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{{Acoustic neuroma}}
{{Acoustic neuroma}}
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== Overview==
== Overview==
The predominant therapy for acoustic neuroma is surgical resection. Adjunctive radiation and radiosurgery may be required. Since acoustic neuromas tend to be slow-growing and are [[benign]] tumors, careful observation over a period of time may be appropriate for some patients.<ref>{{Cite web | title =Wikipedia  Acoustic neuroma treatment| url =https://en.wikipedia.org/wiki/Vestibular_schwannoma }}</ref>
The mainstay of [[therapy]] for acoustic neuroma is [[surgery]] and [[radiation therapy]]. Since acoustic neuroma tends to be slow-growing and is a [[benign]] tumor, careful observation with follow-up [[Magnetic resonance imaging|MRI scans]] every 6 to 12 months may be appropriate for elderly [[Patient|patients]], [[Patient|patients]] with small [[Tumor|tumors]], [[Patient|patients]] with significant [[medical conditions]], and [[Patient|patients]] who refuse treatment.
   
   
==Medical Therapy==
==Medical Therapy==
Medical therapy for acoustic neuroma includes radiation therapy.
The mainstay of [[therapy]] for acoustic neuroma is [[surgery]] and [[radiation therapy]]. Since acoustic neuroma tends to be slow-growing and is a [[benign]] tumor, careful observation with follow-up [[Magnetic resonance imaging|MRI scans]] every 6 to 12 months may be appropriate among the following groups of [[Patient|patients]]:<ref>{{Cite journal
Factors that affect the selection of the right treatment include:
| author = [[Wissame El Bakkouri]], [[Romain E. Kania]], [[Jean-Pierre Guichard]], [[Guillaume Lot]], [[Philippe Herman]] & [[Patrice Tran Ba Huy]]
*Age
| title = Conservative management of 386 cases of unilateral vestibular schwannoma: tumor growth and consequences for treatment
*Other medical conditions
| journal = [[Journal of neurosurgery]]
*Severity of the symptoms
| volume = 110
*Size of the tumor
| issue = 4
*[[Tumor]] growth
| pages = 662–669
| year = 2009
| month = April
| doi = 10.3171/2007.5.16836
| pmid = 19099381
}}</ref><ref>{{Cite journal
| author = [[Eric E. Smouha]], [[Michael Yoo]], [[Kristi Mohr]] & [[Raphael P. Davis]]
| title = Conservative management of acoustic neuroma: a meta-analysis and proposed treatment algorithm
| journal = [[The Laryngoscope]]
| volume = 115
| issue = 3
| pages = 450–454
| year = 2005
| month = March
| doi = 10.1097/01.mlg.0000175681.52517.cf
| pmid = 15744156
}}</ref>
*[[Patients]] with a [[tumor]] in their only [[hearing]] or better [[Hearing (sense)|hearing]] [[ear]]
*When the [[tumor]] is of a size that hearing preservation with treatment would be unlikely
*Elderly [[Patient|patients]]
*Small [[Tumor|tumors]] in older individuals that do not grow
*[[Patient|Patients]] with small [[Tumor|tumors]] with good [[Hearing (sense)|hearing]]
*[[Patient|Patients]] with [[medical conditions]] that increase the risk of [[Complication (medicine)|complications]] of [[surgery]]
*[[Patient|Patients]] who refuse treatment
*[[Patient|Patients]] with a [[tumor]] on the side of an only [[Hearing (sense)|hearing]] [[ear]] or only [[Sight|seeing]] [[eye]]
 
