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Surgical outcome in smaller symptomatic vestibular schwannomas. Is there a role for surgery?

  • Original Article - Tumor - Schwannoma
  • Published:
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Abstract

Background

Currently, there is no consensus in the initial management of small vestibular schwannomas (VSs). They are routinely watched and/or referred for radiosurgical treatment, although surgical removal is also an option. We hereby evaluate clinical outcomes of patients who have undergone surgical removal of smaller symptomatic VSs.

Methods

Patients with vestibular schwannomas (grade T1–T3b according to Hannover classification) were reviewed. Patients with symptomatic tumors who underwent surgery were evaluated. Their preoperative hearing status was based on the guideline of the committee on hearing and equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) foundation. Their postoperative facial nerve function, hearing status, vestibular symptoms, and degree of tumor resection were assessed.

Results

Thirty patients were selected for surgery via a retrosigmoid approach based on their age, symptoms, and their own decision-making after discussion of management options. Most patients presented with hearing loss. Seventeen patients had useful hearing preoperatively. Among them, 10 patients (59%) preserved useful hearing (class A or B) postoperatively. MRI at 1-year follow-up confirmed complete resection in 26/29 patients. Also, 29 patients (97%) had HB grade I–II, and 1 patient had HB III at 1-year follow-up. Except for 1 patient with CSF leak, 1 patient with delayed facial nerve palsy, and 2 patients with asymptomatic sigmoid sinus occlusion, there were no other new morbidities.

Conclusion

Although both observation and radiosurgery are valid options in the management of smaller size vestibular schwannomas, surgical treatment seems to offer a high rate of facial nerve preservation, a reasonable rate of hearing sparing, and a high total resection rate. Clinicians should consider surgical treatment as a valid option in the initial management of symptomatic small vestibular schwannomas in younger patients.

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References

  1. Ahmad RARL, Sivalingam S, Topsakal V, Russo A, Taibah A, Sanna M (2012) Rate of recurrent vestibular schwannoma after total removal via different surgical approaches. Ann Otol Rhinol Laryngol 121(3):156–161

    Article  Google Scholar 

  2. Anaizi AN, DiNapoli VV, Pensak M, Theodosopoulos PV (2016) Small vestibular schwannomas: does surgery remain a viable treatment option? J Neurol Surg B Skull Base 77(3):212–218

    Article  Google Scholar 

  3. Arts HA, Telian SA, El-Kashlan H, Thompson BG (2006) Hearing preservation and facial nerve outcomes in vestibular schwannoma surgery: results using the middle cranial fossa approach. Otol Neurotol 27(2):234–241

    Article  Google Scholar 

  4. Babu R, Sharma R, Bagley JH, Hatef J, Friedman AH, Adamson C (2013) Vestibular schwannomas in the modern era: epidemiology, treatment trends, and disparities in management. J Neurosurg 119(1):121–130

    Article  Google Scholar 

  5. Baschnagel AM, Chen PY, Bojrab D, Pieper D, Kartush J, Didyuk O, Naumann IC, Maitz A, Grills IS (2013) Hearing preservation in patients with vestibular schwannoma treated with Gamma Knife surgery: clinical article. J Neurosurg 118(3):571–578

    Article  Google Scholar 

  6. Breivik CN, Nilsen RM, Myrseth E, Finnkirk MK, Lund-Johansen M (2013) Working disability in Norwegian patients with vestibular schwannoma: vertigo predicts future dependence. World Neurosurg 80(6):e301–e305

    Article  Google Scholar 

  7. Breivik CN, Nilsen RM, Myrseth E, Pedersen PH, Varughese JK, Chaudhry AA, Lund-Johansen M (2013) Conservative management or gamma knife radiosurgery for vestibular schwannoma: tumor growth, symptoms, and quality of life. Neurosurgery 73(1):48–56 discussion 56–7

    Article  Google Scholar 

  8. Carlson ML, Jacob JT, Pollock BE, Neff BA, Tombers NM, Driscoll CLW, Link MJ (2013) Long-term hearing outcomes following stereotactic radiosurgery for vestibular schwannoma: patterns of hearing loss and variables influencing audiometric decline. J Neurosurg 118(3):579–587

