A Paradigm Shift in Salvage Surgery for Radiated Vestibular Schwannoma

Friedman, Rick A.; Berliner, Karen I.; Bassim, Marc K.; Ursick, Joseph A; Slattery, William H.; Schwartz, Marc S.; Brackmann, Derald E.

doi:10.1097/mao.0b013e31822e5b76

Cited by 41 publications

(39 citation statements)

References 21 publications

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“…With RS, the size limitations are generally recommended to be around 1.5-3 cm, with a known increase in side effects to normal tissue with increasing size [35,36]. Besides size, dose has a significant impact on toxicity, with common recommendations aiming at surrounding doses of 10-13 Gy [13][14][15]17,28,[37][38][39]. Hypofracionated concepts have also been followed, however, only smaller series are available with this concept.…”

Section: Discussionmentioning

confidence: 96%

“…Preservation of hearing as well as cranial nerve function are a main advantage of highly conformal RT alternatives. With radiosurgery (RS), applying the dose in a single fraction, hearing preservation is commonly between 50 and 80% with modern RS techniques and marginal doses limited to 13 Gy [12][13][14][15][16][17][18][19][20][21][22]. Yet, single-dose approaches are limited by tumor size, with increasing rates of side effects not only with dose, but with volume.…”

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confidence: 99%

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Long-term outcome after highly advanced single-dose or fractionated radiotherapy in patients with vestibular schwannomas – Pooled results from 3 large German centers

Combs

Engelhard

Kopp

et al. 2015

Radiotherapy and Oncology

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Section: Discussionmentioning

confidence: 96%

mentioning

confidence: 99%

Long-term outcome after highly advanced single-dose or fractionated radiotherapy in patients with vestibular schwannomas – Pooled results from 3 large German centers

Combs

Engelhard

Kopp

et al. 2015

Radiotherapy and Oncology

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“…For this reason, many studies have advocated partial resections, 2-stage resections, and combined partial resection with radiation therapy. 3,17,40,42 Moreover, questions remain regarding the surgical approach that provides the optimal facial nerve outcome.…”

mentioning

confidence: 99%

Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

Gurgel

Doğru

Amdur³

et al. 2012

FOC

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Object The object of this study was to evaluate facial nerve outcomes in the surgical treatment of large vestibular schwannomas (VSs; ≥ 2.5 cm maximal or extrameatal cerebellopontine angle diameter) based on both the operative approach and extent of tumor resection. Methods A PubMed search was conducted of English language studies on the treatment of large VSs published from 1985 to 2011. Studies were then evaluated and included if they contained data regarding the size of the tumor, surgical approach, extent of resection, and postoperative facial nerve function. Results Of the 536 studies initially screened, 59 full-text articles were assessed for eligibility, and 30 studies were included for analysis. A total of 1688 tumor resections were reported. Surgical approach was reported in 1390 patients and was significantly associated with facial nerve outcome (ϕ= 0.29, p < 0.0001). Good facial nerve outcomes (House-Brackmann Grade I or II) were produced in 62.5% of the 555 translabyrinthine approaches, 65.2% of the 601 retrosigmoid approaches, and 27.4% of the 234 extended translabyrinthine approaches. Facial nerve outcomes from translabyrinthine and retrosigmoid approaches were not significantly different from each other, but both showed significantly more good facial nerve outcomes, compared with the extended translabyrinthine approach (OR for translabyrinthine vs extended translabyrinthine = 4.43, 95% CI 3.17–6.19, p < 0.0001; OR for retrosigmoid vs extended translabyrinthine = 4.98, 95% CI 3.57–6.95, p < 0.0001). There were 471 patients for whom extent of resection was reported. There was a strong and significant association between degree of resection and outcome (ϕ= 0.38, p < 0.0001). Of the 80 patients receiving subtotal resections, 92.5% had good facial nerve outcomes, compared with 74.6% (n = 55) and 47.3% (n = 336) of those who received near-total resections and gross-total resections, respectively. In the 2-way comparison of good versus suboptimal/poor outcomes (House-Brackmann Grade III–VI), subtotal resection was significantly better than near-total resection (OR = 4.21, 95% CI 1.50–11.79; p = 0.004), and near-total resection was significantly better than gross-total resection (OR = 3.26, 95% CI 1.71–6.20; p = 0.0002) in producing better facial nerve outcomes. Conclusions In a pooled patient population from studies evaluating the treatment of large VSs, subtotal and near-total resections were shown to produce better facial nerve outcomes when compared with gross-total resections. The translabyrinthine and retrosigmoid surgical approaches are likely to result in similar rates of good facial nerve outcomes. Both of these approaches show better facial nerve outcomes when compared with the extended translabyrinthine approach, which is typically reserved for especially large tumors. The reported literature on treatment of large VSs is extremely heterogeneous and minimal consistency in reporting outcomes was observed.

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“…Persistent, sequential tumor growth, not to be confused with pseudo-progression, following radiation treatment may require either additional radiation treatment or microsurgical excision. Surgical excision following STR is more challenging due to changes in tumor texture and vascularity and increased adherence/ scarring to the FN resulting in sub-total tumor extirpation to optimize FN outcomes [58].…”

Section: Complicationsmentioning

confidence: 99%

Vestibular Schwannomas: Surgical and Nonsurgical Management

2015

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Management options of vestibular schwannomas continue to evolve as surgical, radiation, and radiologic imaging techniques and technology change and improve over time. Currently, three options for these tumors exist and include primary surgical extirpation, stereotactic radiation, and observation with serial imaging. Skull base surgeons are charged with providing the patient with a comprehensive discussion of each option based on the inherit risks and benefits of each option to craft a management plan based on numerous factors that include age, tumor location, and size, hearing level at presentation and any medical comorbidities that may influence functional outcomes and quality of life. The purpose of this article was to review the surgical and non-surgical approaches to tumor management highlighting the risks and benefits and ongoing controversies between modalities regarding optimal functional outcomes. A particular emphasis is placed on hearing preservation and facial nerve function after treatment.

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A Paradigm Shift in Salvage Surgery for Radiated Vestibular Schwannoma

Abstract: Failed radiosurgery is an increasing indication for salvage surgery in patients with posterior fossa tumors. A conservative approach with a willingness to perform partial and near-total tumor removals leads to better facial nerve outcomes with no current evidence of treatment compromise.

Cited by 41 publications

References 21 publications

Long-term outcome after highly advanced single-dose or fractionated radiotherapy in patients with vestibular schwannomas – Pooled results from 3 large German centers

Long-term outcome after highly advanced single-dose or fractionated radiotherapy in patients with vestibular schwannomas – Pooled results from 3 large German centers

Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

Vestibular Schwannomas: Surgical and Nonsurgical Management

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