestibular schwannomas (VSs) with subtotal resection (STR) followed by Gamma Knife radiosurgery (GKRS) for progression of tumor residual is a strategy that balances maximal tumor resection with preservation of neurological function. The effect of timing of GKRS for residual and recurrent VSs remains poorly defined. We developed a simple and practical treatment algorithm for the timing of GKRS after STR of VSs and reviewed our follow-up results to determine outcomes between patients treated with early vs. late GKRS. PATIENTS AND METHODS Patients that underwent STR between 1999 and 2017 for a VS at Tufts Medical Center were identified and included in the study cohort. Patients who received GKRS ≤ 12 months after STR were included in the early intervention group. Patients who received GKRS > 12 months after STR or did not have tumor progression on follow-up thus not requiring GKRS were included in the observation/delayed intervention group. RESULTS STR of VSs was performed on 23 patients. Mean patient age at the time of STR was 53.0 years (range: 20-86.2). The mean follow-up was 4.2 years (range: 1 month-15.5 years). Patients most frequently presented with hearing loss. There were 5 patients (21.7 %) in the early intervention group and 18 (78.3 %) patients in the observation/delayed intervention group. Ten of 23 patients (43.5 %) required GKRS. Thirteen (56.5 %) did not receive GKRS. None of the patients in the early intervention group or the observation/delayed intervention group had changes in House-Brackmann (HB) Grade either after GKRS or at the end of the study period. CONCLUSIONS GKRS of residual or recurrent tumor is safe following STR of VS and appears to carry a low risk of worsening facial nerve function when performed for progressive tumor growth.
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Affiliation(s)
- Isaac B Ng
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Robert S Heller
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Carl B Heilman
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Julian K Wu
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA.
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13
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Yao L, Alahmari M, Temel Y, Hovinga K. Therapy of Sporadic and NF2-Related Vestibular Schwannoma. Cancers (Basel) 2020; 12:cancers12040835. [PMID: 32244314 PMCID: PMC7226024 DOI: 10.3390/cancers12040835] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022] Open
Abstract
Vestibular schwannoma (VS) is a benign primary brain tumor that occurs sporadic or as part of a genetic syndrome. The most common cause is the mutation of the NF2 tumor suppressor gene that is involved in the production of the protein merlin. Merlin plays a role in cell growth and cell adhesion. In patients with NF2, the VSs arise bilaterally and coincide with other brain tumors. In sporadic VS, the tumor is typically unilateral and does not coincide in combination with other tumors. MRI is the standard imaging technique and can be used to assess the size and aspect of the tumor as well as the progression of disease. The preferred management of large VS in both VS types is surgery with or without adjuvant radiation. The management for the medium- or small-sized VS includes wait and scan, radiotherapy and/or surgery. This choice depends on the preference of the patient and institutional protocols. The outcomes of surgical and radiotherapy treatments are improving due to progress in surgical equipment/approaches, advances in radiation delivery techniques and dose optimizations protocols. The main purpose of the management of VS is preserving function as long as possible in combination with tumor control.
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Affiliation(s)
- Longping Yao
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
| | - Mohammed Alahmari
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
- Department of Radiology, King Fahad Hospital of Imam Abdulrahman Bin Faisal University, P.O. Box 40046, 31952 AL-Khobar, Saudi Arabia
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
| | - Koos Hovinga
- Department of Neurosurgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (L.Y.); (M.A.); (Y.T.)
- Correspondence: ; Tel.: +31-43-387-50-01
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14
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Lim SH, Park CK, Park BJ, Lim YJ. Long-Term Outcomes of Gamma Knife Radiosurgery for Cystic Vestibular Schwannomas. World Neurosurg 2019; 132:e34-e39. [DOI: 10.1016/j.wneu.2019.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/01/2019] [Accepted: 09/03/2019] [Indexed: 10/26/2022]
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15
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Zumofen DW, Guffi T, Epple C, Westermann B, Krähenbühl AK, Zabka S, Taub E, Bodmer D, Mariani L. Intended Near-Total Removal of Koos Grade IV Vestibular Schwannomas: Reconsidering the Treatment Paradigm. Neurosurgery 2019; 82:202-210. [PMID: 28383680 DOI: 10.1093/neuros/nyx143] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 03/20/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The goals of treating Koos grade IV vestibular schwannomas are to relieve brainstem compression, preserve or restore neurological function, and achieve long-term tumor control while minimizing tumor- and treatment-related morbidity. OBJECTIVE To propose a treatment paradigm involving the intentional near-total removal of Koos grade IV vestibular schwannomas, in which a small amount of residual tumor is not dissected off the cisternal portion of the facial nerve. Patients are then followed by a wait-and-scan approach. Any subsequent volumetric progression of the residual tumor is treated with radiosurgery. METHODS This is a case series of 44 consecutive unselected patients who underwent intended near-total resection of a Koos grade IV vestibular schwannoma through a retrosigmoid approach from January 2009 to December 2015. Pre- and postoperative volumetric analyses were performed on routine magnetic resonance imaging sequences (constructive interference in steady state and gadolinium-enhanced T1-weighted sequence). RESULTS The mean preoperative tumor volume was 10.9 cm3. The mean extent of resection was 89%. At the last clinical follow-up, facial nerve function was good [House and Brackmann (HB) I-II] in 89%, fair (HB III) in 9%, and poor (HB IV-VI) in 2% of the patients. At the last radiological follow-up, the residual tumor had become smaller or remained the same size in 84% of patients. Volumetric progression was negatively correlated with the original extent of resection and positively correlated with postoperative residual tumor volume (P = .01, P < .001, respectively). CONCLUSION Intended near-total removal results in excellent preservation of facial nerve function and has a low recurrence rate. Any progressive residual tumor may be treated by radiosurgery.