===Observation===
===Observation===
Since acoustic neuromas tend to be slow-growing and are [[benign]] tumors, careful observation over a period of time may be appropriate for some patients.The patient is observed for [[facial nerve]] function, [[hearing]], [[tinnitus]] and [[ataxia]]. An [[MRI]] is performed every 6 months or yearly depending on the rate of [[tumor]] growth. The average growth rate of tumor is 1.15 to  2.4 mm per year. If the tumor grows or causes serious symptoms, treatment is suggested. If the scans show the tumor is growing or if the tumor causes progressive symptoms or other difficulties, you may need to undergo treatment. Observation is recommended in the following patients:<ref>{{Cite web | title =Wikipedia  Acoustic neuroma treatment| url =https://en.wikipedia.org/wiki/Vestibular_schwannoma }}</ref>  
The strategies for [[patient]] [[observation]] include:
*Patients with a tumor in their only [[hearing]] or better hearing ear
* Assessment of [[facial nerve]] function, [[hearing]], [[tinnitus]], and [[ataxia]].  
*When the tumor is of a size that hearing preservation with treatment would be unlikely
* An [[MRI]] is performed every 6 months or yearly depending on the rate of [[tumor]] growth.  
*Elderly patients
* The average growth rate of [[tumor]] is 1.15 to  2.4 mm per year. If the [[tumor]] grows or causes serious [[Symptom|symptoms]], treatment is suggested. If the scans show [[tumor]] growth or if the [[tumor]] causes progressive [[Symptom|symptoms]] or other difficulties, considering [[Surgery|surgical intervention]] is mandatory. <ref>{{Cite journal|last=Wissame el Bakkouri, M.D., romain e. kania, M.D., Ph.D., Jean-Pierre Guichard, M.D., Guillaume lot, M.D., Philippe herman, M.D., Ph.D., and Patrice tran Ba huy, M.D.|first=|date=2007|title=Conservative management of 386 cases of unilateral vestibular schwannoma: tumor growth and consequences for treatment|url=|journal=J Neurosurg|volume=11|pages=662|via=}}</ref>
*Small tumors in older individuals that do not grow
*Patients with small tumors with good hearing
*Patients with medical conditions that  increase the risk of [[surgery]]
*Patients who refuse treatment
*Patients with a [[tumor]] on the side of an only hearing ear or only seeing [[eye]]


===Radiation Therapy===
===Radiation Therapy===
Another treatment option for an acoustic neuroma is [[radiation]]. Radiation therapy approaches that have been used in patients with acoustic neuroma include:<ref>{{Cite web | title =Wikipedia  Acoustic neuroma treatment| url =https://en.wikipedia.org/wiki/Vestibular_schwannoma }}</ref>
[[Radiation therapy]] approaches that have been used in [[Patient|patients]] with acoustic neuroma include:
*Stereotactic [[radiosurgery]]
* [[Stereotactic surgery|Stereotactic radiosurgery]]
*Stereotactic [[radiotherapy]]
* Stereotactic [[Radiation therapy|radiotherapy]]
*[[Proton]] beam therapy
* Proton beam [[therapy]]
*Conventional fractionated [[radiation]] therapy
===Stereotactic Radiotherapy===
The multi-dose treatment, FSR, delivers smaller doses of radiation over a period of time, requiring the patient to return to the treatment location on a daily basis, from 3 to 30 times, generally over several weeks. Each visit lasts a few minutes and most patients are free to go about their daily business before and after each treatment session. Early data indicates that FSR may result in better hearing preservation when compared to single-session SRS.
===Proton beam therapy===
*The use of [[proton]] beam therapy permits the delivery of high doses of radiotherapy to the target volume while limiting the dose received by surrounding tissues. It provides maximum local tumor control with minimum [[cranial nerve]] injuries.
 
