Outcome and Toxicity of Proton Therapy for Vestibular Schwannoma: A Cohort Study

Koetsier, Kimberley S.; Hensen, Erik F.; Niemierko, Andrzej; Dewyer, Nicholas A.; Chapman, Paul H.; Lamba, Nayan; Bussière, Marc R.; Vulpen, Marco van; McKenna, Michael J.; Loeffler, Jay S.; Shih, Helen A.

doi:10.1097/mao.0000000000003313

Cited by 9 publications

(18 citation statements)

References 32 publications

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“…Proton radiotherapy consisted of stereotactic proton radiosurgery in 11 patients and fractionated stereotactic proton radiotherapy in 23 patients. These patients were part of a cohort that has been described before ( 15 ). We evaluated MRI and audiometry before treatment and during follow-up, specifically the first available MRI and audiometry after treatment and the most recent available MRI and audiometry after treatment.…”

Section: Resultsmentioning

confidence: 99%

Labyrinthine Fluid Signal Intensity on T2-Weighted MR Imaging in Patients With Vestibular Schwannomas Undergoing Proton Radiotherapy: A Longitudinal Assessment

Koetsier¹,

Mehan

Buch³

et al. 2022

Otol Neurotol

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Objective: In vestibular schwannoma patients, a loss of signal intensity (SI) on T2-weighted magnetic resonance imaging (MRI) has been reported within the ipsilateral labyrinth. The purpose of this study was to quantitatively evaluate the occurrence and course of this intensity loss in relation to proton radiotherapy and its possible association with hearing loss. Study Design: Retrospective chart review. Setting: Tertiary referral center. Patients: Patients who received proton therapy for a vestibular schwannoma and underwent at least two high-resolution T2-weighted cisternographic sequence (constructive interference in steady state/ fast imaging employing steady-state acquisition/DRIVE) MRIs and audiometry assessments. Main Outcome Measures: Relative T2 SIs from the vestibules and basal/apical cochlear turns of the labyrinth, bilaterally. Results: Ninety-five MRI scans from 34 patients were included. The apical turn of the ipsilateral cochlea showed a lower mean co-chlear SI than on the contralateral side (±3.5 versus 5.0). The mean relative cochlear SI did not significantly change after proton radiotherapy. The ipsilateral vestibule showed a higher SI than the cochlea. The relative mean cochlear SI was not directly correlated to (the degree of ) hearing loss before or after proton radiotherapy, nor did it predict future hearing loss. Conclusion:The relative mean cochlear SI on cisternographic T2-MRI in vestibular schwannoma patients is diminished on the treated side, when compared with the ipsilateral vestibule and the contralateral cochlea/vestibule. The SI of the ipsilateral cochlea does not further decrease after proton radiotherapy and seems to be related to the tumor rather than the therapy. The diminished cochlear SI does not correlate with subsequent loss of hearing.

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Section: Resultsmentioning

confidence: 99%

Labyrinthine Fluid Signal Intensity on T2-Weighted MR Imaging in Patients With Vestibular Schwannomas Undergoing Proton Radiotherapy: A Longitudinal Assessment

Koetsier¹,

Mehan

Buch³

et al. 2022

Otol Neurotol

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“…To our knowledge, this is the first report on the clinical outcome and toxicity of PRT for VS in a cohort of NF2 patients to date; however, various studies have reported on PRT for sporadic VS [ 18 , 27 ]. In these studies, a combined total of 497 VS patients received passive-scatter PRT in a variety of treatment regimens between 1991 and 2018, with a prescribed dosage ranging from 12 to 60 Gy(RBE).…”

Section: Discussionmentioning

confidence: 99%

“…The local tumor control after PRT in sporadic VS ranged from 85% to 100% (median follow-up 2.2–7.4 years), which is somewhat higher than in the present NF2 patient cohort, of whom 75% did not require salvage treatment. Additionally, we found more treatment-related toxicities in our NF2 cohort than were reported in sporadic VS: hearing loss occurred in 21% to 78% of the patients, facial nerve function loss in 0% to 10% of the patients, and trigeminal neuropathy was reported in 0% to 9% of the patients after PRT in sporadic VS. One study additionally reported on vestibular symptoms and tinnitus [ 18 ]. Severe dizziness was reported in 6%, while 29% experienced mild symptoms.…”

Section: Discussionmentioning

confidence: 99%

“…Especially in a tumor-predisposing syndrome like NF2, a reduction of the radiation dose could be important as patients are genetically prone to malignant transformation of irradiated tumors or the occurrence of new primary tumors. As reports on VS treatment with PRT in NF2 patients are scarce, it is currently unclear whether PRT can reduce treatment-related toxicities for NF2 patients [ 17 , 18 , 19 , 20 ].…”

