322 Rate of Residual Tumor Growth After Primary Subtotal Resection (STR) and the Role of Upfront Versus Salvage Stereotactic Radiosurgery (SRS) for Sporadic Vestibular Schwannomas

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 270-270
Author(s):  
Jonathan D Breshears ◽  
Carlene Partow ◽  
Tarik Tihan ◽  
Michael William McDermott ◽  
Patricia Sneed ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Salvage Surgery ◽  
Residual Tumor ◽  
Salvage Treatment ◽  
Vestibular Schwannomas ◽  
Subtotal Resection

Abstract INTRODUCTION Maximal safe resection is an optimal surgical strategy for moderate-to-large vestibular schwannomas, however data on the long-term outcomes of residual tumor after STR is lacking. The goal of this study was to review our rates of residual tumor growth, and the control rates of salvage versus upfront stereotactic radiosurgery (SRS). METHODS This retrospective single-institution study included all sporadic vestibular schwannomas treated primarily with STR at our institution from 2002 2015. The primary outcome was tumor growth requiring salvage treatment, and response to salvage treatment (surgery or SRS). Patients treated with upfront SRS after surgery were analyzed separately. RESULTS >295 patients underwent primary surgery for a vestibular schwannoma between 2002 - 2015, including 140 STRs. 49 cases with <1 year follow-up were excluded. 17 cases received upfront SRS after surgery (12 Gamma Knife, 12Gy; 5 CyberKnife, 25Gy in 5 fractions), with 2 failures requiring salvage surgery at 1.6 and 2.6 years (88% control rate at 1.8 years). Seventy-four residual tumors were managed with observation after STR. 57 (77%) remained stable at a median 4.1 years. 17 tumors (23%) progressed, requiring salvage treatment at a median of 2.8 years. Eleven received Gamma Knife (12.5 Gy) with a 100% control rate 2.3 years after SRS. One received Cyber Knife (18Gy, 3 fractions), ultimately requiring repeat surgery 3 years later. 4 residual tumors received salvage surgery at a median interval of 5 years after STR, and one was lost to follow-up. The control rate of salvage SRS was 92% at 2.3 years median follow-up. CONCLUSION A majority (77%) of residual vestibular schwannomas remained stable after a primary STR. Both upfront and salvage SRS had good control rates (∼90%) in our series. Further study is needed to define the role of upfront versus salvage SRS after a primary STR.

scholarly journals The role of radiosurgery for hemangiopericytomas

2003 ◽  
Vol 14 (5) ◽  
pp. 1-5 ◽  
Author(s):  
Steven D. Chang ◽  
Gordon T. Sakamoto
Keyword(s):  
Stereotactic Radiosurgery ◽  
Distant Metastases ◽  
Residual Tumor ◽  
High Rate ◽  
Tumor Control ◽  
Small Subset ◽  
Patient Database ◽  
The Mean

Object Hemangiopericytomas represent a small subset of meningeal tumors. Despite their relatively uncommon nature, they are aggressive tumors known for recurrence. Resection is the standard treatment in most, although regrowth and metastases are common even after resection. The authors evaluate the role of stereotactic radiosurgery in the treatment of recurrent hemangiopericytomas. Methods In a review of the Stanford radiosurgery patient database between 1989 and 2002, the authors found eight patients with recurrent hemangiopericytoma who underwent stereotactic radiosurgery. The mean age of this population was 45.1 years (range 24–67 years). All patients had been previously treated with resection, and five patients (63%) had undergone conventional radiotherapy. The mean radiosurgery dose to the tumor margin was 20.5 Gy (range 16–24 Gy). The mean clinical and radiographic follow-up period was 44 months (range 8–77 months). Of the eight tumors treated with radiosurgery, six decreased in size and two ultimately progressed. There were no radiosurgery-related complications. Conclusions Stereotactic radiosurgery of hemangiopericytomas can result in increased tumor control and should be considered as a treatment option for patients in whom the diagnosis has been established and in whom residual tumor is demonstrated postoperatively. Close clinical and radiographic follow-up evaluation is necessary in this patient population because of the high rate of local recurrence and distant metastases.

