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Hideyuki Kano, Douglas Kondziolka, Aftab Khan, John C. Flickinger and L. Dade Lunsford

. References 1 Chang SD , Gibbs IC , Sakamoto GT , Lee E , Oyelese A , Adler JR Jr : Staged stereotactic irradiation for acoustic neuroma . Neurosurgery 56 : 1254 – 1263 , 2005 2 Chopra R , Kondziolka D , Niranjan A , Lunsford LD , Flickinger JC : Long-term follow-up of acoustic schwannoma radiosurgery with marginal tumor doses of 12 to 13 Gy . Int J Radiat Oncol Biol Phys 68 : 845 – 851 , 2007 3 Delbrouck C , Hassid S , Massager N , Choufani G , David P , Devriendt D , : Preservation of hearing in

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John C. Flickinger, Douglas Kondziolka, Ajay Niranjan and L. Dade Lunsford

R adiosurgery is an alternative to microsurgical resection of acoustic neuroma (vestibular schwannoma) and is associated with lower patient morbidity and comparable long-term tumor-control rates. 6, 11, 13–15, 17 An analysis of our first 5 years of experience with radiosurgery of acoustic neuromas, which was performed using marginal tumor doses on the order of 16 Gy, revealed significant rates of subsequent facial weakness (21%), facial numbness (27%), and decreased hearing (49%). 11 We subsequently modified our radiosurgical method in two major ways. First

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Brian R. Subach, Douglas Kondziolka, L. Dade Lunsford, David J. Bissonette, John C. Flickinger and Ann H. Maitz

N eurofibromatosis Type 2 (NF2) is found both as a sporadic and a genetically transmitted neurocutaneous disorder. It typically afflicts younger patients, and the presence of bilateral acoustic neuromas is pathognomonic of the disease. Unlike the solitary, sporadic tumors that tend to displace the auditory portion of the eighth cranial nerve, tumors associated with NF2 tend to form grapelike clusters that often infiltrate and engulf the cochlear nerve. 18 Typical presenting symptoms include gradual sensorineural hearing loss, high-pitched tinnitus, and

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Douglas Kondziolka, L. Dade Lunsford and John C. Flickinger

Management options for patients with vestibular schwannomas (acoustic neuromas) include observation, tumor resection, stereotactic radiosurgery, and fractionated radiotherapy. In this report the authors review their 15-year experience with radiosurgery and discuss indications and expectations in relation to the different approaches. They conducted a survey of neurosurgeons to determine management preferences in two different cases of intra- and extra-canalicular tumor presentations. Patient decisions must be based on quality information derived from peer-reviewed literature.

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Brian R. Subach, Douglas Kondziolka, L. Dade Lunsford, David J. Bissonette, John C. Flickinger and Ann H. Maitz

Object

Stereotactically guided radiosurgery is one of the primary treatment modalities for patients with acoustic neuromas (vestibular schwannomas). The goal of radiosurgery is to arrest tumor growth while preserving neurological function. Patients with acoustic neuromas associated with neurofibromatosis Type 2 (NF2) represent a special challenge because of the risk of complete deafness. To better define the tumor control rate and long-term functional outcome, the authors reviewed their 10-year experience in treating these lesions.

Methods

Forty patients underwent stereotactic radiosurgery at the University of Pittsburgh, 35 of them for solitary tumors. The other five underwent staged procedures for bilateral lesions (10 tumors, 45 total). Thirteen patients (with 29% of tumors) had undergone a median of two prior resections. The mean tumor volume at radiosurgery was 4.8 ml and the mean tumor margin dose was 15 Gy (range 12–20 Gy).

The overall tumor control rate was 98%. During the median follow-up period of 36 months, 16 (36%) tumors regressed, 28 (62%) remained unchanged, and one (2%) grew. In the 10 patients for whom more than 5 years of clinical and neuroimaging follow-up results were available (median 92 months), five tumors were smaller and five remained unchanged. Surgical resection was performed in three patients (7%) after radiosurgery; only one showed radiographic evidence of progression. Useful hearing (Gardner-Robertson Class I or II) was preserved in six (43%) of 14 patients and this rate improved to 67% after modifications made in 1992. Normal facial nerve function (House-Brackmann Grade 1) was preserved in 25 (81%) of 31 patients. Normal trigeminal nerve function was preserved in 34 (94%) of 36 patients.

