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Acoustic Neuromas

Why Gamma Knife treatment

The Gamma Knife produces over 200 precise beams of low-dose radiation that all focus and intersect directly on the tumor, killing the tumor, yet keeping normal healthy brain tissue safe.

The head is fixed in a frame that keeps the brain stable and secure, setting up a GPS-like coordinate system that allows the doctors to target the tumor with sub-millimeter precision. The surgeon numbs up the areas where the frame is placed (much like a dentist numbs the gums) so there is little discomfort. Other treatments that do not use a head frame simply are not as accurate, and therefore more normal brain tissue is at risk.

Also, unlike other forms of treatment, it will only take us one day to treat these tumors and get patients back to their medical oncologist.

For this reason, we recommend that lung cancer patients have an MRI of their brain immediately upon diagnosis, before beginning chemotherapy. It is possible to have metastatic brain tumors without having symptoms. Gamma Knife of Spokane can treat these brain tumors and systemic treatment of the lung cancer can start as soon as the next day. However, once chemotherapy has begun, Gamma Knife treatment must wait.

Why Gamma Knife of Spokane

You are in good hands at Gamma Knife of Spokane. As one of the top 10 Gamma Knife treatment centers in the country for the number of patients treated, no one in the region has more experience in treating brain tumors. No one. Over 60% of the patients we have treated at Gamma Knife of Spokane have come to us with brain metastases.

With Gamma Knife of Spokane, patients have access to a $5 million, 45,000 pound cancer-killing machine that can, in a few hours, deliver a dose of radiation that can stop the growth of most tumors or even eliminate tumors altogether.

In addition to our experience of over a decade treating patients, we have one of the most prolific clinical research departments in the country (7th of 130 centers). We are frequently asked to write book chapters for oncology textbooks. The national medical community considers us experts in the field of brain tumor research and treatment.

Clinical Outcomes of Gamma Knife Treatment

You are in good hands
Dr. Neil Giddings is a board certified neurotologist (since 1988), and he has been using the Gamma Knife extensively for the last ten years. His training includes the Medical College of Ohio (1982), General Surgery internship at Cleveland Clinic Foundation (1983) and General Surgery and Otolaryngology residencies at Geisinger Medical Center (1988). His neurotology fellowship was done at House Ear Clinic in Los Angeles (1989-90).

Dr. Giddings joined Spokane Ear Nose and Throat Clinic in 1993 and has co-authored and presented over 20 papers. He has particular expertise in surgical and non-surgical approaches for hearing preservation with acoustic neuromas.

The treatment process
The patient arrives in the morning and is fitted with a head frame and taken to MRI. The surgeon plans the treatment and the radiation oncologist prescribes the dose of radiation. Treatment is completed in one sitting and the patient goes home the same day with only mild discomfort.

Day of treatment

2 years after treatment

6 years after treatment

Acoustic Neuroma Over 6 Years

Images showing progressive improvement of an acoustic neuroma over a period of 6 years following Gamma Knife treatment.

CLINICAL RESEARCH

Surgical Solution

Acoustic neuroma surgery outcomes


Kaylie DM, Gilbert E, Horgan MA, Delashaw JB, McMenomey SO.


Otol Neurotol 2001 Sep;22(5):686-9


Department of Otolaryngology, Head and Neck Surgery, Oregon Health Sciences University, Portland, Oregon 97201, USA.


OBJECTIVE: The outcomes of surgery for acoustic neuromas have improved dramatically since the development of modern surgical techniques, the operating microscope, magnetic resonance imaging (MRI), and cranial nerve monitoring. The goals of acoustic neuroma surgery are now preservation of facial nerve function and, when feasible, hearing preservation. Many large series do not report standardized hearing and facial function grading, and they include patients who did not benefit from the most modern techniques. The purpose of this study was to present the results of acoustic neuroma surgery using the most modern techniques and equipment, using standardized grading systems. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: 97 patients who underwent surgical removal of acoustic neuromas from 1992 to 1998.

INTERVENTION: All patients underwent acoustic neuroma surgery and had preoperative audiograms and MRI with contrast. In addition, all patients had preoperative and postoperative facial function graded by the House-Brackmann scale and intraoperative facial nerve monitoring. Hearing preservation was attempted in patients with tumors of any size who had preoperative function of grade A or B according to the Committee on Hearing and Equilibrium guidelines for reporting results of acoustic neuroma surgery.

MAIN OUTCOME MEASURES: Hearing preservation was considered successful if the patient retained serviceable hearing grade A or B. House-Brackmann grade 1 or 2 was considered excellent facial function. Complications were recorded.

RESULTS: Facial nerve integrity was preserved in 96 of 97 patients (99%). Eight of 8 (100%) patients with intracanalicular tumors had excellent facial nerve function (HB 1-2). Fifty-two of 55 (95%) of patients with small tumors had excellent facial nerve function, and 15 of 24 (63%) with medium tumors had HB grade 1-2. Hearing was preserved in 29% of patients with tumors under 2 cm. The overall complication rate was 20%; cerebrospinal fluid leak was the most common.

