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Newly diagnosed patients with Acoustic Neuroma (Individuals Considering Microsurgery) Richard J. Wiet, MD FACS Northwestern & Ear Institute of Chicago Acknowledgements : • • • • • 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 • • • • 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 • • • • 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 • • • • 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 – – – – 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