scholarly journals Evolution in Surgical Treatment of Vestibular Schwannomas

2021 ◽  
Author(s):  
Marcos Tatagiba ◽  
Florian H. Ebner ◽  
Taishi Nakamura ◽  
Georgios Naros
Keyword(s):  
Surgical Treatment ◽  
Cranial Nerve ◽  
Radiation Treatment ◽  
Tumor Resection ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Consecutive Series ◽  
Additional Tool ◽  
Neuroprotective Strategy

Abstract Purpose of Review Management of vestibular schwannomas (VSs) is multimodal and include watchful observation, radiation treatment, and surgery. Over the past decades, a shift in treatment strategy toward radiation treatment has gradually displaced surgery from the main treatment option for VS. In recent years, however, surgery has been further refined by developments of microsurgical and endoscopic techniques and advances in intraoperative application of neuroprotective drugs. This article presents outcomes of modern surgical treatment of VS in the era of radiosurgery and reviews recent published advancements relevant to VS management. Recent Findings Following VS surgery, excellent tumor resection rates and cranial nerve outcomes were achieved in a consecutive series of 572 adult patients with mean postoperative follow up of 4 years. Innovations in surgical technique include endoscopic technique as additional tool to microsurgery, exploration of semi-sitting position for large tumors, and intraoperative use of vasoactive agents as neuroprotective strategy. Summary Despite great developments in radiation treatment of VS, surgery remains the key solution for the majority of the cases in order to achieve cure of the disease, long-term tumor control, and preservation of cranial nerve function at long-term.

Radiosurgery of vestibular schwannomas: summary of experience in 829 cases

2005 ◽  
Vol 102 ◽  
pp. 195-199 ◽  
Author(s):  
L. Dade Lunsford ◽  
Ajay Niranjan ◽  
John C. Flickinger ◽  
Ann Maitz ◽  
Douglas Kondziolka
Keyword(s):  
Quality Of Life ◽  
Gamma Knife ◽  
Cranial Nerve ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Content Type ◽  
Dose Planning ◽  
Fine Print

Object.Management options for vestibular schwannomas (VSs) have greatly expanded since the introduction of stereotactic radiosurgery. Optimal outcomes reflect long-term tumor control, preservation of cranial nerve function, and retention of quality of life. The authors review their 15-year experience.Methods.Between 1987 and 2002, some 829 patients with VSs underwent gamma knife surgery (GKS). Dose selection, imaging, and dose planning techniques evolved between 1987 and 1992 but thereafter remained stable for 10 years. The average tumor volume was 2.5 cm3. The median margin dose to the tumor was 13 Gy (range 10–20 Gy).No patient sustained significant perioperative morbidity. The average duration of hospital stay was less than 1 day. Unchanged hearing preservation was possible in 50 to 77% of patients (up to 90% in those with intracanalicular tumors). Facial neuropathy risks were reduced to less than 1%. Trigeminal symptoms were detected in less than 3% of patients whose tumors reached the level of the trigeminal nerve. Tumor control rates at 10 years were 97% (no additional treatment needed).Conclusions.Superior imaging, multiple isocenter volumetric conformal dose planning, and optimal precision and dose delivery contributed to the long-term success of GKS, including in those patients in whom initial microsurgery had failed. Gamma knife surgery provides a low risk, minimally invasive treatment option for patients with newly diagnosed or residual VS. Cranial nerve preservation and quality of life maintenance are possible in long-term follow up.

Radiosurgery of vestibular schwannomas: summary of experience in 829 cases

2005 ◽  
Vol 102 (Special_Supplement) ◽  
pp. 195-199 ◽  
Author(s):  
L. Dade Lunsford ◽  
Ajay Niranjan ◽  
John C. Flickinger ◽  
Ann Maitz ◽  
Douglas Kondziolka
Keyword(s):  
Quality Of Life ◽  
Gamma Knife ◽  
Cranial Nerve ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Content Type ◽  
Dose Planning ◽  
Fine Print