Conclusions

Stereotactically guided radiosurgery is a safe and effective treatment for patients with acoustic tumors in the setting of NF2. The rate of hearing preservation may be better with radiosurgery than with other available techniques.

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Vestibular schwannoma management

Part I. Failed microsurgery and the role of delayed stereotactic radiosurgery

Bruce E. Pollock, L. Dade Lunsford, John C. Flickinger, Brent L. Clyde and Douglas Kondziolka

C urrently , surgical resection is the most frequently recommended management strategy for patients in whom vestibular schwannomas (acoustic neuromas) have been newly diagnosed. 24 Studies on the natural history of untreated vestibular schwannomas have shown that the majority of tumors will grow within 3 years 2, 4, 17, 27 and that the growth rate can vary from 0.1 to 3 cm per year. Consequently, observation with serial imaging is recommended only for elderly patients who experience no symptoms from mass effect. 5, 34–36, 38 The results of microsurgical

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Olusola K. Ogunrinde, L. Dade Lunsford, John C. Flickinger and Douglas Kondziolka

MD , Harvey C , Fagan P : Acoustic neuroma hearing preservation surgery: five-year follow-up results , in Tos M , Thomsen J (eds): Acoustic Neuroma. Amsterdam : Kugler , 1992 , pp 681 – 687 Atlas MD, Harvey C, Fagan P: Acoustic neuroma hearing preservation surgery: five-year follow-up results, in Tos M, Thomsen J (eds): Acoustic Neuroma. Amsterdam: Kugler, 1992, pp 681–687 2. Bederson JB , von Ammon K , Wichmann WW , et al : Conservative treatment of patients with acoustic tumors

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Vestibular schwannoma management

Part II. Failed radiosurgery and the role of delayed microsurgery

Bruce E. Pollock, L. Dade Lunsford, Douglas Kondziolka, Raymond Sekula, Brian R. Subach, Robert L. Foote and John C. Flickinger

. Clinical worsening is common when microsurgery is performed after radiosurgery. However, no clear relationship could be established between prior radiosurgery and the subsequent difficulty in resecting a vestibular schwannoma. To maximize patient outcomes, a subtotal tumor resection should be considered for patients who require surgical resection of their tumor after vestibular schwannoma radiosurgery. References 1. Beatty CW , Ebersold MJ , Harner SG : Residual and recurrent acoustic neuromas. Laryngoscope 97 : 1168 – 1171

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Douglas Kondziolka, Seyed H. Mousavi, Hideyuki Kano, John C. Flickinger and L. Dade Lunsford

V estibular schwannomas (acoustic neuromas) are generally slow-growing, intracranial extraaxial benign tumors that usually develop from the vestibular portion of the eighth cranial nerve. The incidence is thought be 1 per 100,000. Although some patients note disequilibrium, vertigo, or tinnitus, progressive unilateral hearing decline is the most common symptom that leads to the diagnosis of a vestibular schwannoma. 22 Because of the earlier use of higher-quality MRI, an increasing number of vestibular schwannomas are diagnosed at a time when patients

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Stephen Johnson, Hideyuki Kano, Andrew Faramand, Ajay Niranjan, John C. Flickinger and L. Dade Lunsford

authors: Kano. Statistical analysis: Kano. Study supervision: Kano. References 1 Akpinar B , Mousavi SH , McDowell MM , Niranjan A , Faraji AH , Flickinger JC , : Early radiosurgery improves hearing preservation in vestibular schwannoma patients with normal hearing at the time of diagnosis . Int J Radiat Oncol Biol Phys 95 : 729 – 734 , 2016 2 Atlas MD , Harvey C , Fagan PA : Hearing preservation in acoustic neuroma surgery: a continuing study . Laryngoscope 102 : 779 – 783 , 1992 3 Betchen SA , Walsh J , Post KD : Long