Retreatment of vestibular schwannoma with Gamma Knife radiosurgery: clinical outcome, tumor control, and review of literature

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OBJECTIVE

Gamma Knife radiosurgery (GKRS) has become an accepted treatment for vestibular schwannoma, with a high rate of tumor control and good clinical outcome. In a small number of cases, additional treatment is needed. This retrospective study examines the clinical outcome, reproducibility of volumetric response patterns, and tumor control rate after administering a second GKRS to treat vestibular schwannomas.

METHODS

A total of 38 patients were included: 28 patients underwent a radiosurgical procedure as the initial treatment (Group 1), and 10 patients underwent microsurgical resection with adjuvant radiosurgery on the tumor remnant as the initial treatment (Group 2). The indication for a second GKRS treatment was growth observed on follow-up imaging. The median margin dose was 11.0 Gy for the first procedure and 11.5 Gy for the second procedure. Tumor control after retreatment was assessed through volumetric analysis. Clinical outcome was assessed through medical chart review.

RESULTS

Median tumor volume at retreatment was 3.6 cm3, with a median treatment interval of 49 months. All patients showed tumor control in a median follow-up period of 75 months after the second radiosurgical procedure. Volumetric tumor response after the second procedure did not correspond to response after the first procedure. After retreatment, persisting House-Brackmann Grade II facial nerve dysfunction was observed in 3 patients (7.9%), facial spasms in 5 patients (13%), and trigeminal nerve hypesthesia in 3 patients (7.9%). Hearing preservation was not evaluated because of the small number of patients with serviceable hearing at the second procedure.

CONCLUSIONS

Repeat GKRS after a failed first treatment appears to be an effective strategy in terms of tumor control. The volumetric response after a repeat procedure could not be predicted by the volumetric response observed after first treatment. This justifies considering repeat GKRS even for tumors that do not show any volumetric response and show continuous growth after first treatment. An increased risk of mild facial and trigeminal nerve dysfunction was observed after the second treatment compared with the first treatment.

ABBREVIATIONS GKRS = Gamma Knife radiosurgery; GKRS 1 = first GKRS procedure; GKRS 2 = second GKRS procedure.

Article Information

Correspondence Jeroen B. Verheul, Gamma Knife Center, St. Elisabeth Hospital, PO Box 90151, Tilburg, 5000 LC, The Netherlands. email: j.verheul@etz.nl.

INCLUDE WHEN CITING Published online October 6, 2017; DOI: 10.3171/2017.3.JNS162033.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Patient inclusion flow chart. MSR = microsurgical resection; VS = vestibular schwannoma.

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    Examples of volumetric response patterns. Graphs of 2 patients after GKRS 1 and GKRS 2. Time 0 indicates the time of treatment. Continuous growth (A), direct regression after retreatment (B), transient expansion and regrowth (C), and transient expansion and regression after retreatment (D) are shown. Note the peak transient expansion volume at 12 months.

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