Object. Management options for vestibular schwannomas (VSs) have greatly expanded since the introduction of stereotactic radiosurgery. Optimal outcomes reflect long-term tumor control, preservation of cranial nerve function, and retention of quality of life. The authors review their 15-year experience. Methods. Between 1987 and 2002, some 829 patients with VSs underwent gamma knife surgery (GKS). Dose selection, imaging, and dose planning techniques evolved between 1987 and 1992 but thereafter remained stable for 10 years. The average tumor volume was 2.5 cm3. The median margin dose to the tumor was 13 Gy (range 10–20 Gy). No patient sustained significant perioperative morbidity. The average duration of hospital stay was less than 1 day. Unchanged hearing preservation was possible in 50 to 77% of patients (up to 90% in those with intracanalicular tumors). Facial neuropathy risks were reduced to less than 1%. Trigeminal symptoms were detected in less than 3% of patients whose tumors reached the level of the trigeminal nerve. Tumor control rates at 10 years were 97% (no additional treatment needed). Conclusions. Superior imaging, multiple isocenter volumetric conformal dose planning, and optimal precision and dose delivery contributed to the long-term success of GKS, including in those patients in whom initial microsurgery had failed. Gamma knife surgery provides a low risk, minimally invasive treatment option for patients with newly diagnosed or residual VS. Cranial nerve preservation and quality of life maintenance are possible in long-term follow up.

RADT-30. MULTISESSION RADIOSURGERY ALONE FOR TREATMENT OF PRESUMED MENINGIOMAS: AN INTERIM REPORT FROM A SINGLE INSTITUTION PROTOCOL

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi47-vi48
Author(s):  
Michael Carrasquilla ◽  
Alexander Tai ◽  
Matthew Forsthoefel ◽  
Edina Wang ◽  
Siyuan Lei ◽  
...  
Keyword(s):  
Local Control ◽  
Tumor Resection ◽  
Symptom Improvement ◽  
Tumor Control ◽  
Single Institution ◽  
Robotic Radiosurgery ◽  
Early Results ◽  
Alternative Treatment Option

Abstract PURPOSE Meningiomas are the most commonly diagnosed primary intracranial tumor. Resection and single-fraction radiosurgery are treatment options with well-established long-term outcomes data. Multisession radiosurgery is an alternative treatment option with promising early results. However, mature outcomes literature does not yet exist. In this study, we report our institution’s interim results on the efficacy and safety of 5-fraction radiosurgery alone for radiographically diagnosed meningiomas. MATERIALS AND METHODS Between 2005-2015 all patients who completed treatment on a single institution protocol utilizing 5-fraction robotic radiosurgery alone for the treatment of progressing radiographically diagnosed meningiomas were eligible for inclusion. Local control was calculated using the Kaplan-Meier Method. RESULTS Forty-four consecutive predominately female patients (84%) ranging in age from 33-85 (median: 59) were included in the present study. Median tumor volume was 4.05mm3 (range: 0.94-15.4mm3) and the majority of tumors were located at the base of skull (66%). A median dose of 25Gy (range: 25Gy-35Gy), was delivered to a median isodose line of 82%, (range: 70%-90%) over a median of 7 days (range: 5-11 days). Acute toxicity was minimal with 7 patients (15%) requiring a short course of steroids for symptomatic edema during treatment. Of 16 patients who presented with a cranial nerve deficit, symptom improvement was noted in 11 patients (69%). No permanent treatment related toxicity was noted in our cohort. The median radiographic follow-up was 6.9 years (range: 0.5-14.8 years). The 5 and 8-year local control rates were 100% and 95%. The median time to local failure (n=2) in our cohort was 8.2 years. CONCLUSIONS The treatment of radiographically diagnosed meningiomas with 5-fraction robotic radiosurgery provides excellent local control to date, with low rates of acute and late toxicity. However, with late failures noted in our series, continued follow-up is needed to determine the optimal dose required for long-term tumor control.

Longitudinal Analysis of Visual Outcomes After Surgical Treatment of Adult Craniopharyngiomas

Neurosurgery ◽  
2012 ◽  
Vol 71 (3) ◽  
pp. 715-721 ◽  
Author(s):  
Young-Hoon Kim ◽  
Chae-Yong Kim ◽  
Jin Wook Kim ◽  
Yong Hwy Kim ◽  
Jung Ho Han ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Visual Impairment ◽  
Tumor Recurrence ◽  
Significant Risk ◽  
Tumor Control ◽  
Total Removal ◽  
Short Term ◽  
Visual Outcomes ◽  
Short And Long Term