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Affiliation(s)
- Daniel Walter Zumofen
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland.,Division of Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel, Switzerland
| | - Tommaso Guffi
- Faculty of Medicine, University of Lausanne, Lausanne, Switzerland
| | - Christian Epple
- Department of Biomedicine, Basel University Hospital, Basel, Switzerland
| | - Birgit Westermann
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland
| | | | - Susanne Zabka
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland
| | - Ethan Taub
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland
| | - Daniel Bodmer
- Department of Otolaryngology, Basel University Hospital, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland
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16
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Akinduro OO, Lundy LB, Quinones-Hinojosa A, Lu VM, Trifiletti DM, Gupta V, Wharen RE. Outcomes of large vestibular schwannomas following subtotal resection: early post-operative volume regression and facial nerve function. J Neurooncol 2019; 143:281-8. [PMID: 30989621 DOI: 10.1007/s11060-019-03157-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/25/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Subtotal resection (STR) of vestibular schwannoma (VS) tumors remains controversial and little is known regarding post-operative volume changes. METHODS Authors retrospective reviewed the medical records from January 1st 2002 to January 1st 2018, for all patients who had undergone primary STR of large VS at a single tertiary academic institution. RESULTS Our series consists of 34 patients with a mean age of 53.9 (median 53; range 21-87) years that had STR of their VS tumor. The mean pre-operative tumor diameter and volume was 3.9 cm (median 3.0 cm; range 1.6-6.0 cm) and 11.7 cm3 (median 9.6 cm3; range 2.8-44.3 cm3), respectively, with a mean extent of resection of 86% (median 90%; range 53-99%). The mean radiographic and clinical follow-up was 40 months (range 6-120 months) and 51 months (range 7-141 months), respectively. 85% of patients had optimal House-Brackmann (HB) scores (Grade 1 & 2) immediately post-operatively, and 91% at 1 year; 94% of patients had normal (HB 1) at last follow-up. There was significant regression of residual tumor volume at 1 year (p = 0.006) and 2 years (p = 0.02), but not at 3 years (p = 0.08), when compared to the prior year. There was significant regression of size over time, with a mean slope estimate of - 0.70 units per year (p < 0.001). CONCLUSION Excellent clinical facial nerve outcomes can be obtained with STR of large VS tumors. Maximal reduction in tumor size occurs at 2-year post-operatively. Thus, in patients undergoing surgery for large VS, STR and a "watch and wait" strategy is a reasonable treatment option that may optimize facial nerve outcomes.
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17
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Tuleasca C, Daniel RT, Starnoni D, George M, Maire R, Levivier M. Letter to the Editor Regarding "Adjunctive Gamma Knife Surgery or Wait and Scan Policy After Optimal Resection of Large Vestibular Schwannomas: Clinical and Radiologic Outcomes". World Neurosurg 2019; 122:719-721. [PMID: 30716877 DOI: 10.1016/j.wneu.2018.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/04/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Constantin Tuleasca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland; University of Lausanne (Unil), Faculty of Biology and Medicine (FBM), Lausanne, Switzerland; Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Sorbonne University, Faculty of Medicine, Paris, France.
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland; University of Lausanne (Unil), Faculty of Biology and Medicine (FBM), Lausanne, Switzerland
| | - Daniele Starnoni
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Mercy George
- Department of Otorhinolaryngology, Head & Neck Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Raphael Maire
- Department of Otorhinolaryngology, Head & Neck Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland; University of Lausanne (Unil), Faculty of Biology and Medicine (FBM), Lausanne, Switzerland
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18
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Suero Molina E, van Eck ATCJ, Sauerland C, Schipmann S, Horstmann G, Stummer W, Brokinkel B. Local Tumor Control and Clinical Symptoms After Gamma Knife Radiosurgery for Residual and Recurrent Vestibular Schwannomas. World Neurosurg 2018; 122:e1240-e1246. [PMID: 30447443 DOI: 10.1016/j.wneu.2018.11.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The use of Gamma Knife radiosurgery (GKRS) for recurrent or residual vestibular schwannoma (VS) after microsurgery (MS) has been investigated in several retrospective studies. The purpose of this study was to identify potential risk factors for both neurologic deterioration and tumor progression after GKRS for previously operated VSs in a prospective setting. METHODS Patients who underwent GKRS for previously operated and histopathologically confirmed VS between 1998 and 2015 were prospectively followed-up. Risk factors for therapy side effects and predictors for tumor control were investigated in uni- and multivariate analyses. RESULTS A total of 160 individuals with a median age of 55 years were included. Median tumor volume prior to GKRS was 1.40 cm3 (range, 0.06-35.80 cm3). After a median follow-up of 36 months, hearing and facial nerve function were serviceable (modified Gardner-Robertson and House-Brackmann grades I and II) in 7 (5%) and 82 (55%) patients, respectively. Deterioration to a nonserviceable facial nerve function after GKRS was found in 3% (3/89) and tended to increase with rising tumor volume (odds ratio, 1.65 per cm3; 95% confidence interval, 1.00-2.71; P = 0.051). Median tumor volume prior to GKRS was higher in patients with radiologic (P = 0.020) or clinical tumor progression (P < 0.001). Critical tumor volume prior to GKRS to predict clinical and radiologic tumor progression was 1.30 cm3 (P < 0.001) and 3.30 cm3 (P = 0.019), respectively. However, in multivariate analyses, none of the analyzed variables were found to independently predict tumor progression. CONCLUSIONS Intended submaximal resection followed by GKRS is a viable treatment for VS. Because tumor remnant size after MS is an important predictor for recurrence after adjuvant GKRS, both brainstem and cerebellar decompression and maximal safely achievable resection should remain major goals of microsurgery.
