Vestibular schwannoma management

Part II. Failed radiosurgery and the role of delayed microsurgery

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Object. The indications, operative findings, and outcomes of vestibular schwannoma microsurgery are controversial when it is performed after stereotactic radiosurgery. To address these issues, the authors reviewed the experience at two academic medical centers.

Methods. During a 10-year interval, 452 patients with unilateral vestibular schwannomas underwent gamma knife radiosurgery. Thirteen patients (2.9%) underwent delayed microsurgery at a median of 27 months (range 7–72 months) after they had undergone radiosurgery. Six of the 13 patients had undergone one or more microsurgical procedures before they underwent radiosurgery. The indications for surgery were tumor enlargement with stable symptoms in five patients, tumor enlargement with new or increased symptoms in five patients, and increased symptoms without evidence of tumor growth in three patients. Gross-total resection was achieved in seven patients and near-gross-total resection in four patients. The surgery was described as more difficult than that typically performed for schwannoma in eight patients, no different in four patients, and easier in one patient. At the last follow-up evaluation, three patients had normal or near-normal facial function, three patients had moderate facial dysfunction, and seven had facial palsies. Three patients were incapable of caring for themselves, and one patient died of progression of a malignant triton tumor.

Conclusions. Failed radiosurgery in cases of vestibular schwannoma was rare. No clear relationship was demonstrated between the use of radiosurgery and the subsequent ease or difficulty of delayed microsurgery. Because some patients have temporary enlargement of their tumor after radiosurgery, the need for surgical resection after radiosurgery should be reviewed with the neurosurgeon who performed the radiosurgery and should be delayed until sustained tumor growth is confirmed. A subtotal tumor resection should be considered for patients who require surgical resection of their tumor after vestibular schwannoma radiosurgery.

Article Information

Address reprint requests to: L. Dade Lunsford, M.D., Department of Neurological Surgery, University of Pittsburgh Medical Center, Suite B-400, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Axial gadolinium-enhanced MR images obtained in a 79-year-old woman who underwent radiosurgery 4 months after she had undergone subtotal resection of tumor. Left: Image obtained at the time of radiosurgery. Right: Image obtained 12 months after radiosurgery. The tumor is unchanged in size, but has lost its central enhancement. The patient underwent repeated surgical resection 6 months later.

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    Case 2. Axial (left) and coronal (right) gadolinium-enhanced MR images obtained in a 47-year-old man who had undergone two previous subtotal resections of a vestibular schwannoma. Upper: Images obtained at the time of radiosurgery. Center: Images obtained 22 months after radiosurgery showing tumor growth. Lower: Images obtained 1 month after repeated subotal resection of the tumor.

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    Case 3. Axial gadolinium-enhanced MR images obtained in a 65-year-old man who presented with hearing loss and progressive tumor enlargement. Left: Image obtained at the time of radiosurgery. Center: Image obtained 12 months after he underwent radiosurgery. The tumor measured 1 mm larger than at the time of radiosurgery. Note the loss of central tumor enhancement. Right: Image obtained 24 months after radiosurgery showing that the tumor has continued to enlarge. The patient underwent surgical resection at this time.

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