The Outcome of Hypofractionated Stereotactic Radiosurgery for Large Vestibular Schwannomas

Teo, Mario; Zhang, Michael; Li, Amy; Thompson, Patricia A.; Tayag, Armine; Wallach, John R.; Gibbs, Iris C.; Soltys, Scott G.; Hancock, Steven; Chang, Steven D.

doi:10.1016/j.wneu.2016.06.080

Cited by 29 publications

(17 citation statements)

References 41 publications

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“…36 Studies have shown that the best strategy for tumor control is to achieve a high level of tumor resection while being mindful of facial nerve function. 41 A single-institution series from Samii et al 34 showed that of 50 patients with large vestibular schwannomas treated with gross-total resection, 92% had anatomical preservation of the facial nerve. At their last follow-up, 75% of patients had excellent or good facial nerve function, 19% had fair function, and 6% had poor function.…”

Section: Discussionmentioning

confidence: 99%

“…Although radiosurgery has been reported to produce similar facial nerve outcomes for Koos grade 3 tumors (mean volume 9 cm 3 ), its role in the context of large vestibular schwannomas remains controversial and it may be indicated only in patients with minimal symptoms of brainstem compression, surgical contraindications, or significant residual tumor mass despite attempted debulking. 4,15,25,41,43,44,47,50 A proposal to stage large vestibular schwannomas between 2 surgeries has been shown to improve facial nerve outcome and morbidity. 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.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

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%

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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“…Teo and colleagues assessed the outcome of hypofractionated SRS for large VS, comparing solid to cystic tumors, but also including 13 patients who had serviceable hearing prior to treatment. 48 They found that 38.4% of patients maintained serviceable hearing, concluding that their outcome may be indicative of the "high likelihood that patients experience some degree of auditory sequelae after CyberKnife-related VS treatment." 48 In the largest series to date, Hansasuta et al reported on 370 VS patients who received multisession SRS with the CyberKnife Robotic Radiosurgical System (Accuray, Sunnyvale, California, United States), with 90% of patients receiving three fractions for a total dose of 18 Gy and a median isodose line of 80%.…”

Section: Fractionationmentioning

confidence: 99%

“…48 They found that 38.4% of patients maintained serviceable hearing, concluding that their outcome may be indicative of the "high likelihood that patients experience some degree of auditory sequelae after CyberKnife-related VS treatment." 48 In the largest series to date, Hansasuta et al reported on 370 VS patients who received multisession SRS with the CyberKnife Robotic Radiosurgical System (Accuray, Sunnyvale, California, United States), with 90% of patients receiving three fractions for a total dose of 18 Gy and a median isodose line of 80%. 49 With 198 patients with serviceable hearing and a median posttreatment follow-up of 3.0 years, 76% maintained serviceable hearing, with smaller tumor volume associated with higher hearing preservation rates, and a trend toward hearing preservation for younger age and intracanalicular tumors.…”

Section: Fractionationmentioning

confidence: 99%

Hearing Preservation in Stereotactic Radiosurgery for Vestibular Schwannoma

Tolisano

Hunter

2019

J Neurol Surg B

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Despite no universally accepted definition of hearing preservation following vestibular schwannoma (VS) treatment, numerous variables have been identified as possible factors that may affect hearing outcomes following radiotherapy. Age, pretreatment hearing, radiation dose, tumor location and size, length of follow-up, fractionation, and timing of radiation have all been explored, among other variables, as factors related to hearing outcomes following radiation. These variables and associated hearing outcomes will be explored in detail, summarizing the literature to date to improve patient counseling for those patients who present with serviceable hearing and are considering their VS management options.

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“…3,[6][7][8] This is more apparent for larger tumors, where the balance between adequate tumor control and toxicity of native tissue is often easier to attain with multifraction SRS. 3,[9][10][11] Multifraction SRS may be particularly suitable for controlling symptomatic mass effect of large tumors causing brainstem compression. 12 Following radiosurgery, patients are followed with serial imaging to assess for tumor changes and supplement the clinical examination to evaluate the need for salvage therapy.…”

Section: Introductionmentioning

confidence: 99%

Longitudinal Radiographic Outcomes of Vestibular Schwannoma in Single and Fractionated Stereotactic Radiosurgery: A Retrospective Cohort Study

Khattab

Newman

Wharton

et al. 2019

J Neurol Surg B Skull Base

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Management of vestibular schwannoma (VS) includes stereotactic radiosurgery (SRS) in single or fractionated treatments. There is a paucity of literature on the three-dimensional (3D) volumetric kinetics and radiological changes following SRS and no consensus on appropriate post-SRS surveillance imaging timeline. This is a retrospective cohort study with institutional review board approval. A total of 55 patients met study criteria. We collected volumetric kinetic data in VS treated with SRS over time using a target volume contouring software. We also tracked radiographic phenomena such as pseudoprogression and necrosis. A secondary objective was to describe our overall treatment success rate and any failures. For all treatments groups, pseudoprogression most typically occurred within 12 months post-SRS, after which tumor volumes on average normalized and then decreased from pretreatment size at the last follow-up. Only two patients required salvage therapy post-SRS and were considered SRS treatment failures. Both patients were in the five-fraction cohort but with a lower biologically equivalent dose. Our study is first to collect 3D volumetric kinetics of VS following single and fractionated SRS in contrast to extrapolations from single and two-dimensional measurements. Our longitudinal data also show initial increases in volume in the first 12 months post-SRS followed by later declines, setting up interesting questions regarding the utility of early posttreatment surveillance imaging in the asymptomatic patient. Finally, we show low rates of treatment failure (3.6%) and show in our cohort that SRS dose de-escalation posed a risk of treatment failure.

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The Outcome of Hypofractionated Stereotactic Radiosurgery for Large Vestibular Schwannomas

Cited by 29 publications

References 41 publications

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

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

Hearing Preservation in Stereotactic Radiosurgery for Vestibular Schwannoma

Longitudinal Radiographic Outcomes of Vestibular Schwannoma in Single and Fractionated Stereotactic Radiosurgery: A Retrospective Cohort Study

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