    Article  Google Scholar 

  9. Carlson ML, Tveiten OV, Driscoll CL et al (2015) Long-term quality of life in patients with vestibular schwannoma: an international multicenter cross-sectional study comparing microsurgery, stereotactic radiosurgery, observation, and nontumor controls. J Neurosurg 122(4):833–842

    Article  Google Scholar 

  10. Carlson ML, Vivas EX, McCracken DJ, Sweeney AD, Neff BA, Shepard NT, Olson JJ (2018) Congress of Neurological Surgeons systematic review and evidence-based guidelines on hearing preservation outcomes in patients with sporadic vestibular schwannomas. Neurosurgery 82(2):E35–E39

    Article  Google Scholar 

  11. Chen L, Chen L-H, Ling F, Liu Y-S, Samii M, Samii A (2010) Removal of vestibular schwannoma and facial nerve preservation using small suboccipital retrosigmoid craniotomy. Chin Med J 123(3):274–280

    PubMed  Google Scholar 

  12. Chopra R, Kondziolka D, Niranjan A, Lunsford LD, Flickinger JC (2007) Long-term follow-up of acoustic schwannoma radiosurgery with marginal tumor doses of 12 to 13 Gy. Int J Radiat Oncol Biol Phys 68(3):845–851

    Article  Google Scholar 

  13. Friedman RA, Brackmann DE, Hitselberger WE, Schwartz MS, Iqbal Z, Berliner KI (2005) Surgical salvage after failed irradiation for vestibular schwannoma. Laryngoscope 115(10):1827–1832

    Article  Google Scholar 

  14. Golfinos JG, Hill TC, Rokosh R, Choudhry O, Shinseki M, Mansouri A, Friedmann DR, Thomas Roland J Jr, Kondziolka D (2016) A matched cohort comparison of clinical outcomes following microsurgical resection or stereotactic radiosurgery for patients with small- and medium-sized vestibular schwannomas. J Neurosurg 125(6):1472–1482

    Article  Google Scholar 

  15. Haines SJ, Levine SC (1993) Intracanalicular acoustic neuroma: early surgery for preservation of hearing. J Neurosurg 79(4):515–520

    Article  CAS  Google Scholar 

  16. Hasegawa T, Kida Y, Kato T, Iizuka H, Kuramitsu S, Yamamoto T (2013) Long-term safety and efficacy of stereotactic radiosurgery for vestibular schwannomas: evaluation of 440 patients more than 10 years after treatment with Gamma Knife surgery. J Neurosurg 118(3):557–565

    Article  Google Scholar 

  17. Heerma H, Braun V, Richter HP (2000) Effect of microneurosurgical operation in acoustic neurinoma on symptoms of vertigo and tinnitus. HNO 48(5):372–377

    Article  CAS  Google Scholar 

  18. Hilton CW, Haines SJ, Agrawal A, Levine SC (2011) Late failure rate of hearing preservation after middle fossa approach for resection of vestibular schwannoma. Otol Neurotol 32(1):132–135

    Article  Google Scholar 

  19. Horiba A, Hayashi M, Chernov M, Kawamata T, Okada Y (2016) Hearing preservation after low-dose gamma knife radiosurgery of vestibular schwannomas. Neurol Med Chir 56(4):186–192

    Article  Google Scholar 

  20. Husseini ST, Piccirillo E, Taibah A, Almutair T, Sequino G, Sanna M (2013) Salvage surgery of vestibular schwannoma after failed radiotherapy: the Gruppo Otologico experience and review of the literature. Am J Otolaryngol 34(2):107–114

    Article  Google Scholar 

  21. Kirchmann M, Karnov K, Hansen S, Dethloff T, Stangerup S-E, Caye-Thomasen P (2017) Ten-year follow-up on tumor growth and hearing in patients observed with an intracanalicular vestibular schwannoma. Neurosurgery 80(1):49–56

    PubMed  Google Scholar 

  22. Kleijwegt M, Ho V, Visser O, Godefroy W, van der Mey A (2016) Real incidence of vestibular schwannoma? Estimations from a National Registry. Otol Neurotol 37(9):1411–1417