The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas

2014 ◽  
Vol 120 (6) ◽  
pp. 1278-1287 ◽  
Author(s):  
Zhengnong Chen ◽  
Sampath Chandra Prasad ◽  
Filippo Di Lella ◽  
Marimar Medina ◽  
Enrico Piccirillo ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Residual Tumor ◽  
Vestibular Schwannomas ◽  
Subtotal Resection ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Incomplete Excision ◽  
Kaplan Meier ◽  
Tumor Regrowth

Object The authors evaluated the behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas (VSs). Methods The case records of all patients who underwent surgical treatment of VSs were analyzed. All patients in whom an incomplete excision had been performed were analyzed. Incomplete excision was defined as near-total resection (NTR), subtotal resection (STR), and partial resection (PR). Tumors in the NTR and STR categories were followed up with a wait-and-rescan approach, whereas the tumors in the PR category were subjected to a second-stage surgery and were excluded from this series. All patients included in the study underwent baseline MRI at the 3rd and 12th postoperative months, and repeat imaging was subsequently performed every year for 7–10 years postoperatively or as indicated clinically. Preoperative and postoperative facial function was noted. Results Of the 2368 patients who underwent surgery for VS, 111 patients who had incomplete excisions of VSs were included in the study. Of these patients, 73 (65.77%) had undergone NTR and 38 (34.23%) had undergone STR. Of the VSs, 62 (55.86%) were cystic and 44 (70.97%) of these cystic VSs underwent NTR. The residual tumor was left behind on the facial nerve alone in 62 patients (55.86%), on the facial nerve and vessels in 2 patients (1.80%), on the facial nerve and brainstem in 15 patients (13.51%), and on the brainstem alone in 25 patients (22.52%). In the 105 patients with normal preoperative facial nerve function, postoperative facial nerve function was House-Brackmann (HB) Grades I and II in 51 patients (48.57%), HB Grade III in 34 patients (32.38%), and HB Grades IV–VI in 20 patients (19.05%). Seven patients (6.3%) showed evidence of tumor regrowth on follow-up MRI. All 7 patients (100%) who showed evidence of tumor regrowth had undergone STR. No patient in the NTR group exhibited regrowth. The Kaplan-Meier plot demonstrated a 5-year tumor regrowth-free survival of 92%, with a mean disease-free interval of 140 months (95% CI 127–151 months). The follow-up period ranged from 12 to 156 months (mean 45.4 months). Conclusions The authors' report and review of the literature show that there is undoubtedly merit for NTR and STR for preservation of the facial nerve. On the basis of this they propose an algorithm for the management of incomplete VS excisions. Patients who undergo incomplete excisions must be subjected to follow-up MRI for a period of at least 7–10 years. When compared with STR, NTR via an enlarged translabyrinthine approach has shown to have a lower rate of regrowth of residual tumor, while having almost the same result in terms of facial nerve function.

scholarly journals Stereotactic radiosurgery in hemangioblastoma: Experience over 14 years

2016 ◽  
Vol 7 (01) ◽  
pp. 23-27 ◽  
Author(s):  
Nishant Goyal ◽  
Deepak Agrawal ◽  
Raghav Singla ◽  
Shashank Sharad Kale ◽  
Manmohan Singh ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Clinical History ◽  
Peripheral Dose ◽  
Von Hippel Lindau ◽  
Cyst Volume ◽  
Von Hippel Lindau Disease ◽  
Cerebellar Symptoms

ABSTRACT Background: Although gamma knife has been advocated for hemangioblastomas, it is not used widely by neurosurgeons. Objective: We review our experience over 14 years in an attempt to define the role of stereotactic radiosurgery (SRS) in the management of hemangioblastomas. Patients and Methods: A retrospective study was conducted on all patients of hemangioblastoma who underwent SRS at our institute over a period of 14 years (1998–2011). Gamma knife plans, clinical history, and radiology were reviewed for all patients. Results: A total of 2767 patients underwent gamma knife during the study period. Of these, 10 (0.36%) patients were treated for 24 hemangioblastomas. Eight patients (80%) had von Hippel-Lindau disease while two had sporadic hemangioblastomas. The median peripheral dose (50% isodose) delivered to the tumors was 29.9 Gy. Clinical and radiological follow-up data were available for eight patients. Of these, two were re-operated for persisting cerebellar symptoms. The remaining six patients were recurrence-free at a mean follow-up of 48 months (range 19–108 months). One patient had an increase in cyst volume along with a decrease in the size of the mural nodule. Conclusions: SRS should be the first option for asymptomatic hemangioblastomas. Despite the obvious advantages, gamma knife is not widely used as an option for hemangioblastomas.