Section: Introductionmentioning

confidence: 99%

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Proton Radiotherapy for Vestibular Schwannomas in Patients with NF2-Related Schwannomatosis: A Case Series

et al. 2023

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(1) Background: This study aimed to evaluate the efficacy and treatment-related toxicity of proton radiotherapy (PRT) for vestibular schwannoma (VS) in patients with neurofibromatosis type 2-related schwannomatosis (NF2). (2) Methods: Consecutive NF2 patients treated with PRT for VS between 2004 and 2016 were retrospectively evaluated, focusing on tumor volume, facial and trigeminal nerve function, hearing, tinnitus, vestibular symptoms, and the need for salvage therapy after PRT. (3) Results: Eight patients were included (median age 36 years, 50% female). Median follow-up was 71 months. Five (63%) patients received fractionated PRT and three (38%) received PRT radiosurgery for VS. Six patients (75%) received prior VS surgery; three also received bevacizumab. Six patients (75%) did not require salvage therapy after PRT. Two patients (25%) with residual hearing lost it after PRT, and six had already lost ipsilateral hearing prior to PRT. Tumor and treatment-related morbidity could be evaluated in six patients. Following PRT, conditions that occurred or worsened were: facial paresis in five (83%), trigeminal hypoesthesia in two (33%), tinnitus in two (33%), and vestibular symptoms in four patients (67%). (4) Conclusion: After PRT for VS, the majority of the NF2 patients in the cohort did not require additional therapy. Tumor and/or treatment-related cranial nerve deficits were common. This is at least partly explained by the use of PRT as a salvage treatment after surgery or bevacizumab, in the majority of cases. There remains the further opportunity to elucidate the efficacy and toxicity of proton radiotherapy as a primary treatment.

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“…6,7 Comparisons of hearing results between vestibular schwannoma studies or treatment groups are further hampered by differences in patient selection (eg, in pretreatment hearing levels, the average patients' age, or tumor size), different follow-up durations, and different standards for reporting on hearing (eg, the Gardner-Robertson Classification, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), or hearing presented as a binary outcome, as either "serviceable" or "non-serviceable," using the "50/50 rule"). [8][9][10] As a result, the reported rates of patients experiencing significant HL after vestibular schwannoma treatment range widely between 10% and 100%. 11 An additional disadvantage of using binary outcomes for hearing is that the hearing of patients with slightly better speech discrimination than 50% is classified as "serviceable," while their hearing performance is actually severely diminished.…”

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confidence: 99%

The Course of Hearing Loss in Patients With a Progressive Vestibular Schwannoma

Koetsier

Locher

Koot

et al. 2023

Otolaryngol.--head neck surg.

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ObjectiveThis study evaluates the natural course of hearing loss (HL) prior to treatment in patients with progressive tumors and an indication for active intervention. Evaluating this patient group specifically can put hearing outcomes after vestibular schwannoma therapy into an adequate context.Study DesignRetrospective cohort study.SettingTertiary referral center.MethodsInclusion criteria comprised unilateral vestibular schwannomas prior to active treatment, with ≥2 mm extracanalicular (EC) tumor growth and ≥2 audiograms. We performed a comprehensive assessment of hearing using multiple outcome parameters including (the annual decrease in) pure‐tone averages (PTAs; an average of 0.5, 1, 2, and 3 kHz). Predictors for HL were evaluated (patient age, tumor size/progression, follow‐up duration, baseline hearing).ResultsAt presentation, 86% of patients suffered from sensorineural HL on the affected side (≥20 dB PTA) with a median of 39 dB (interquartile rate [IQR]: 27‐51 dB). The median follow‐up duration was 21 months (IQR: 13‐34 months), after which 58% (187/322) of patients experienced progressive HL (≥10 dB), with a median increase of 6.4 dB/year. At the last follow‐up, the median PTA was 56 dB (IQR: 37‐73). Median speech discrimination scores deteriorated from 90% (IQR: 70%‐100%) to 65% (IQR: 35%‐100%). Tumor progression (maximal EC diameter) was significantly correlated to the progression of sensorineural HL, corrected for follow‐up (F(2,228) = 10.4, p < .001, R2 = 8%).ConclusionThe majority of patients (58%) with radiologically confirmed progressive vestibular schwannomas experience progressive sensorineural HL during observation. Tumor progression rate, EC tumor extension, and longer follow‐up are factors associated with more sensorineural HL.

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Outcome and Toxicity of Proton Therapy for Vestibular Schwannoma: A Cohort Study

Abstract: Supplemental Digital Content is available in the text

Cited by 9 publications

References 32 publications

Labyrinthine Fluid Signal Intensity on T2-Weighted MR Imaging in Patients With Vestibular Schwannomas Undergoing Proton Radiotherapy: A Longitudinal Assessment

Labyrinthine Fluid Signal Intensity on T2-Weighted MR Imaging in Patients With Vestibular Schwannomas Undergoing Proton Radiotherapy: A Longitudinal Assessment

Proton Radiotherapy for Vestibular Schwannomas in Patients with NF2-Related Schwannomatosis: A Case Series

The Course of Hearing Loss in Patients With a Progressive Vestibular Schwannoma

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