Abstract BACKGROUND: Craniopharyngiomas (CRPs) often cause visual deterioration (VD) due to the close vicinity of the optic apparatus. OBJECTIVE: To evaluate longitudinal visual outcomes after surgery of CRP and determine the prognostic factors thereof. METHODS: One hundred forty-six adult patients who underwent surgery for newly diagnosed CRP were retrospectively reviewed. There were 87 male patients (60%), and the median age was 41 years (range, 18–75). The mean follow-up duration was 88.7 months (range, 24–307). A visual impairment score was used to assess the short-term (<1 month) and long-term (>2 years) visual outcomes. RESULTS: Gross total removal was performed in 53 patients (36%), and tumor recurrence occurred in 40 patients (27%). The average preoperative, short- and long-term visual impairment scores were 44.4, 38.5, and 38.1, respectively, on a 0- to 100-point scale (with 100 indicating the worst vision). Short- and long-term VD occurred in 28 (19%) and 39 patients (27%), respectively. Subtotal removal (STR) alone (P = .010; OR = 4.8), short-term VD (P < .001; OR = 39.7), and tumor recurrence (P < .001; OR = 28.2) were significant risk factors for long-term VD in the multivariate analysis. Patients undergoing STR alone had higher tumor recurrence rates in comparison with those who underwent gross total removal or STR with adjuvant therapy (P < .001). CONCLUSION: Short-term VD secondary to the surgical insult and the recurrence of the tumor were strong predictors of long-term visual outcomes after surgical treatment for CRP. STR alone may be an ineffective strategy for achieving tumor control and optimal visual outcomes in patients with CRP.

Long-term outcomes of Gamma Knife radiosurgery in patients with vestibular schwannomas

2011 ◽  
Vol 114 (2) ◽  
pp. 432-440 ◽  
Author(s):  
Erin S. Murphy ◽  
Gene H. Barnett ◽  
Michael A. Vogelbaum ◽  
Gennady Neyman ◽  
Glen H. J. Stevens ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Tumor Diameter ◽  
Long Term Effects ◽  
Median Dose ◽  
The Mean

Object The authors sought to determine the long-term tumor control and side effects of Gamma Knife radiosurgery (GKRS) in patients with vestibular schwannomas (VS). Methods One hundred seventeen patients with VS underwent GKRS between January 1997 and February 2003. At the time of analysis, at least 5 years had passed since GKRS in all patients. The mean patient age was 60.9 years. The mean maximal tumor diameter was 1.77 ± 0.71 cm. The mean tumor volume was 1.95 ± 2.42 ml. Eighty-two percent of lesions received 1300 cGy and 14% received 1200 cGy. The median dose homogeneity ratio was 1.97 and the median dose conformality ratio was 1.78. Follow-up included MR imaging or CT scanning approximately every 6–12 months. Rates of progression to surgery were calculated using the Kaplan-Meier method. Results Of the 117 patients in whom data were analyzed, 103 had follow-up MR or CT images and 14 patients were lost to follow-up. Fifty-three percent of patients had stable tumors and 37.9% had a radiographically documented response. Imaging-documented tumor progression was present in 8 patients (7.8%), but in 3 of these the lesion eventually stabilized. Only 5 patients required a neurosurgical intervention. The estimated 1-, 3-, and 5-year rates of progression to surgery were 1, 4.6, and 8.9%, respectively. One patient (1%) developed trigeminal neuropathy, 4 patients (5%) developed permanent facial neuropathy, 3 patients (4%) reported vertigo, and 7 patients (18%) had new gait imbalance following GKRS. Conclusions Gamma Knife radiosurgery results in excellent local control rates with minimal toxicity for patients with VS. The authors recommend standardized follow-up to gain a better understanding of the long-term effects of GKRS.

scholarly journals Stereotactic radiosurgery for vestibular schwannomas: average 10-year follow-up results focusing on long-term hearing preservation

2016 ◽  
Vol 125 (Supplement_1) ◽  
pp. 64-72 ◽  
Author(s):  
Shinya Watanabe ◽  
Masaaki Yamamoto ◽  
Takuya Kawabe ◽  
Takao Koiso ◽  
Tetsuya Yamamoto ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Tumor Volume ◽  
Hearing Preservation ◽  
Interquartile Range ◽  
Vestibular Schwannomas ◽  
Long Term Results ◽  
Tumor Control ◽  
Univariable Analysis

