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Upfront Gamma Knife surgery for facial nerve schwannomas: retrospective case series analysis and systematic review

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Abstract

Introduction

Facial nerve schwannomas are rare tumors and account for less than 2% of intracranial neurinomas, despite being the most common tumors of the facial nerve. The optimal management is currently under debate and includes observation, microsurgical resection, radiosurgery (RS), and fractionated radiotherapy. Radiosurgery might be a valuable alternative, as a minimally invasive technique, in symptomatic patients and/or presenting tumor growth.

Methods

We review our series of four consecutive cases, treated with Gamma Knife surgery (GKS) between July 2010 and July 2017 in Lausanne University Hospital, Switzerland. Clinical and dosimetric parameters were assessed. Radiosurgery was performed using Leksell Gamma Knife Perfexion. We additionally performed a systematic review, which included 23 articles and 193 treated patients from the current literrature.

Results

The mean age at the time of the GKS was 44.25 years (median 43.5, range 34–56). Mean follow-up period was 31.8 months (median 36, range 3–60). Two cases presented with facial palsy and other two with hemifacial spasm. Pretherapeutically, House–Brackmann (HB) grade was II for one case, III for two, and VI for one. The mean gross tumor volume (GTV) was 0.406 ml (median 0.470 ml, range 0.030–0.638 ml). The mean marginal prescribed dose was 12 Gy at the mean 54% isodose line (median 50%, range 50–70). The mean prescription isodose volume (PIV) was 0.510 ml (median 0.596 ml, range 0.052–0.805 ml). The mean dose received by the cochlea was 4.2 Gy (median 4.1 Gy, range 0.1–10). One patient benefited from a staged-volume GKS. At last follow-up, tumor volume was stable in one and decreased in three cases. Facial palsy remained stable in two patients (one HB II and one HB III) and improved in two (from HB III to II and from HB VI to HB III). Regarding hemifacial spasm, both patients presenting one pretherapeutically had a decrease in its frequency and intensity after GKS. All patients kept stable Gardner–Robertson class 1 at last follow-up.

Conclusion

In our experience, RS and particularly GKS, using standard, yet low doses of radiation, appear to be a safe and effective therapeutic option in the management of these rare tumors. The results as from our systematic review are also encouraging with satisfactory rates of clinical stabilization and/or improvement and high rate of tumor control. Complications are infrequent and mostly transient.

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Acknowledgments

Lausanne University Hospital.

Funding

Lausanne University Hospital.

Author information

Author notes

  1. Jean-Nicolas Comps and Constantin Tuleasca contributed equally to this work.

Authors and Affiliations

  1. Neurosciences Department, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Rue du Bugnon 44-46, BH-08, CH-1011, Lausanne, Switzerland

    Jean-Nicolas Comps, Constantin Tuleasca & Marc Levivier

  2. Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland

    Constantin Tuleasca & Marc Levivier

  3. Swiss Federal Institute of Technology, Signal Processing Laboratory (LTS5), Lausanne, Switzerland

    Constantin Tuleasca

  4. ENT Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland

    Beatrice Goncalves-Matoso

  5. Radiotherapy Department, Lausanne University Hospital, Lausanne, Switzerland

    Luis Schiappacasse

  6. Institute of Radiation Physics Lausanne, Lausanne, Switzerland

    Maud Marguet

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  1. Jean-Nicolas Comps
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  2. Constantin Tuleasca
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  5. Maud Marguet
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  6. Marc Levivier
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Corresponding author

Correspondence to Constantin Tuleasca.

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The authors declare that they have no conflict of interest.

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For this type of study, no ethical committee approval is necessary. The patients agree to the publication of the clinical image, in the present format.

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Comments

Comps et al. provide us with an interesting paper about the neurosurgical management of motor facial nerve schwannomas. This series, although small with a short follow-up, has the merit to point a especially interesting indication of radiosurgery. Gamma Knife radiosurgery (GKRS) has clearly demonstrated in five comparative studies its superiority over microsurgical resection in term of motor facial nerve functional preservation (1–5). However, at least in small vestibular schwannoma,, a good percentage of patients can expect a satisfactory motor facial nerve function preservation after radical removal. This is not the case for motor facial nerve schwannomas carrying a 100% risk of complete facial palsy (HB6) after radical removal. Grafting after such disabling surgery, in the very best case, is bringing a chance to go back to a HB3 but not to a full recovery. The natural history of these lesions is also leading, more or less rapidly and more or less abruptly to a severe facial palsy. Thus, the potential of Gamma Knife radiosurgery to cure these tumors while preserving the functional status of the facial motor nerve is invaluable for these frequently young patients. Although GKRS has already been demonstrated in the literature with larger patient cohorts and longer follow-ups (6, 7) this paper provides us with an excellent review of the literature confirming the unique safety efficacy of GKRS in this indication and the absence of benefit of hypofractionation. We believe like the authors that early, upfront GKRS is today the treatment of choice for small facial motor nerve schwannomas or residual tumor after resection (8).

Jean-Marie Regis

Marseille, France

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Comps, JN., Tuleasca, C., Goncalves-Matoso, B. et al. Upfront Gamma Knife surgery for facial nerve schwannomas: retrospective case series analysis and systematic review. Acta Neurochir 160, 987–996 (2018). https://doi.org/10.1007/s00701-018-3503-2

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