Gamma Knife surgery in vestibular schwannomas: impact on the anterior and posterior labyrinth

2010 ◽  
Vol 113 (Special_Supplement) ◽  
pp. 128-135 ◽  
Author(s):  
Massimo Gerosa ◽  
Nazarena Mesiano ◽  
Michele Longhi ◽  
Antonio De Simone ◽  
Roberto Foroni ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Gamma Knife ◽  
Growth Control ◽  
Hearing Preservation ◽  
Gamma Knife Surgery ◽  
Vestibular Schwannomas ◽  
Medium Size ◽  
Tumor Control ◽  
Brainstem Response

Object During the past decades, in small-to-medium size vestibular schwannomas, Gamma Knife surgery (GKS) has become a reliable therapeutic option because of either excellent local tumor control or minimal morbidity, with cranial neuropathy becoming increasingly rare. Although still insufficiently analyzed in larger cohorts of patients with long-term follow-ups, adequate chances of hearing preservation and vestibular sparing seem clinically guaranteed. However, deeper investigations are needed in this regard, expanding the number of cases and the follow-up period. Methods A small group of patients with vestibular schwannomas (74 patients, including 41 men and 33 women) treated between 2003 and 2009 using GKS at the authors' institution were analyzed—both before and after GKS—with computerized static stabilometry and electronystagmography for balance disorders, vertigo, and ataxia on 1 side and pure tone average, vocal speech discrimination score, auditory brainstem response, and so forth for hearing impairment and tinnitus on the other side. Eligibility criteria for this prospective study included previously untreated unilateral lesions and a Gardner-Robertson hearing class of I–III. Dosimetry plans had been programmed at the lower effective dosages for these tumors (median surface dose 12.4 Gy, range 10–13 Gy), carefully avoiding even minimal toxic dosages on the most vulnerable targets: the cochlea (never > 6 Gy) and the vestibular canals (< 7.5 Gy). Results To date, tumor growth control rates remain satisfactory; at a mean follow-up of 50 months, the rate was 96%. The overall level of hearing preservation was 72%, with 81% having Gardner-Robertson Class I hearing. Tinnitus decreased, from 52% to 28% of patients (p < 0.01). Significant improvements were also observed in vestibular symptoms, with computerized static stabilometry abnormalities decreasing from 62% to 32% (p < 0.001) and electronystagmography abnormalities reducing from 48% to 14% (p < 0.001). Conclusions Using appropriate radiodosimetry planning, GKS seems to guarantee not only adequate tumor growth control rates, but also better levels of hearing preservation, with a documented, long-lasting improvement in vestibular functions.

scholarly journals Fate of Residual Tumor After Subtotal-resected, Previously-irradiated Vestibular Schwannoma: Long-term Follow-up of a Single Institutional Series

2021 ◽  
Author(s):  
Joonho Byun ◽  
Sang Woo Song ◽  
Young-Hoon Kim ◽  
Chang Ki Hong ◽  
Jeong Hoon Kim
Keyword(s):  
Vestibular Schwannoma ◽  
Salvage Surgery ◽  
Residual Tumor ◽  
Cyst Formation ◽  
Subtotal Resection ◽  
Total Resection ◽  
Salvage Resection ◽  
Long Term Follow Up ◽  
History Of

Abstract Background: The fate of residual tumor after salvage surgery for recurrent vestibular schwannoma (VS) after radiosurgery has not been elucidated. We reviewed our surgical series of salvage surgery for recurrent VS and the natural history of the residual tumor after salvage surgery.Methods: This study enrolled 14 patients who were received salvage surgical resection in our institute and were followed-up for >12 months.Results: There were 3 male and 11 female patients with a median age of 55 years (range: 16-70). The pre-SRS tumor volume was a median 6591 mm3. All patients were treated by GKS. The median duration from GKS to surgery was 52 months (range: 10-116). Solid tumor growth was observed in 6 (42.9%) patients and cyst formation was observed in 8 patients (57.1%). Subtotal resection was performed in 13 (92.9%) patients and gross total resection was only achieved in one (7.1%) patient. Postoperative facial paresis occurred in 5 (35.7%) patients. Postoperative surgical complications occurred in 2 (14.3%) patients. After salvage resection for irradiated VS, no patient showed tumor progression or recurrence during the follow-up period (13 subtotal resection and 1 total resection). In addition, 2 patients in the subtotal resection group showed residual tumor shrinkage after salvage surgery during the follow-up periodConclusion: The behavior of residual tumors after salvage surgery for irradiated VS was stable. Adjuvant treatment for these residual tumors may not be necessary.