*Follow-up after SRS and FSR typically involves an MRI scan and audiogram at six months, one year, then yearly for several years, then every second or third year indefinitely to make sure the tumor does not start to grow again. All types of radiation therapy for acoustic neuromas may result in "tumor control" in which the tumor [[cells]] die and [[necrosis]] occurs. Tumor control means that the tumor growth may slow or stop and, in some cases, the tumor may shrink in size. These techniques are performed in the outpatient setting, not requiring general [[anesthesia]] or a hospital stay. The purpose of these techniques is to arrest the growth of the [[tumor]] causing the tumor to die, which is called [[necrosis]]. This treatment has not been well studied and thus it is unclear if it is better than observation or [[surgery]]. Tumors under 2.5 - 3.0 cm, without significant involvement of the [[brainstem]], are more favorable for radiation treatment. Side effects can occur when the brainstem is irradiated and in some cases of large tumors, radiation is contraindicated. Studies are beginning to appear for the other modalities. All of the techniques use computers to create three dimensional models of the tumor and surrounding neural structures. Radiation physicists then create dosimetry maps showing the level of radiation to be received by the tumor and the normal [[tissues]]. Surgeons, radiation therapists and physicists then modify the dosimetry to maximize tumor doses and minimize radiation toxicity to surrounding normal tissues. The head is stabilized with a metal frame pinned to the [[head]] ([[Gamma Knife]]) or a fitted mask shield (CyberKnife, linear accelerator, fractionated XRT). Treatments generally last 30–60 minutes. Just like for surgery, the experience of the team in treating acoustic neuromas with all modalities (surgery and radiation) can affect outcomes. There are a multitude of studies supporting short-term (<5 yrs.) and longer-term (over 10 yrs.) tumor control with radiation. Unfortunately, as is the case with microsurgical studies, most have inconsistent follow-up to draw definitive conclusions.


*Several types of machines deliver focused radiation treatment suitable for treating acoustic neuromas. The underlying premise is to treat the tumor with a high dose of radiation while sparing the nerves and [[brain]] tissues. Much of the long term data comes from the [[Gamma Knife]] literature since this was one of the earliest techniques used to radiate acoustic neuromas on a large scale. The machines suitable for treating acoustic neuroma include:
==== Stereotactic Radiosurgery ====
*[[Gamma Knife]]  
[[Stereotactic surgery|Stereotactic radiosurgery (SRS)]], is a treatment option for [[Patient|patients]] with [[Tumor|tumors]] smaller than 3 cm or for enlarging [[Tumor|tumors]] in [[patients]] with significant [[medical conditions]] and are not candidates for [[surgery]]. It delivers multiple precisely-targeted radiation convergent beams to minimize [[injury]] to adjacent structures. This can be accomplished with either the [[Gamma Knife|gamma knife]] or a [[Linear particle accelerator|linear accelerator]].<ref>{{Cite journal
**The Gamma Knife uses 195-201 fixed [[cobalt]]-60 radiation sources that are "collimated" to intersect at the site of the tumor and is a single dose treatment. In this way, each individual beam of radiation has very little effect, but where they all intersect produces a maximum effect on the tumor. Very similar results can be obtained using a linear accelerator (LINAC) as the radiation source, such as with the Novalis or CyberKnife with multi-dose treatment.
| author = [[Marianna Karpinos]], [[Bin S. Teh]], [[Otto Zeck]], [[L. Steven Carpenter]], [[Chris Phan]], [[Wei-Yuan Mai]], [[Hsin H. Lu]], [[J. Kam Chiu]], [[E. Brian Butler]], [[William B. Gormley]] & [[Shiao Y. Woo]]
*Linear accelerator (LINAC)
| title = Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery
*CyberKnife
| journal = [[International journal of radiation oncology, biology, physics]]
*Novalis
| volume = 54
*Trilogy
| issue = 5
| pages = 1410–1421
| year = 2002
| month = December
| pmid = 12459364
}}</ref><ref>{{Cite journal
| author = [[Joseph C. T. Chen]] & [[Michael R. Girvigian]]
| title = Stereotactic radiosurgery: instrumentation and theoretical aspects-part 1
| journal = [[The Permanente journal]]
| volume = 9
| issue = 4
| pages = 23–26
| year = 2005
| month = Fall
| pmid = 22811641
}}</ref>


===Advantages of radiation therapy===
====Stereotactic radiotherapy====
*Decreased length of stay
* Stereotactic [[Radiation therapy|radiotherapy]] (SRT) and fractionated stereotactic [[Radiation therapy|radiotherapy]] deliver smaller [[Dose|doses]] of [[Radiation therapy|radiation]] over a period of time, requiring the [[patient]] to return to the treatment location on a daily basis, from 3 to 30 times, generally over several weeks.


