Surgery After Primary Radiation Treatment for Sporadic Vestibular Schwannomas: Case Series

2017 ◽  
Vol 13 (4) ◽  
pp. 441-447 ◽  
Author(s):  
Jonathan D. Breshears ◽  
Joseph A. Osorio ◽  
Steven W. Cheung ◽  
Igor J. Barani ◽  
Philip V. Theodosopoulos
Keyword(s):  
Facial Nerve ◽  
Surgical Resection ◽  
Radiation Treatment ◽  
Salvage Surgery ◽  
Case Series ◽  
Technical Difficulty ◽  
Vestibular Schwannomas ◽  
Primary Radiation ◽  
Subtotal Resection ◽  
Total Resection

Abstract BACKGROUND: As radiation has become an increasingly popular primary treatment option for sporadic vestibular schwannomas, there is a minority of tumors that do not respond favorably to radiation. Data on repeat radiosurgery are emerging, and salvage surgery has been associated with increased technical difficulty and poor facial nerve outcomes. OBJECTIVE: To review the current literature and report our results with surgical resection of sporadic vestibular schwannomas that have failed primary radiation treatment. METHODS: This is a retrospective, single-surgeon case series of patients with sporadic vestibular schwannomas who failed primary radiation treatment and underwent subsequent surgical resection. We analyze demographics, clinical information, and intraoperative findings, focusing on facial nerve functional outcomes and extent of resection. RESULTS: Between 2006 and 2015, 10 patients with sporadic vestibular schwannomas whose only prior treatment was radiation underwent microsurgical resection. Eight of 10 patients had a postoperative House-Brackmann score of 1 at a median follow-up of 14 months, while 2 patients had House-Brackmann score of 4. Gross total resection was achieved in 7 of 10 cases. Near total resection was achieved in 2 cases, and only subtotal resection was achieved in 1 case. CONCLUSION: Salvage surgery is a safe and effective option after failure of primary radiation and may offer benefits over repeat radiosurgery.

scholarly journals Facial nerve outcomes after surgery for large vestibular schwannomas: do surgical approach and extent of resection matter?

2012 ◽  
Vol 33 (3) ◽  
pp. E16 ◽  
Author(s):  
Richard K. Gurgel ◽  
Salim Dogru ◽  
Richard L. Amdur ◽  
Ashkan Monfared
Keyword(s):  
Facial Nerve ◽  
Surgical Approach ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Vestibular Schwannomas ◽  
Surgical Approaches ◽  
Subtotal Resection ◽  
Total Resection ◽  
Translabyrinthine Approach ◽  
Better Than

Object The object of this study was to evaluate facial nerve outcomes in the surgical treatment of large vestibular schwannomas (VSs; ≥ 2.5 cm maximal or extrameatal cerebellopontine angle diameter) based on both the operative approach and extent of tumor resection. Methods A PubMed search was conducted of English language studies on the treatment of large VSs published from 1985 to 2011. Studies were then evaluated and included if they contained data regarding the size of the tumor, surgical approach, extent of resection, and postoperative facial nerve function. Results Of the 536 studies initially screened, 59 full-text articles were assessed for eligibility, and 30 studies were included for analysis. A total of 1688 tumor resections were reported. Surgical approach was reported in 1390 patients and was significantly associated with facial nerve outcome (ϕ= 0.29, p < 0.0001). Good facial nerve outcomes (House-Brackmann Grade I or II) were produced in 62.5% of the 555 translabyrinthine approaches, 65.2% of the 601 retrosigmoid approaches, and 27.4% of the 234 extended translabyrinthine approaches. Facial nerve outcomes from translabyrinthine and retrosigmoid approaches were not significantly different from each other, but both showed significantly more good facial nerve outcomes, compared with the extended translabyrinthine approach (OR for translabyrinthine vs extended translabyrinthine = 4.43, 95% CI 3.17–6.19, p < 0.0001; OR for retrosigmoid vs extended translabyrinthine = 4.98, 95% CI 3.57–6.95, p < 0.0001). There were 471 patients for whom extent of resection was reported. There was a strong and significant association between degree of resection and outcome (ϕ= 0.38, p < 0.0001). Of the 80 patients receiving subtotal resections, 92.5% had good facial nerve outcomes, compared with 74.6% (n = 55) and 47.3% (n = 336) of those who received near-total resections and gross-total resections, respectively. In the 2-way comparison of good versus suboptimal/poor outcomes (House-Brackmann Grade III–VI), subtotal resection was significantly better than near-total resection (OR = 4.21, 95% CI 1.50–11.79; p = 0.004), and near-total resection was significantly better than gross-total resection (OR = 3.26, 95% CI 1.71–6.20; p = 0.0002) in producing better facial nerve outcomes. Conclusions In a pooled patient population from studies evaluating the treatment of large VSs, subtotal and near-total resections were shown to produce better facial nerve outcomes when compared with gross-total resections. The translabyrinthine and retrosigmoid surgical approaches are likely to result in similar rates of good facial nerve outcomes. Both of these approaches show better facial nerve outcomes when compared with the extended translabyrinthine approach, which is typically reserved for especially large tumors. The reported literature on treatment of large VSs is extremely heterogeneous and minimal consistency in reporting outcomes was observed.