    Article  Google Scholar 

  23. Klijn S, Verheul JB, Beute GN, Leenstra S, Mulder JJS, Kunst HPM, Hanssens PEJ (2016) Gamma Knife radiosurgery for vestibular schwannomas: evaluation of tumor control and its predictors in a large patient cohort in the Netherlands. J Neurosurg 124(6):1619–1626

    Article  Google Scholar 

  24. Liu W, Ni M, Jia W, Zhou D, Zhang Q, Jiang Y, Jia G (2015) How to address small- and medium-sized acoustic neuromas with hearing: a systematic review and decision analysis. World Neurosurg 84(2):283–291.e1

    Article  Google Scholar 

  25. Lloyd SKW, Kasbekar AV, Baguley DM, Moffat DA (2010) Audiovestibular factors influencing quality of life in patients with conservatively managed sporadic vestibular schwannoma. Otol Neurotol 31(6):968–976

    Article  Google Scholar 

  26. Loeffler JS, Niemierko A, Chapman PH (2003) Second tumors after radiosurgery: tip of the iceberg or a bump in the road? Neurosurgery 52(6):1436–1440 discussion 1440–2

    Article  Google Scholar 

  27. Martin TPC, Tzifa K, Kowalski C, Holder RL, Walsh R, Irving RM (2008) Conservative versus primary surgical treatment of acoustic neuromas: a comparison of rates of facial nerve and hearing preservation. Clin Otolaryngol 33(3):228–235

    Article  CAS  Google Scholar 

  28. Matthies C, Samii M (1997) Management of 1000 vestibular schwannomas (acoustic neuromas): clinical presentation. Neurosurgery 40(1):1–9 discussion 9–10

    CAS  PubMed  Google Scholar 

  29. Meyer TA, Canty PA, Wilkinson EP, Hansen MR, Rubinstein JT, Gantz BJ (2006) Small acoustic neuromas: surgical outcomes versus observation or radiation. Otol Neurotol 27(3):380–392

    Article  Google Scholar 

  30. Mousavi SH, Kano H, Faraji AH, Gande A, Flickinger JC, Niranjan A, Monaco E 3rd, Lunsford LD (2015) Hearing preservation up to 3 years after gamma knife radiosurgery for Gardner-Robertson class I patients with vestibular schwannomas. Neurosurgery 76(5):584–590 discussion 590–1

    Article  Google Scholar 

  31. Myrseth E, Møller P, Wentzel-Larsen T, Goplen F, Lund-Johansen M (2006) Untreated vestibular schwannomas: vertigo is a powerful predictor for health-related quality of life. Neurosurgery 59(1):67–76 discussion 67–76

    Article  Google Scholar 

  32. Myrseth E, Møller P, Pedersen P-H, Lund-Johansen M (2009) Vestibular schwannoma: surgery or Gamma Knife radiosurgery? A prospective, nonrandomized study. Neurosurgery 64(4):654–661 discussion 661–3

    Article  Google Scholar 

  33. Pollock BE, Driscoll CLW, Foote RL, Link MJ, Gorman DA, Bauch CD, Mandrekar JN, Krecke KN, Johnson CH (2006) Patient outcomes after vestibular schwannoma management: a prospective comparison of microsurgical resection and stereotactic radiosurgery. Neurosurgery 59(1):77–85 discussion 77–85

    Article  Google Scholar 

  34. Quist TS, Givens DJ, Gurgel RK, Chamoun R, Shelton C (2015) Hearing preservation after middle fossa vestibular schwannoma removal: are the results durable? Otolaryngol Head Neck Surg 152(4):706–711

    Article  Google Scholar 

  35. Rabelo de Freitas M, Russo A, Sequino G, Piccirillo E, Sanna M (2012) Analysis of hearing preservation and facial nerve function for patients undergoing vestibular schwannoma surgery: the middle cranial fossa approach versus the retrosigmoid approach--personal experience and literature review. Audiol Neurootol 17(2):71–81

    Article  Google Scholar 

  36. Raheja A, Bowers CA, MacDonald JD, Shelton C, Gurgel RK, Brimley C, Couldwell WT (2016) Middle fossa approach for vestibular schwannoma: good hearing and facial nerve outcomes with low morbidity. World Neurosurg 92:37–46