OBJECTIVEThe aim of this study was to reappraise long-term treatment outcomes of stereotactic radiosurgery (SRS) for vestibular schwannomas (VSs). The authors used a database that included patients who underwent SRS with a unique dose-planning technique, i.e., partial tumor coverage designed to avoid excess irradiation of the facial and cochlear nerves, focusing on tumor control and hearing preservation. Clinical factors associated with post-SRS tumor control and long-term hearing preservation were also analyzed.METHODSThis institutional review board–approved, retrospective cohort study used the authors' prospectively accumulated database. Among 207 patients who underwent Gamma Knife SRS for VSs between 1990 and 2005, 183 (who were followed up for at least 36 post-SRS months) were studied. The median tumor volume was 2.0 cm3 (range 0.05–26.2 cm3). The median prescribed dose at the tumor periphery was 12.0 Gy (range 8.8–15.0 Gy; 12.0 Gy was used in 171 patients [93%]), whereas tumor portions facing the facial and cochlear nerves were irradiated with 10.0 Gy. As a result, 72%–99% of each tumor was irradiated with the prescribed dose. The mean cochlear doses ranged from 2.3 to 5.7 Gy (median 4.1 Gy).RESULTSThe median durations of imaging and audiometric follow-up were 114 months (interquartile range 73–144 months) and 59 months (interquartile range 33–109 months), respectively. Tumor shrinkage was documented in 110 (61%), no change in 48 (27%), and enlargement in the other 22 (12%) patients. A further procedure (FP) was required in 15 (8%) patients. Thus, the tumor growth control rate was 88% and the clinical control rate (i.e., no need for an FP) was 92%. The cumulative FP-free rates were 96%, 93%, and 87% at the 60th, 120th, and 180th post-SRS month, respectively. Six (3%) patients experienced facial pain, and 2 developed transient facial palsy. Serviceable hearing was defined as a pure tone audiogram result better than 50 dB. Among the 66 patients with serviceable hearing before SRS who were followed up, hearing acuity was preserved in 23 (35%). Actuarial serviceable hearing preservation rates were 49%, 24%, and 12% at the 60th, 120th, and 180th post-SRS month, respectively. On univariable analysis, only cystic-type tumor (HR 3.36, 95% CI 1.18–9.36; p = 0.02) was shown to have a significantly unfavorable association with FP. Multivariable analysis followed by univariable analysis revealed that higher age (≥ 65 years: HR 2.66, 95% CI 1.16–5.92; p = 0.02), larger tumor volume (≥ 8 cm3: HR 5.36, 95% CI 1.20–17.4; p = 0.03), and higher cochlear dose (mean cochlear dose > 4.2 Gy: HR 2.22, 95% CI 1.07–4.77; p = 0.03) were unfavorable factors for hearing preservation.CONCLUSIONSStereotactic radiosurgery achieved good long-term results in this series. Tumor control was acceptable, and there were few serious complications in patients with small- to medium-sized VSs. Unfortunately, hearing preservation was not satisfactory. However, the longer the observation period, the more important it becomes to compare post-SRS hearing decreases with the natural decline in untreated cases.

Gamma Knife radiosurgery for treatment of growing vestibular schwannomas in patients with neurofibromatosis Type 2: a matched cohort study with sporadic vestibular schwannomas

2018 ◽  
Vol 128 (1) ◽  
pp. 49-59 ◽  
Author(s):  
Ivo J. Kruyt ◽  
Jeroen B. Verheul ◽  
Patrick E. J. Hanssens ◽  
Henricus P. M. Kunst
Keyword(s):  
Gamma Knife ◽  
Tumor Volume ◽  
Gamma Knife Radiosurgery ◽  
Neurofibromatosis Type ◽  
Hearing Preservation ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Nerve Function

OBJECTIVENeurofibromatosis Type 2 (NF2) is a tumor syndrome characterized by an autosomal dominant pattern of inheritance. The hallmark of NF2 is the development of bilateral vestibular schwannomas (VSs), generally by 30 years of age. One of the first-line treatment options for small to medium-large VSs is radiosurgery. Although radiosurgery shows excellent results in sporadic VS, its use in NF2-related VS is still a topic of dispute. The aim of this study was to evaluate long-term tumor control, hearing preservation rates, and factors influencing outcome of optimally dosed, contemporary Gamma Knife radiosurgery (GKRS) for growing VSs in patients with NF2 and compare the findings to data obtained in patients with sporadic VS also treated by means of GKRS.METHODSThe authors performed a retrospective analysis of 47 growing VSs in 34 NF2 patients who underwent GKRS treatment performed with either the Model C or Perfexion Leksell Gamma Knife, with a median margin dose of 11 Gy. Actuarial tumor control rates were estimated using the Kaplan-Meier method. For patient- and treatment-related factors, a Cox proportional hazards model was used to identify predictors of outcome. Trigeminal, facial, and vestibulocochlear nerve function were assessed before and after treatment. NF2-related VS patients were matched 1:1 with sporadic VS patients who were treated in the same institute, and the same indications for treatment, definitions, and dosimetry were used in order to compare outcomes.RESULTSActuarial tumor control rates in NF2 patients after 1, 3, 5, and 8 years were 98%, 89%, 87%, and 87%, respectively. Phenotype and tumor volume had significant hazard rates of 0.086 and 22.99, respectively, showing that Feiling-Gardner phenotype and a tumor volume not exceeding 6 cm3 both were associated with significantly better outcome. Actuarial rates of serviceable hearing preservation after 1, 3, 5, and 7 years were 95%, 82%, 59%, and 33%, respectively. None of the patients experienced worsening of trigeminal nerve function. Facial nerve function worsened in 1 patient (2.5%). No significant differences in tumor control, hearing preservation, or complications were found in comparing the results of GKRS for NF2-related VS versus GKRS for sporadic VS.CONCLUSIONSWith modern GKRS, the use of low margin doses for treating growing VSs in patients with NF2 demonstrates good long-term tumor control rates. Feiling-Gardner phenotype and tumor volume smaller than 6 cm3 seem to be independently associated with prolonged progression-free survival, highlighting the clinical importance of phenotype assessment before GKRS treatment. In addition, no significant differences in tumor control rates or complications were found in the matched-control cohort analysis comparing GKRS for VS in patients with NF2 and GKRS for sporadic VS. These results show that GKRS is a valid treatment option for NF2-related VS, in addition to being a good option for sporadic VS, particularly in patients with the Feiling-Gardner phenotype and/or tumors that are small to medium in size. Larger tumors in patients with the Wishart phenotype appear to respond poorly to radiosurgery, and other treatment modalities should therefore be considered in such cases.