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Affiliation(s)
- Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | | | - Cristina Sauerland
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | | | | | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
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19
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Seidel K, Biner MS, Zubak I, Rychen J, Beck J, Raabe A. Continuous dynamic mapping to avoid accidental injury of the facial nerve during surgery for large vestibular schwannomas. Neurosurg Rev 2018; 43:241-248. [PMID: 30367353 DOI: 10.1007/s10143-018-1044-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/23/2018] [Accepted: 10/16/2018] [Indexed: 11/24/2022]
Abstract
In vestibular schwannoma (VS) surgery postoperative facial nerve (CN VII) palsy is reducing quality of life. Recently, we have introduced a surgical suction device for continuous dynamic mapping to provide feedback during tumor resection without switching to a separate stimulation probe. The objective was to evaluate the reliability of this method to avoid CN VII injury. Continuous mapping for CN VII was performed in large VS (08/2014 to 11/2017) additionally to standard neurophysiological techniques. A surgical suction-and-mapping probe was used for surgical dissection and continuous monopolar stimulation. Stimulation was performed with 0.05-2 mA intensities (0.3 msec pulse duration, 2.0 Hz). Postoperative CNVII outcome was assessed by the House-Brackmann-Score (HBS) after 1 week and 3 months following surgery. Twenty patients with Koos III (n = 2; 10%) and Koos IV (n = 18; 90%) VS were included. Preoperative HBS was 1 in 19 patients and 2 in 1 patient. Dynamic mapping reliably indicated the facial nerve when resection was close to 5-10 mm. One week after surgery, 7 patients presented with worsening in HBS. At 3 months, 4 patients' facial weakness had resolved and 3 patients (15%) had an impairment of CN VII (HBS 3 and 4). Of the 3 patients, near-total removal was attempted in 2. The continuous dynamic mapping method using an electrified surgical suction device might be a valuable additional tool in surgery of large VS. It provides real-time feedback indicating the presence of the facial nerve within 5-10 mm depending on stimulation intensity and may help in avoiding accidental injury to the nerve.
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Affiliation(s)
- Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland.
| | - Matthias S Biner
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| | - Irena Zubak
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| | - Jonathan Rychen
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
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20
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Troude L, Boucekine M, Montava M, Lavieille JP, Régis JM, Roche PH. Adjunctive Gamma Knife Surgery or Wait and Scan Policy After Optimal Resection of Large Vestibular Schwannomas: Clinical and Radiologic Outcomes. World Neurosurg 2018; 118:e895-e905. [DOI: 10.1016/j.wneu.2018.07.093] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
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21
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Daniel RT, Tuleasca C, Rocca A, George M, Pralong E, Schiappacasse L, Zeverino M, Maire R, Messerer M, Levivier M. The Changing Paradigm for the Surgical Treatment of Large Vestibular Schwannomas. J Neurol Surg B Skull Base 2018; 79:S362-S370. [PMID: 30210991 DOI: 10.1055/s-0038-1668540] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022] Open
Abstract
Objective Planned subtotal resection followed by Gamma Knife surgery (GKS) in patients with large vestibular schwannoma (VS) has emerged during the past decade, with the aim of a better functional outcome for facial and cochlear function. Methods We prospectively collected patient data, surgical, and dosimetric parameters of a consecutive series of patients treated by this method at Lausanne University Hospital during the past 8 years. Results A consecutive series of 47 patients were treated between July 2010 and January 2018. The mean follow-up after surgery was 37.5 months (median: 36, range: 0.5-96). Mean presurgical tumor volume was 11.8 mL (1.47-34.9). Postoperative status showed normal facial nerve function (House-Brackmann I) in all patients. In a subgroup of 28 patients, with serviceable hearing before surgery and in which cochlear nerve preservation was attempted at surgery, 26 (92.8%) retained serviceable hearing. Nineteen had good or excellent hearing (Gardner-Robertson class 1) before surgery, and 16 (84.2%) retained it after surgery. Mean duration between surgery and GKS was 6 months (median: 5, range: 3-13.9). Mean residual volume as compared with the preoperative one at GKS was 31%. Mean marginal dose was 12 Gy (11-12). Mean follow-up after GKS was 34.4 months (6-84). Conclusion Our data show excellent results in large VS management with a combined approach of microsurgical subtotal resection and GKS on the residual tumor, with regard to the functional outcome and tumor control. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control.