    Article  Google Scholar 

  37. Régis J, Carron R, Park MC, Soumare O, Delsanti C, Thomassin JM, Roche P-H (2010) Wait-and-see strategy compared with proactive Gamma Knife surgery in patients with intracanalicular vestibular schwannomas. J Neurosurg 113(Suppl):105–111

    PubMed  Google Scholar 

  38. Roos DE, Potter AE, Zacest AC (2011) Hearing preservation after low dose linac radiosurgery for acoustic neuroma depends on initial hearing and time. Radiother Oncol 101(3):420–424

    Article  Google Scholar 

  39. Samii M, Matthies C, Tatagiba M (1991) Intracanalicular acoustic neurinomas. Neurosurgery 29(2):189–198 discussion 198–9

    Article  CAS  Google Scholar 

  40. Samii M, Matthies C, Tatagiba M (1997) Management of vestibular schwannomas (acoustic neuromas): auditory and facial nerve function after resection of 120 vestibular schwannomas in patients with neurofibromatosis 2. Neurosurgery 40(4):696–705 discussion 705–6

    Article  CAS  Google Scholar 

  41. Samii M, Metwali H, Gerganov V (2016) Efficacy of microsurgical tumor removal for treatment of patients with intracanalicular vestibular schwannoma presenting with disabling vestibular symptoms. J Neurosurg:1–6

  42. Schulder M, Sreepada GS, Kwartler JA, Cho ES (1999) Microsurgical removal of a vestibular schwannoma after stereotactic radiosurgery: surgical and pathologic findings. Am J Otol 20(3):364–367 discussion 368

    CAS  PubMed  Google Scholar 

  43. Schumacher AJ, Lall RR, Lall RR et al (2016) Low-dose Gamma Knife radiosurgery for vestibular schwannomas: tumor control and cranial nerve function preservation after 11 Gy. J Neurol Surg B Skull Base. https://doi.org/10.1055/s-0036-1584231

    Article  Google Scholar 

  44. Springborg JB, Poulsgaard L, Thomsen J (2008) Nonvestibular schwannoma tumors in the cerebellopontine angle: a structured approach and management guidelines. Skull Base 18(4):217–227

    Article  Google Scholar 

  45. Stangerup S-E, Caye-Thomasen P, Tos M, Thomsen J (2008) Change in hearing during “wait and scan” management of patients with vestibular schwannoma. J Laryngol Otol 122(7):673–681

    Article  Google Scholar 

  46. Sughrue ME, Yang I, Aranda D, Kane AJ, Parsa AT (2010) Hearing preservation rates after microsurgical resection of vestibular schwannoma. J Clin Neurosci 17(9):1126–1129

    Article  Google Scholar 

  47. Timmer FCA, van Haren AEP, Mulder JJS, Hanssens PEJ, van Overbeeke JJ, Cremers CWRJ, Graamans K (2010) Quality of life after gamma knife radiosurgery treatment in patients with a vestibular schwannoma: the patient’s perspective. Eur Arch Otorhinolaryngol 267(6):867–873

    Article  Google Scholar 

  48. Tveiten OV, Carlson ML, Goplen F, Vassbotn F, Link MJ, Lund-Johansen M (2015) Long-term auditory symptoms in patients with sporadic vestibular schwannoma: an international cross-sectional study. Neurosurgery 77(2):218–227 discussion 227

    Article  Google Scholar 

  49. Wang AC, Chinn SB, Than KD, Arts HA, Telian SA, El-Kashlan HK, Thompson BG (2013) Durability of hearing preservation after microsurgical treatment of vestibular schwannoma using the middle cranial fossa approach. J Neurosurg 119(1):131–138

    Article  Google Scholar 

  50. Wanibuchi M, Fukushima T, Friedman AH, Watanabe K, Akiyama Y, Mikami T, Iihoshi S, Murakami T, Sugino T, Mikuni N (2014) Hearing preservation surgery for vestibular schwannomas via the retrosigmoid transmeatal approach: surgical tips. Neurosurg Rev 37(3):431–444 discussion 444

    Article  Google Scholar 

  51. Woodson EA, Dempewolf RD, Gubbels SP, Porter AT, Oleson JJ, Hansen MR, Gantz BJ (2010) Long-term hearing preservation after microsurgical excision of vestibular schwannoma. Otol Neurotol 31(7):1144–1152

