Clinicopathological factors related to regrowth of vestibular schwannoma after incomplete resection

Clinical article

Restricted access

Object

The authors retrospectively analyzed various clinicopathological factors to determine which are related to regrowth during a long-term follow-up period in patients who underwent incomplete vestibular schwannoma (VS) resection.

Methods

This study involved 74 patients (25 men and 49 women) in whom a VS was treated surgically via the lateral suboccipital approach, and who had postoperative follow-up periods exceeding 5 years. The mean follow-up was 104.1 months (range 60–241 months), and the mean patient age at surgery was 48.1 years (range 19–75 years). The tumors ranged in size from 0 mm (localized within the internal auditory canal) to 56 mm (28.3 ± 12.2 mm [mean ± SD]).

Results

Gross-total resection (GTR) was performed in 41 (55%) of the 74 patients; subtotal resection ([STR]; 90–99%) in 25 (34%); and partial resection ([PR]; < 90%) in 8 (11%). Regrowth rates in the GTR, STR, and PR groups were 2.4% (1 of 41 cases), 52% (13 of 25), and 62.5% (5 of 8), respectively, and the times to regrowth ranged from 6 to 76 months (median 31.9 months). The regrowth-free survival curves differed significantly between the complete (GTR) and incomplete (STR and PR) resection groups. Eighteen (54.5%) of the 33 patients who underwent incomplete resection showed evidence of regrowth during follow-up. Univariate and multivariate analyses of various factors revealed that both the thickness of the residual tumor, based on MR imaging after surgery, and the MIB-1 index were positively related to residual tumor regrowth. The receiver operating characteristic curves, plotted for both the thickness of the residual tumor and the MIB-1 index, identified the optimal cutoff points for these values as 7.4 mm (sensitivity 83.3%, specificity 86.7%) and 1.6 (sensitivity 83.3%, specificity 66.7%), respectively.

Conclusions

Greater residual tumor thickness, based on MR imaging after the initial surgery, and a higher MIB-1 index are both important factors related to postoperative tumor regrowth in patients who have undergone incomplete VS resection. These patients require frequent neuroimaging investigation during follow-up to assure early detection of tumor regrowth.

Abbreviations used in this paper: GKS = Gamma Knife surgery; GTR = gross-total resection; IAC = internal auditory canal; PR = partial resection; ROC = receiver operating characteristics; STR = subtotal resection; VS = vestibular schwannoma.

Article Information

Address correspondence to: Masafumi Fukuda, M.D., Department of Neurosurgery, Brain Research Institute, University of Niigata, 1-757 Asahimachi-dori, Niigata-City 951-8585, Japan. email: mfuku529@bri.niigata-u.ac.jp.

Please include this information when citing this paper: published online January 7, 2011; DOI: 10.3171/2010.11.JNS101041.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Postoperative MR image obtained in a representative patient with a residual VS. The enlarged image shows the residual tumor surrounded by a white dotted line and the maximum diameter (arrow). The enhanced areas showed tumor remnants along the facial nerve in one patient (left) and within the IAC and surface of the brainstem at the level of the root exit zone of the facial nerve in another (right).

  • View in gallery

    Kaplan-Meier plot for patients who underwent complete (dotted line) and incomplete (solid line) resection, showing tumor control after surgery.

  • View in gallery

    Case 25. Magnetic resonance imaging at various stages. A: Preoperative MR image with Gd enhancement showing a solid VS in the left cerebellopontine angle. B: Axial MR image obtained 4 months after the first surgery showing residual tumor within the IAC and along the facial nerve. The enlarged image shows the residual tumor surrounded by a white dotted line and the maximum diameter (arrow, 7.5 mm). C: Axial MR image obtained 52 months after the initial surgery showing regrowth of the residual tumor. The patient underwent a second surgery at 55 months. The tumor was strongly adherent to the brainstem, and therefore had to be left behind. D: Final MR image obtained 69 months after initial surgery, showing no regrowth of the residual tumor.

