Management of large vestibular schwannoma. Part II. Primary Gamma Knife surgery: radiological and clinical aspects

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

doi:10.3171/2011.6.jns101963

Cited by 61 publications

(66 citation statements)

References 59 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%

“…These rates are consistent with comparable series of large VSs. 2,14,26,28 It should be noted that typically a CSF diversion procedure is considered less technically demanding than a large VS resection, and the associated morbidity is also significantly lower. Six patients (25%) required additional treatment in the large VS group for tumor progression after initial GKS, 3 each treated with resection or GKS, while none of the patients with small VSs required further treatment.…”

Section: Clinical Outcomementioning

confidence: 99%

“…22 Among our patients with large VSs, the tumor control rate at 5 years is clearly lower (81.8%); however, our data are consistent with other recent reports of GKS for large VSs (82%-94% tumor control rate). 2,14,26,28 Table 5 provides a comparison of radiosurgical series treating large VSs. Previously, Hasegawa et al analyzed a series of VSs of all sizes treated with GKS (n = 317) and found that large volume (> 15 ml) brainstem compression or effacement of the fourth ventricle were predictors of tumor progression.…”

Section: Tumor Controlmentioning

confidence: 99%

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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%

Section: Clinical Outcomementioning

confidence: 99%

Section: Tumor Controlmentioning

confidence: 99%

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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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“…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%

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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“…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%

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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Management of large vestibular schwannoma. Part II. Primary Gamma Knife surgery: radiological and clinical aspects

Cited by 61 publications

References 59 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

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

Multisession stereotactic radiosurgery for large vestibular schwannomas

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