    Article  Google Scholar 

  52. Yamakami I, Ito S, Higuchi Y (2014) Retrosigmoid removal of small acoustic neuroma: curative tumor removal with preservation of function. J Neurosurg 121(3):554–563

    Article  Google Scholar 

  53. Yang I, Sughrue ME, Han SJ, Fang S, Aranda D, Cheung SW, Pitts LH, Parsa AT (2009) Facial nerve preservation after vestibular schwannoma Gamma Knife radiosurgery. J Neuro-Oncol 93(1):41–48

    Article  Google Scholar 

  54. Zygourakis CC, Oh T, Sun MZ, Barani I, Kahn JG, Parsa AT (2014) Surgery is cost-effective treatment for young patients with vestibular schwannomas: decision tree modeling of surgery, radiation, and observation. Neurosurg Focus 37(5):E8

    Article  Google Scholar 

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Acknowledgements

We greatly appreciate Ms. Joanna Fishbein, MPH, for her assistance with parts of the statistical analyses.

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Authors and Affiliations

  1. Department of Neurosurgery, Northwell Neuroscience Institute, North Shore University Hospital, 300 Community Dr. 9T, Manhasset, NY, 11030, USA

    Amrit K. Chiluwal, Alyssa Rothman & Amir R. Dehdashti

  2. Department of Otolaryngology, North Shore University Hospital, Manhasset, NY, USA

    Maja Svrakic

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  1. Amrit K. Chiluwal
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  2. Alyssa Rothman
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  4. Amir R. Dehdashti
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Correspondence to Amrit K. Chiluwal.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Hofstra-Northwell School of Medicine) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

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Comments

Small vestibular schwannomas (sVS) are a constant source of controversies in neurosurgery, and for many reasons. First, the ultimate endpoint of tumor control becomes more valid the longer the follow-up time, and it is indeed challenging to keep a study going for, say, ten years. Other endpoints, such as hearing and in particular facial function, may be subject to bias, and they are usually evaluated and reported by the treating doctor. Even more, it has become increasingly apparent that it may not be the tumor per se that constitutes the real problem from the patients’ perspective, but instead the complaints. This brings in the issue of patient-reported data, adding even more information into the broil. Further, there are three main treatment options which are fundamentally different. And finally, even if tens of thousands of patients have received treatment, only a few hundred have entered into comparative studies. The few studies which are done suggest better outcomes for radiosurgery than for microsurgery. In the present issue of Acta, Chiluwal (1) and coworkers present outcomes of patients operated by one surgeon in one center. The tumor removal, hearing, and facial nerve outcomes are excellent, exceeding those from the comparative studies. As indicated by the authors, the outcomes would be even more valid if they were presented as part of a multicenter comparative prospective study. The international neurosurgical community should meet the challenge in establishing such studies. Until then, we have to base our practice on case series like the one presented here.

Morten Lund-Johansen

Bergen, Norway

Chiluwal AK, Rothman A, Svrakic M, et al., (2018) Surgical outcome in smaller symptomatic vestibular schwannomas. Is there a role for surgery? Acta Neurochirurgica

The incidence of vestibular schwannomas is increasing, and the tumor size at diagnosis is steadily decreasing. Today, most patients are diagnosed with smaller tumors that do not compress the brainstem or adjacent cranial nerves. Any form of active treatment will decrease the patients quality of life compared to patients who are just followed by serial MRI scans. Unless the tumor is growing, the primary, or only, reason for active treatment should, therefore, be hearing preservation, and the results of any active treatment must be compared to the spontaneous course of the disease. In none of the 30 patients in the present study, tumor growth was documented, and the results should therefore primarily be compared to the natural history of similar-sized tumors. In light of this, I would contest the authors’ final conclusions about surgical treatment of smaller VS without documented growth.

Jacob Bertram Springborg

Denmark

This article is part of the Topical Collection on Tumor—Schwannoma

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Chiluwal, A.K., Rothman, A., Svrakic, M. et al. Surgical outcome in smaller symptomatic vestibular schwannomas. Is there a role for surgery?. Acta Neurochir 160, 2263–2275 (2018). https://doi.org/10.1007/s00701-018-3674-x

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  • DOI: https://doi.org/10.1007/s00701-018-3674-x

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