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Acoustic Schwannoma/Neuroma

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Less then 1 cm tumour / no hearing impairment
- Observation
- Yearly MallRI scan & audiometry
Early sm tumor: (size <2.5>3.5 cm) / brainstem compression
- Facial Nr preservation not possible: Surgery
- Facial Nr Preservation possible: Surgery only with complication
Safe Surgery + radiosurgery
- Surgery not possible: Fractionated radiotherapy

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Acoustic Schwannoma/Neuroma

  1. 1. Acoustic schwannoma/ neuroma Less then 1 cm tumour / no hearing impairment - Observation - Yearly MRI scan & audiometry Early small tumor: (size <2.5 cm) - Hearing function present: Radiosurgery - Hearing function not present: Radiosurgery or surgery Larger tumour (>3.5 cm) / brainstem compression - Facial Nr preservation not possible: Surgery - Facial Nr Preservation possible: Surgery only with complication Safe Surgery + radiosurgery - Surgery not possible: Fractionated radiotherapy Copyright@www.radiosurgery-india.com
  2. 2. Stage I: IAC fill Stage II: Protrude through opening of IAC on the brain Stage III: Growth comes in contact with brainstem Stage IV: brainstem compression AN: Koos Classification Copyright@www.radiosurgery-india.com
  3. 3. Prospective studies: >100 Total number of patient treated with RS: >10,000 Follow up period: ≈20 yrs In AN <2.5 cm treated with SRS, PFS at 20 years – 95-98% Facial Nr palsy – 0.5% Symptomatic Progression – 2-3% Severe toxicity – 0.1% Copyright@www.radiosurgery-india.com
  4. 4. AN: Radiosurgery – Early studies Higher dose; lower hearing function preservation Preservation rate (%) Author (yr) FU (mo) n Vol (cc) Marginal dose (Gy) Local control (%) CN V CN VII Hearing Leksell (1971) 44.4 160 <3 cm 18-25 81 82 86 20 Flickinger (1993) 24 134 2.57 12-20 89.2 67.1 71 35 Foote (1995) 16 36 3.14 16-20 100 41.4 33.5 41.7 Mendenhall (1996) >12 56 - 10-22.5 95 78.6 78.6 NA Kondziolka (1998) >60 162 2.2 cm 16.6 98 73 73 51 Suh (2000) 49 29 2.1 8-24 94 85 68 26 Copyright@www.radiosurgery-india.com
  5. 5. AN: Radiosurgery – Dose <13 Gy, long term FU Author (yr) n FU (yr) Vol (cc) Median Dose (Gy) Local control (%) CN V CN VII Hearing Prasad (2000) 153 4.27 2.6 13 92 98.3 98.4 58 Unger (2002) 100 6.3 3.4 13 96 100 98 55 Chopra (2007) 216 5.7 1.3 13 93 96 94 68 Hasegawa (2005) 317 >5 - 12 93 100 94 60 Myrseth (2005) 103 >4 - 12.5 93 - 98.3 33.3 Kim (2007) 59 6 3.4 12 93 - 98.3 32 Iwai (2008) 25 7.4 0.27 12 100 100 100 64 Niranjan (2008) 96 3.5 - 13 99 100 100 64.5 Fukuoka (2009) 152 >5 2 12 94 97.4 100 64.5 Murphy (2010) 103 3.6 1.95 13 91.5 92 95 55 Combs (2006) 26 9 2.2 12.5 99 99.3 99.3 NA Friedman (2006) 295 3.3 1.5 13 91 92 95 55 Kalogeridi (2009) 19 4.6 11 13 99.3 99.3 99.3 NA Lower dose; Higher hearing function preservation; less toxicity Copyright@www.radiosurgery-india.com
  6. 6. Enlargement of tumour after radiosurgery? Post-SRS transient enlargement of tumour occurs Due to radiation effect on tumour and replacement with granulation tissue Subsides/ regress after 1.5 to 2 yr Kapoor S et al; IJROBP 2010Copyright@www.radiosurgery-india.com
  7. 7. Kondziolka et al NEJM 1998 Prospective evaluation of AN pts (n=162) Regression of tumour in majority of pts Regression is slow & occurs over years