Wait-and-see strategy compared with proactive Gamma Knife surgery in patients with intracanalicular vestibular schwannomas

2010 ◽  
Vol 113 (Special_Supplement) ◽  
pp. 105-111 ◽  
Author(s):  
Jean Régis ◽  
Romain Carron ◽  
Michael C. Park ◽  
Outouma Soumare ◽  
Christine Delsanti ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Treatment Failure ◽  
Gamma Knife ◽  
Tumor Size ◽  
Gamma Knife Surgery ◽  
Vestibular Schwannomas ◽  
Control Group ◽  
Wait And See ◽  
The Mean

Object The roles of the wait-and-see strategy and proactive Gamma Knife surgery (GKS) in the treatment paradigm for small intracanalicular vestibular schwannomas (VSs) is still a matter of debate, especially when patients present with functional hearing. The authors compare these 2 methods. Methods Forty-seven patients (22 men and 25 women) harboring an intracanalicular VS were followed prospectively. The mean age of the patients at the time of inclusion was 54.4 years (range 20–71 years). The mean follow-up period was 43.8 ± 40 months (range 9–222 months). Failure was defined as significant tumor growth and/or hearing deterioration that required microsurgical or radiosurgical treatment. This population was compared with a control group of 34 patients harboring a unilateral intracanalicular VS who were consecutively treated by GKS and had functional hearing at the time of radiosurgery. Results Of the 47 patients in the wait-and-see group, treatment failure (tumor growth requiring treatment) was observed in 35 patients (74%), although conservative treatment is still ongoing for 12 patients. Treatment failure in the control (GKS) group occurred in only 1 (3%) of 34 patients. In the wait-and-see group, there was no change in tumor size in 10 patients (21%), tumor growth in 36 patients (77%), and a mild decrease in tumor size in 1 patient (2%). Forty patients in the wait-and-see group were available for a hearing level study, which demonstrated no change in Gardner-Robertson hearing class for 24 patients (60%). Fifteen patients (38%) experienced more than 10 db of hearing loss and 2 of them became deaf. At 3, 4, and 5 years, the useful hearing preservation rates were 75%, 52%, and 41% in the wait-and-see group and 77%, 70%, and 64% in the control group, respectively. Thus, the chances of maintaining functional hearing and avoiding further intervention were much higher in cases treated by GKS (79% and 60% at 2 and 5 years, respectively) than in cases managed by the wait-and-see strategy (43% and 14% at 2 and 5 years, respectively). Conclusions These data indicate that the wait-and-see policy exposes the patient to elevated risks of tumor growth and degradation of hearing. Both events may occur independently in the mid-term period. This information must be presented to the patient. A careful sequential follow-up may be adopted when the wait-and-see strategy is chosen, but proactive GKS is recommended when hearing is still useful at the time of diagnosis. This recommendation may be a main paradigm shift in the practice of treating intracanalicular VSs.

Resection of vestibular schwannomas after stereotactic radiosurgery: a systematic review

2020 ◽  
pp. 1-9
Author(s):  
Max Whitmeyer ◽  
Bledi C. Brahimaj ◽  
André Beer-Furlan ◽  
Sameer Alvi ◽  
Madeline J. Epsten ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Facial Nerve ◽  
Stereotactic Radiosurgery ◽  
Surgical Approach ◽  
Salvage Surgery ◽  
Vestibular Schwannomas ◽  
Cochrane Library ◽  
Nerve Preservation ◽  
Facial Nerve Preservation ◽  
Primary Indication

