Salvatore Di Maio

Prospective comparison of quality of life before and after observation, radiation, or surgery for vestibular schwannomas

OBJECT The best management strategy for small-to medium-sized vestibular schwannomas (VSs) remains controversial between observation, radiation, and microsurgical resection (surgery). The authors undertook a prospective observational cohort study comparing all 3 therapeutic modalities in patients with VSs, focusing on quality of life (QOL) outcomes. METHODS All patients in the study completed the 36-Item Short Form Health Survey at regular intervals, with a mean follow-up of 31.8 months. Two hundred five (77.7%) of 264 patients completed questionnaires, including 47 who underwent observation, 48 who received either linear accelerator radiosurgery or fractionated radiotherapy (radiation group), and 134 who underwent surgery (of whom 37 had tumors > 3 cm in diameter). Patients allocated to the observation group had smaller tumors than those in the other groups (mean 1.3 cm; p < 0.001). Patients who received radiation were older than patients in the other groups (mean 60.0 years; p < 0.001). RESULTS There were no baseline QOL differences between the observation, radiation, and surgery (tumors <or= 3 cm) groups. Quality of life remained unchanged for the observation and radiation groups throughout the follow-up period. In the surgery group with tumors <or= 3 cm, a significant improvement in total score and composite mental dimension was observed at 24 months. In the surgery group with tumors > 3 cm, there was an early improvement in composite mental dimension at 1.5 months, as well as at 24 months; total score and composite physical dimension were improved at 24 months in this group as well. CONCLUSIONS Based on the current management protocol, patients with VSs enjoy similar QOL throughout the follow-up period after undergoing observation, radiation therapy, or surgery.

Hearing preservation after microsurgical resection of large vestibular schwannomas.

BACKGROUND:Hearing, which is often still clinically useful at presentation even with larger tumors, is a major determinant of quality of life in vestibular schwannoma (VS) patients. OBJECTIVE:To present the hearing preservation rate after surgery in patients with large (≥3 cm) VSs and identify clinical or radiologic predictors of hearing preservation. METHODS:From April 2003 to March 2009, 192 patients underwent resection of a VS, including 46 large (≥3 cm) tumors, of whom 28 had serviceable hearing preoperatively. Six of 28 patients (21.4%) had preserved hearing postoperatively. RESULTS:Mean tumor diameter was 3.6 cm (range, 3.0-5.0 cm) and tumor volume was 17.2 mL (range, 6.9-45.2 mL). For patients with grade A Sanna-Fukushima hearing, the hearing preservation rate was 4 of 11 (36.4%). Complete resection was achieved in 6 of 6 cases with hearing preservation (41/47 for all patients). Six of 6 patients with preserved hearing had a cerebrospinal fluid cleft in the internal auditory canal (IAC) compared with 9 of 16 patients without preoperative hearing and 9 of 20 for patients with serviceable hearing that was lost postoperatively (P = .045). Six of 6 patients with preserved hearing had less than 35% of the tumor anterior to the longitudinal axis of the IAC compared with 13 of 20 in the serviceable hearing that was lost group (P = .036). CONCLUSION:Our series demonstrates hearing preservation is possible for patients with large VSs and should be attempted in all patients with preoperative hearing. The quality of preoperative hearing, a cerebrospinal fluid cleft at the apex of the IAC, and a smaller proportion of tumor anterior to the IAC were positively associated with hearing preservation.

The endoscopic hemi-transseptal approach to the sella turcica: operative technique and case-control study.

Background The hemi-transeptal (Hemi-T) approach was developed to facilitate a binasal two-surgeon endoscopic approach for sellar tumors, with preservation of the nasoseptal flap and selective mobilization for reconstruction. Methods A retrospective case-control study was performed comparing the Hemi-T approach with previously used methods of sellar exposure and reconstruction. Outcome measures included operative time and postoperative nasal morbidity. Results A total of 23 patients underwent the Hemi-T approach versus 42 in whom traditional exposure was performed. Operative time was significantly shorter using the Hemi-T technique (152.6 ± 56.8 versus 205.2 ± 61.3 minutes; p = 0.001), as was the length of hospital stay (3.3 ± 1.9 versus 5.4 ± 3.6 days; p = 0.004). There was no difference in the rates of intraoperative or postoperative cerebrospinal fluid leak, cartilage necrosis, septal perforation, or mucosal adhesions. Conclusion The Hemi-T approach facilitates binasal two-surgeon access to the sella without compromise of the pedicle during the extended sphenoidotomies and tumor removal. Operative time and nasal morbidity is not increased, and iatrogenic injury to the nasal cavity is minimized when a flap is not required.