  8. 8. MarginalDose(Gy) Year 7-45 Gy 20 Gy 15 Gy 12 Gy Local control maintained (>95% at 10 years) Toxicities have come down Hearing preservation increased RT dose (Gy) Complication rate (%) 10-12.5 13 15-17.5 (TV<5.5 cm3 ) 9 15-17.5 (TV>5.5 cm3 ) 71 20-22.5 100 Dose reduction have reduced toxicity without compromise on local control Mendenhal et al 2000 Copyright@www.radiosurgery-india.com
  9. 9. Hydrocephalus Vertigo/ tinnitus Cranial Nr Palsy Complications depends upon dosage schedule
  10. 10. Surgery possible after SRS ? After SRS only few patients progress, they need surgery SRS causes regression of blood supply, hence should be easy for resection In a study, 8/13 pts with progression after SRS had difficult surgery !! No clear contraindication of surgery after RS Pollock et al; J Neurosurg 1998 Copyright@www.radiosurgery-india.com
  11. 11. Higher risk of second malignancy after SRS ? After radiosurgery risk of second malignancy is very low No report of any second malignancy after 7500 AN pt treatment in 18 yrs Estimated risk 1: 1000 (0.001%) Only two reported case of second malignancy 1. In Japan 4 yrs after surgery 2. Temporal lobe GBM 7.5 yrs after radiosurgery Kondziolka et al 2000 Copyright@www.radiosurgery-india.com
  12. 12. AN: Radiotherapy – Long-term follow up (>10 yrs) Local control: 95-98%; Hearing function preservation: 70-80% Author (yr) n FU (mo) Vol (cc) Median Dose (Gy) LC (%) CN V CN VII Hearing Kalapurakal (1999) 19 54 3.5 cm 36/6# 100 100 100 100 Fuss (2000) 51 42 8.6 57.6/30# 100 95.2 100 85 Meijer (2003) 80 33 2.5 cm 25/5# 94 98 97 61 Sawamura (2003) 101 45 1.9 cm 50/25# 91.4 96 100 71 Selch (2004) 48 36 2.5 54/30# 100 97.8 97.9 93 Chan (2005) 70 45.3 2.4 54/30# 100 96 99 84 Lin (2005) 16 48 1.75 cm 54/30# NA NA NA 90 Combs (2005) 106 48.5 3.9 57.6/30# 96.6 96.6 97.7 94 Koh (2007) 60 31.9 4.9 50/25# 100 100 100 77.3 Thomas (2007) 34 36.5 1 45/25# 100 100 94 63 Copyright@www.radiosurgery-india.com
  13. 13. Comparative study: Fractionated RT Vs SRS Author (yr) RT type n FU (mo) Dose (Gy) LC (%) CN V CN VII Hearing Andrews Philadelphia (2001) FSRT 56 115 Wk 50/25# 97 93 98 81 SRS 69 115 Wk 12 98 95 98 33 Combs Hiedelburg (2010) FSRT 172 75 mo 57.6/33# 96 97 98 78 SRS 19 75 mo <13Gy 96 100 95 78 SRS 11 75 mo >13Gy 96 93 88 NA Kopp Germany (2011) FSRT 47 32.1 54/30# 97.9 NA 100 79 SRS 68 30.1 12 98.5 NA 100 85 Collen Belgium (2011) FSRT 78 62 50/25# 95 NA 88 68 SRS 41 62 12.5 95 NA 88 59 No difference in local control, hearing preservation & toxicity profile Copyright@www.radiosurgery-india.com
  14. 14. Fractionated RT Vs SRS (n=202) Local Control: FSRT vs SRS ( FU= 75 mo) Coumb et al IJROBP 2000 FSRT vs SRS: No difference in local control
  15. 15. FSRT vs SRS <13 Gy dose Coumb et al IJROBP 2000 FSRT vs SRS: No difference in hearing function preservation Hearing function preservation Copyright@www.radiosurgery-india.com
  16. 16. CLINICAL INVESTIGATION LONG-TERM OUTCOMES OF VESTIBULAR SCHWANNOMAS TREATED WITH FRACTIONATED STEREOTACTIC RADIOTHERAPY: AN INSTITUTIONAL EXPERIENCE SUMIT KAPOOR, M.B.B.S., M.P.H.,* SACHIN BATRA, M.B.B.S., M.P.H.,* KATHRYN CARSON, SC.M.,y JOHN SHUCK, B.A.,* SIDDHARTH KHARKAR, M.B.B.S., M.H.S.,* RAHUL GANDHI,* JUAN JACKSON, C.M.D.,z JAN WEMMER, C.R.N.P.,z STEPHANIE TEREZAKIS, M.D.,z ORI SHOKEK, M.D.,z LAWRENCE KLEINBERG, M.D.,z AND DANIELE RIGAMONTI, M.D.