Enlarged Translabyrinthine Approach With Transapical Extension in the Management of Giant Vestibular Schwannomas

Angeli, Roberto Dihl; Piccirillo, Enrico; Trapani, Giuseppe Di; Sequino, Giulio; Taibah, Abdelkader; Sanna, Mario

doi:10.1097/mao.0b013e3181ff7562

Cited by 31 publications

(31 citation statements)

References 26 publications

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“…Several authors have reported that TLA and the retrosigmoid approach are two major surgical options for the removal of a large or giant VS [2,3,5,7,9,28,29]. In our department, TLA is used to remove all kinds of VSs where hearing preservation is not essential, while the retrosigmoid approach is only used to remove a VS of <20 mm with hearing level in class A or B.…”

Section: Discussionmentioning

confidence: 99%

“…There are several authors who have reported their successful experience with removal of large or giant VSs via the translabyrinthine approach (TLA) in large series [2,5,6,7,8]. Also, it is difficult to achieve a postoperative functional outcome in large or giant VSs which is as good as that observed in small or medium VSs.…”

Section: Introductionmentioning

confidence: 99%

“…Also, it is difficult to achieve a postoperative functional outcome in large or giant VSs which is as good as that observed in small or medium VSs. The surgical outcome in VSs depends on several factors: tumor size, cystic degeneration, surgical approach used, surgeon’s experience, use of cranial nerve monitoring, adhesion between tumor and adjacent tissue, and the correct treatment of perioperative complications [5,9,10,11,12,13]. …”

Section: Introductionmentioning

confidence: 99%

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Removal of Large or Giant Sporadic Vestibular Schwannomas via Translabyrinthine Approach: A Report of 115 Cases

Zhang

Wang

Huang

et al. 2012

ORL

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Background/Aims: The present study was a retrospective analysis of surgical outcomes of large or giant vestibular schwannomas (VSs) via a translabyrinthine approach (TLA). Methods: One hundred and fifteen sporadic large or giant VSs (maximal diameter in the cerebellopontine angle ≥31 mm) were operated via TLA between January 2001 and December 2010. We divided patients into two groups: cystic VS (CVS) and solid VS (SVS) group. The surgical outcomes were recorded and compared. Results: Total, near total, and subtotal tumor removal rate was 89.6, 7.8, and 2.6%, respectively. The near total removal rate in CVS was higher than that in SVS (16.7 vs. 3.8%). The anatomical facial nerve (FN) integrity was preserved in 101 patients (87.8%). More FNs in CVS were interrupted (22.2%). There were 29.6, 56.5, and 13.9% of patients who had a short-term (1 month) FN function of House-Brackmann grade I or II, III or IV, and V or VI, respectively. The CVS had worse FN function than the SVS group. The mortality rate was 0.9%. Cerebrospinal fluid leakage occurred in 8 patients (7.0%). Four (3.5%) patients had recurrence. Conclusions: Cyst formation is a crucial factor for surgical outcome of VS. With near total or subtotal tumor removal, worse functional outcomes in large or giant CVSs should be foreseen.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Removal of Large or Giant Sporadic Vestibular Schwannomas via Translabyrinthine Approach: A Report of 115 Cases

Zhang

Wang

Huang

et al. 2012

ORL

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“…These modifications included the translabyrinthine-transapical exposure described by Angeli et al 2 in which the IAC is opened with greater than 300° of exposure, or the combined translabyrinthine-retrosigmoid exposure as described by Anderson et al 1 The definition of what constitutes an NTR compared with an STR varies by author, with no universally agreedupon definition. Some authors have subjectively defined the residual tumor with words such as "minimal," "tiny," "small" amount, or "thin layer" of residual tumor, as defined by the operative surgeon.…”

Section: Surgical Approach and Extent Of Resectionmentioning

confidence: 99%

Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

Gurgel

Doğru

Amdur³

et al. 2012

FOC

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Object The object of this study was to evaluate facial nerve outcomes in the surgical treatment of large vestibular schwannomas (VSs; ≥ 2.5 cm maximal or extrameatal cerebellopontine angle diameter) based on both the operative approach and extent of tumor resection. Methods A PubMed search was conducted of English language studies on the treatment of large VSs published from 1985 to 2011. Studies were then evaluated and included if they contained data regarding the size of the tumor, surgical approach, extent of resection, and postoperative facial nerve function. Results Of the 536 studies initially screened, 59 full-text articles were assessed for eligibility, and 30 studies were included for analysis. A total of 1688 tumor resections were reported. Surgical approach was reported in 1390 patients and was significantly associated with facial nerve outcome (ϕ= 0.29, p < 0.0001). Good facial nerve outcomes (House-Brackmann Grade I or II) were produced in 62.5% of the 555 translabyrinthine approaches, 65.2% of the 601 retrosigmoid approaches, and 27.4% of the 234 extended translabyrinthine approaches. Facial nerve outcomes from translabyrinthine and retrosigmoid approaches were not significantly different from each other, but both showed significantly more good facial nerve outcomes, compared with the extended translabyrinthine approach (OR for translabyrinthine vs extended translabyrinthine = 4.43, 95% CI 3.17–6.19, p < 0.0001; OR for retrosigmoid vs extended translabyrinthine = 4.98, 95% CI 3.57–6.95, p < 0.0001). There were 471 patients for whom extent of resection was reported. There was a strong and significant association between degree of resection and outcome (ϕ= 0.38, p < 0.0001). Of the 80 patients receiving subtotal resections, 92.5% had good facial nerve outcomes, compared with 74.6% (n = 55) and 47.3% (n = 336) of those who received near-total resections and gross-total resections, respectively. In the 2-way comparison of good versus suboptimal/poor outcomes (House-Brackmann Grade III–VI), subtotal resection was significantly better than near-total resection (OR = 4.21, 95% CI 1.50–11.79; p = 0.004), and near-total resection was significantly better than gross-total resection (OR = 3.26, 95% CI 1.71–6.20; p = 0.0002) in producing better facial nerve outcomes. Conclusions In a pooled patient population from studies evaluating the treatment of large VSs, subtotal and near-total resections were shown to produce better facial nerve outcomes when compared with gross-total resections. The translabyrinthine and retrosigmoid surgical approaches are likely to result in similar rates of good facial nerve outcomes. Both of these approaches show better facial nerve outcomes when compared with the extended translabyrinthine approach, which is typically reserved for especially large tumors. The reported literature on treatment of large VSs is extremely heterogeneous and minimal consistency in reporting outcomes was observed.

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“…The enlarged translabyrinthine approach in VS surgery has the advantages of a low rate of morbidity and a short hospital stay, and in our opinion this is the best approach for the removal of large VSs. 3,31 Our policy for incomplete resections is to try to achieve NTR in as many cases as possible and proceed to an STR only in the remaining cases. All patients undergo follow-up for 7-10 years.…”

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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Enlarged Translabyrinthine Approach With Transapical Extension in the Management of Giant Vestibular Schwannomas

Abstract: Results indicate the enlarged translabyrinthine approach with transapical extension as an elective approach for removal of giant VS. The method permits achievement of a high rate of total removal with low incidence of complications.

Cited by 31 publications

References 26 publications

Removal of Large or Giant Sporadic Vestibular Schwannomas via Translabyrinthine Approach: A Report of 115 Cases

Removal of Large or Giant Sporadic Vestibular Schwannomas via Translabyrinthine Approach: A Report of 115 Cases

Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

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

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