Download Newly Diagnosed Patients with Acoustic Neuroma

Newly diagnosed patients with
Acoustic Neuroma
(Individuals Considering Microsurgery)
Richard J. Wiet, MD FACS
Northwestern & Ear Institute of
Chicago
Acknowledgements :
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Neurosurgeons
Colleagues in Neurotology
Neurological nursing OR
Neuro-anesthesia
Neuro-ICU Nursing
Acoustic Neuromas
• 10% of intra-cranial tumors
• Arise in the balance nerve sheath
• 90% are vestibular schwannoma
• Most grow about 2.0 mm / year
Growth rate of schwannoma
• Probable that most are stable for years, but if
observed for a decade, likely it will grow
• Rapid growth is rare; however, there are
exceptions
• Measure either INTRA-canilicular (small) or the
EXTRA-canilicular (greatest dimension) by
sequential MRI
Newly diagnosed, now what?
• Understanding of Natural History of tumor
– Growth rate
– Exceptions to slow growth - discussion
• Classification of these tumors: Jackler
• Watch for any sign of neurological change
Category or classification
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Intra-canilicular
Cisternal
Brain stem compressive
Hydrocephalic (may be life threatening)
• Small > 1.0 cm
• Medium 1.0 – 2.5
• Large (giant) 2.5 to 4.0 or larger
Your first visit to physician
• Bring the actual MRI
• Expect a hearing test
• Inquire as to the level of experience—
team & Neuro ICU. Who is in charge?
Warning about rapid growth
• Sudden change in neurological status
– Observation phase & change
– Post radiation---rare
– Intra tumor hemorrhage---very rare
• Pregnant?
• NF-2
• Cystic tumors
2003 MRI
2007 MRI
Conservative posture
• Elder patient with small tumor
• Infirmed health
• Small tumors in middle life and beyond
(50% show little growth 3 years)
• Does not apply to a young NF2 patient
Microsurgery generally
recommended
• Large tumors – young patients
• NF 2 – especially young patients
• Cystic tumors
• Patient’s choice, after fair explanation of
options
• Post radiotherapy failure
• Intra tumor hemorrhage
Where controversy lies
• Small to medium tumor : surgery (cure?)vs
stereotactic radiotherapy (control?)
• Not controversial for Large Brainstem
compressive disease--surgery
• No controversy that long term follow up
needed for both
Types of surgery
• Hearing preservation attempts
– Middle fossa surgery---ideal < 1.0 cm
– Retro sigmoid
• Remainder of surgery
– Translabyrinthine
– Trans otic
Recent Advances in Surgery
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Endoscopic developments
Lasers developed at MIT
Ultra-sonic aspirators for tumor removal
More sophisticated monitoring
• Studies of combining surgery first,
radiotherapy second—”near total “
Hearing conservation
• ABR
• ENG
• ASSR (research)
• Which nerve is involved?
• Value of the MRI presentation
Types of surgical discussions
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Total removal & risks
Staged surgery
Subtotal removal : capsule remains
Near total removal < “wafer” remains
• Rate of facial paralysis –goes up in tumors
2.0 cm or larger
Post radiation failures
• Focused stereotactic surgery may fail in 2 - 4%
of patients
• Fractionated vs. single dose
• How is failure defined: 1 mm growth in 2
dimensions, 2 mm in one dimension
beyond initial treatment-(may be reported at 60 months after stereotactic
radiosurgery)
Goals of surgery
• Preservation of life & with a reasonable
quality of life
• Preservation of the facial nerve—cannot
be guaranteed
• Preservation of hearing---most difficult
What happens when tumor surgery
is not centralized ?
• CENTALIZED
– Mortality rate : < 1%
– Rate of F. N. paralysis, and CSF leak low
• NOT CENTRALIZED
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Mortality rates of 8.5%
1/3 patients have permanent paralysis
36% CSF leak
Residual tumor
Danish study
Recommendations
• Based on age alone: first option is Surgery for those
less than 55 years old; VS. second option :
Stereotactic radiation
• Based on size: first option is Surgery if more than
2.5 cm in greatest dimension
1.1 to 2.5 cm: Surgery or Stereotactic
• Based on deficit: if neurological deficits are present,
consider Surgery
• Not NU policy
• Based on 25+ years experience
ANA 2007-2008 Patient Survey
• Symptoms related to acoustic neuroma
– 88% of respondents experienced single-sided
hearing loss or deafness
– 73% experienced tinnitus
– 59% experienced vertigo
ANA 2007-2008 Patient Survey
• Surgical approach most frequently chosen option
– Translabyrinthine approach for 33% of respondents
– Retrosigmoid approach for 17% of respondents
– Middle fossa approach for 10% of respondents
• Radiosurgery/Radiotherapy
– Chosen by 20% of respondents in 2007-2008 survey
compared to 5% in the 1998 survey
• Observation
– Chosen by 20% of respondents in 2007-2008 survey
compared to 4% in the 1998 survey
Criteria to consider change
(from observation) :
• Tumor growth of more than 2mm / year
• Tumor size > 25% from prior scan
• Progressive hearing loss, severe
imbalance or progression in facial nerve
symptoms
What I have learned
• Never regretted being conservative with
very small tumors (false + MRI’s)
• Learned most from my complications, how
to avoid them in future
• There is room for all 3 areas of
management
Summary
• Decision about surgery is a personal one
made between patient and physician
• Multiple factors enter into the equation
• It should be a careful decision, with an
analysis of RISK & EXPERIENCE &
PATIENT PREFERENCE