* Departmentsof *Neurosurgery and z Radiation Oncology, JohnsHopkins Hospital, Baltimore, MD; and y Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Purpose: We assessed clinical outcome and long-term tumor control after fractionated stereotactic radiotherapy (FSRT) for unilateral schwannoma. Methods and Materials: Between 1995 and 2007, 496 patients were treated with fractionated stereotactic radio- therapy at Johns Hopkins Hospital (Baltimor e, MD); 385 patients had radiologic follow-up that met the inclusion criteria. The primary endpoint was treatment failure. Secondary endpoints were radiologic progression and clin- ical outcome. Logistic regression analysis assessed the association of age, race, tumor side, sex, and pretreatment symptoms. Results: In 11patients(3%) treatment failed, and they required salvage(microsurgical) treatment. Radiologic pro- gression was observed in 116 patients (30.0%), including 35 patients (9%) in whom the treatment volume more than doubled during the follow-up period, although none required surgical resection. Tumors with baseline vol- umesof lessthan 1 cm3 were18.02 timesmorelikely to progressthan thosewith tumor volumesof 1cm3 or greater (odds ratio, 18.02; 95% confidence interval, 4.25–76.32). Treatment-induced neurologic morbidity included 8 pa- tients(1.6%) with new facial weakness, 12 patients(2.8%) with new trigeminal paresthesias, 4patients(0.9%) with hydrocephalus (1 communicating and 3 obstructive), and 2 patients (0.5%) with possibly radiation-induced neo- plasia. Conclusions: Although the rate of treatment failure islow (3%), careful follow-up shows that radiologic progres- sion occurs frequently. When reporting outcome, the ‘‘no salvage surgery needed’’ and ‘‘no additional treatment needed’’ criteria for treatment success need to be complemented by the radiologic data. Ó 2010 Elsevier Inc. Vestibular schwannoma, Fractionated stereotactic radiotherapy, Tumor progression, Clinical outcomes. N=496 Median FU= 52 mo Range= 5-138 mo Salvage surgery= 11 (3%) Radiological progression: 30% Vol doubled: 9% Facial weakness: 1.6% Trigimenal: 2.8% Hydrocephalus: 0.9% RT dose: 25Gy/5#: 76% pt 30Gy/10#: 24% pt Copyright@www.radiosurgery-india.com
  17. 17. Larger volume tumour treated with high dose have radiological progression Radiological progression with fSRT Copyright@www.radiosurgery-india.com
  18. 18. Gender (M:F) 7:9 Age Median (range) (yrs) 51(19-74) Side (R:L:BL) 9:21:2 Pre-SRS hearing function Serviceable HL 20 (63%) Non-Serviceable HL 12 (37%) Pre-SRS facial function status H-B Scale I 22(69%) H-B Scale II 3 (9%) H-B Scale III 5 (15%) H-B Scale IV - H-B Scale V 2 (7%) SRS Technique Frameless Framebased 19 (59%) 13 (41%) Dose Median (range) (Gy) 14 (12-26.2) FU Median (range) (mo) 6.5 (6-8) ASH Experience: (n=32) Balaji, Mahadev, Dutta et al, AROICON 2011 N=32 CyberKnife: 19 pt BrainLAB: 13 pt Serviceable hearing function : 20 pt N=32 CyberKnife: 19 pt BrainLAB: 13 pt Serviceable hearing function : 20 pt
  19. 19. Grade   PT ave (dB) Grade I (good- excellent) 0-30 Grade II (serviceable) 31-50 Grade III (non-serviceable) 51-90 Grade IV (poor) 91-max Grade V (none) Not testable Hearing function assessment Gardner Robertson Scale Gardner G, Robertson JH (1988 )Hearing preservation in unilateral acoustic neuroma surgery. Ann Otol Rhinol Laryngol 97: 55–66. Objective assessment of auditory function Copyright@www.radiosurgery-india.com
  20. 20. Grade Description Measurement Function % I Normal 8/8 100 II Slight 7/8 76 - 99 III Moderate 5/8 - 6/8 51 - 75 IV Moderately Severe 3/8 - 4/8 26 - 50 V Severe 1/8 - 2/8 1 – 25 VI Total 0/8 0 House Brackman Scale "Measurement" is determined by measuring the superior movement of mid-portion of the superior eye brow and the lateral movement of oral commissure. A scale point of 1 is assigned for each 0.25 cm of motion up to 1 cm for both eye brow and commissure movement. The points are then added together. Facial function assessment
