An Evidence-Based Vestibular Schwannoma Surgical Outcome Grading Scale for Large-to-Giant Vestibular Schwannomas

Mapping Intimacies ◽

10.21203/rs.3.rs-1167597/v1 ◽

2021 ◽

Author(s):

Nida Fatima ◽

Gregory P. Lekovic

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Extent Of Resection ◽

Subtotal Resection ◽

Grading System ◽

Nerve Function ◽

Facial Nerve Function ◽

Total Resection ◽

Mesh Terms ◽

Large Vestibular Schwannoma

Abstract Objectives: The objective of this study was to determine the relationship between facial nerve function and extent of resection (EOR) as outcomes in the surgical management of large vestibular schwannoma (VS) (≥ 2.5 cm maximal) and evaluate use of a new grading system that incorporates both outcomes.Methods: We conducted a systematic review of the electronic databases using different MeSH terms from 1990 to 2021. 5,623 patients from 56 studies were found appropriate for inclusion in the study. Surgical approach was reported in 5,144 patients, including translabyrinthine approach (TL) in 43.3% (n=2,225), retrosigmoid (RS) approach in 56.3% (n=2,899), retrolabyrinthine (RL) approach in 0.3% (n=16), and extended translabyrinthine (EX) approach in 0.1% (n=4). The proposed VS Grading System defines outcomes of gross total resection (GTR), near total resection (NTR) and subtotal resection (STR) with good facial nerve function [House-Brackmann (HB) Grade I-II] as Classes A, B and C respectively. Those with poor facial nerve outcome (HB III-VI) are graded as Classes D, E and F, respectively. Results:. As expected, patients with STR had a higher likelihood of better facial nerve outcomes (HB I-II) compared to NTR [Odds Ratio (OR): 7.30, 95%CI: 2.45-12.1, p=0.004] and GTR (OR: 9.61, 95%CI: 3.61-15.6, p=0.002), while NTR had better facial nerve outcome than GTR (OR: 1.5, 95%CI: 1.14-4.6, p<0.0001). A Class A result, representing the best possible outcome, was obtained in 55.8% of TL vs. 49.4% undergoing RS approach. Conclusion: Complete surgical resection with preservation of facial nerve function is the gold standard for large VS.

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Predictive Factors of Early Postoperative and Long-Term Facial Nerve Function After Large Vestibular Schwannoma Surgery

World Neurosurgery ◽

10.1016/j.wneu.2019.03.218 ◽

2019 ◽

Vol 127 ◽

pp. e599-e608 ◽

Cited By ~ 5

Author(s):

Lucas Troude ◽

Mohamed Boucekine ◽

Marion Montava ◽

Jean-Pierre Lavieille ◽

Jean-Marie Régis ◽

...

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Predictive Factors ◽

Nerve Function ◽

Facial Nerve Function ◽

Large Vestibular Schwannoma

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Macrophage Density Predicts Facial Nerve Outcome and Tumor Growth after Subtotal Resection of Vestibular Schwannoma

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1627474 ◽

2018 ◽

Vol 79 (05) ◽

pp. 482-488

Author(s):

Christopher Graffeo ◽

Avital Perry ◽

Aditya Raghunathan ◽

Trynda Kroneman ◽

Mark Jentoft ◽

...

Keyword(s):

Tumor Growth ◽

Facial Nerve ◽

Tumor Progression ◽

Vestibular Schwannoma ◽

Subtotal Resection ◽

Nerve Function ◽

Facial Nerve Function ◽

Macrophage Density ◽

Primary Endpoints ◽

Percent Positivity

Introduction Vestibular schwannoma (VS) behavior following subtotal resection (STR) is highly variable. Overall progression rates have been reported as high as 44%, and optimal treatment is controversial. Correspondingly, identification of a reliable clinical or pathologic marker associated with progression after STR would help guide decision-making. Methods A prospectively maintained institutional VS registry from 1999 to 2014 was retrospectively reviewed for sporadic VS patients who underwent primary STR without preceding stereotactic radiosurgery (SRS) by a single neurosurgery-neurotology team. Primary endpoints included tumor progression and postoperative facial nerve function. Pathologic specimens were stained for Ki67, CD68, S100, and SOX10 and were quantitated by digital imaging analysis. Macrophage density was defined as the ratio of CD68+ macrophages to S100+ macrophages and Schwannian tumor cells. Clinical outcomes were correlated with pathologic markers. Results Forty-six patients met the study inclusion criteria. Thirteen (28%) progressed during a mean 57 months of follow-up (range 15–149). Favorable postoperative facial nerve function (House–Brackmann I–II) was achieved in 37 (80%). CD68+ cells were present at significantly higher concentrations in tumors that progressed (p = 0.03). Higher macrophage density was significantly associated with both tumor progression (p = 0.02) and unfavorable facial nerve function (p = 0.02). Ki67 percent positivity was not significantly associated with either primary endpoint (p = 0.83; p = 0.58). Conclusions Macrophage density may provide an important marker for individuals at the highest risk for progression of VS after STR, potentially prompting closer surveillance or consideration for upfront SRS following STR. This finding supports preceding conclusions that an intratumoral macrophage-predominant inflammatory response may be a marker for tumor growth and a potential therapeutic target.