OBJECTIVEMultiple short series have evaluated the efficacy of salvage microsurgery (MS) after stereotactic radiosurgery (SRS) for treatment of vestibular schwannomas (VSs); however, there is a lack of a large volume of patient data available for interpretation and clinical adaptation. The goal of this study was to provide a comprehensive review of tumor characteristics, management, and surgical outcomes of salvage of MS after SRS for VS.METHODSThe Medline/PubMed, Scopus, CINAHL, Cochrane Library, and Google Scholar databases were queried according to PRISMA guidelines. All English-language and translated publications were included. Studies lacking adequate study characteristics and outcomes were excluded. Cases involving neurofibromatosis type 2, previous MS, or malignant transformation were excluded when possible.RESULTSTwenty studies containing 297 cases met inclusion criteria. Three additional cases from Rush University Medical Center were added for 300 total cases. Tumor growth with or without symptoms was the primary indication for salvage surgery (92.3% of cases), followed by worsening of symptoms without growth (4.6%) and cystic enlargement (3.1%). The average time to MS after SRS was 39.4 months. The average size and volume of tumor at surgery were 2.44 cm and 5.92 cm3, respectively. The surgical approach was retrosigmoid (42.8%) and translabyrinthine (57.2%); 59.5% of patients had a House-Brackmann (HB) grade of I or II. The facial nerve was preserved in 91.5% of cases. Facial nerve preservation and HB grades were lower for the translabyrinthine versus retrosigmoid approach (p = 0.31 and p = 0.18, respectively); however, fewer complications were noted in the translabyrinthine approach (p = 0.29). Gross-total resection (GTR) was completed in 55.7% of surgeries. Studies that predominantly used subtotal resection (STR) were associated with a lower rate of facial nerve injury (5.3% vs 11.3%, p = 0.07) and higher rate of HB grade I or II (72.9% vs 48.0%, p = 0.00003) versus those using predominantly GTR. However, majority STR was associated with a recurrence rate of 3.6% as compared to 1.4% for majority GTR (p = 0.29).CONCLUSIONSThis study showed that the leading cause of MS after SRS was tumor growth at an average of 39.4 months after radiation. There were no significant differences in outcomes of facial nerve preservation, postoperative HB grade, or complication rate based on surgical approach. Patients who underwent STR showed statistically significant better HB outcomes compared with GTR. MS after SRS was considered by most authors to be more difficult than primary MS. These data support the notion that the surgical goals of salvage surgery are debulking of tumor mass, decreasing compression of the brainstem, and not necessarily pursuing GTR.

scholarly journals Fate of residual tumor after subtotal-resected, previously-irradiated vestibular schwannoma: Long-term follow-up of a single institutional series

2021 ◽  
Author(s):  
Joonho Byun ◽  
Sang Woo Song ◽  
Young-Hoon Kim ◽  
Chang Ki Hong ◽  
Jeong Hoon Kim
Keyword(s):  
Vestibular Schwannoma ◽  
Salvage Surgery ◽  
Residual Tumor ◽  
Cyst Formation ◽  
Subtotal Resection ◽  
Total Resection ◽  
Salvage Resection ◽  
Long Term Follow Up ◽  
History Of

Abstract Background The fate of residual tumor after salvage surgery for recurrent vestibular schwannoma (VS) after radiosurgery has not been elucidated. We reviewed our surgical series of salvage surgery for recurrent VS and the natural history of the residual tumor after salvage surgery. Methods This study enrolled 14 patients who were received salvage surgical resection in our institute and were followed-up for > 12 months. Results There were 3 male and 11 female patients with a median age of 55 years (range: 16–70). The pre-SRS tumor volume was a median 6591 mm3. All patients were treated by GKS. The median duration from GKS to surgery was 52 months (range: 10–116). Solid tumor growth was observed in 6 (42.9%) patients and cyst formation was observed in 8 patients (57.1%). Subtotal resection was performed in 13 (92.9%) patients and gross total resection was only achieved in one (7.1%) patient. Postoperative facial paresis occurred in 5 (35.7%) patients. Postoperative surgical complications occurred in 2 (14.3%) patients. After salvage resection for irradiated VS, no patient showed tumor progression or recurrence during the follow-up period (13 subtotal resection and 1 total resection). In addition, 2 patients in the subtotal resection group showed residual tumor shrinkage after salvage surgery during the follow-up period Conclusion The behavior of residual tumors after salvage surgery for irradiated VS was stable. Adjuvant treatment for these residual tumors may not be necessary.

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