Lausanne University Hospital University of Lausanne

Preserving normal
facial nerve function and improving hearing outcome
in large vestibular schwannomas with a combined approach:
planned subtotal resection followed by Gamma Knife

Constantin Tuleasca, MD-PhD

Chief resident neurosurgeon
Roy Thomas Daniel, Constantin Tuleasca, Mercy George, Etienne Pralong, Luis
Schiappacasse, Michele Zeverino, Raphael Maire, Marc Levivier
Background

Objective

Methods

Results

Discussion

Conclusion
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Facial nerve preservation

in large VSs surgery

Background

Objective

Methods

Results

Discussion

Conclusion
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Cochlear nerve preservation

in large VSs surgery

Background

Objective

Methods

Results

Discussion

Conclusion
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Overall outcomes
in large VSs surgery
44 patients
Mean vol: 10.9 cc
Extent of resection:
89%
Background Oncological control:
84%
Objective

Methods

Results

Discussion

Conclusion
 Radiosurgery for vestibular schwannomas
ü Long-term clinical & scientific track record
(mostly Gamma Knife experience, > 20 years)
ü De-escalation of dose prescription
Technical improvement
Background
o long-term tumor control (97-98 %)
Objective
o improved of clinical outcome:
Methods
= risk for facial nerve < 1%
Results = hearing preservation ≥ 70%

Discussion ü Facing patients large VS:

o not suitable for upfront radiosurgery
Conclusion o surgical indication
o high expectations regarding functional results
(equivalent to radiosurgery … )
 Radiosurgery for vestibular schwannomas

Cochlear dose

Background

Objective

Methods Vestibular dose> 8 Gy

increased risk of vestibular problems
Results

Discussion
Vestibule dose= 3.4 Gy

Conclusion

Vestibule dose= 8.4 Gy

 Perform subtotal resection
of large vestibular schwannomas

Background
Followed by
Objective
Gamma Knife radiosurgery (GKR)
Methods

Results

Discussion Aiming at optimal function for

facial and cochlear nerves
Conclusion

MR images from Lausanne University Hospital

artistic image from https://www.nidcd.nih.gov/health/vestibular-schwannoma-acoustic-neuroma-and-neurofibromatosis
Background

Objective

Methods

Results

Discussion

Conclusion
 Combined approach for large VSs:
the concept

Background Management of
large VSs:
Objective
combined approach
Methods planned subtotal removal
followed by GKR
Results

Discussion

Conclusion
 Combined approach for large VSs:
the concept

Management of
Background large VSs:
combined approach
Objective
planned subtotal removal
Methods followed by GKR

Results

Discussion

Conclusion
 Combined approach for large VSs:
the concept

Background

Objective

Methods

Results

Discussion

Conclusion
 Combined approach for large VSs:
the concept
#1 before surgery #2 immediate
after surgery

Background

Objective

Methods

Results #3 six months #4 at the time of GKR

after surgery
Discussion

Conclusion
 Basic demographic data

July 2010 – October 2018:

ü 50 patients with combined approach
ü 46 had surgery and GKR
Background
Pre-operative data (46 patients)
Objective ü Facial nerve function: 45 patients = H-B 1
1 patient = H-B 4
Methods ü 26 patients (56.5%) useful hearing (G-R 1, 2 and 3)
Results
Microsurgery (46 patients)
Discussion ü 40 first treatment
ü 4 GKR failures; 1 Linac-RS & 1 FRT failure
Conclusion ü 5 staged surgeries (residual tumor too large for GK)
 Microsurgery results
Facial nerve function (all patients, n = 46) :
No facial palsy
(all patients H-B I, incl. 1 recovery H-B IV)
Background
Cochlear nerve function (in patients with pre-op hearing):
Objective
Gardner-Robertson class
Before surgery After surgery
Methods GR1 GR1
GR2 GR2
Results
GR3 GR3
Discussion GR4 GR4
GR5 GR5
Conclusion
26 patients in G-R 1, and 3 24 (92.3%) remained G-R 1-3
17 patients in G-R 1 14 (82.3%) remained G-R 1
 Results by groups

Preservation of Preservation of
facial alone facial & cochlear
(n=20) (n=26)
Background

Objective
Mean 14.7 cc (3.6 – 34.9) 8.7 cc (3.6 – 25) *
presurgical volume * p < 0.05
Methods

Results
Mean 35.7 mm (26.1 – 45) 30 mm (20.2 – 42) *
maximal diameter * p < 0.05
Discussion

Conclusion Mean 3.6 cc (0.9 - 12.8) 2.9 cc (0.7 – 7.7)

residual volume 26.3% (6 – 45.3) 35.8% (20.3 – 46.7)
at time of GKR
(% of presurgical volume)
 Results related to Gamma Knife

ü Mean duration between microsurgery & GKR:

6 months (4 – 14)
Median = 6 months
Background ü Prescription dose: 11.9 Gy (11 – 12)
Target volume: 3.2 cc (0.5 – 9.9)
Objective
% of presurgical volume: 31.7 %
Methods ü No new cranial nerve deficit
3 shunt
Results
ü Current follow-up period after surgery:
Discussion
mean 36.9 months (range 6 – 96 months)
Conclusion ü Current follow-up period after GKR:
mean 33 months (range 1 – 84 months)
 Tumour control

4 failures (8.7%)
ü 3 patients who had a second combined approach
(after a first failed combined approach)
Background
o Patients #3, #9, #11
Objective F, 34 y; M, 34 y; F, 32 y (mean 51 y, < 55 y in all VS)
(Very) large pre-opeartive volumes (11, 35, 25 cc)
Methods 2 x staged-surgery
Large post-op volumes (4.0, 12.8, 7.7 cc)
Results
o 2nd combined approach (after 2.6, 2.0, 1.3 Y)
Discussion cranial nerves functions unchanged
Conclusion ü 1 patient (#5) who had a second GKR
(tumor decreased at 1 year follow-up after second GKR)
 Successful combined approach illustration

Background

Objective

Methods

Results

Discussion

Conclusion

Tuleasca, Daniel, Levivier, World Neurosurgery, 2018

 Failure illustration (with second combined approach)

Background

Objective

Methods

Results

Discussion

Conclusion

3 years after second combined approach

 Failure illustration (with second combined approach)
2.495 cc 4.135 cc

Second Gamma Knife 6 months later

Background
4.525 cc 1.566 cc
Objective

Methods

Results 18 months later 48 months later

Discussion

Conclusion

3 years after second combined approach

 Failure illustration (with second Gamma Knife)

Background
Second Gamma Knife
Objective

Methods

Results
6 months later
Discussion

Conclusion

12 months later
Background 9 studies, including 248 patients
ü Tumor control : 93.9% (salvage 5%)
Objective ü HB I-II : 96.1%
ü Serviceable hearing (GR 1-2) : 59.9%
Methods

Results

Discussion

Conclusion
Background

Objective

Methods

Results

Discussion

Conclusion
Background

Objective

Methods

Results

Discussion

Conclusion
 Preliminary results in our small series
ü no impairment of facial nerve function
ü high level of hearing preservation (92.3%)

Background
Paradigm shift
Objective
in the microsurgical technique
Methods “Nerve-centered approach”

Results

Discussion
Allow to match/approach expectations
Conclusion
of upfront GKR
Thank you for your attention