  • View in gallery

    Left: Scatterplot comparing residual tumor thickness in patients with and those without recurrence. The residual tumor was significantly thicker in the recurrence group (p < 0.001). Right: Scatterplot comparing the MIB-1 index in the recurrence group and the no recurrence group. The MIB-1 index was significantly higher in the recurrence group (p = 0.005). Error bars represent the mean ± SD.

  • View in gallery

    The ROC curves for residual (remained) tumor thickness (solid line) and the MIB-1 index (dotted line) had areas under the curves of 0.863 and 0.787, respectively. The most discriminative cutoff point for residual tumor thickness (asterisk) is 7.4 mm, with a sensitivity of 83.3% and specificity of 86.7%. For the MIB-1 index, the point denoted by double asterisks corresponds to a cutoff of 1.6, with a sensitivity of 83.3% and specificity of 66.7%.

References

  • 1

    Aguiar PHTatagiba MDankoweit-Timpe EMatthies CSamii MOstertag H: Proliferative activity of acoustic neurilemomas without neurofibromatosis determined by monoclonal antibody MIB 1. Acta Neurochir (Wien) 134:35391995

    • Search Google Scholar
    • Export Citation
  • 2

    Bakkouri WEKania REGuichard JPLot GHerman PHuy PTB: Conservative management of 386 cases of unilateral vestibular schwannoma: tumor growth and consequences for treatment. Clinical article. J Neurosurg 110:6626692009

    • Search Google Scholar
    • Export Citation
  • 3

    Bedavanija ABrieger JLehr HAMaurer JMann WJ: Association of proliferative activity and size in acoustic neuroma: implications for timing of surgery. J Neurosurg 98:8078112003

    • Search Google Scholar
    • Export Citation
  • 4

    Bederson JBvon Ammon KWichmann WWYaşargil MG: Conservative treatment of patients with acoustic tumors. Neurosurgery 28:6466511991

    • Search Google Scholar
    • Export Citation
  • 5

    Bennett MLJackson CGKaufmann RWarren F: Postoperative imaging of vestibular schwannomas. Otolaryngol Head Neck Surg 138:6676712008

    • Search Google Scholar
    • Export Citation
  • 6

    Bloch DCOghalai JSJackler RKOsofsky MPitts LH: The fate of the tumor remnant after less-than-complete acoustic neuroma resection. Otolaryngol Head Neck Surg 130:1041122004

    • Search Google Scholar
    • Export Citation
  • 7

    Charabi SEngel PCharabi BJacobsen GKOvergaard JThomsen J: Growth of vestibular schwannomas: in situ model employing the monoclonal antibody Ki-67 and DNA flow cytometry. Am J Otol 17:3013061996

    • Search Google Scholar
    • Export Citation
  • 8

    Charabi STos MThomsen JCharabi BMantoni M: Vestibular schwannoma growth: the continuing controversy. Laryngoscope 110:172017252000

    • Search Google Scholar
    • Export Citation
  • 9

    El-Kashlan HKZeitoun HArts HAHoff JTTelian SA: Recurrence of acoustic neuroma after incomplete resection. Am J Otol 21:3893922000

    • Search Google Scholar
    • Export Citation
  • 10

    Fundová PCharabi STos MThomsen J: Cystic vestibular schwannoma: surgical outcome. J Laryngol Otol 114:9359392000

  • 11

    Herwadker AVokurka EAEvans DGRamsden RTJackson A: Size and growth rate of sporadic vestibular schwannoma: predictive value of information available at presentation. Otol Neurotol 26:86922005

    • Search Google Scholar
    • Export Citation
  • 12

    House JWBrackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 93:1461471985

  • 13

    Hwang SKKim DGPaek SHKim CYKim MKChi JG: Aggressive vestibular schwannomas with postoperative rapid growth: clinicopathological analysis of 15 cases. Neurosurgery 51:138113912002