Facial Nerve Outcome and Tumor Control Rate as a Function of Degree of Resection in Treatment of Large Acoustic Neuromas

Neurosurgery ◽  
2015 ◽  
Vol 79 (2) ◽  
pp. 194-203 ◽  
Author(s):  
Ashkan Monfared ◽  
Carlton E. Corrales ◽  
Philip V. Theodosopoulos ◽  
Nikolas H. Blevins ◽  
John S. Oghalai ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Tumor Size ◽  
Gross Total Resection ◽  
Vestibular Schwannomas ◽  
Tumor Control ◽  
Subtotal Resection ◽  
Tumor Diameter ◽  
Total Resection ◽  
Repeat Surgery ◽  
Tumor Regrowth

Abstract BACKGROUND: Patients with large vestibular schwannomas are at high risk of poor facial nerve (cranial nerve VII [CNVII]) function after surgery. Subtotal resection potentially offers better outcome, but may lead to higher tumor regrowth. OBJECTIVE: To assess long-term CNVII function and tumor regrowth in patients with large vestibular schwannomas. METHODS: Prospective multicenter nonrandomized cohort study of patients with vestibular schwannoma ≥2.5 cm who received gross total resection, near total resection, or subtotal resection. Patients received radiation if tumor remnant showed signs of regrowth. RESULTS: Seventy-three patients had adequate follow-up with mean tumor diameter of 3.33 cm. Twelve received gross total resection, 22 near total resection, and 39 subtotal resection. Fourteen (21%) remnant tumors continued to grow, of which 11 received radiation, 1 had repeat surgery, and 2 no treatment. Four of the postradiation remnants (36%) required surgical salvage. Tumor regrowth was related to non-cystic nature, larger residual tumor, and subtotal resection. Regrowth was 3 times as likely with subtotal resection compared to gross total resection and near total resection. Good CNVII function was achieved in 67% immediately and 81% at 1-year. Better immediate nerve function was associated with smaller preoperative tumor size and percentage of tumor left behind on magnetic resonance image. Degree of resection defined by surgeon and preoperative tumor size showed weak trend toward better late CNVII function. CONCLUSION: Likelihood of tumor regrowth was 3 times higher in subtotal resection compared to gross total resection and near total resection groups. Rate of radiation control of growing remnants was suboptimal. Better immediate but not late CNVII outcome was associated with smaller tumors and larger tumor remnants.

scholarly journals Revision Surgery for Vestibular Schwannomas

2018 ◽  
Vol 79 (06) ◽  
pp. 528-532 ◽  
Author(s):  
Brian Chen ◽  
Mark Lorenz ◽  
Gregory Lekovic ◽  
Marc Schwartz ◽  
William Slattery ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Revision Surgery ◽  
Case Series ◽  
Gross Total Resection ◽  
Vestibular Schwannomas ◽  
Csf Leak ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Retrospective Case ◽  
Total Resection

Objectives To describe clinical outcomes of patients undergoing revision surgery for vestibular schwannomas. Design Retrospective case series. Setting Tertiary private neurotologic practice. Participants Patients who underwent revision surgeries for recurrent/residual vestibular schwannomas between 1985 and 2015. Main Outcome Measures Degree of resection, facial nerve function, cerebrospinal fluid (CSF) leak. Results A total of 234 patients underwent 250 revision surgeries for recurrent/residual vestibular schwannomas. Of these, 86 carried a diagnosis of neurofibromatosis type 2 (NF2). The mean number of prior surgeries was 1.26, and 197 (85%) prior surgeries had been performed elsewhere. The average age at surgery was 43. The most common approach employed at the time of revision surgery was translabyrinthine (87%), followed by transcochlear (6%), middle fossa (5%), and retrosigmoid (2%). Gross total resection was achieved in 212 revision surgeries (85%). Preoperative House–Brackmann facial nerve function was similar in non-NF2 and NF2 groups (mean: 2.7). Mean postoperative facial nerve function at last follow-up was 3.8 in the non-NF2 group and 3.9 in the NF2 group. History of radiation and the extent of resection were not associated with differences in facial nerve function preoperatively or postoperatively. CSF leaks occurred after 21 surgeries (8%), and six (2%) patients required reoperation. Conclusions This is the largest series of revision surgery for vestibular schwannomas to date. Our preferred approach is the translabyrinthine craniotomy, which can be readily modified to include the transcochlear approach for improved access. CSF leak rate slightly exceeds that of primary surgery, and gross total resection is achievable in the vast majority of patients.