CONCLUSION: These results show that with modern imaging and surgical techniques, acoustic neuroma surgery is extremely safe and outcomes are very good. Surgery remains the treatment of choice for most tumors until alternative therapies, such as gamma knife, use uniform grading scales and show long-term facial and hearing results.

Gamma Knife Solution

Acoustic Neuroma Study


Douglas Kondziolka, MD, MSc, FRCS(C), L. Dade Lunsford, MD, Mark R. McLaughlin, MD, John C. Flickinger, MD


Published in The New England Journal of Medicine 339(20): 1426-1433, 1998


We evaluated 162 consecutive acoustic tumor patients who underwent radiosurgery between 1987 and 1992 using serial imaging tests, clinical evaluations, and a patient survey between five and ten years later.

RESULTS

  • The clinical tumor control rate (no resection required) was 98%.
  • One hundred tumors (61.7%) were smaller
  • 53 remained unchanged in size (32.7%)
  • 9 were slightly larger (5.6%)
  • Resection was performed in 4 patients (2.4%), all within four years.
  • Normal facial function was preserved in 77% of patients (House-Brackmann Grade I)
  • Normal trigeminal function in 73%.
  • Fifty-one percent of patients had no change in hearing grade.
  • No delayed neurologic deficits occurred beyond 28 months following radiosurgery.
  • An outcomes survey was returned by 115 patients (77% of those still living).
  • Fifty-four patients (47%) were employed at the time of radiosurgery and 37 (69%) remained so.
  • Radiosurgery was believed "successful" by 30 of 30 patients who had undergone prior surgery and by 81 (96%) of those who had not had prior resection.
  • At least one complication was described by 36 patients (31%), 56% of which resolved.

CONCLUSIONS: Five to ten years after radiosurgery, 97% of surveyed patients believed that radiosurgery provided a satisfactory outcome for their acoustic tumor. Overall, 98% of patients required no other tumor surgery. Morbidity in this early experience was usually transitory, and relatively mild. Radiosurgery provided long-term tumor control associated with high rates of neurologic function preservation and patient satisfaction.

Long-term results of radiosurgery for vestibular schwannomas

Unger F, Walch C, Papaefthymiou G, Eustacchio S, Feichtinger K, Quehenberger F, Pendl G.


Zentralbl Neurochir 2002;63(2):52-8


Department of Neurosurgery, Karl-Franzens University, Graz, Austria. frank.unger@klinikum-graz.at


Radiosurgery is either a primary or an adjunct management approach used to treat patients with vestibular schwannomas. The goals are long-term tumour growth control, maintenance of cranial nerve function and prevention of new neurologic deficiencies. We sought to determine long-term outcomes measuring the potential benefits against the neurological risks of radiosurgery.


METHODS: 278 patients with vestibular schwannomas underwent Gamma Knife radiosurgery as a treatment modality for from April 1992 to November 2001. The long-term results of 60 patients were evaluated who received radiosurgery as primary treatment. 12 cases presented with previously performed subtotal microsurgical resection or recurrence of disease (12-96 months, median 39). The median treatment volume was 3.8 ccm and the median dose to the tumour margin was 12 Gy. The median patient follow-up time was 88 months (range 72-114 months).

RESULTS: Four tumours progressed after primary radiosurgery. Tumour control rate was 93%. Useful hearing (Gardner-Robertson I/II) was preserved in 16 patients (55%). Clinical neurological improvement occurred in 36 patients (60%). Adverse effects comprised neurological symptoms (incomplete facial palsy) (House-Brackman II/III) in five cases (three recovered completely), mild trigeminal neuropathy in three cases, and morphological changes displaying rapid enlargement of preexisting macrocysts in two patients and tumour growth in two other ones. Microsurgical resection was performed in three cases (5%) and one patient underwent a shunting procedure because of hydrocephalus formation. In patients who had undergone previous microsurgery, neither new cranial nerve deficit nor any tumour growth was observed.

CONCLUSIONS: Radiosurgery performed with current techniques proved to be an effective method for growth control of vestibular schwannomas with both a low mortality rate and a good quality of life. An increasing percentage of patients will undergo radiosurgery as accessibility to this alternative increases, and more data regarding long-term follow-up are available. It is a post-operative complementary treatment for partially removed tumours. Accordingly, radiosurgery is a useful method for the management of properly selected patients.

PMID: 12224030 [PubMed - indexed for MEDLINE]

Treatment of acoustic neuroma: stereotactic radiosurgery vs. microsurgery.

Karpinos M, Teh BS, Zeck O, Carpenter LS, Phan C, Mai WY, Lu HH, Chiu JK, Butler EB, Gormley WB, Woo SY.


Int J Radiat Oncol Biol Phys 2002 Dec 1;54(5):1410-21


Department of Radiology/Section of Radiation Oncology, Baylor College of Medicine, Houston, TX 77030, USA.


PURPOSE: Two major treatment options are available for patients with acoustic neuroma, microsurgery and radiosurgery. Our objective was to compare these two treatment modalities with respect to tumor growth control, hearing preservation, development of cranial neuropathies, complications, functional outcome, and patient satisfaction.

