title: Surgical management of vestibular schwannomas after failed radiation treatment.
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.
authors.affiliation: Division of Neurosurgery, Duke University Medical Center, 1000 Trent Drive 4520 Hosp South, Durham, NC, 27710, Box 3807, USA. ynonaka1971@yahoo.co.jp.|Department of Neurosurgery, Fukushima Takanori Skull Base Center, Shin-yurigaoka General Hospital, 255 Furusawa Asao-ku, Kawasaki, Kanagawa, 215-0026, Japan. ynonaka1971@yahoo.co.jp.
authors.forename: Yoichi
authors.initials: Y
authors.lastname: Nonaka
authors.affiliation: Division of Neurosurgery, Duke University Medical Center, 1000 Trent Drive 4520 Hosp South, Durham, NC, 27710, Box 3807, USA.|Carolina Neuroscience Institute, 4030 Wake Forest Rd suite 115, Raleigh, NC, 27612, USA.
authors.forename: Takanori
authors.initials: T
authors.lastname: Fukushima
authors.affiliation: Division of Neurosurgery, Duke University Medical Center, 1000 Trent Drive 4520 Hosp South, Durham, NC, 27710, Box 3807, USA.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Watanabe
authors.affiliation: Division of Neurosurgery, Duke University Medical Center, 1000 Trent Drive 4520 Hosp South, Durham, NC, 27710, Box 3807, USA.
authors.forename: Allan H
authors.initials: AH
authors.lastname: Friedman
authors.affiliation: Duke Otolaryngology-Head & Neck Surgery, 3480 Wake Forest Road, Suite 404, Raleigh, NC, 27609, USA.
authors.forename: Calhoun D
authors.initials: CD
authors.lastname: Cunningham
authors.affiliation: Division of Neurosurgery, Duke University Medical Center, 1000 Trent Drive 4520 Hosp South, Durham, NC, 27710, Box 3807, USA.
authors.forename: Ali R
authors.initials: AR
authors.lastname: Zomorodi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005154:Facial Nerve / Q000473:pathology / Q000601:surgery*; D005158:Facial Paralysis / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009464:Neuroma, Acoustic / Q000532:radiotherapy / Q000601:surgery*; D011183:Postoperative Complications / Q000601:surgery; D016634:Radiosurgery / Q000009:adverse effects; D016879:Salvage Therapy; D016896:Treatment Outcome; D055815:Young Adult
keywords: Acoustic neuroma; Radiosurgery; Salvage microsurgery; Stereotactic radiation therapy; Vestibular schwannoma