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Affiliation(s)
- Roy Thomas Daniel
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
| | - Constantin Tuleasca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Medical Image Analysis Laboratory (MIAL), Lausanne University Hospital, Lausanne, VauD, Switzerland.,Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne, Lausanne, VauD, Switzerland
| | - Alda Rocca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland
| | - Mercy George
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Department of Otorhinolaryngology/Head & Neck Surgery, Lausanne University Hospital, Lausanne, VauD, Switzerland
| | - Etienne Pralong
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
| | - Luis Schiappacasse
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Radiation Oncology Service, Lausanne, VauD, Switzerland
| | - Michele Zeverino
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Institute of Radiation Physics, Lausanne University Hospital (CHUV), Lausanne, VauD, Switzerland
| | - Raphael Maire
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland.,Department of Otorhinolaryngology/Head & Neck Surgery, Lausanne University Hospital, Lausanne, VauD, Switzerland
| | - Mahmoud Messerer
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital, Lausanne, VauD, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, VauD, Switzerland
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Abstract
The surgical management of cerebral and skull base lesions has evolved greatly in the last few decades. Still, a complete resection of lesions abutting critical neurovascular structures carries significant morbidity. Stereotactic radiosurgery (SRS) has emerged as an increasingly accepted treatment option. Minimally invasive, SRS results in excellent tumor control and low complication rates in patients with moderate-size tumors. The management of large cerebral and skull base tumors remains a formidable challenge. In such large tumors, radical surgical extirpation offers a significantly higher risk of neurological deficit, and SRS alone cannot be used because of the elevated incidence of radiation-induced complications known to be associated with large-volume tumors. With increasing treatment volumes, SRS-associated tumor control rates decrease and complication rates increase. Planned subtotal resection (STR) with adjuvant SRS (adaptive hybrid surgery [AHS]) has gained increasing interest in recent years as a multimodal approach. In AHS, a planned STR (aimed at decreasing surgical morbidity) followed by SRS to a preplanned residual tumor aids in harnessing advantages offered by both approaches. Although intuitive and reasonable, this paradigm shift from maximal resection at all cost has not been adopted widely. Combining open microsurgery with SRS requires a good understanding of both surgical and SRS modalities and their respective safety-efficacy features. We present a review and discussion on AHS as a modern, multidisciplinary treatment approach. Available data and views are discussed for vestibular schwannoma (VS) as a sample tumor. Other indications for AHS are mentioned in brief.
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Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, Rambam Maimonides Health Care Campus, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Department of Neurological Surgery and Gamma-Knife Center, University of Virginia Health Care Campus, Charlottesville, VA, USA
- To whom correspondence should be addressed. E-mail:
| | - Gil E Sviri
- Department of Neurological Surgery, Rambam Maimonides Health Care Campus, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
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Mackenzie R, Sporns P, Zoubi T, Koopmann M, Ewelt C, Stummer W, Brokinkel B, Suero Molina E. The difficulty of predicting clinical outcome after intended submaximal resection of large vestibular Schwannomas. J Clin Neurosci 2018; 50:62-8. [DOI: 10.1016/j.jocn.2018.01.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/08/2018] [Indexed: 11/22/2022]
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Starnoni D, Daniel RT, Tuleasca C, George M, Levivier M, Messerer M. Systematic review and meta-analysis of the technique of subtotal resection and stereotactic radiosurgery for large vestibular schwannomas: a “nerve-centered” approach. Neurosurg Focus 2018; 44:E4. [DOI: 10.3171/2017.12.focus17669] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDuring the last decade, the primary objective for large vestibular schwannoma (VS) management has progressively shifted, from tumor excision to nerve preservation by using a combined microsurgical and radiosurgical approach. The aim of this study was to provide a systematic review and meta-analysis of the available literature regarding the combined strategy of subtotal resection (STR) followed by stereotactic radiosurgery (SRS) for large VSs.METHODSThe authors performed a systematic review and meta-analysis in compliance with the PRISMA guidelines for article identification and inclusion using the PubMed, Embase, and Cochrane databases. Established inclusion criteria were used to screen all identified relevant articles published before September 2017 without backward date limit.RESULTSThe authors included 9 studies (248 patients). With a weighted mean follow-up of 46 months (range 28–68.8 months), the pooled rate of overall tumor control was 93.9% (95% CI 91.0%–96.8%). Salvage treatment (second STR and/or SRS) was necessary in only 13 (5.24%) of 18 patients who experienced initial treatment failure. According to the House-Brackmann (HB) grading scale, functional facial nerve preservation (HB grade I–II) was achieved in 96.1% of patients (95% CI 93.7%–98.5%). Serviceable hearing after the combined approach was preserved in 59.9% (95% CI 36.5%–83.2%).CONCLUSIONSA combined approach of STR followed by SRS was shown to have excellent clinical and functional outcomes while still achieving a tumor control rate comparable to that obtained with a total resection. Longer-term follow-up and larger patient cohorts are necessary to fully evaluate the rate of tumor control achieved with this approach.
