Management of Residual Tumor after Limited Subtotal Resection of Large Vestibular Schwannomas

 Lessons Learned and a Rationale for Specialized Care

World Neurosurg. 2017 Jun 21;:

Authors: Copeland WR, Carlson ML, Neff BA, Driscoll CLW, Link MJ

Abstract

BACKGROUND: In an era where subtotal resection (STR) is increasingly utilized, we have encountered a growing number of patients referred to our institution with limited resection of large vestibular schwannomas (VS), at times associated with grave complications.

OBJECTIVE: We highlight lessons learned in the management of large VS and provide a rationale for specialized care.

METHODS: A prospectively maintained database of over 2,000 patients with VS evaluated at our institution between 2000 and 2016 was reviewed. Details regarding 10 patients with residual tumor after limited STR are reviewed, three of whom are presented in detail to illustrate key aspects of management.

RESULTS: All but one patient underwent their initial operation at private hospitals without a designated skull base team. The median posterior fossa tumor diameter at the time of initial operation was 4.0cm, whereas that of residual tumor at the time of our evaluation was 3.5cm. Prior to referral, three patients had undergone fractionated radiation therapy following their initial operation; one had undergone stereotactic radiosurgery. Four patients had moderate to severe facial weakness, two had permanent sequela from stroke including hemiparesis and blindness, and seven had ongoing symptomatic brainstem compression and/or hydrocephalus.

CONCLUSIONS: The management of large VS remains challenging, including treatment of presenting hydrocephalus, maximizing the extent of resection while optimizing facial nerve outcome, and avoiding complications. The majority of cases should be approached with the intent of complete resection, realizing that STR may become necessary based on intraoperative findings.

PMID: 28647663 [PubMed - as supplied by publisher]

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