Gamma Knife radiosurgery for larger-volume vestibular schwannomas

Yang, Huai‐Che; Kano, Hideyuki; Awan, Nasir; Lunsford, L. Dade; Niranjan, Ajay; Flickinger, John C.; Novotný, Josef; Bhatnagar, Jagdish P.; Kondziolka, Douglas

doi:10.3171/2010.8.jns10674

Cited by 102 publications

(71 citation statements)

References 26 publications

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“…12,18,24 Given the limitations of treating these larger VSs and the evidence for SRS for small and medium-sized lesions, there have been reports of the use of radiosurgery for the treatment of large VSs with 82%-87% long-term tumor control and reasonable maintenance of neurological function. 2,14,26,28 This tumor control is in contrast to smaller VSs that have long-term tumor control greater than 90%. [3][4][5]11,13,18,19,22 To more thoroughly explore the differences in radiological and clinical outcomes between patients with large VSs (> 3 cm in maximal dimension) and small VSs (≤ 3 cm in maximal dimension), we performed a retrospective analysis comparing outcomes after GKS.…”

Section: ©Aans 2013mentioning

confidence: 82%

Gamma Knife surgery for large vestibular schwannomas: a single-center retrospective case-matched comparison assessing the effect of lesion size

Williams

Xu²,

Salvetti³

et al. 2013

JNS

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Object. Gamma Knife surgery (GKS) is a safe and effective treatment for patients with small to moderately sized vestibular schwannomas (VSs). Reports of stereotactic radiosurgery for large VSs have demonstrated worse tumor control and preservation of neurological function. The authors endeavored to assess the effect of size of VSs treated using GKS.Methods. This study was a retrospective comparison of 24 patients with large VSs (> 3 cm in maximum diameter) treated with GKS compared with 49 small VSs (≤ 3 cm) matched for age, sex, radiosurgical margin and maximal doses, length of follow-up, and indication.Results. Actuarial tumor progression-free survival (PFS) for the large VS cohort was 95.2% and 81.8% at 3 and 5 years, respectively, compared with 97% and 90% for small VSs (p = 0.009). Overall clinical outcome was better in small VSs compared with large VSs (p < 0.001). Patients with small VSs presenting with House-Brackmann Grade I (good facial function) had better neurological outcomes compared with patients with large VSs (p = 0.003). Treatment failure occurred in 6 patients with large VSs; 3 each were treated with resection or repeat GKS. Treatment failure did not occur in the small VS group. Two patients in the large VS group required ventriculoperitoneal shunt placement. Univariate analysis did not identify any predictors of treatment failure among the large VS cohort.Conclusions. Patients with large VSs treated using GKS had shorter PFS and worse clinical outcomes compared with age-, sex-, and indication-matched patients with small VSs. Nevertheless, GKS has efficacy for some patients with large VSs and represents a reasonable treatment option for selected patients.

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Section: ©Aans 2013mentioning

confidence: 82%

Gamma Knife surgery for large vestibular schwannomas: a single-center retrospective case-matched comparison assessing the effect of lesion size

Williams

Xu²,

Salvetti³

et al. 2013

JNS

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“…4,14,16,22,32,45 In a recent publication, Yang et al concluded that if the patient is asymptomatic, the tumor is smaller than 10 cm 3 , and/or the Koos grade is less than 4, SRS could be the first choice of treatment more likely to lead to tumor regression. 45 A similar conclusion was presented by van de Langenberg et al 39 in the first part of a recent study: radiological growth control was achieved in nearly 90% of cases in both series. In his editorial, Kondziolka affirmed-in the absence of ataxia, disabling headache, hydrocephalus, or refractive fifth cranial nerve neuralgia-SRS is a practical option.…”

Section: Discussionmentioning

confidence: 99%

“…This is a generally accepted criterion, 14,22,24,27,30,45 even though stability of tumors that may present after long periods of quiescence can be a misleading appearance of success. A 1-mm-diameter change results in a volume difference of about 10%.…”

Section: Follow-upmentioning

confidence: 99%

“…4,21,35,36 SRS is generally used to treat small-to medium-sized VSs but has also demonstrated satisfactory results with larger lesions as well. 20,30,31,[39][40][41]45 Nevertheless, the latter represent a challenge for both surgeons and radiosurgeons, because a direct correlation between tumor size and facial nerve damage does exist in the postoperative period. Furthermore, the current standard therapeutic dose (12-13 Gy) may be too high and not well tolerated by healthy surrounding nervous structures, with potential adverse radiation effects, without effecting rapid volume reduction.…”

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confidence: 99%

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Multisession stereotactic radiosurgery for large vestibular schwannomas

