title: Staged Gamma Knife radiosurgery after tailored surgical resection: a novel treatment paradigm for glomus jugulare tumors.
abstract: OBJECTIVE
  Although benign and slow growing, glomus jugulare tumors can be locally aggressive because of their proximity to lower cranial nerves and major vascular structures. Surgical resection frequently leads to complications, and radiosurgery alone often does not relieve symptoms. We report a novel treatment paradigm of tailored surgical resection followed by staged radiosurgery that allows for tissue diagnosis and immediate improvement of symptoms and tumor control without the morbidity of radical surgical resection.
  
  
  METHODS
  Five patients with glomus jugulare tumors and contraindications to extensive surgery each underwent an outpatient otologic procedure to resect the portion of the tumor in the middle ear and mastoid with no attempt to remove tumor in the jugular bulb. Each patient returned 2-5 months later for Gamma Knife radiosurgery to the remainder of the tumor, which consisted of one 15-Gy dose prescribed to the 50% isodose curve. Patients were followed through outpatient visits and surveillance MR imaging for up to 3 years.
  
  
  RESULTS
  All patients were successfully treated as outpatients. Each had improvement or resolution of pulsatile tinnitus and otalgia and preserved or improved hearing. One patient developed a delayed facial palsy prior to radiosurgery that resolved completely; there were no other changes in cranial nerve function after either procedure. Tumor volume was stable or reduced in all patients at most recent follow-up, and there were no immediate or delayed complications.
  
  
  CONCLUSIONS
  Staged outpatient microsurgical and radiosurgical therapy for glomus jugulare tumors in the symptomatic patient is safe and yields favorable results regarding tumor size, tinnitus, hearing and cranial nerve status.
authors.affiliation: Department of Neurological Surgery, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, Ohio 44106, USA.
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Miller
authors.forename: Maroun
authors.initials: M
authors.lastname: Semaan
authors.forename: Douglas
authors.initials: D
authors.lastname: Einstein
authors.forename: Cliff A
authors.initials: CA
authors.lastname: Megerian
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Maciunas
mesh_terms: D000368:Aged; D004428:Ear Neoplasms / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D005925:Glomus Jugulare Tumor / Q000601:surgery*; D006801:Humans; D008875:Middle Aged; D008953:Models, Anatomic; D016634:Radiosurgery / Q000009:adverse effects / Q000379:methods*; D012086:Reoperation / Q000009:adverse effects / Q000379:methods*; D012888:Skull Neoplasms / Q000601:surgery*; D016896:Treatment Outcome