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• W2986274572 abstract "To the Editor: We have read with great interest the recent article published in Neurosurgery by Breshears et al1 analyzing, in a retrospective manner, the rates of residual tumor growth after subtotal resection (STR) as well as the factors associated with tumor progression in sporadic vestibular schwannomas (VS). In this single-institution study, 145 patients underwent STRs; patients treated with upfront stereotactic radiosurgery were excluded (n = 35) as well as those with less than 12 mo of imaging follow-up (n = 44). Ultimately, 66 patients were included in the study. In this cohort, 30% of the patients had documented progression within a median follow up period of 3.1 yr. Residual tumor volume (odds ratio 2) and residual disease within the internal auditory canal (odds ratio 3.7) were found to be independent predictors of tumor progression. In particular, a residual tumor volume less than 1.39 cm3 was found to lead to a greater progression-free survival (odds ratio 8.7). Though the authors deserve credit for their contribution in understanding the evolution of the residue after a non-gross total resection, their results have to be interpreted with caution since they may be biased by their selection criteria which excluded 54.5% of the patients who underwent STR. It would be interesting to know why 24% of these patients underwent upfront SRS and what was the residual volume after surgery in this subgroup; did they experience an early progression? Or was it a planned strategy? Although similar rates of recurrence/progression in the case of STR are described in the literature,2-5 we may infer that their results may not be representative of the entire cohort of patients undergoing STR and that the rate of progression may be even higher, thus justifying the rationale of a multimodal approach. In this perspective, we believe that the main issue is not to compare a total vs partial resection, but rather to assess whether a combined multidisciplinary approach can guarantee the same long-term control comparable to that of a total resection surgery. Our previous published study6 which was recently updated7 shows the results of a new surgical paradigm that consists of a “planned subtotal resection” followed by Gamma Knife SRS (Elekta AB) on the remnant VS, after a mean interval period of 6 mo. We reported 89.1% of local progression-free survival (LPS) in our cohort with a mean follow-up of 36.9 mo; these results were confirmed in a larger meta-analysis8 in which we showed an LPS of 93.9% with a mean follow-up duration of 46 mo. Defining the optimal rate of resection is a matter of debate, the definition of subtotal, gross total (GTR), or near total resection suffers from heterogeneity in its definition and it implies, in our opinion, different types of philosophical approaches to achieve the same goal. We believe that any “non-total resection” should primarily focus on preserving the clinical and functional outcome while still guaranteeing the same rate of tumor control. We recently coined the term “nerve-centered approach” to describe this new paradigm which focuses on “planned STR” followed by radiosurgery. The rational of a “planned” STR is that no dissection is attempted between the plane of the nerve and the tumor capsule, thereby maximizing the chances of a normally functioning nerve at the end of surgery. This strategy in our series, allowed the elimination of postoperative facial palsy (House–Brackman grade I in all patients) and preservation of serviceable hearing in 94.1% of patients that had pre-operative functional hearing. Similarly, the pooled data in our meta-analysis8 across several published series with a similar “planned combined technique” showed that House–Brackman grade I-II was achieved in 96.1% of patients (95% CI 93.7%-98.5%), while serviceable hearing was maintained in 59.9% (95% CI 36.5%-83.2%). In stark contrast to these results, Breshears et al1 found a worsened facial function outcome in 40.9% of patients with STR, which is quite high considering that the idea behind this STR is to preserve nerve function. This is possibly due to the fact that the STR was not a planned one and was an intraoperative decision to leave tumor behind tumor on the possible localization of the nerve. In the last decade, there has been a shift in the treatment paradigm of sporadic VS, that now focuses more on the functional outcome and less on the ability to achieve GTR. Based on the expectations of the patient with respect to nerve function and possibilities to have long term follow up (that becomes necessary for STR), when a decision is made to consider STR, this decision is better taken prior to surgery rather that during the surgery. Disclosures Dr Tuleasca gratefully acknowledges receipt of a “Young Researcher in Clinical Research Grant” (Jeune Chercheur en Recherche Clinique) from the University of Lausanne (UNIL), Faculty of Biology and Medicine (FBM) and the Lausanne University Hospital (CHUV). The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article." @default.
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• W2986274572 date "2019-11-06" @default.
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• W2986274572 title "Letter: Residual Tumor Volume and Location Predict Progression After Primary Subtotal Resection of Sporadic Vestibular Schwannomas: A Retrospective Volumetric Study" @default.
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• W2986274572 doi "https://doi.org/10.1093/neuros/nyz492" @default.
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