scholarly journals P.041 Adult craniopharyngioma: case series, systematic review and meta-analysis

2017 ◽  
Vol 44 (S2) ◽  
pp. S24-S24
Author(s):  
C Dandurand ◽  
AA Sepehry ◽  
MH Asadi Lari ◽  
R Akagami ◽  
PA Gooderham
Keyword(s):  
Meta Analysis ◽  
Case Series ◽  
Gross Total Resection ◽  
Subtotal Resection ◽  
Total Resection ◽  
Childhood Population ◽  
Institutional Experience ◽  
The Difference ◽  
Meta Analyses ◽  
Case Basis

Background: The optimal therapeutic approach for adult craniopharyngioma remains controversial. Some advocate for gross total resection (GTR), while others support subtotal resection followed by adjuvant radiotherapy (STR + XRT). Methods: MEDLINE (1946 to July 1st 2016) and EMBASE (1980 to June 30th 2016) were systematically reviewed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed. At our institution, from 1975 to 2013, 33 patients were treated with initial surgical resection for adult onset craniopharyngioma. 22 patients were included in the present case series. Results: Eligible studies (n=21) were identified from the literature in addition to a case series of our institutional experience. Three groups were available for analysis: GTR, STR + XRT, and STR. The rates of recurrence were 17 %, 27 % and 45%, respectively. This differs from childhood population. The difference in risk of recurrence after GTR vs. STR + XRT did not reach significance (OR: 0.63, 95% confidence interval: 0.33-1.24, P=0.18). This maybe because of low pooled sample size (n=99) who underwent STR+XRT. Conclusions: This is the first and largest meta-analysis examining rate of recurrence in adult craniopharyngioma. Thus, when safe and feasible, a goal of gross total resection should be favored. Each patient should be considered on a case-by-case basis.

Facial Schwannoma Management Outcomes: A Systematic Review of the Literature

2020 ◽  
Vol 163 (2) ◽  
pp. 293-301
Author(s):  
Matthew Bartindale ◽  
Jeffrey Heiferman ◽  
Cara Joyce ◽  
Douglas Anderson ◽  
John Leonetti
Keyword(s):  
Systematic Review ◽  
Facial Nerve ◽  
Stereotactic Radiosurgery ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Tumor Location ◽  
Subtotal Resection ◽  
Review Of The Literature ◽  
Total Resection ◽  
Clinical Scenarios

Objective To evaluate facial nerve outcomes of various management strategies for facial schwannomas by assimilating individualized patient data from the literature to address controversies in management. Data Sources PubMed–National Center for Biotechnology Information and Scopus databases. Review Methods A systematic review of the literature was performed for studies regarding facial schwannomas. Studies were included if they presented patient-level data, type of intervention, pre- and postintervention House-Brackmann (HB) grades, and tumor location by facial nerve segment. Results Individualized data from 487 patients were collected from 31 studies. Eighty (16.4%) facial schwannomas were managed with observation, 25 (5.1%) with surgical decompression, 20 (4.1%) with stereotactic radiosurgery, 225 (46.2%) with total resection, and 137 (28.1%) with subtotal resection/stripping surgery. Stripping surgery/subtotal resection with good preoperative facial nerve function maintained HB grade 1 or 2 in 96% of cases. With a total resection of intradural tumors, preoperative HB grade did not significantly affect facial nerve outcome (n = 45, P = .46). However, a lower preoperative HB grade was associated with a better facial nerve outcome with intratemporal tumors (n = 56, P = .009). When stereotactic radiosurgery was performed, 40% of patients had improved, 35% were stable, and 25% had worsened facial function. Facial nerve decompression rarely affected short-term facial nerve status. Conclusion The data from this study help delineate which treatment strategies are best in which clinical scenarios. The findings can be used to develop a more definitive management algorithm for this complicated pathology.