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Retrosigmoid approach for giant cystic vestibular schwannoma: subperineural dissection technique for facial nerve preservation

Neurosurgical Focus: Video ◽

10.3171/2021.7.focvid21128 ◽

2021 ◽

Vol 5 (2) ◽

pp. V7

Author(s):

Ali Tayebi Meybodi ◽

Robert W. Jyung ◽

James K. Liu

Keyword(s):

Facial Nerve ◽

Thin Layer ◽

Vestibular Schwannoma ◽

Cranial Nerve ◽

Retrosigmoid Approach ◽

Nerve Function ◽

Facial Nerve Function ◽

Total Resection ◽

Nerve Preservation ◽

Dissection Technique

In this illustrative video, the authors demonstrate retrosigmoid resection of a giant cystic vestibular schwannoma using the subperineural dissection technique to preserve facial nerve function. This thin layer of perineurium arising from the vestibular nerves is used as a protective buffer to shield the facial and cochlear nerves from direct microdissection trauma. A near-total resection was achieved, and the patient had an immediate postoperative House-Brackmann grade I facial nerve function. The operative nuances and pearls of technique for safe cranial nerve and brainstem dissection, as well as the intraoperative decision and technique to leave the least amount of residual adherent tumor, are demonstrated. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21128

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Efficacy of facial nerve–sparing approach in patients with vestibular schwannomas

Journal of Neurosurgery ◽

10.3171/2011.7.jns101921 ◽

2011 ◽

Vol 115 (5) ◽

pp. 917-923 ◽

Cited By ~ 29

Author(s):

Raqeeb Haque ◽

Teresa J. Wojtasiewicz ◽

Paul R. Gigante ◽

Mark A. Attiah ◽

Brendan Huang ◽

...

Keyword(s):

Facial Nerve ◽

Residual Tumor ◽

Subtotal Resection ◽

Nerve Sparing ◽

Nerve Function ◽

Facial Nerve Function ◽

Total Resection ◽

Nerve Preservation ◽

Facial Nerve Preservation ◽

Microsurgical Resection

Object The goal of this article was to show that a combination of facial nerve–sparing microsurgical resection and Gamma Knife surgery (GKS) for expansion of any residual tumor can preserve good facial nerve function in patients with recurrent vestibular schwannoma (VS). Methods Records of individuals treated by a single surgeon with a facial nerve–sparing technique for a VS between 1998 and 2009 were retrospectively analyzed for tumor recurrence. Of the 383 patients treated for VS, 151 underwent microsurgical resection, and 20 (13.2%) of these patients required postoperative retreatment for a significant expansion of residual tumor after microsurgery. These 20 patients were re-treated with GKS. Results The rate of preservation of good facial nerve function (Grade I or II on the House-Brackmann scale) in patients treated with microsurgery for VS was 97%. Both subtotal and gross-total resection had excellent facial nerve preservation rates (97% vs 96%), although subtotal resection carried a higher risk that patients would require retreatment. In patients re-treated with GKS after microsurgery, the rate of facial nerve preservation was 95%. Conclusions In patients with tumors that cannot be managed with radiosurgery alone, a facial nerve–sparing resection followed by GKS for any significant regrowth provides excellent facial nerve preservation rates.

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A critical comparison between the semisitting and the supine positioning in vestibular schwannoma surgery: subgroup analysis of a randomized, multicenter trial

Journal of Neurosurgery ◽

10.3171/2019.1.jns181784 ◽

2020 ◽

Vol 133 (1) ◽

pp. 249-256 ◽

Cited By ~ 3

Author(s):

Christian Scheller ◽

Stefan Rampp ◽

Marcos Tatagiba ◽

Alireza Gharabaghi ◽

Kristofer F. Ramina ◽

...

