Defining clinically significant tumor size in vestibular schwannoma to inform timing of microsurgery during wait-and-scan management: moving beyond minimum detectable growth

2021 ◽  
pp. 1-9
Author(s):  
Robert J. Macielak ◽  
Katherine P. Wallerius ◽  
Skye K. Lawlor ◽  
Christine M. Lohse ◽  
John P. Marinelli ◽  
...  
Keyword(s):  
Tumor Growth ◽  
Facial Nerve ◽  
Tumor Size ◽  
Optimal Size ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Class A ◽  
Microsurgical Resection ◽  
Size Threshold ◽  
Serial Mri

OBJECTIVE Detection of vestibular schwannoma (VS) growth during observation leads to definitive treatment at most centers globally. Although ≥ 2 mm represents an established benchmark of tumor growth on serial MRI studies, 2 mm of linear tumor growth is unlikely to significantly alter microsurgical outcomes. The objective of the current work was to ascertain where the magnitude of change in clinical outcome is the greatest based on size. METHODS A single-institution retrospective review of a consecutive series of patients with sporadic VS who underwent microsurgical resection between January 2000 and May 2020 was performed. Preoperative tumor size cutpoints were defined in 1-mm increments and used to identify optimal size thresholds for three primary outcomes: 1) the ability to achieve gross-total resection (GTR); 2) maintenance of normal House-Brackmann (HB) grade I facial nerve function; and 3) preservation of serviceable hearing (American Academy of Otolaryngology–Head and Neck Surgery class A/B). Optimal size thresholds were obtained by maximizing c-indices from logistic regression models. RESULTS Of 603 patients meeting inclusion criteria, 502 (83%) had tumors with cerebellopontine angle (CPA) extension. CPA tumor size was significantly associated with achieving GTR, postoperative HB grade I facial nerve function, and maintenance of serviceable hearing (all p < 0.001). The optimal tumor size threshold to distinguish between GTR and less than GTR was 17 mm of CPA extension (c-index 0.73). In the immediate postoperative period, the size threshold between HB grade I and HB grade > I was 17 mm of CPA extension (c-index 0.65). At the most recent evaluation, the size threshold between HB grade I and HB grade > I was 23 mm (c-index 0.68) and between class A/B and C/D hearing was 18 mm (c-index 0.68). Tumors within 3 mm of the 17-mm CPA threshold displayed similarly strong c-indices. Among purely intracanalicular tumors, linear size was not found to portend worse outcomes for all measures. CONCLUSIONS The probability of incurring less optimal microsurgical outcomes begins to significantly increase at 14–20 mm of CPA extension. Although many factors ultimately influence decision-making, when considering timing of microsurgical resection, using a size threshold range as depicted in this study offers an evidence-based approach that moves beyond reflexively recommending treatment for all tumors after detecting ≥ 2 mm of tumor growth on serial MRI studies.

Middle Fossa Approach for Resection of Vestibular Schwannomas: A Decade of Experience

2018 ◽  
Vol 16 (2) ◽  
pp. 147-158 ◽  
Author(s):  
Jennifer A Kosty ◽  
Shawn M Stevens ◽  
Yair M Gozal ◽  
Vincent A DiNapoli ◽  
Smruti K Patel ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Tumor Size ◽  
Pure Tone ◽  
Vestibular Schwannomas ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Pure Tone Average ◽  
Class A ◽  
The Mean

AbstractBACKGROUNDThe middle cranial fossa (MCF) approach is a challenging surgical technique for the resection of small and intermediate sized, primarily intracanalicular, vestibular schwannomas (VS), with the goal of hearing preservation (HP).OBJECTIVETo describe a decade-long, single institutional experience with the MCF approach for resection of VS.METHODSThis is a retrospective cohort study of 63 patients who underwent the MCF approach for resection of VS from 2006 to 2016. Audiometric data included pure-tone average (PTA), low-tone pure-tone average (LtPTA), word recognition score, and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification at presentation and follow-up. Patients with postoperative serviceable (AAO-HNS class A-B) and/or useful (AAO-HNS class A-C) hearing were compared to those without HP. Facial nerve function was assessed using the House–Brackmann scale.RESULTSThe mean age and duration of follow-up were 50 ± 13 yr and 21 ± 21 mo, respectively. The mean tumor size was 10 ± 4 mm. The serviceable and usable HP rates were 54% and 50%, respectively. Some residual hearing was preserved in 71% of patients. Large tumor size (P = .05), volume (P = .03), and extrameatal tumor extension (P = .03) were associated with poor audiometric outcomes. The presence of a fundal fluid cap (P = .01) was a favorable finding. At definitive testing, LtPTA was significantly better preserved than traditional PTA (P = .01). Facial nerve outcomes, tumor control rates, and durability of audiometric outcomes were excellent. 47% of patients pursued aural rehabilitation.CONCLUSIONIn our series, the MCF approach for VS provided excellent rates of tumor and facial nerve function, with durable serviceable HP.