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Affiliation(s)
| | | | - Constantin Tuleasca
- 1Neurosurgery Service and Gamma Knife Center and
- 3Swiss Federal Institute of Technology (EPFL), Laboratory of Transmission Signal (LTS5), Lausanne, Switzerland
| | - Mercy George
- 2ENT Service, Centre Hospitalier Universitaire Vaudois (CHUV), Faculty of Biology and Medicine, University of Lausanne; and
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25
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Daniel RT, Tuleasca C, George M, Pralong E, Schiappacasse L, Zeverino M, Maire R, Levivier M. Preserving normal facial nerve function and improving hearing outcome in large vestibular schwannomas with a combined approach: planned subtotal resection followed by gamma knife radiosurgery. Acta Neurochir (Wien) 2017; 159:1197-211. [PMID: 28516364 DOI: 10.1007/s00701-017-3194-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/24/2017] [Indexed: 11/17/2022]
Abstract
Objective To perform planned subtotal resection followed by gamma knife surgery (GKRS) in a series of patients with large vestibular schwannoma (VS), aiming at an optimal functional outcome for facial and cochlear nerves. Methods Patient characteristics, surgical and dosimetric features, and outcome were collected prospectively at the time of treatment and during the follow-up. Results A consecutive series of 32 patients was treated between July 2010 and June 2016. Mean follow-up after surgery was 29 months (median 24, range 4–78). Mean presurgical tumor volume was 12.5 cm3 (range 1.47–34.9). Postoperative status showed normal facial nerve function (House–Brackmann I) in all patients. In a subgroup of 17 patients with serviceable hearing before surgery and in which cochlear nerve preservation was attempted at surgery, 16 (94.1%) retained serviceable hearing. Among them, 13 had normal hearing (Gardner–Robertson class 1) before surgery, and 10 (76.9%) retained normal hearing after surgery. Mean duration between surgery and GKRS was 6.3 months (range 3.8–13.9). Mean tumor volume at GKRS was 3.5 cm3 (range 0.5–12.8), corresponding to mean residual volume of 29.4% (range 6–46.7) of the preoperative volume. Mean marginal dose was 12 Gy (range 11–12). Mean follow-up after GKRS was 24 months (range 3–60). Following GKRS, there were no new neurological deficits, with facial and hearing functions remaining identical to those after surgery in all patients. Three patients presented with continuous growth after GKRS, were considered failures, and benefited from the same combined approach a second time. Conclusion Our data suggest that large VS management, with planned subtotal resection followed by GKRS, might yield an excellent clinical outcome, allowing the normal facial nerve and a high level of cochlear nerve functions to be retained. Our functional results with this approach in large VS are comparable with those obtained with GKRS alone in small- and medium-sized VS. Longer term follow-up is necessary to fully evaluate this approach, especially regarding tumor control.
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Bailo M, Boari N, Gagliardi F, Franzin A, Piloni M, Spina A, Gemma M, Vecchio AD, Bolognesi A, Mortini P. Gamma Knife Radiosurgery for Residual and Recurrent Vestibular Schwannomas After Previous Surgery: Clinical Results in a Series of 90 Patients and Review of the Literature. World Neurosurg 2017; 98:60-72. [DOI: 10.1016/j.wneu.2016.10.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 12/31/2022]
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Radwan H, Eisenberg MB, Sandberg Knisely JP, Ghaly MM, Schulder M. Outcomes in Patients with Vestibular Schwannoma after Subtotal Resection and Adjuvant Radiosurgery. Stereotact Funct Neurosurg 2016; 94:216-224. [PMID: 27513938 DOI: 10.1159/000447520] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 06/09/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The debate continues with a limited number of publications describing outcomes in patients with vestibular schwannoma (VS) treated with planned subtotal resection (STR) plus stereotactic radiosurgery (SRS). Here we present our experience. METHODS This is a retrospective review of 22 patients with VS Koos grade III and IV who were treated with STR followed by SRS. Tumor volumes, facial nerve function, hearing preservation, and the presence of trigeminal neuropathy were noted. Spearman's rank test was used to correlate facial nerve grade with postoperative tumor residual tumor volume. RESULTS Tumor control was achieved in all patients with a mean follow-up of 28 months. No patient required other treatment beyond the original surgery and adjuvant SRS during this period. After a mean postoperative period of 28 months, 19/22 patients had excellent (House-Brackmann I or II) facial nerve function grading. Improved facial nerve function was positively correlated with larger residual tumor volume (rs = 0.63). Kaplan-Meier curve showed around 80% probability for regaining facial nerve function after initial deterioration. Four patients reported postoperative facial numbness at the side of surgery, with 3 cases showing improvement within a month. Temporary postoperative caudal cranial nerve dysfunction was observed in 2 patients. CONCLUSION Hybrid strategy of STR and adjuvant SRS provides patients with large VS excellent tumor control and a good clinical outcome.
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Affiliation(s)
- Hesham Radwan
- Department of Neurosurgery, Hofstra Northwell School of Medicine, Hempstead, N.Y., USA
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28
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Park CK, Lee SH, Choi MK, Choi SK, Park BJ, Lim YJ. Communicating Hydrocephalus Associated with Intracranial Schwannoma Treated by Gamma Knife Radiosurgery. World Neurosurg 2015; 89:593-600. [PMID: 26585729 DOI: 10.1016/j.wneu.2015.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 11/05/2015] [Accepted: 11/06/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Gamma knife radiosurgery (GKRS) has been established as an effective and safe treatment for intracranial schwannoma. However, serious complications can occur after GKRS, including hydrocephalus. The pathophysiology and 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 244 patients who underwent GKRS to treat intracranial schwannoma. The following parameters were analyzed as potential risk factors for hydrocephalus after GKRS: age, sex, target volume, irradiation dose, prior tumor resection, treatment technique, and tumor enhancement pattern. The tumor enhancement pattern was divided into 2 groups: group A (homogeneous enhancement) and group B (heterogeneous or rim enhancement). RESULTS Of the 244 patients, 14 of them (5.7%) developed communicating hydrocephalus. Communicating hydrocephalus occurred within 2 years after GKRS in most patients (92.8%). No significant association was observed between any of the parameters investigated and the development of hydrocephalus, with the exception of tumor enhancement pattern. Group B exhibited a statistically significant difference by univariate analysis (P = 0.002); this difference was also significant by multivariate analysis (P = 0.006). CONCLUSION Because hydrocephalus is curable, patients should be closely monitored for the development of this disorder after GKRS. In particular, patients with intracranial schwannomas with irregular enhancement patterns or cysts should be meticulously observed.