  21. 21. Post-SRS Pre SRS Total** I II III IV I 3 0 0 0 3 II 4 6 0 0 10 III 1 6 5 0 12 IV 0 0 6 1 7 TOTAL* 8 12 11 1 32 *Total number of pts with corresponding GR scale in column pre-SRS; ** Total number of pts with corresponding GR scale in the row post-SRS; Group of pts, hearing improved or remained within 20-dB considered hearing preservation Gardner Robertson scale: Hearing function Pre & post-SRS (6 month) evaluation (n=32)
  22. 22. Post- SRS Pre-SRS Total** I II III IV V I 21 0 0 0 0 21 II 1 2 0 0 0 3 III 0 2 4 0 0 6 IV 0 0 0 0 0 0 V 0 0 0 0 2 2 TOTAL* 22 4 4 0 2 32 *Total number of patients with corresponding HB scale in the column pre-SRS ** Total number of patients with corresponding HB scale in the row post-SRS House Brackman Grading: Facial Nr Function Pre & post-SRS (6 month) evaluation (n=32)
  23. 23. Dosimetric comparison between BrainLAB & CyberKnife Unilateral AN pt Serviceable hearing function Age <25 years Size <3 cm Contouring done with CT scan & MRI GTV = post-contrast enhancement PTV margin = 2 mm Dose= 13-15 Gy single fraction OARs (Choclea, Brainstem, Mesial temporal lobe) Planning & calculation was done with appropriate calculation algorithms. Isodose plans & DVHs generated by the two systems were compared Prescribed isodose in both the systems were considered adequate to cover at least 95% of PTV Planning with BrainLAB system Forward planning Arc no: 5-9 Planning with CyberKnife system Inverse planning Beamlet no: 70-150 (n=7)
  24. 24. CK BrainLAB p-value* Mean tumour Vol (cc) 1.2±0.9 1.3±1 0.917 Conformity Index (CI) 0.53±0.06 0.58±0.07 0.225 10Gy Vol (cc) 3.2±1.1 5.2±1.6 0.017 5Gy Vol (cc) 11.8±4.9 16.8±6.2 0.129 2.5Gy Vol (cc) 39.9±17.2 52.3±19.8 0.238 Max dose brainstem (Gy) 4.9±3.1 4.7±2.6 0.935 Mean cochlea dose (Gy) 5.4±0.6 6.9±0.7 0.001 Mean mesial temporal lobe dose (Gy) 1.7±0.9 2.6±0.9 0.07 Dutta et al, J Neurooncol 2012 Comparison BrainLAB & CyberKnife plan No difference in target coverage High dose spillage significantly less with CK Dose to critical structures (cochlea & temporal lobe) significantly less with CK *Non parametric test
  25. 25. Pt survey: Sx vs SRS (n=1553) Issues Surgery^ RS* Mean tumour size 25 mm 22 mm Offers positive recommendation 74% 95% No change in employment 68% 69% New balance problem 78% 7% New onset tinnitus 57% 3% New facial Nr Dysfunction 63% 10% ^ Martin etal Skull Base Surg 1996 * Kondziolka et al J Neurosurg 2001 Patient acceptance & toxicity profile better with radiosurgery (n=1553) New symptoms Hearing function preservation is possible with SRS
  26. 26. SRS for AN FU >5 yrs ; <10 yrs Q. Radiosurgery met your expectation? YES 92% Q. Was radiosurgery good treatment? YES 95% Q. Will you recommend radiosurgery to any one? YES 95% (n=115) Patient satisfaction survey* Kondziolka et al NEJM 1998
  27. 27. Conclusions Koos I&II: (AN <2.5 cm) Serviceable hearing function: SRS preferred Non-serviceable hearing function: SRS or surgery Koos III&IV: (Larger tumour/ brainstem compression) Facial Nr preservation not possible: Surgery Facial Nr Preservation possible: Surgery / Safe Surgery + SRS Surgery not possible: FSRT Copyright@www.radiosurgery-india.com
  28. 28. Practice survey: Neurosurgeons choice* 37 yr male, 2.5 cm AN Unilateral symptomatic, serviceable hearing function *Congress of Neurological Surgeons July 2002 Neurosurgeon’s age (n=663) Copyright@www.radiosurgery-india.com

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