Facial nerve function after vestibular schwannoma surgery

2011 ◽  
Vol 115 (4) ◽  
pp. 820-826 ◽  
Author(s):  
Maurizio Falcioni ◽  
Paolo Fois ◽  
Abdelkader Taibah ◽  
Mario Sanna
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Tumor Size ◽  
Middle Cranial Fossa ◽  
Optimal Size ◽  
Tumor Diameter ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Tumor Removal ◽  
Total Tumor Removal

Object The object of this study was to evaluate long-term postoperative facial nerve (FN) function in patients undergoing vestibular schwannoma (VS) surgery. Methods The authors retrospectively reviewed the clinical course of patients affected by isolated VSs with normal preoperative FN function, with no previous surgical or radiotherapeutic treatment, and who underwent surgery between 1987 and 2007. Facial nerve function was clinically evaluated according to the House-Brackmann (HB) scale. The minimum postoperative follow-up was 12 months. Results Among the 1550 patients surgically treated at the authors' center, 1151 matched inclusion criteria for the present study. The FN was anatomically interrupted in 48 cases (4.2%), and 51 patients (4.4%) underwent subtotal tumor removal and were considered separately. Among the 1052 patients with anatomically preserved FNs and total tumor removal, 684 (65%) enjoyed postoperative HB Grade I or II and 309 (29.4%) enjoyed Grade III, with the remaining 59 cases (5.6%) suffering unsatisfactory results (HB Grades IV–VI). As expected, FN function results deteriorated in cases of larger tumors. Conclusions The main factor influencing postoperative FN function was tumor size. Although there was a progressive deterioration in FN function outcome in relation to tumor size, a cutoff point between satisfactory and unsatisfactory results could be identified at around 2 cm in maximum extrameatal tumor diameter, with the “optimal size” for surgery identified at < 1 cm. This finding emphasizes the importance of an early diagnosis and should be kept in mind when selecting the correct timing for VS removal. For small lesions, the results following a middle cranial fossa approach were significantly worse as compared with those following the translabyrinthine and retrosigmoidretrolabyrinthine approaches.

Sporadic unilateral vestibular schwannoma in the pediatric population

2009 ◽  
Vol 4 (2) ◽  
pp. 125-129 ◽  
Author(s):  
Brian P. Walcott ◽  
Ganesh Sivarajan ◽  
Bronislava Bashinskaya ◽  
Douglas E. Anderson ◽  
John P. Leonetti ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Tumor Size ◽  
Pediatric Population ◽  
Neurofibromatosis Type ◽  
Neurofibromatosis Type 2 ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Duration Of Symptoms

Object Vestibular schwannomas (VSs) are rare in the pediatric population. Most often, these lesions manifest as a bilateral disease process in the setting of neurofibromatosis Type 2. Even in the absence of additional clinical diagnostic criteria, the presentation of a unilateral VS in a young patient may be a harbinger of future penetrance for this hereditary tumor syndrome. Methods The authors retrospectively reviewed the charts of a cohort of 7 patients who presented with apparently sporadic, unilateral VSs. These patients had previously undergone surgery via translabyrinthine, retrosigmoid, or combined approaches. Clinical outcomes were reviewed with emphasis on facial nerve function and follow-up for signs and symptoms of a heritable disorder. Results All patients underwent microsurgical resection in a multidisciplinary effort by the senior authors. The average tumor size was 4.57 cm, with an average duration of symptoms prior to definitive diagnosis of 31.2 months. The tumor size at the time of presentation followed a trend different from reports in adults, while the duration of symptoms did not. At a follow-up average of 6.3 years (range 1–12 years), 100% of patients demonstrated good facial function (House-Brackmann Grade I or II). No patient in this cohort demonstrated symptoms, objective signs, or genetic analysis indicating the presence of neurofibromatosis Type 2. Conclusions Diagnosis and management of sporadic, unilateral VSs in children is complicated by clinical presentations and surgical challenges unique from their adult counterparts. Careful consideration should be given to a heritable genetic basis for sporadic unilateral VS in the pediatric population. Results of genetic testing do not preclude the necessity for long-term follow-up and systemic investigation. In patients who present with large tumors, preliminary experience leads the authors to suggest that a combined retrosigmoid-translabyrinthine approach offers the greatest opportunity for preservation of facial nerve function.