METHODS AND MATERIALS: To compare radiosurgery with microsurgery, we analyzed 96 patients with unilateral acoustic neuromas treated with Leksell Gamma Knife or microsurgery at Memorial Hermann Hospital, Houston, Texas, between 1993 and 2000. Radiosurgery technique involved multiple isocenter (1-30 single fraction fixed-frame magnetic resonance imaging) image-based treatment with a mean dose prescription of 14.5 Gy. Microsurgery included translabyrinthine, suboccipital, and middle fossa approaches with intraoperative neurophysiologic monitoring. Preoperative patient characteristics were similar except for tumor size and age. Patients undergoing microsurgery were younger with larger tumors compared to the radiosurgical group. The tumors were divided into small <2.0 cm, medium 2.0-3.9 cm, or large >4.0 cm. Median follow-up of the radiosurgical group was longer than the microsurgical group, 48 months (3-84 months) vs. 24 months (3-72 months).

RESULTS: There was no statistical significance in tumor growth control between the two groups, 100% in the microsurgery group vs. 91% in the radiosurgery group (p > 0.05). Radiosurgery was more effective than microsurgery in measurable hearing preservation, 57.5% vs. 14.4% (p = 0.01). There was no difference in serviceable hearing preservation between the two groups. Microsurgery was associated with a greater rate of facial and trigeminal neuropathy in the immediate postoperative period and at long-term follow-up. The rate of development of facial neuropathy was significantly higher in the microsurgical group than in the radiosurgical group (35% vs. 0%, p < 0.01 in the immediate postsurgical period and 35.3% vs. 6.1%, p = 0.008, at long-term follow-up). Similarly, the rate of trigeminal neuropathy was significantly higher in the microsurgical group than in the radiosurgical group (17% vs. 0% in the immediate postoperative period, p < 001, and 22% vs. 12.2%, p = 0.009, at long-term follow-up). There was no significant difference in exacerbation of preoperative tinnitus, imbalance, dysarthria, dysphagia, and headache. Patients treated with microsurgery had a longer hospital stay (2-16 days vs. 1-2 days, p < 0.01) and more perioperative complications (47.8% vs. 4.6%, p < 0.01) than did patients treated with radiosurgery. There was no correlation between the microsurgical approach used and postoperative symptoms. There was no difference in the postoperative functioning level, employment, and overall patient satisfaction. There was no correlation between the radiation dose, tumor size, number of isocenters used, and postoperative symptoms in the radiosurgical group.


CONCLUSION: Radiosurgical treatment for acoustic neuroma is an alternative to microsurgery. It is associated with a lower rate of immediate and long-term development of facial and trigeminal neuropathy, postoperative complications, and hospital stay. Radiosurgery yields better measurable hearing preservation than microsurgery and equivalent serviceable hearing preservation rate and tumor growth control.

Peer-reviewed Journals

A review of treatment modalities for vestibular schwannoma.
Arthurs BJ, Fairbanks RK, Demakas JJ, Lamoreaux WT, Giddings NA, Mackay AR, Cooke BS, Elaimy AL, Lee CM. Neurosurg Rev. 2011 Jul;34(3):265-79.
View PDF
Gamma knife radiosurgery for vestibular schwannomas: tumor control and functional preservation in 70 patients.
Arthurs BJ, Lamoreaux WT, Mackay AR, Demakas JJ, Giddings NA, Fairbanks RK, Cooke BS, Elaimy AL, Peressini B, Lee CM. Am J Clin Oncol. 2011 Jun;34(3):265-9.
View PDF
Gamma knife radiosurgery for vestibular schwannoma: case report and review of the literature.
Arthurs BJ, Lamoreaux WT, Giddings NA, Fairbanks RK, Mackay AR, Demakas JJ, Cooke BS, Lee CM. World J Surg Oncol. 2009 Dec 18;7:100.
View PDF
Vestibular schwannoma: gamma knife radiosurgery (method).
Arthurs BJ, Fairbanks RK, Demakas JJ, Lamoreaux WT, Giddings NA, Mackay AR, Cooke BS, Elaimy AL, Lee CM. Tumors of the Central Nervous System. Ed. M.A. Hayat. Springer: New York, 2011. In press.

The content of this web site is for informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider. If you have a medical problem or a health-related question, consult your physician or call our center at 509.473.3800 for an appointment with one of our neurosurgeons.

Gamma Knife: The best solution

Caring with precision

Treating brain tumors and other conditions in the brain requires absolute precision, because every bit of healthy tissue helps make you who you are. And nothing provides more precision than Gamma Knife stereotactic radiosurgery, especially in the hands of a caring, superbly skilled and experienced team of neurosurgeons and radiation oncologists.

In fact, Gamma Knife of Spokane ranks in the top 10 Gamma Knife Centers in the U.S. for published clinical research and patient volumes.

It's YOUR brain. Call us at 1.800.927.5051 and we can help you determine whether Gamma Knife treatment is a helpful option for you.

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