Extent of resection and the long-term durability of vestibular schwannoma surgery

Sughrue, Michael E.; Kaur, Ramandeep; Rutkowski, Martin J.; Kane, Ari J.; Kaur, Gurvinder; Yang, Isaac; Pitts, Lawrence H.; Parsa, Andrew T.

doi:10.3171/2010.11.jns10257

Cited by 88 publications

(72 citation statements)

References 16 publications

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“…30 Staging the tumor resection was decided intraoperatively if there was cerebellar or The extent of resection is another important factor, with several studies demonstrating significantly lower rates of recurrence with complete or near-complete resections compared with subtotal or partial debulking. 7,40 For patients with partial or subtotal tumor resection, residual tumor thickness (7 mm or thicker) on postoperative MRI and the MIB-1 index are important predictors of regrowth. 12 In this series, comparable facial nerve preservation rates, greater tumor resection rates, lower surgical morbidity rates, and long-term tumor control were achieved without the need for a standard craniotomy or craniectomy, or a second operation.…”

Section: Discussionmentioning

confidence: 99%

Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes

Hoshide

Faulkner

Teo³

et al. 2018

Neurosurgical Focus

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OBJECTIVEThere are numerous treatment strategies in the management for large vestibular schwannomas, including resection only, staged resections, resections followed by radiosurgery, and radiosurgery only. Recent evidence has pointed toward maximal resection as being the optimum strategy to prevent tumor recurrence; however, durable tumor control through aggressive resection has been shown to occur at the expense of facial nerve function and to risk other approach-related complications. Through a retrospective analysis of their single-institution series of keyhole neurosurgical approaches for large vestibular schwannomas, the authors aim to report and justify key techniques to maximize tumor resection and reduce surgical morbidity.METHODSA retrospective chart review was performed at the Centre for Minimally Invasive Neurosurgery. All patients who had undergone a keyhole retrosigmoid approach for the resection of large vestibular schwannomas, defined as having a tumor diameter of ≥ 3.0 cm, were included in this review. Patient demographics, preoperative cranial nerve status, perioperative data, and postoperative follow-up were obtained. A review of the literature for resections of large vestibular schwannomas was also performed. The authors’ institutional data were compared with the historical data from the literature.RESULTSBetween 2004 and 2017, 45 patients met the inclusion criteria for this retrospective chart review. When compared with findings in a historical cohort in the literature, the authors’ minimally invasive, keyhole retrosigmoid technique for the resection of large vestibular schwannomas achieved higher rates of gross-total or near-total resection (100% vs 83%). Moreover, these results compare favorably with the literature in facial nerve preservation (House-Brackmann I–II) at follow-up after gross-total resections (81% vs 47%, p < 0.001) and near-total resections (88% vs 75%, p = 0.028). There were no approach-related complications in this series.CONCLUSIONSIt is the experience of the senior author that complete or near-complete resection of large vestibular schwannomas can be successfully achieved via a keyhole approach. In this series of 45 large vestibular schwannomas, a greater extent of resection was achieved while demonstrating high rates of facial nerve preservation and low approach-related and postoperative complications compared with the literature.

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Section: Discussionmentioning

confidence: 99%

Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes

Hoshide

Faulkner

Teo³

et al. 2018

Neurosurgical Focus

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“…7,13,20,22 The recurrence rate of VS has been shown to be 2.6%-11.0% after gross-total resection, and 20%-50% of VS tumors progress after subtotal resection. 1,2,12,19,20,22,24,25,26,28 Since the development of the Gamma Knife (GK) technology, stereotactic radiosurgery (SRS) has become an increasingly used alternative or adjuvant VS management tool that eliminates many risks associated with resection.14,23 Initial SRS for VS has improved hearing retention rates in 60%-90% of patients and reduced facial neuropa-ABBREVIATIONS GK = Gamma Knife; G-R = Gardner-Robertson; HB = House-Brackmann; QOL = quality of life; SRS = stereotactic radiosurgery; VS = vestibular schwannoma. The Center for Image-Guided Neurosurgery and the Departments of 1 Neurological Surgery and 2 Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania OBJECTIVE The goal of this retrospective cohort study was to assess long-term outcomes in patients with vestibular schwannoma (VS) who underwent stereotactic radiosurgery (SRS) after initial microsurgical resection.…”

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confidence: 99%

Stereotactic radiosurgery for recurrent vestibular schwannoma after previous resection

