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

Clinical article

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Object

In large vestibular schwannoma (VS), microsurgery is the main treatment option, and complete resection is considered the primary goal. However, previous studies have documented suboptimal facial nerve outcomes in patients who undergo complete resection of large VSs. Subtotal resection is likely to reduce the risk of facial nerve injury but increases the risk of lesion regrowth. Gamma Knife surgery (GKS) can be performed to achieve long-term growth control of residual VS after incomplete resection. In this study the authors report on the results in patients treated using planned subtotal resection followed by GKS with special attention to volumetric growth, control rate, and symptoms.

Methods

Fifty consecutive patients who underwent the combined treatment strategy of subtotal microsurgical removal and GKS for large VSs between 2002 and 2009 were retrospectively analyzed. Patients with neurofibromatosis Type 2 were excluded. Patient charts were reviewed for clinical symptoms. Audiograms were evaluated to classify hearing pre- and postoperatively. Preoperative and follow-up contrast-enhanced T1-weighted MR images were analyzed using volume-measuring software.

Results

Surgery was performed via a translabyrinthine (25 patients) or retrosigmoid (25 patients) approach. The median follow-up was 33.8 months. Clinical control was achieved in 92% of the cases and radiological control in 90%. One year after radiosurgery, facial nerve function was good (House-Brackmann Grade I or II) in 94% of the patients. One of the two patients who underwent surgery to preserve hearing maintained serviceable hearing after resection followed by GKS.

Conclusions

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.

Abbreviations used in this paper: GKS = Gamma Knife surgery; HB = House-Brackmann; VS = vestibular schwannoma.

Article Information

Address correspondence to: Rick van de Langenberg, M.D., Maastricht University Medical Center, Department of Otolaryngology, Head and Neck Surgery, PO Box 5800, 6202 AZ Maastricht, The Netherlands. email: rickvandelangenberg@hotmail.com.

Please include this information when citing this paper: published online August 12, 2011; DOI: 10.3171/2011.6.JNS101958.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Axial contrast-enhanced T1-weighted MR images obtained in a 68-year-old patient. Preoperative image (A) showing a 35.9-cm3 left-sided VS (Koos Grade IV). The patient underwent a retrosigmoidal subtotal resection, resulting in a 3.9-cm3 remnant (B). Four months postoperatively, GKS was performed. During the 4 years of follow-up, the remnant remained stable, and the patient was in good clinical condition, with facial nerve function scored as HB Grade II (C).

  • View in gallery

    Kaplan-Meier analysis of clinical control during follow-up after subtotal resection followed by GKS for large VSs.

  • View in gallery

    Kaplan-Meier analysis of radiological control during follow-up after subtotal resection followed by GKS for large VSs.

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