scholarly journals Long-Term Facial Nerve Outcomes after Microsurgical Resection of Vestibular Schwannomas in Patients with Preoperative Facial Nerve Palsy

2017 ◽  
Vol 79 (03) ◽  
pp. 309-313 ◽  
Author(s):  
Michael Mooney ◽  
Benjamin Hendricks ◽  
Christina Sarris ◽  
Robert Spetzler ◽  
Randall Porter ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Nerve Palsy ◽  
Facial Nerve Palsy ◽  
Tumor Diameter ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Microsurgical Resection ◽  
Grade Iii

Objectives This study aimed at evaluating facial nerve outcomes in vestibular schwannoma patients presenting with preoperative facial nerve palsy. Design A retrospective review. Setting Single-institution cohort. Participants Overall, 368 consecutive patients underwent vestibular schwannoma resection. Patients with prior microsurgery or radiosurgery were excluded. Main Outcome Measures Incidence, House–Brackmann grade. Results Of 368 patients, 9 had confirmed preoperative facial nerve dysfunction not caused by prior treatment, for an estimated incidence of 2.4%. Seven of these nine patients had Koos grade 4 tumors. Mean tumor diameter was 3.0 cm (range: 2.1–4.4 cm), and seven of nine tumors were subtotally resected. All nine patients were followed up clinically for ≥ 6 months. Of the six patients with a preoperative House–Brackmann grade of II, two improved to grade I, three were stable, and one patient worsened to grade III. Of the three patients with grade III or worse, all remained stable at last follow-up. Conclusions Preoperative facial nerve palsy is rare in patients with vestibular schwannoma; it tends to occur in patients with relatively large lesions. Detailed long-term outcomes of facial nerve function after microsurgical resection for these patients have not been reported previously. We followed nine patients and found that eight (89%) of the nine patients had either stable or improved facial nerve outcomes after treatment. Management strategies varied for these patients, including rates of subtotal versus gross-total resection and the use of stereotactic radiosurgery in patients with residual tumor. These results can be used to help counsel patients preoperatively on expected outcomes of facial nerve function after treatment.

Medial acoustic neuromas: clinical and surgical implications

2014 ◽  
Vol 120 (5) ◽  
pp. 1095-1104 ◽  
Author(s):  
Ian F. Dunn ◽  
Wenya Linda Bi ◽  
Kadir Erkmen ◽  
Paulo A. S. Kadri ◽  
David Hasan ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Growth Patterns ◽  
Maximum Diameter ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Class A ◽  
Acoustic Neuromas ◽  
Facial Function