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Affiliation(s)
- Chang Kyu Park
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Man Kyu Choi
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Seok Keun Choi
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Bong Jin Park
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Young Jin Lim
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea.
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Iwai Y, Ishibashi K, Watanabe Y, Uemura G, Yamanaka K. Functional Preservation After Planned Partial Resection Followed by Gamma Knife Radiosurgery for Large Vestibular Schwannomas. World Neurosurg 2015; 84:292-300. [DOI: 10.1016/j.wneu.2015.03.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/09/2015] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
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Brokinkel B, Sauerland C, Holling M, Ewelt C, Horstmann G, van Eck ATCJ, Stummer W. Gamma Knife radiosurgery following subtotal resection of vestibular schwannoma. J Clin Neurosci 2014; 21:2077-82. [PMID: 25065850 DOI: 10.1016/j.jocn.2014.03.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 03/22/2014] [Accepted: 03/29/2014] [Indexed: 10/25/2022]
Abstract
During treatment of large vestibular schwannomas, incomplete resection (IR) followed by Gamma Knife surgery (GKS; Elekta AB, Stockholm, Sweden) possibly offers tumor growth control and good clinical outcome, and is being discussed as an alternative to complete tumor removal with its inherent risks, especially for facial nerve function. However, available data for this concept are limited due to the small number of published studies. To analyze the effects of combined therapy in a larger cohort, we reviewed the currently available data. Six studies comprising 159 patients with a tumor diameter of at least 2 cm were included (median volume 19.95 cm(3) in four studies, n=137). GKS was performed on average 6 months postoperatively with a mean marginal dose of 11.88 Gy (mean target volume 4.42 cm(3), mean diameter 18.45 mm). Preoperatively facial nerve function was serviceable (House and Brackmann Grades I+II) in 158 of 159 patients (99.4%) and in 125 of 151 patients (82.8%, 95% confidence interval [CI] 76-88%) postoperatively. Hearing was serviceable in 29 of 151 patients (19.2%) preoperatively and in 16 of 79 patients postoperatively (20.2%, 95%CI 12-31%). Within a mean follow-up time of 50 months (range 12-102 months), facial nerve function and hearing after IR remained serviceable in 142 of 151 (94.0%, 95%CI 89-97%) and 15 of 129 patients (11.6%, 95%CI 7-18%). Tumor growth control was achieved in 149 of 159 patients (93.8%). Six patients were subjected to repeated therapy. Minimal complications were reported for microsurgery and GKS. Combined therapy was shown to be beneficial regarding both tumor control and adverse side effects among all analyzed studies.
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Affiliation(s)
- Benjamin Brokinkel
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany.
| | - Cristina Sauerland
- Institute of Biostatistics and Clinical Research, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Christian Ewelt
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | | | | | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
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Miller T, Lau T, Vasan R, Danner C, Samy Youssef A, van Loveren H, Agazzi S. Reporting success rates in the treatment of vestibular schwannomas: Are we accounting for the natural history? J Clin Neurosci 2014; 21:914-8. [DOI: 10.1016/j.jocn.2013.11.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 11/14/2013] [Indexed: 11/26/2022]
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Maniakas A, Saliba I. Microsurgery versus stereotactic radiation for small vestibular schwannomas: a meta-analysis of patients with more than 5 years' follow-up. Otol Neurotol 2012; 33:1611-20. [PMID: 22996165 DOI: 10.1097/MAO.0b013e31826dbd02] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the long-term outcome of hearing and tumor outcome of small vestibular schwannomas treated with stereotactic radiation and microsurgery. DATA SOURCES A thorough search for English-language publications and "in process" articles dating from 1948 to December 2011 was conducted using Ovid MEDLINE. STUDY SELECTION The principal criteria were patients having had microsurgery or radiation therapy as their sole treatment, with a follow-up of at least 5 years, and a useful hearing level at diagnosis. DATA EXTRACTION Sixteen studies met our criteria. Hearing preservation outcome (worse or preserved) and tumor outcome (failure, control) data, as well as all other significant observations, were collected from the articles. Stereotactic radiation was the only radiation therapy analyzed. DATA SYNTHESIS The Pearson χ test was our primary statistical analysis. CONCLUSION Stereotactic radiation showed significantly better long-term hearing preservation outcome rates than microsurgery (p < 0.001). However, long-term tumor outcome was not significantly different in stereotactic radiation as compared with microsurgery (p = 0.122). Although stereotactic radiation demonstrates a more favorable long-term hearing preservation outcome as compared with microsurgery, additional studies are required to provide the medical field with a better understanding of vestibular schwannoma treatment.