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Supine Position ◽

Subgroup Analysis ◽

Patient Positioning ◽

Extent Of Resection ◽

Multicenter Trial ◽

Nerve Function ◽

Facial Nerve Function ◽

Postoperative Course

OBJECTIVEPatient positioning in vestibular schwannoma (VS) surgery is a matter of ongoing discussion. Factors to consider include preservation of cranial nerve functions, extent of tumor resection, and complications. The objective of this study was to determine the optimal patient positioning in VS surgery.METHODSA subgroup analysis of a randomized, multicenter trial that investigated the efficacy of prophylactic nimodipine in VS surgery was performed to investigate the impact of positioning (semisitting or supine) on extent of resection, functional outcomes, and complications. The data of 97 patients were collected prospectively. All procedures were performed via a retrosigmoid approach. The semisitting position was chosen in 56 patients, whereas 41 patients were treated while supine.RESULTSComplete resection was obtained at a higher percentage in the semisitting as compared to the supine position (93% vs 73%, p = 0.002). Logistic regression analysis revealed significantly better facial nerve function in the early postoperative course in the semisitting group (p = 0.004), particularly concerning severe facial nerve paresis (House-Brackmann grade IV or worse; p = 0.002). One year after surgery, facial nerve function recovered. However, there was still a tendency for better facial nerve function in the semisitting group (p = 0.091). There were no significant differences between groups regarding hearing preservation rates. Venous air embolism with the necessity to terminate surgery occurred in 2 patients in the semisitting position (3.6%). Supplementary analysis with a 2-tailed permutation randomization with 10,000 permutations of treatment choice and a propensity score matching showed either a tendency or significant results for better facial nerve outcomes in the early postoperative course and extent of resection in the semisitting group.CONCLUSIONSAlthough the results of the various statistical analyses are not uniform, the data indicate better results concerning both a higher rate of complete removal (according to the intraoperative impression of the surgeon) and facial nerve function after a semisitting as compared to the supine position. These advantages may justify the potential higher risk for severe complications of the semisitting position in VS surgery. The choice of positioning has to consider all individual patient parameters and risks carefully.

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Predominance of M1 subtype among tumor-associated macrophages in phenotypically aggressive sporadic vestibular schwannoma

Journal of Neurosurgery ◽

10.3171/2019.7.jns19879 ◽

2020 ◽

Vol 133 (6) ◽

pp. 1637-1645 ◽

Cited By ~ 5

Author(s):

Avital Perry ◽

Christopher S. Graffeo ◽

Lucas P. Carlstrom ◽

Aditya Raghunathan ◽

Colin L. W. Driscoll ◽

...

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Immunohistochemical Analysis ◽

Tumor Control ◽

Subtotal Resection ◽

Nerve Function ◽

Facial Nerve Function ◽

Tumor Associated Macrophages ◽

Clinical Endpoints ◽

Percent Positivity

OBJECTIVETumor-associated macrophages (TAMs) have been implicated as pathologic actors in phenotypically aggressive vestibular schwannoma (VS), potentially mediated via programmed death-ligand 1 (PD-L1). The authors hypothesized that PD-L1 is a key regulator of the VS immune microenvironment.METHODSForty-six consecutive, radiation-naïve, sporadic VSs that were subtotally resected at primary surgery were assessed via immunohistochemical analysis, including analysis of CD163 and PD-L1 expression. Pathologic data were correlated with clinical endpoints, including tumor control, facial nerve function, and complications.RESULTSBaseline parameters were equivalent between stable and progressive post–subtotal resection (STR) VS. CD163 percent positivity and M2 index were significantly increased among tumors that remained stable (34% vs 21%, p = 0.02; 1.13 vs 0.99, p = 0.0008), as well as patients with favorable House-Brackmann grade I or II facial nerve function (31% vs 13%, p = 0.04; 1.11 vs 0.97, p = 0.05). PD-L1 percent positivity was significantly associated with tumor progression (1% vs 11%, p = 0.01) and unfavorable House-Brackmann grade III–VI facial nerve function (1% vs 38%, p = 0.02). On multivariate analysis, PD-L1 was independently significant in all models (likelihood ratio 4.4, p = 0.04), while CD163 was dependent in all iterations.CONCLUSIONSIn contrast to prior reports, in this study, the authors observed significantly increased levels of M1, CD163+ TAMs in association with VS that progressed after STR. Progressive tumors are characterized by increased PD-L1, potentially highlighting a mechanism of immune evasion that results in TAM deactivation, tumor growth, and further infiltration of anti-tumor immune cells. Targeting PD-1/PD-L1 may offer therapeutic promise, particularly in the setting of disease control after STR.

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Management of large vestibular schwannoma. Part I. Planned subtotal resection followed by Gamma Knife surgery: radiological and clinical aspects

Journal of Neurosurgery ◽

10.3171/2011.6.jns101958 ◽

2011 ◽

Vol 115 (5) ◽

pp. 875-884 ◽

Cited By ~ 66

Author(s):

Rick van de Langenberg ◽

Patrick E. J. Hanssens ◽

Jacobus J. van Overbeeke ◽

Jeroen B. Verheul ◽

Patty J. Nelemans ◽

...

Keyword(s):

Facial Nerve ◽

Gamma Knife ◽

Treatment Option ◽

Growth Control ◽

Complete Resection ◽

Subtotal Resection ◽

Nerve Function ◽

Facial Nerve Function ◽

Large Vestibular Schwannoma

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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