Huang

Kano

Mousavi

et al. 2017

Journal of Neurosurgery

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V estibular schwannomas (VSs), also known as acoustic neuromas, are benign primary intracranial tumors that arise from the Schwann cells of the vestibulocochlear nerve. The incidence of VS is estimated to be 1 per 100,000 individuals per year, and it accounts for approximately 8% of all intracranial tumors in adults. 3,14 These tumors are typically slow growing (0-3.9 mm per year), but without management, most VS tumors will grow within 3 years. 4,6,14,15,18,20 For many years, microsurgical resection remained the most commonly recommended treatment for patients with newly diagnosed unilateral VS. 3,20 Although surgical outcomes have improved over the last 30 years, resection of VS was frequently associated with impaired facial nerve function and loss of hearing. 7,13,20,22 The recurrence rate of VS has been shown to be 2.6%-11.0% after gross-total resection, and 20%-50% of VS tumors progress after subtotal resection. 1,2,12,19,20,22,24,25,26,28 Since the development of the Gamma Knife (GK) technology, stereotactic radiosurgery (SRS) has become an increasingly used alternative or adjuvant VS management tool that eliminates many risks associated with resection.14,23 Initial SRS for VS has improved hearing retention rates in 60%-90% of patients and reduced facial neuropa-ABBREVIATIONS GK = Gamma Knife; G-R = Gardner-Robertson; HB = House-Brackmann; QOL = quality of life; SRS = stereotactic radiosurgery; VS = vestibular schwannoma. The Center for Image-Guided Neurosurgery and the Departments of 1 Neurological Surgery and 2 Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania OBJECTIVE The goal of this retrospective cohort study was to assess long-term outcomes in patients with vestibular schwannoma (VS) who underwent stereotactic radiosurgery (SRS) after initial microsurgical resection. METHODS From the authors' database of 1770 patients with VS, the authors retrospectively analyzed data from 173 Gamma Knife SRS procedures for VS after 1 (128 procedures) or multiple (45 procedures) microsurgical resections. The median length of the interval between the last resection and SRS was 42 months (range 2-329 months). The median length of clinical follow-up was 74 months (range 6-285 months). Progression-free survival after SRS was determined with Kaplan-Meier analysis. RESULTS At the time of SRS, the hearing of 161 patients (93%) was Gardner-Robertson Class V, and 81 patients (47%) had facial neuropathy (i.e., facial function with House-Brackmann [HB] grades of III-VI), 87 (50%) had trigeminal neuropathy, and 71 (41%) reported imbalance or disequilibrium disorders. The median tumor volume was 2.7 cm 3 (range 0.2-21.6 cm 3 ), and the median dose to the tumor margin was 13 Gy (range 11-20 Gy). Radiosurgery controlled growth of 163 (94%) tumors. Progression-free survival after SRS was 97% at 3 years, 95% at 5 years, and 90% at 10 years. Four patients with delayed tumor progression underwent repeat SRS at a median of 35 months (range 23-64 months) after the first SRS. Four patients (2.3%) w...

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“…The answer depends on how confident you want to be in your answer and the risk of tumor recurrence that is acceptable to you and your patient. This article by Sughrue and colleagues, 2 however, provides us with good data to consider when contemplating this question. As we are faced with increasing amounts of data like these, we will have to better understand their underlying uncertainties to effectively integrate them into our medical decision making.…”

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confidence: 99%

“…If a doubling of the risk of tumor recurrence over time-commonly referred to as the hazard rate-is clinically important to us and our patients, then there is 58% chance of our failing to observe this difference when a doubling really exists 1 based on the data presented by Sughrue and colleagues. 2 If as little as a 10% increase in the risk of recurrence is important, then there is a 96% chance of failing to observe this difference-that is, making the wrong conclusion-when such a difference really exists. In other words, if these differences in recurrence rate are important, we cannot confidently conclude that GTR doesn't matter.…”

mentioning

confidence: 99%

“…In present issue, Sughrue and colleagues 2 from the University of California at San Francisco, explore the effects of the extent of resection on the rate of vestibular schwannoma (VS) recurrence. The authors retrospectively review data that was prospectively collected in 772 patients who underwent gross-total resection (GTR), neartotal resection, or subtotal resection (STR) as assessed primarily by the surgeon.…”

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Editorial: Resection of vestibular schwannomas

Sampson¹,

Herndon

2011

JNS

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In present issue, Sughrue and colleagues 2 from the University of California at San Francisco, explore the effects of the extent of resection on the rate of vestibular schwannoma (VS) recurrence. The authors retrospectively review data that was prospectively collected in 772 patients who underwent gross-total resection (GTR), neartotal resection, or subtotal resection (STR) as assessed primarily by the surgeon. The authors' conclusion is a powerful one:…long-term rates of tumor control do not differ between patients who undergo GTR and those in whom a small amount of tumor is left behind. This finding argues against heroic attempts to achieve GTR in difficult cases, because tumor control is probably not improved markedly by these efforts… Contrary to the authors' conclusions, Fig. 1 seems to support the widely held notion that, in fact, GTR does reduce the risk of tumor recurrence. The authors, however, are careful to point out that this apparent reduced risk of recurrence after a GTR based on their data is not statistically significant-hence their conclusion. So what are we to conclude?Statistics aren't magic. They simply estimate the uncertainty of the conclusions we make based on a given set of data. If we conclude that there is no difference in tumor recurrence rate between GTR and STR for VSs, as the authors have here, we accept some uncertainty associated with that conclusion. If we are wrong, we are said to have committed a Type II statistical error by failing to observe a difference when one really exists-a false negative.The power of a statistical analysis is essentially the probability that we will not make the wrong conclusions based on insufficient data. To the authors' credit, they provide us with a detailed power analysis. A power analysis should always accompany important negative findings like the ones reported here as it gives us a measure of the confidence we can have in the conclusions we derive from the data. (Other factors also need to be considered such as biases in study and the specific patient population being studied.) With larger sample sizes, our confidence in the data increases and the likelihood we will make these wrong conclusions decreases. The power of a study with an end point like time-to-recurrence and our confidence in the study's conclusions depend on the number of recurrences, not the overall number of patients in the study. As such, the confidence we should have in the conclusions derived from these data depends on the 58 patients with recurrent tumors and not on the total number of 772 patients who underwent surgery. Other factors that influence the statistical power of such a study include the relative proportion of patients in each resection group and the duration of follow-up for each patient.One way to evaluate the conclusions that we derive from negative studies such as this one is to ask, "What increased risk of recurrence would our patients accept in exchange for the surgical risks of a GTR?" For simplicity's sake, let's just consider the comparison between GTR and...

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Extent of resection and the long-term durability of vestibular schwannoma surgery

Cited by 88 publications

References 16 publications

Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes

Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes

Stereotactic radiosurgery for recurrent vestibular schwannoma after previous resection

Editorial: Resection of vestibular schwannomas

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