*Decreased cost
* Each visit lasts a few minutes and most [[Patient|patients]] are free to go about their daily business before and after each treatment session.
*Low immediate posttreatment, [[morbidity]], and [[mortality]]
* Early [[data]] indicates that SRT may result in better [[Hearing (sense)|hearing]] preservation when compared to single-session SRS.<ref>{{Cite journal
| author = [[Marianna Karpinos]], [[Bin S. Teh]], [[Otto Zeck]], [[L. Steven Carpenter]], [[Chris Phan]], [[Wei-Yuan Mai]], [[Hsin H. Lu]], [[J. Kam Chiu]], [[E. Brian Butler]], [[William B. Gormley]] & [[Shiao Y. Woo]]
| title = Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery
| journal = [[International journal of radiation oncology, biology, physics]]
| volume = 54
| issue = 5
| pages = 1410–1421
| year = 2002
| month = December
| pmid = 12459364
}}</ref>


===Disadvantages of Radiation therapy===
====Proton beam therapy====
*In almost no cases have acoustic neuroma tumors been completely eliminated by radiation treatments. Radiation does not remove the tumor like [[microsurgery]] can.
*The use of [[proton]] beam [[therapy]] permits the delivery of high [[Dose|doses]] of [[Radiation therapy|radiation]] to the target volume while limiting the dose received by surrounding [[Tissue (biology)|tissues]]. It provides maximum local [[tumor]] control with minimum [[cranial nerve]] injuries.<ref>{{Cite journal
*Radiotherapy patients require lifetime follow-up with [[MRI scans]].  
| author = [[W. P. Levin]], [[H. Kooy]], [[J. S. Loeffler]] & [[T. F. DeLaney]]
*Rare reports of [[malignant]] degeneration (a [[benign tumor]] becoming malignant) after radiotherapy have been found.
| title = Proton beam therapy
*In some cases the tumor does not die and continues to grow. In those instances, another treatment is necessary - either microsurgery or sometimes another dose of radiation.  
| journal = [[British journal of cancer]]
*Higher [[incidence]] of [[trigeminal]] nerve injury.
| volume = 93
*Unknown incidence of secondary malignancies.  
| issue = 8
*Long-term balance dysfunction.
| pages = 849–854
| year = 2005
| month = October
| doi = 10.1038/sj.bjc.6602754
| pmid = 16189526
}}</ref>
*In comparison with conventional [[radiation therapy]] where [[electromagnetic waves]] in [[x-rays]] pass through target and adjacent [[Tissue (biology)|tissues]], in [[proton]] beam [[therapy]], [[energy]] is carried by [[proton]] beams and the majority of the [[energy]] being deposited within the target.  
*It provides excellent local control of acoustic neuromas with acceptable preservation of [[Hearing (sense)|hearing]] and [[Facial nerve|facial]] and [[trigeminal nerve]] function.<ref>{{Cite journal
| author = [[David A. Bush]], [[Calvin J. McAllister]], [[Lilia N. Loredo]], [[Walter D. Johnson]], [[James M. Slater]] & [[Jerry D. Slater]]
| title = Fractionated proton beam radiotherapy for acoustic neuroma
| journal = [[Neurosurgery]]
| volume = 50
| issue = 2
| pages = 270–273
| year = 2002
| month = February
| pmid = 11844261
}}</ref>


==References==
==References==
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Latest revision as of 19:17, 26 April 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2] Mohsen Basiri M.D.

Overview

The mainstay of therapy for acoustic neuroma is surgery and radiation therapy. Since acoustic neuroma tends to be slow-growing and is a benign tumor, careful observation with follow-up MRI scans every 6 to 12 months may be appropriate for elderly patients, patients with small tumors, patients with significant medical conditions, and patients who refuse treatment.