Casentini

Fornezza

Perini

et al. 2015

JNS

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OBJECT Microsurgery is not the only option for larger vestibular schwannomas (VSs); recent reviews have confirmed the feasibility and efficacy of radiosurgery for larger VSs. This study illustrates the outcomes of a series of large VSs after multisession stereotactic radiosurgery (SRS). METHODS A series of 33 VSs larger than 8 cm3 (range 8–24 cm3, mean 11 cm3, median 9.4 cm3) were treated using the CyberKnife from 2003 to 2011 with the multisession SRS technique in 2–5 fractions (14–19.5 Gy). Five patients had undergone surgical removal and 5 had ventriculoperitoneal shunts. Nine patients were eligible for but refused surgery. Twelve patients were older than 70 years and 5 were younger than 40 years. Two female patients had neurofibromatosis. RESULTS The follow-up period ranged from 12 to 111 months (median 48 months); radiological growth control was achieved in 94% of cases: 19 tumors (58%) displayed no size variation or reduction in tumor diameter; 12 (36%), after a transient enlargement, presented with arrested growth or shrinkage. Seven patients had a volume reduction of more than 50%. Two patients (6%) needed debulking and 2 were treated with ventriculoperitoneal shunts. Actuarial progressionfree survival rates at 1 year and 5 years were 97% and 83%, respectively. Hearing was retained in 7 of the 8 patients with serviceable baseline hearing. Adverse events were limited to 1 case each of vertigo, tongue paresthesia, and trigeminal neuralgia. CONCLUSIONS The good control rate obtained with multisession SRS deepens the controversy of the radiobiology of VSs and may extend the indication of radiation therapy (fractionated or SRS) for large VSs to include patients without symptoms of mass effect. The limited number of cases and short follow-up period do not provide sufficient support for widespread application of multisession SRS in young patients. Further studies with multisession SRS are warranted.

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“…63 This former method has recently been advocated as the primary therapy for larger tumors, but there is a lack of data on outcomes of radiosurgery in patients with larger VSs. 96 Three different approaches are generally considered when planning VS surgery, and opinions abound about when to use a particular approach. To this end, some criteria have been consistently established in the literature, and factors for consideration have been named: tumor size, patient age and overall health status, anatomy of the vestibule and CPA, involvement of the brainstem and facial nerve, and extent of involvement of the IAC.…”

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confidence: 99%

Surgery for vestibular schwannomas: a systematic review of complications by approach

Ansari

Terry

Cohen-Gadol

2012

FOC

240

206

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Object Various studies report outcomes of vestibular schwannoma (VS) surgery, but few studies have compared outcomes across the various approaches. The authors conducted a systematic review of the available data on VS surgery, comparing the different approaches and their associated complications. Methods MEDLINE searches were conducted to collect studies that reported information on patients undergoing VS surgery. The authors set inclusion criteria for such studies, including the availability of follow-up data for at least 3 months, inclusion of preoperative and postoperative audiometric data, intraoperative monitoring, and reporting of results using established and standardized metrics. Data were collected on hearing loss, facial nerve dysfunction, persistent postoperative headache, CSF leak, operative mortality, residual tumor, tumor recurrence, cranial nerve (CN) dysfunction involving nerves other than CN VII or VIII, and other neurological complications. The authors reviewed data from 35 studies pertaining to 5064 patients who had undergone VS surgery. Results The analyses for hearing loss and facial nerve dysfunction were stratified into the following tumor categories: intracanalicular (IC), size (extrameatal diameter) < 1.5 cm, size 1.5–3.0 cm, and size > 3.0 cm. The middle cranial fossa approach was found to be superior to the retrosigmoid approach for hearing preservation in patients with tumors < 1.5 cm (hearing loss in 43.6% vs 64.3%, p < 0.001). All other size categories showed no significant difference between middle cranial fossa and retrosigmoid approaches with respect to hearing loss. The retrosigmoid approach was associated with significantly less facial nerve dysfunction in patients with IC tumors than the middle cranial fossa method was; however, neither differed significantly from the translabyrinthine corridor (4%, 16.7%, 0%, respectively, p < 0.001). The middle cranial fossa approach differed significantly from the translabyrinthine approach for patients with tumors < 1.5 cm, whereas neither differed from the retrosigmoid approach (3.3%, 11.5%, and 7.2%, respectively, p = 0.001). The retrosigmoid approach involved less facial nerve dysfunction than the middle cranial fossa or translabyrinthine approaches for tumors 1.5–3.0 cm (6.1%, 17.3%, and 15.8%, respectively; p < 0.001). The retrosigmoid approach was also superior to the translabyrinthine approach for tumors > 3.0 cm (30.2% vs 42.5%, respectively, p < 0.001). Postoperative headache was significantly more likely after the retrosigmoid approach than after the translabyrinthine approach, but neither differed significantly from the middle cranial fossa approach (17.3%, 0%, and 8%, respectively; p < 0.001). The incidence of CSF leak was significantly greater after the retrosigmoid approach than after either the middle cranial fossa or translabyrinthine approaches (10.3%, 5.3%, 7.1%; p = 0.001). The incidences of residual tumor, mortality, major non-CN complications, residual tumor, tumor recurrence, and dysfunction of other cranial nerves were not significantly different across the approaches. Conclusions The middle cranial fossa approach seems safest for hearing preservation in patients with smaller tumors. Based on the data, the retrosigmoid approach seems to be the most versatile corridor for facial nerve preservation for most tumor sizes, but it is associated with a higher risk of postoperative pain and CSF fistula. The translabyrinthine approach is associated with complete hearing loss but may be useful for patients with large tumors and poor preoperative hearing.

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Gamma Knife radiosurgery for larger-volume vestibular schwannomas

Abstract: Although microsurgical resection remains the primary management choice in patients with low comorbidities, most vestibular schwannomas with a maximum diameter less than 4 cm and without significant mass effect can be managed satisfactorily with Gamma Knife radiosurgery.

Cited by 102 publications

References 26 publications

Gamma Knife surgery for large vestibular schwannomas: a single-center retrospective case-matched comparison assessing the effect of lesion size

Gamma Knife surgery for large vestibular schwannomas: a single-center retrospective case-matched comparison assessing the effect of lesion size

Multisession stereotactic radiosurgery for large vestibular schwannomas

Surgery for vestibular schwannomas: a systematic review of complications by approach

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