Surgical Resection of a Recurrent Intramedullary Spinal Epidermoid Cyst: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (5) ◽  
pp. E204-E204 ◽  
Author(s):  
Noah Nichols ◽  
Ketan Yerneni ◽  
Joseph A Osorio ◽  
Michael McDermott ◽  
Lee A Tan
Keyword(s):  
Surgical Resection ◽  
Epidermoid Cyst ◽  
Radiation Treatment ◽  
Tumor Location ◽  
Gross Total Resection ◽  
Spinal Tumors ◽  
Adjuvant Radiation ◽  
Total Resection ◽  
Epidermoid Cysts ◽  
Patient Consent

Abstract Intramedullary spinal epidermoid cysts are rare tumors and only account for 1% of all spinal tumors in adults. Epidermoid cysts can develop from ectodermal tissue that was inappropriately positioned in the primitive neural tube during closure; acquired forms exist for epidermoid cysts as they can emerge in an iatrogenic manner following repeated lumbar punctures. Malignant progression of epidermoid cysts is extremely rare, and symptoms typically depend on tumor location. Surgical resection is the preferred treatment. Gross total resection is ideal; however, partial resections have demonstrated satisfactory long-term outcomes.  We present a 54-yr-old man with symptomatic recurrence of thoracic intramedullary epidermoid cyst after two prior resections (25 yr and 11 yr ago, respectively). The patient noted worsening back pain, leg spasticity and weakness. Magnetic resonance imaging (MRI) of the thoracic spine demonstrated interval expansion of the upper thoracic intramedullary epidermoid cyst compared to surveillance MRI from 3 yr prior.  Given the progressive nature of symptoms, the patient elected to have surgical resection of the tumor. This operative video highlights the technique and surgical nuances of gross-total resection of a recurrent thoracic intramedullary spinal epidermoid cyst. This patient was noted to have a stable neurological exam at the 6-mo follow-up visit with planned adjuvant radiation treatment.  There is no identifying information in this video. Patient consent was obtained for publishing of the material included in the video.

Posttransplant Lymphoproliferative Disorder in Adult Lung Transplant Recipients: A Report on Twenty-Seven Patients.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 4425-4425
Author(s):  
Sophie D. Stein ◽  
Jamal Misleh ◽  
Vivek Ahya ◽  
Robert Kotloff ◽  
Jason Christie ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Lymphoproliferative Disorder ◽  
Lung Transplant ◽  
Radiation Treatment ◽  
Case Series ◽  
Complete Response ◽  
Transplant Recipients ◽  
Posttransplant Lymphoproliferative Disorder ◽  
Primary Treatment Modality ◽  
Lung Transplant Recipients

Abstract Posttransplant lymphoproliferative disorder (PTLD) is a serious complication of organ transplantation. We report a case series on the diagnosis, treatment and outcome of PTLD in lung transplant recipients. From 1991 to 2006, 27 (5%) of the 502 lung transplant recipients at our institution developed PTLD. The median age at transplant was 51.5 years (range 21–65 years) and the median time from transplant to PTLD diagnosis was 33.7 months (range 1–174 months). Most cases had an elevated LDH (86%) and were EBV-positive (85%). Of the cases tested (n=14), 64% were monoclonal. PTLD was most commonly diagnosed in the lung (56%) and gastrointestinal tract (26%). Three patients were diagnosed at autopsy, while the remaining 24 received therapy. Eight patients were initially treated with reduced immunosuppression (RI) alone, but only 3 (38%) obtained a complete response (CR). Rituxan (R) was used alone (n=3) or in combination with RI (n=3) as initial therapy in six patients, four of whom obtained a CR. Five patients utilized RI +/− surgical resection as a primary treatment modality, all of whom achieved a CR. However, all of them relapsed and required further treatment. Of these five patients initially treated with RI +/− surgical resection, a CR was reestablished in 3 using rituxan alone (1/3), combined rituxan and reduced immunosuppression (1/3) and radiation treatment alone (1/3). The remaining five patients from the 24 patients receiving induction therapy for PTLD were given other treatments. With an average follow-up of 28 months (range 1-130 months), 81% of patients have died. However, only 18% of deaths were directly related to progressive PTLD. The remaining 17 deaths were due to: infection unrelated to PTLD treatment (15%), multi-organ failure (7%), graft failure not due to RI (30%), stroke (4%), and renal failure (4%). Most deaths can be attributed to disease specific and posttransplant complications rather than PTLD. Although an unfortunate diagnosis, PTLD is responsive to therapy, particularly reduced immunosuppression and rituximab.

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