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Arlt F, Trantakis C, Seifert V, Bootz F, Strauss G, Meixensberger J. Recurrence rate, time to progression and facial nerve function in microsurgery of vestibular schwannoma. Neurol Res 2012; 33:1032-7. [PMID: 22196755 DOI: 10.1179/1743132811y.0000000027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Recurrence rate, time to progression, and facial nerve function were analysed by comparing patients with complete and near total tumor removal after suboccipital craniotomy for vestibular schwannoma surgery. METHODS From 1996 to 2004, 118 patients with vestibular schwannoma were operated with an interdisciplinary approach. Fifty patients fulfilled the inclusion criteria and were included in the study. Progression was defined as an increase of ⩾2 mm in the largest diameter in the magnetic resonance imaging. Preoperative tumor size, facial nerve function estimated using the House-Brackmann score (HBS), time to progression, and recurrence rate were analysed and related to the extent of resection. RESULTS In 28 cases (group I), a capsular remnant was left. In 22 cases (group II), tumor removal was complete. In group I, nine patients (32·1%) showed progression. In group II, two patients (9·1%) developed a recurrent tumor, no significance (P = 0·085). In groups I and II, 53·6 and 59·6% had a good function of the facial nerve (HBS I+II), 28·6% in group I and 13·5% in group II had a moderate disturbance (HBS III+IV), and 17·9% in group I and 27·7% in group II had a poor function (HBS V+VI). There was no significant difference between median preoperative tumor size and facial nerve function within patients with HBS III and IV. CONCLUSION Complete tumor removal may be associated with a risk of functional loss, whereas near total tumor removal may be associated with a higher risk of progression.
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Affiliation(s)
- F Arlt
- Department of Neurosurgery, University Hospital Leipzig, Germany.
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36
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Timmer FCA, Mulder JJS, Hanssens PEJ, van Overbeeke JJ, Donders RT, Cremers CWRJ, Graamans K. Gamma knife radiosurgery for vestibular schwannomas: Identification of predictors for continued tumor growth and the influence of documented tumor growth preceding radiation treatment. Laryngoscope 2011; 121:1834-8. [DOI: 10.1002/lary.21908] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 04/18/2011] [Accepted: 04/21/2011] [Indexed: 11/11/2022]
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van de Langenberg R, Hanssens PEJ, van Overbeeke JJ, Verheul JB, Nelemans PJ, de Bondt BJ, Stokroos RJ. Management of large vestibular schwannoma. Part I. Planned subtotal resection followed by Gamma Knife surgery: radiological and clinical aspects. J Neurosurg 2011; 115:875-84. [PMID: 21838510 DOI: 10.3171/2011.6.jns101958] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In large vestibular schwannoma (VS), microsurgery is the main treatment option, and complete resection is considered the primary goal. However, previous studies have documented suboptimal facial nerve outcomes in patients who undergo complete resection of large VSs. Subtotal resection is likely to reduce the risk of facial nerve injury but increases the risk of lesion regrowth. Gamma Knife surgery (GKS) can be performed to achieve long-term growth control of residual VS after incomplete resection. In this study the authors report on the results in patients treated using planned subtotal resection followed by GKS with special attention to volumetric growth, control rate, and symptoms. METHODS Fifty consecutive patients who underwent the combined treatment strategy of subtotal microsurgical removal and GKS for large VSs between 2002 and 2009 were retrospectively analyzed. Patients with neurofibromatosis Type 2 were excluded. Patient charts were reviewed for clinical symptoms. Audiograms were evaluated to classify hearing pre- and postoperatively. Preoperative and follow-up contrast-enhanced T1-weighted MR images were analyzed using volume-measuring software. RESULTS Surgery was performed via a translabyrinthine (25 patients) or retrosigmoid (25 patients) approach. The median follow-up was 33.8 months. Clinical control was achieved in 92% of the cases and radiological control in 90%. One year after radiosurgery, facial nerve function was good (House-Brackmann Grade I or II) in 94% of the patients. One of the two patients who underwent surgery to preserve hearing maintained serviceable hearing after resection followed by GKS. CONCLUSIONS Considering the good tumor growth control and facial nerve function preservation as well as the possibility of preserving serviceable hearing and the low number of complications, subtotal resection followed by GKS can be the treatment option of choice for large VSs.
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Affiliation(s)
- Rick van de Langenberg
- Departments of Otolaryngology, Head and Neck Surgery, Maastricht University, Maastricht, The Netherlands.
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van de Langenberg R, Hanssens PEJ, Verheul JB, van Overbeeke JJ, Nelemans PJ, Dohmen AJC, de Bondt BJ, Stokroos RJ. Management of large vestibular schwannoma. Part II. Primary Gamma Knife surgery: radiological and clinical aspects. J Neurosurg 2011; 115:885-93. [PMID: 21838503 DOI: 10.3171/2011.6.jns101963] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In large vestibular schwannomas (VSs), microsurgery is the main treatment option. A wait-and-scan policy or radiosurgery are generally not recommended given concerns of further lesion growth or increased mass effect due to transient swelling. Note, however, that some patients do not present with symptomatic mass effect or may still have serviceable hearing. Moreover, others may be old, suffer from severe comorbidity, or refuse any surgery. In this study the authors report the results in patients with large, growing VSs primarily treated with Gamma Knife surgery (GKS), with special attention to volumetric growth, control rate, and symptoms. METHODS The authors retrospectively analyzed 33 consecutive patients who underwent GKS for large, growing VSs, which were defined as > 6 cm(3) and at least indenting the brainstem. Patients with neurofibromatosis Type 2 were excluded from analysis, as were patients who had undergone previous treatment. Volume measurements were performed on contrast-enhanced T1-weighted MR images at the time of GKS and during follow-up. Medical charts were analyzed for clinical symptoms. RESULTS Radiological growth control was achieved in 88% of cases, clinical control (that is, no need for further treatment) in 79% of cases. The median follow-up was 30 months, and the mean VS volume was 8.8 cm(3) (range 6.1-17.7 cm(3)). No major complications occurred, although ventriculoperitoneal shunts were placed in 2 patients. The preservation of serviceable hearing and facial and trigeminal nerve function was achieved in 58%, 91%, and 86% of patients, respectively, with any facial and trigeminal neuropathy being transient. In 92% of the patients presenting with trigeminal hypesthesia before GKS, the condition resolved during follow-up. No patient- or VS-related feature was correlated with growth. CONCLUSIONS Primary GKS for large VSs leads to acceptable radiological growth rates and clinical control rates, with the chance of hearing preservation. Although a higher incidence of clinical control failure and postradiosurgical morbidity is noted, as compared with that for smaller VSs, primary radiosurgery is suitable for a selected group of patients. The absence of symptomatology due to mass effect on the brainstem or cerebellum is essential, as are close clinical and radiological follow-ups, because there is little reserve for growth or swelling.