Analysis of Potential Determinants of a Reduced Intercarotid Distance in Patients Undergoing Endoscopic Transsphenoidal Surgery

Objectives: (1) Evaluate the anatomic variability of the distance between the internal carotid arteries (ICA) at the paraclival, intracavernous, and paraclinoid segments in normal variants and in patients with sellar or parasellar lesions. (2) Identify clinicopathologic factors associated with a reduced intercarotid distance (ICD) and identify subgroups at higher risk for ICA injury during endoscopic skull base surgery. Methods: A retrospective case-control study was performed at an academic tertiary care center. The smallest distance between the ICAs at the paraclival, intracavernous. and paraclinoid segments on coronal T2-weighted magnetic resonance imaging was measured in patients with sellar or parasellar tumors and in nontumor controls. Factors such as demographic profiles, cephalometric measurements, tumor dimensions, and sphenoid configuration were assessed as potential predictors of the ICD. Results: In total, 154 cases and 34 controls were analyzed. Patients with growth hormone (GH) secreting adenomas had a markedly reduced ICD at the paraclival segment as compared to controls (1.59 cm and 1.77 cm, respectively; P = .02; 95% confidence interval [CI] [0.03-0.32]). The paraclinoid ICD was reduced in patients with a planum sphenoidale meningioma (1.09 cm and 1.33 cm, respectively; P = .04; 95% CI [0.01-0.45]). The transverse dimension of pituitary adenomas was linearly correlated to the ICD (P < .001). No narrowing of the ICD was associated with sphenoid configuration or cephalometric measurements. Conclusions: Patients with a GH secreting adenoma or planum sphenoidale meningioma had a reduced ICD. Identifying these populations can help surgeons recognize constraints imposed by a reduced ICD to endoscopic access of the skull base and avoid inadvertent ICA injury.

Current comprehensive management of cranial base chordomas: 10-year meta-analysis of observational studies: Clinical article

OBJECT The role of surgery and adjuvant radiation therapy for cranial base chordomas is not well established. This meta-analysis measures the relationship of complete resection and type of adjuvant radiation therapy to 5-year progression-free survival (PFS) and overall survival (OS) of cranial base chordomas. METHODS A systematic MEDLINE search (1999-present) yielded 23 observational studies and 807 patients who fit inclusion criteria. The following analyses were performed: 1) Kaplan-Meier 5-year PFS and OS compared based on the extent of resection and type of adjuvant radiation therapy using the log-rank method; 2) a random-effects model comparing 5-year PFS with complete or incomplete resection; and 3) paired z-test comparisons of weighted average 5-year OS and PFS grouped by type of adjuvant radiation therapy. RESULTS The weighted average follow-up was 53.6 months. The weighted average 5-year PFS and OS were 50.8% and 78.4%, respectively. Complete resection conferred a higher 5-year PFS than incomplete resection from the random effects model (mean difference in PFS 20.7%; 95% CI 6.57%-34.91%). Patients with incomplete resection were 3.83 times more likely to experience a recurrence (95% CI 1.63-9.00) and 5.85 times more likely to die (95% CI 1.40-24.5) at 5 years versus patients with complete resection. There was no difference in 5-year OS by type of adjuvant radiation, although 5-year PFS was lower in patients receiving Gamma Knife surgery relative to carbon ion radiotherapy (p = 0.042) on paired z-test. No survival difference occurred between radiation therapy techniques on Kaplan-Meier analysis of compiled patient data. CONCLUSIONS Patients with complete resection of cranial base chordomas have a prolonged 5-year PFS and OS. Adjuvant proton-beam, carbon ion, and modern fractionated photon radiation therapy techniques offered a similar rate of PFS and OS at 5 years.

Management of Vestibular Schwannoma Patients: Quality of Life Outcomes After Treatment

The optimum management of vestibular schwannoma patients remains controversial. With improvement in patient outcomes and differing goals of contemporary treatment modalities, patient evaluated ‘quality of life (QOL)’ as an outcome measure has become important. The literature regarding comparison of QOL outcomes between treatment modalities for vestibular schwannoma patients are reviewed. Three prospective Level II studies were identified. Two studies compared gamma knife radiosurgery with surgery, and one study compared observation with surgery as well as LINAC-based stereotactic radiation treatments (fractionated radiotherapy or radiosurgery). All three studies included measures of QOL using the SF-36 inventory. All three studies demonstrated comparable outcomes with regards to tumor growth control. Grade I-II facial nerve preservation was more frequent for radiation in two studies and equivalent with surgery in the third. Hearing preservation was less frequent in the surgical cohorts. SF-36 scores at last follow-up were equivalent between surgery and radiation therapy in two studies; in the third study, there were only small differences. Despite differences in “physician-evaluated” outcome measures between surgery and radiation therapy, and early retrospective patient surveys showing less favorable surgical outcomes, contemporary patients with vestibular schwannomas appear to enjoy good QOL regardless of treatment modality.