title: Multisession stereotactic radiosurgery for large vestibular schwannomas.
abstract: OBJECTIVE
  Microsurgery is not the only option for larger vestibular schwannomas (VSs); recent reviews have confirmed the feasibility and efficacy of radiosurgery for larger VSs. This study illustrates the outcomes of a series of large VSs after multisession stereotactic radiosurgery (SRS).
  
  
  METHODS
  A series of 33 VSs larger than 8 cm(3) (range 8-24 cm(3), mean 11 cm(3), median 9.4 cm(3)) were treated using the CyberKnife from 2003 to 2011 with the multisession SRS technique in 2-5 fractions (14-19.5 Gy). Five patients had undergone surgical removal and 5 had ventriculoperitoneal shunts. Nine patients were eligible for but refused surgery. Twelve patients were older than 70 years and 5 were younger than 40 years. Two female patients had neurofibromatosis.
  
  
  RESULTS
  The follow-up period ranged from 12 to 111 months (median 48 months); radiological growth control was achieved in 94% of cases: 19 tumors (58%) displayed no size variation or reduction in tumor diameter; 12 (36%), after a transient enlargement, presented with arrested growth or shrinkage. Seven patients had a volume reduction of more than 50%. Two patients (6%) needed debulking and 2 were treated with ventriculoperitoneal shunts. Actuarial progressionfree survival rates at 1 year and 5 years were 97% and 83%, respectively. Hearing was retained in 7 of the 8 patients with serviceable baseline hearing. Adverse events were limited to 1 case each of vertigo, tongue paresthesia, and trigeminal neuralgia.
  
  
  CONCLUSIONS
  The good control rate obtained with multisession SRS deepens the controversy of the radiobiology of VSs and may extend the indication of radiation therapy (fractionated or SRS) for large VSs to include patients without symptoms of mass effect. The limited number of cases and short follow-up period do not provide sufficient support for widespread application of multisession SRS in young patients. Further studies with multisession SRS are warranted.
authors.affiliation: Center of Stereotactic Radiosurgery, S. Bortolo City Hospital, Vicenza; and.
authors.forename: Leopoldo
authors.initials: L
authors.lastname: Casentini
authors.forename: Umberto
authors.initials: U
authors.lastname: Fornezza
authors.forename: Zeno
authors.initials: Z
authors.lastname: Perini
authors.forename: Egle
authors.initials: E
authors.lastname: Perissinotto
authors.forename: Federico
authors.initials: F
authors.lastname: Colombo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004307:Dose-Response Relationship, Radiation; D005260:Female; D005500:Follow-Up Studies; D006309:Hearing; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009464:Neuroma, Acoustic / Q000473:pathology / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D016634:Radiosurgery / Q000379:methods*; D016019:Survival Analysis; D016896:Treatment Outcome; D014722:Vestibule, Labyrinth / Q000473:pathology
keywords: BED = biologically effective dose; CyberKnife; IQR = interquartile range; NF = neurofibromatosis; SRS = stereotactic radiosurgery; VS = vestibular schwannoma; multisession radiosurgery; radiosensitivity; stereotactic radiosurgery; vestibular schwannoma; α/β ratio