Medical Therapy

The mainstay of therapy for acoustic neuroma is surgery and radiation therapy. Since acoustic neuroma tends to be slow-growing and is a benign tumor, careful observation with follow-up MRI scans every 6 to 12 months may be appropriate among the following groups of patients:[1][2]

Observation

The strategies for patient observation include:

Radiation Therapy

Radiation therapy approaches that have been used in patients with acoustic neuroma include:

Stereotactic Radiosurgery

Stereotactic radiosurgery (SRS), is a treatment option for patients with tumors smaller than 3 cm or for enlarging tumors in patients with significant medical conditions and are not candidates for surgery. It delivers multiple precisely-targeted radiation convergent beams to minimize injury to adjacent structures. This can be accomplished with either the gamma knife or a linear accelerator.[4][5]

Stereotactic radiotherapy

  • Stereotactic radiotherapy (SRT) and fractionated stereotactic radiotherapy deliver smaller doses of radiation over a period of time, requiring the patient to return to the treatment location on a daily basis, from 3 to 30 times, generally over several weeks.
  • Each visit lasts a few minutes and most patients are free to go about their daily business before and after each treatment session.
  • Early data indicates that SRT may result in better hearing preservation when compared to single-session SRS.[6]

Proton beam therapy

References

  1. ↑ Wissame El Bakkouri, Romain E. Kania, Jean-Pierre Guichard, Guillaume Lot, Philippe Herman & Patrice Tran Ba Huy (2009). "Conservative management of 386 cases of unilateral vestibular schwannoma: tumor growth and consequences for treatment". Journal of neurosurgery. 110 (4): 662–669. doi:10.3171/2007.5.16836. PMID 19099381. Unknown parameter |month= ignored (help)
  2. ↑ Eric E. Smouha, Michael Yoo, Kristi Mohr & Raphael P. Davis (2005). "Conservative management of acoustic neuroma: a meta-analysis and proposed treatment algorithm". The Laryngoscope. 115 (3): 450–454. doi:10.1097/01.mlg.0000175681.52517.cf. PMID 15744156. Unknown parameter |month= ignored (help)
  3. ↑ Wissame el Bakkouri, M.D., romain e. kania, M.D., Ph.D., Jean-Pierre Guichard, M.D., Guillaume lot, M.D., Philippe herman, M.D., Ph.D., and Patrice tran Ba huy, M.D. (2007). "Conservative management of 386 cases of unilateral vestibular schwannoma: tumor growth and consequences for treatment". J Neurosurg. 11: 662.
  4. ↑ Marianna Karpinos, Bin S. Teh, Otto Zeck, L. Steven Carpenter, Chris Phan, Wei-Yuan Mai, Hsin H. Lu, J. Kam Chiu, E. Brian Butler, William B. Gormley & Shiao Y. Woo (2002). "Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery". International journal of radiation oncology, biology, physics. 54 (5): 1410–1421. PMID 12459364. Unknown parameter |month= ignored (help)
  5. ↑ Joseph C. T. Chen & Michael R. Girvigian (2005). "Stereotactic radiosurgery: instrumentation and theoretical aspects-part 1". The Permanente journal. 9 (4): 23–26. PMID 22811641. Unknown parameter |month= ignored (help)
  6. ↑ Marianna Karpinos, Bin S. Teh, Otto Zeck, L. Steven Carpenter, Chris Phan, Wei-Yuan Mai, Hsin H. Lu, J. Kam Chiu, E. Brian Butler, William B. Gormley & Shiao Y. Woo (2002). "Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery". International journal of radiation oncology, biology, physics. 54 (5): 1410–1421. PMID 12459364. Unknown parameter |month= ignored (help)
  7. ↑ W. P. Levin, H. Kooy, J. S. Loeffler & T. F. DeLaney (2005). "Proton beam therapy". British journal of cancer. 93 (8): 849–854. doi:10.1038/sj.bjc.6602754. PMID 16189526. Unknown parameter |month= ignored (help)
  8. ↑ David A. Bush, Calvin J. McAllister, Lilia N. Loredo, Walter D. Johnson, James M. Slater & Jerry D. Slater (2002). "Fractionated proton beam radiotherapy for acoustic neuroma". Neurosurgery. 50 (2): 270–273. PMID 11844261. Unknown parameter |month= ignored (help)

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