Long-term Changes in Serum IGF-1 Levels After Successful Surgical Treatment of Growth Hormone–Secreting Pituitary Adenoma

Neurosurgery ◽  
2013 ◽  
Vol 73 (3) ◽  
pp. 473-479 ◽  
Author(s):  
Mi-Seon Shin ◽  
Ji Hee Yu ◽  
Jong Han Choi ◽  
Chang Hee Jung ◽  
Jenie Yoonoo Hwang ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Growth Hormone ◽  
Surgical Treatment ◽  
Magnetic Resonance ◽  
Serum Insulin ◽  
Tumor Resection ◽  
Oral Glucose ◽  
Resonance Imaging ◽  
Long Term Changes

Abstract BACKGROUND: Successful treatment of acromegaly is known to normalize serum insulin-like growth factor 1 (IGF-1) levels within days after surgery. However, our clinical observations indicate that many cases of acromegaly show delayed normalization of serum IGF-1 levels after complete tumor resection. OBJECTIVE: To study long-term changes of the serum IGF-1 levels in acromegalic patients for whom surgical treatment was thought to be successful. METHODS: A retrospective observational study was performed with 46 acromegalic patients with no residual tumor on sellar magnetic resonance imaging, and a nadir growth hormone of less than 0.4 μg/L on a postoperative oral glucose tolerance test. RESULTS: In all patients, serum IGF-1 levels returned to the normal reference values for age and sex during the observational period (12-132 months). The mean duration from the time of surgery until IGF-1 normalization was 10 months (range, 3 days-57 months). Twenty-seven patients (59%) reached normal IGF-1 ranges within 3 months of surgery, whereas 19 patients (41%) experienced delayed (>3 months) IGF-1 normalization. Eleven patients (24%) recovered normal IGF-1 levels 12 to 57 months after surgery. The possibility of delayed IGF-1 cure was increased 8.8-fold with an immediate postoperative IGF-1 level increase of 100 μg/L. CONCLUSION: Satisfactory remission of acromegaly by IGF-1 criteria was delayed in a large proportion of acromegalic patients, especially those with high postoperative IGF-1 levels. Hence, additional treatment can be delayed in clinically stable acromegalic patients who show no evidence of residual tumors on postoperative magnetic resonance imaging and a normal growth hormone suppressive response to a glucose load.

Contemporary Surgical Management of Vestibular Schwannomas: Analysis of Complications and Lessons Learned Over the Past Decade

2012 ◽  
Vol 72 (2) ◽  
pp. ons103-ons115 ◽  
Author(s):  
Yoichi Nonaka ◽  
Takanori Fukushima ◽  
Kentaro Watanabe ◽  
Allan H. Friedman ◽  
John H. Sampson ◽  
...  
Keyword(s):  
Vestibular Schwannoma ◽  
Clinical Status ◽  
Neurological Complication ◽  
Tumor Resection ◽  
Hearing Preservation ◽  
Lessons Learned ◽  
Vestibular Schwannomas ◽  
Consecutive Series ◽  
Lower Cranial Nerve

Abstract BACKGROUND: Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery. OBJECTIVE: To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications. METHODS: Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1–116 months; mean, 32.7 months). RESULTS: Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were <20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors <20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%. CONCLUSION: Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.

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