Object Medial acoustic neuroma is a rare entity that confers a distinct clinical syndrome. It is scarcely discussed in the literature and is associated with adverse features. This study evaluates the clinical and imaging features, pertinent surgical challenges, and treatment outcome in a large series of this variant. The authors postulate that the particular pathological anatomy with its arachnoidal rearrangement has a profound implication on the surgical technique and outcome. Methods The authors conducted a retrospective analysis of 52 cases involving 33 women and 19 men who underwent resection of medial acoustic neuromas performed by the senior author (O.A.) over a 20-year period (1993–2013). Clinical, radiological, and operative records were reviewed, with a specific focus on the neurological outcomes and facial nerve function and hearing preservation. Intraoperative findings were analyzed with respect to the effect of arachnoidal arrangement on the surgeon's ability to resect the lesion and the impact on postoperative function. Results The average tumor size was 34.5 mm (maximum diameter), with over 90% of tumors being 25 mm or larger and 71% being cystic. Cerebellar, trigeminal nerve, and facial nerve dysfunction were common preoperative findings. Hydrocephalus was present in 11 patients. Distinguishing intraoperative findings included marked tumor adherence to the brainstem and frequent hypervascularity, which prompted intracapsular dissection resulting in enhancement on postoperative MRI in 18 cases, with only 3 demonstrating growth on follow-up. There was no mortality or major postoperative neurological deficit. Cerebrospinal fluid leak was encountered in 7 patients, with 4 requiring surgical repair. Among 45 patients who had intact preoperative facial function, only 1 had permanent facial nerve paralysis on extended follow-up. Of the patients with preoperative Grade I–II facial function, 87% continued to have Grade I–II function on follow-up. Of 10 patients who had Class A hearing preoperatively, 5 continued to have Class A or B hearing after surgery. Conclusions Medial acoustic neuromas represent a rare subgroup whose site of origin and growth patterns produce a distinct clinical presentation and present specific operative challenges. They reach giant size and are frequently cystic and hypervascular. Their origin and growth pattern lead to arachnoidal rearrangement with marked adherence against the brainstem, which is critical in the surgical management. Excellent surgical outcome is achievable with a high rate of facial nerve function and attainable hearing preservation. These results suggest that similar or better results may be achieved in less complex tumors.

Hearing preservation surgery for vestibular schwannoma: experience with the middle fossa approach

2012 ◽  
Vol 33 (3) ◽  
pp. E10 ◽  
Author(s):  
Franco DeMonte ◽  
Paul W. Gidley
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Nerve Function ◽  
Middle Fossa ◽  
Facial Nerve Function ◽  
Middle Fossa Approach ◽  
Class A ◽  
Csf Leakage ◽  
Class B ◽  
Class C

Object In the early 1960s William F. House developed the middle fossa approach for the removal of small vestibular schwannomas (VSs) with the preservation of hearing. It is the best approach for tumors that extend laterally to the fundus of the internal auditory canal, although it does have the potential disadvantage of increased facial nerve manipulation, especially for tumors arising from the inferior vestibular nerve. The aim of this study was to monitor the hearing preservation and facial nerve outcomes of this approach. Methods A prospective database was constructed, and data were retrospectively reviewed. Results Between December 2004 and January 2012, 30 patients with small VSs underwent surgery via a middle fossa approach for hearing preservation. The patients consisted of 13 men and 17 women with a mean age of 46 years. Tumor size ranged from 7 to 19 mm. Gross-total resection was accomplished in 25 of 30 patients. Preoperative hearing was American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Class A in 21 patients, Class B in 5, Class C in 3, and undocumented in 1. Postoperatively, hearing was graded as AAO-HNS Class A in 15 patients, Class B in 7, Class C in 1, Class D in 2, and undocumented in 5. Facial nerve function was House-Brackmann (HB) Grade I in all patients preoperatively. Postoperatively, facial nerve function was HB Grade I in 28 patients, Grade III in 1, and Grade IV in 1. There were 3 complications: CSF leakage in 1 patient, superficial wound infection in 1, and extradural hematoma (asymptomatic) in 1. The overall hearing preservation rate of at least 73% and HB Grade I facial nerve outcome of 93% in this cohort are in keeping with other contemporary reports. Conclusions The middle fossa approach for the resection of small VSs with hearing preservation is a viable and relatively safe option. It should be considered among the various options available for the management of small, growing VSs.

Durability of hearing preservation after microsurgical treatment of vestibular schwannoma using the middle cranial fossa approach

2013 ◽  
Vol 119 (1) ◽  
pp. 131-138 ◽  
Author(s):  
Anthony C. Wang ◽  
Steven B. Chinn ◽  
Khoi D. Than ◽  
H. Alexander Arts ◽  
Steven A. Telian ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Middle Cranial Fossa ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Class A ◽  
Class D ◽  
Class B ◽  
Class C

