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

Langenberg, R; Hanssens, Patrick; Overbeeke, J.J. van; Verheul, Jeroen B; Nelemans, Patty J.; Bondt, Bert-Jan de; Stokroos, Robert J.

doi:10.3171/2011.6.jns101958

Cited by 122 publications

(103 citation statements)

References 69 publications

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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: Discussionsupporting

confidence: 67%

“…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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Section: Discussionsupporting

confidence: 67%

mentioning

confidence: 99%

Multisession stereotactic radiosurgery for large vestibular schwannomas

Casentini

Fornezza

Perini

et al. 2015

JNS

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“…The debate continues over complete versus incomplete removal as the best management strategy for patients with VS. To date, there have only been a few studies involving a limited number of patients in which outcomes of subtotal removal followed by adjuvant radiosurgery in the treatment of large VS have been analyzed [11,12,13,14,15,16,17]. In the present study, we achieved a 100% tumor control rate, with 87% of our patients showing excellent facial nerve function in the follow-up.…”

Section: Discussionsupporting

confidence: 56%

Outcomes in Patients with Vestibular Schwannoma after Subtotal Resection and Adjuvant Radiosurgery

Radwan

Eisenberg²,

Knisely³

et al. 2016

Stereotact Funct Neurosurg

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Background: The debate continues with a limited number of publications describing outcomes in patients with vestibular schwannoma (VS) treated with planned subtotal resection (STR) plus stereotactic radiosurgery (SRS). Here we present our experience. Methods: This is a retrospective review of 22 patients with VS Koos grade III and IV who were treated with STR followed by SRS. Tumor volumes, facial nerve function, hearing preservation, and the presence of trigeminal neuropathy were noted. Spearman's rank test was used to correlate facial nerve grade with postoperative tumor residual tumor volume. Results: Tumor control was achieved in all patients with a mean follow-up of 28 months. No patient required other treatment beyond the original surgery and adjuvant SRS during this period. After a mean postoperative period of 28 months, 19/22 patients had excellent (House-Brackmann I or II) facial nerve function grading. Improved facial nerve function was positively correlated with larger residual tumor volume (r_s = 0.63). Kaplan-Meier curve showed around 80% probability for regaining facial nerve function after initial deterioration. Four patients reported postoperative facial numbness at the side of surgery, with 3 cases showing improvement within a month. Temporary postoperative caudal cranial nerve dysfunction was observed in 2 patients. Conclusion: Hybrid strategy of STR and adjuvant SRS provides patients with large VS excellent tumor control and a good clinical outcome.

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“…There have been encouraging reports wherein large VSs have been managed by planned STR followed by SRS. 36 Preservation of facial nerve function is reportedly good following SRS. 36 Indications and protocols for SRS are still evolving, and more reports are likely to emerge in the future that will increase the role for SRS.…”

Section: Management Algorithmmentioning

confidence: 99%

“…36 Preservation of facial nerve function is reportedly good following SRS. 36 Indications and protocols for SRS are still evolving, and more reports are likely to emerge in the future that will increase the role for SRS. However, a drawback is that of malignant transformation after SRS and although this has not been proven in a large study, this could lie between 1 in 1000 and 3 in 200,000 treated patients.…”

Section: Management Algorithmmentioning

confidence: 99%

The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas

Chen

Prasad²,

Lella³

et al. 2014

JNS

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Object The authors evaluated the behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas (VSs). Methods The case records of all patients who underwent surgical treatment of VSs were analyzed. All patients in whom an incomplete excision had been performed were analyzed. Incomplete excision was defined as near-total resection (NTR), subtotal resection (STR), and partial resection (PR). Tumors in the NTR and STR categories were followed up with a wait-and-rescan approach, whereas the tumors in the PR category were subjected to a second-stage surgery and were excluded from this series. All patients included in the study underwent baseline MRI at the 3rd and 12th postoperative months, and repeat imaging was subsequently performed every year for 7–10 years postoperatively or as indicated clinically. Preoperative and postoperative facial function was noted. Results Of the 2368 patients who underwent surgery for VS, 111 patients who had incomplete excisions of VSs were included in the study. Of these patients, 73 (65.77%) had undergone NTR and 38 (34.23%) had undergone STR. Of the VSs, 62 (55.86%) were cystic and 44 (70.97%) of these cystic VSs underwent NTR. The residual tumor was left behind on the facial nerve alone in 62 patients (55.86%), on the facial nerve and vessels in 2 patients (1.80%), on the facial nerve and brainstem in 15 patients (13.51%), and on the brainstem alone in 25 patients (22.52%). In the 105 patients with normal preoperative facial nerve function, postoperative facial nerve function was House-Brackmann (HB) Grades I and II in 51 patients (48.57%), HB Grade III in 34 patients (32.38%), and HB Grades IV–VI in 20 patients (19.05%). Seven patients (6.3%) showed evidence of tumor regrowth on follow-up MRI. All 7 patients (100%) who showed evidence of tumor regrowth had undergone STR. No patient in the NTR group exhibited regrowth. The Kaplan-Meier plot demonstrated a 5-year tumor regrowth-free survival of 92%, with a mean disease-free interval of 140 months (95% CI 127–151 months). The follow-up period ranged from 12 to 156 months (mean 45.4 months). Conclusions The authors' report and review of the literature show that there is undoubtedly merit for NTR and STR for preservation of the facial nerve. On the basis of this they propose an algorithm for the management of incomplete VS excisions. Patients who undergo incomplete excisions must be subjected to follow-up MRI for a period of at least 7–10 years. When compared with STR, NTR via an enlarged translabyrinthine approach has shown to have a lower rate of regrowth of residual tumor, while having almost the same result in terms of facial nerve function.

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

Abstract: 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.

Cited by 122 publications

References 69 publications

Multisession stereotactic radiosurgery for large vestibular schwannomas

Multisession stereotactic radiosurgery for large vestibular schwannomas

Outcomes in Patients with Vestibular Schwannoma after Subtotal Resection and Adjuvant Radiosurgery

The behavior of residual tumors and facial nerve outcomes after incomplete excision of vestibular schwannomas

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