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Affiliation(s)
- Rick van de Langenberg
- Departments of Otolaryngology, Head and Neck Surgery, Maastricht University MedicalCentre, The Netherlands.
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Abstract
Object
Widespread use of MR imaging has contributed to the more frequent diagnosis of vestibular schwannomas (VSs). These tumors represent 10% of primary adult intracranial neoplasms, and if they are symptomatic, they usually present with hearing loss and tinnitus. Currently, there are 3 treatment options for quality of life (QOL): wait and scan, microsurgery, and radiosurgery. In this paper, the authors' purpose is to determine which treatment modality yields the highest QOL at 5- and 10-year follow-up, considering the likelihood of recurrence and various complications.
Methods
The MEDLINE, Embase, and Cochrane online databases were searched for English-language articles published between 1990 and June 2008, containing key words relating to VS. Data were pooled to calculate the prevalence of treatment complications, tumor recurrence, and QOL with various complications. For parameters in which incidence varied with time of follow-up, the authors used meta-regression to determine the mean prevalence rates at a specified length of follow-up. A decision-analytical model was constructed to compare 5- and 10-year outcomes for a patient with a unilateral tumor and partially intact hearing. The 3 treatment options, wait and scan, microsurgery, and radiosurgery, were compared.
Results
After screening more than 2500 abstracts, the authors ultimately included 113 articles in this analysis. Recurrence, complication rates, and onset of complication varied with the treatment chosen. The relative QOL at the 5-year follow-up was 0.898 of normal for wait and scan, 0.953 for microsurgery, and 0.97 for radiosurgery. These differences are significant (p < 0.0052). Data were too scarce at the 10-year follow-up to calculate significant differences between the microsurgery and radiosurgery strategies.
Conclusions
At 5 years, patients treated with radiosurgery have an overall better QOL than those treated with either microsurgery or those investigated further with serial imaging. The authors found that the complications associated with wait-and-scan and microsurgery treatment strategies negatively impacted patient lives more than the complications from radiosurgery. One limitation of this study is that the 10-year follow-up data were too limited to analyze, and more studies are needed to determine if the authors' results are still consistent at 10 years.
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Affiliation(s)
| | | | | | - Michael Ruckenstein
- 2Otorhinolaryngology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Pannullo SC, Fraser JF, Moliterno J, Cobb W, Stieg PE. Stereotactic radiosurgery: a meta-analysis of current therapeutic applications in neuro-oncologic disease. J Neurooncol 2011; 103:1-17. [DOI: 10.1007/s11060-010-0360-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 08/09/2010] [Indexed: 10/18/2022]
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Henzel M, Hamm K, Sitter H, Gross MW, Surber G, Kleinert G, Engenhart-Cabillic R. Comparison of Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy of Acoustic Neurinomas According to 3-D Tumor Volume Shrinkage and Quality of Life. Strahlenther Onkol 2009; 185:567-73. [DOI: 10.1007/s00066-009-1959-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 06/02/2009] [Indexed: 10/20/2022]
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Plotkin SR, Halpin C, Blakeley JO, Slattery WH, Welling DB, Chang SM, Loeffler JS, Harris GJ, Sorensen AG, McKenna MJ, Barker FG. Suggested response criteria for phase II antitumor drug studies for neurofibromatosis type 2 related vestibular schwannoma. J Neurooncol 2009; 93:61-77. [PMID: 19430883 DOI: 10.1007/s11060-009-9867-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 03/16/2009] [Indexed: 01/31/2023]
Abstract
Neurofibromatosis type 2 (NF2) is a tumor suppressor gene syndrome characterized by multiple schwannomas, especially vestibular schwannomas (VS), and meningiomas. Anticancer drug trials are now being explored, but there are no standardized endpoints in NF2. We review the challenges of NF2 clinical trials and suggest possible response criteria for use in initial phase II studies. We suggest two main response criteria in such trials. Objective radiographic response is defined as a durable 20% or greater reduction in VS volume based on post-contrast T1-weighted MRI images collected with 3 mm or finer cuts through the internal auditory canal. Hearing response is defined as a statistically significant improvement in word recognition scores using 50-word recorded lists in audiology. A possible composite endpoint incorporating both radiographic response and hearing response is outlined. We emphasize pitfalls in response assessment and suggest guidelines to minimize misinterpretations of response. We also identify research goals in NF2 to facilitate future trial conduct, such as identifying the expectations for time to tumor progression and time to measurable hearing loss in untreated NF2-related VS, and the relation of both endpoints to patient prognostic factors (such as age, baseline tumor volume, and measures of disease severity). These data would facilitate future use of endpoints based on stability of tumor size and hearing, which might be more appropriate for testing certain drugs. We encourage adoption of standardized endpoints early in the development of phase II trials for this population to facilitate comparison of results across trials of different agents.
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Affiliation(s)
- Scott R Plotkin
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA 02114, USA
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