Object The middle cranial fossa (MCF) approach is a microsurgical technique described as a primary option in the treatment of small, intracanalicular schwannomas involving the eighth cranial nerve. Excellent rates of complete tumor resection, hearing preservation, preservation of facial nerve function, and low complication rates have been reproduced using this technique. However, the durability of hearing preservation attained using the various treatment options has not been adequately assessed. The purpose of this study was to evaluate the durability of long-term hearing preservation in patients with vestibular schwannoma (VS) treated via the MCF approach. The authors hypothesize that hearing preservation in these patients will prove to be durable years after treatment in a high percentage of cases. Methods Retrospective medical chart review was performed in 103 consecutive patients undergoing resection of VS via a modified MCF approach between 1999 and 2008. Patients in whom surgical goals were gross-total resection and hearing preservation were included. Preoperative and postoperative hearing assessment was performed using standard audiometric testing, and classified according to American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) guidelines as a primary outcome measure. Outcomes and neurological complications initially, and at 1, 3, and 5 years following operation were analyzed. Results Initial hearing preservation rates were in keeping with the best previously published results. At initial postoperative audiometric follow-up, of the patients presenting with Class A hearing, 67% remained Class A, 17% were Class B, 1% were Class C, and 15% were Class D. Of patients presenting with Class B hearing, 24% were Class A, 53% remained Class B, 6% were Class C, and 18% were Class D. Of patients presenting with Class C hearing, 100% remained Class C. To assess the durability of hearing preservation in our patients, the authors evaluated hearing function at regular intervals after the initial postoperative audiometric follow-up. Audiometric data were available for 56 patients at 5-year follow-up. Of the 20 patients with Class A hearing at initial postoperative follow-up with 5-year follow-up, 13 (65%) remained Class A, 6 (30%) were Class B, and 1 (5%) was Class C. Of the 12 patients with Class B hearing at initial postoperative follow-up with 5-year follow-up, 4 (33%) were Class A, 4 (33%) remained Class B, and 4 (33%) were Class C. Of the 3 patients with Class C hearing at initial postoperative follow-up with 5-year follow-up, all 3 (100%) remained Class C. Conclusions A majority of patients with preserved hearing following the MCF approach for treatment of VS experience durability of their preserved hearing at 5-year follow-up. The initial AAO-HNS classification was preserved in 13 (65%) of the 20 patients who had Class A hearing at 5 years, and in 8 (67%) of the 12 who had Class B hearing at 5 years. Overall, a decline in AAO-HNS classification was noted in 15% of patients with preserved Class A hearing, and in 33% of those with preserved Class B hearing. Facial nerve function was preserved in 91% of cases. Superior hearing preservation as well as good outcomes in facial nerve function and few serious complications can be accomplished using the MCF approach for resection of small VSs.

A Multifactorial Analysis of Facial Nerve Results in Surgery for Cerebellopontine Angle Tumors

1997 ◽  
Vol 76 (1) ◽  
pp. 37-40 ◽  
Author(s):  
Alan J. Nissen ◽  
Ashley Sikand ◽  
Joseph E. Welsh ◽  
Frank S. Curto ◽  
John Gardi
Keyword(s):  
Facial Nerve ◽  
Surgical Approach ◽  
Tumor Size ◽  
Tumor Resection ◽  
Outcome Data ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Nerve Monitoring ◽  
Use Of Data ◽  
Facial Nerve Monitoring

Preserving the function of the facial nerve remains a paramount objective in acoustic neuroma surgery. This study was undertaken to determine the influence of four independent variables on facial nerve outcome by means of a retrospective review of 111 surgical cases: 1) tumor size; 2) use of intraoperative facial nerve monitoring (IFNM); 3) completeness of tumor resection; and 4) surgical approach used. Partial tumor resection appeared to result in improved facial nerve outcome for patients with large tumors. Results indicated that tumor size did not correlate with facial nerve functional outcome, with no statistically significant differences observed among the three size categories. Facial nerve function was not found to depend on selection of either a translabyrinthine (n=47) or a suboccipital (n—55) surgical approach in that results were similar for both groups. Outcome data showed a trend in support of the use of IFNM, especially for large tumors, even though the differences between monitored and unmonitored groups were not statistically significant. This study describes the independent impact of the four factors generally thought to affect facial nerve outcome and, in addition, recommends the use of data stratification in reporting facial nerve function results.

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