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Surgical management of vestibular schwannomas after failed radiation treatment

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Abstract

Increasing numbers of patients with vestibular schwannoma (VS) have been treated with focused-beam stereotactic radiation treatment (SRT) including Gamma knife, CyberKnife, X-knife, Novalis, or proton beam therapy. The purpose of this study was to document the incidence of tumor regrowth or symptoms that worsened or first developed following SRT and to discuss surgical strategies for patients who have failed SRT for VS. A consecutive series of 39 patients with SRT failed VS were surgically treated. Clinical symptoms, tumor regrowth at follow-up, intraoperative findings, and surgical outcome were evaluated. There were 15 males and 24 females with a mean age of 51.8 years. Thirty-six patients (92.3 %) demonstrated steady tumor growth after SRT. Two (5.1 %) patients with slight increase of the mass underwent surgical resection because of development of unbearable facial pain. Symptoms that worsened or newly developed following SRT in this series were deafness (41 %), dizziness (35.9 %), facial numbness (25.6 %), tinnitus (20.5 %), facial nerve palsy (7.7 %), and facial pain (7.7 %). Intraoperative findings demonstrated fibrous changes of the tumor mass, cyst formation, and brownish-yellow or purple discoloration of the tumor capsule. Severe adhesions between the tumor capsule and cranial nerves, vessels, and the brainstem were observed in 69.2 %. Additionally, the facial nerve was more fragile and irritable in all cases. Gross total resection (GTR) was achieved in 33.3 % of patients, near-total resection (NTR) in 35.9 %, and subtotal resection (STR) in 30.8 % of patients. New facial nerve palsy was seen in seven patients (19.4 %) postoperatively. Our findings suggest that patients with VS who fail SRT with either tumor progression or worsening of clinical symptoms will have an increased rate of adhesions to the neurovascular structures and may have radiation-influenced neuromalacia. Salvage surgery of radiation-failed tumors is more difficult and will have a higher risk of postoperative complications. Radical total resection may not be feasible, and conservative modality of subtotal resection needs to be considered to avoid new neurologic deficits.

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Acknowledgments

The authors wish to thank Tsutomu Masuda, MD, Hiromi Gotoh, MD, Takuro Inoue, MD, Hikaru Mizobuchi, MD, and Kenichi Sakamoto, MD, for providing the follow-up studies and examinations.

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Authors and Affiliations

  1. Division of Neurosurgery, Duke University Medical Center, 1000 Trent Drive 4520 Hosp South, Durham, NC, 27710, Box 3807, USA

    Yoichi Nonaka, Takanori Fukushima, Kentaro Watanabe, Allan H. Friedman & Ali R. Zomorodi

  2. Carolina Neuroscience Institute, 4030 Wake Forest Rd suite 115, Raleigh, NC, 27612, USA

    Takanori Fukushima

  3. Duke Otolaryngology-Head & Neck Surgery, 3480 Wake Forest Road, Suite 404, Raleigh, NC, 27609, USA

    Calhoun D. Cunningham III

  4. Department of Neurosurgery, Fukushima Takanori Skull Base Center, Shin-yurigaoka General Hospital, 255 Furusawa Asao-ku, Kawasaki, Kanagawa, 215-0026, Japan

    Yoichi Nonaka

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  1. Yoichi Nonaka
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Correspondence to Yoichi Nonaka.

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

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Rick A. Friedman, Los Angeles, USA

This is a well-written retrospective analysis of surgical salvage after prior radiation treatment. The authors are very experienced and outline the difficulties inherent in treating previously irradiated tumors. Of significant note, and something we are observing as well, the number of radiation failures appears to be on the rise. This article adds significantly to the literature and acknowledges that we must all be prepared for these difficult cases and patients undergoing radiation for VS must be followed long-term.

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Nonaka, Y., Fukushima, T., Watanabe, K. et al. Surgical management of vestibular schwannomas after failed radiation treatment. Neurosurg Rev 39, 303–312 (2016). https://doi.org/10.1007/s10143-015-0690-7

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