    • Search Google Scholar
    • Export Citation
  • 14

    Kasantikul VNetsky MGGlasscock ME IIIHays JW: Acoustic neurilemmoma. Clinicoanatomical study of 103 patients. J Neurosurg 52:28351980

    • Search Google Scholar
    • Export Citation
  • 15

    Kemink JLLangman AWNiparko JKGraham MD: Operative management of acoustic neuromas: the priority of neurologic function over complete resection. Otolaryngol Head Neck Surg 104:96991991

    • Search Google Scholar
    • Export Citation
  • 16

    Kremer PForsting MHamer JSartor K: MR enhancement of the internal auditory canal induced by tissue implant after resection of acoustic neurinoma. AJNR Am J Neuroradiol 19:1151181998

    • Search Google Scholar
    • Export Citation
  • 17

    Lesser THJanzer RCKleihues PFisch U: Clinical growth rate of acoustic schwannomas: correlation with the growth fraction as defined by the monoclonal antibody ki-67. Skull Base Surg 1:11151991

    • Search Google Scholar
    • Export Citation
  • 18

    Lownie SPDrake CG: Radical intracapsular removal of acoustic neurinomas. Long-term follow-up review of 11 patients. J Neurosurg 74:4224251991

    • Search Google Scholar
    • Export Citation
  • 19

    Nedzelski JMCanter RJKassel EERowed DWTator CH: Is no treatment good treatment in the management of acoustic neuromas in the elderly?. Laryngoscope 96:8258291986

    • Search Google Scholar
    • Export Citation
  • 20

    Niemczyk KVaneecloo FMLecomte MHLejeune JPLemaitre LSkarzyński H: Correlation between Ki-67 index and some clinical aspects of acoustic neuromas (vestibular schwannomas). Otolaryngol Head Neck Surg 123:7797832000

    • Search Google Scholar
    • Export Citation
  • 21

    Ogawa KKanzaki JOgawa SYamamoto MIkeda SShiobara R: The growth rate of acoustic neuromas. Acta Otolaryngol Suppl 487:1571631991

    • Search Google Scholar
    • Export Citation
  • 22

    Rosenberg SI: Natural history of acoustic neuromas. Laryngoscope 110:4975082000

  • 23

    Schmerber SPalombi OBoubagra KCharachon RChirossel JPGay E: Long-term control of vestibular schwannoma after a translabyrinthine complete removal. Neurosurgery 57:6936982005

    • Search Google Scholar
    • Export Citation
  • 24

    Seol HJKim CHPark CKKim CHKim DGChung YS: Optimal extent of resection in vestibular schwannoma surgery: relationship to recurrence and facial nerve preservation. Neurol Med Chir (Tokyo) 46:1761812006

    • Search Google Scholar
    • Export Citation
  • 25

    Shelton C: Unilateral acoustic tumors: how often do they recur after translabyrinthine removal?. Laryngoscope 105:9589661995

  • 26

    Silverstein HMcDaniel ANorrell HWazen J: Conservative management of acoustic neuroma in the elderly patient. Laryngoscope 95:7667701985

    • Search Google Scholar
    • Export Citation
  • 27

    Tanaka YHongo KTada TKobayashi S: What is the best method for reporting tumor diameter in vestibular schwannoma?. Neurosurgery 53:6346382003

    • Search Google Scholar
    • Export Citation
  • 28

    Thomassin JMPellet WEpron JPBraccini FRoche PH: [Recurrent acoustic neurinoma after complete surgical resection]. Ann Otolaryngol Chir Cervicofac 118:3102001. (Fr)

    • Search Google Scholar
    • Export Citation
  • 29

    Umezu HSeki Y: Postoperative magnetic resonance imaging after acoustic neuroma surgery: influence of packing materials in the drilled internal auditory canal on assessment of residual tumor. Neurol Med Chir (Tokyo) 39:1411491999

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 231 234 21
Full Text Views 148 107 1
PDF Downloads 134 109 2
EPUB Downloads 0 0 0

PubMed

Google Scholar