ANA Discussion Forum
Treatment Options => Microsurgical Options => Topic started by: jerseygirl on October 15, 2010, 02:02:56 pm
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Hi,
I think this study was posted somewhere before but I can't find it, just the mention that it was ready for publication. Anyway, here is a link:
http://www.medicalnewstoday.com/articles/204655.php
I am going to call SBI and see if I can get the entire study that is going to be printed. Comments, anybody?
Eve
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Eve ~
This is very encouraging.
I've long thought that endoscopic surgery to remove an acoustic neuroma was going to be the Next Big Thing in neurosurgery. The medical community, especially when it comes to brain surgery, is very cautious and slow to embrace innovation due to the inevitable risks and possible unintended negative consequences of that advance. However, the study, self-serving in the respect that SBI performed it and the results are positive for endoscopic surgery on ANs, will, no doubt, be criticized by some - but it has to be considered. I think younger surgeons and those who welcome better ways of removing an acoustic neuroma in a way that offers the patient the best opportunity for a good outcome that doesn't negatively impact their quality of life will begin to think seriously about moving forward, studying and eventually employing endoscopic surgery on AN patients. This SBI study could act as a catalyst for such advancement.
Jim
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Interesting, but I am skeptical until I learn more.
The report states that "100% of patients experienced preservation of their facial nerve." It doesn't explain whether that means anatomical continuity or 100% preservation of function. In fact, the nerve may be left completely intact by conventional surgical approaches such as retrosigmoid, yet the function of the nerve may (or may not) be severely impacted despite the nerve being physically intact.
Similarly, claims of hearing preservation are unqualified in the report. The term "hearing preservation" has been bandied about by many neurosurgeons and practitioners of radiosurgery/radiotherapy alike. It does not mean 100% preservation of hearing, but can mean one of two things (depending on who is making the statement): 1. Some useful hearing (however little) remains, or 2. hearing may have deteriorated significantly but not enough to move the patient into a different hearing Class (a Class denotes a range of hearing and is a more broad and less stringent characterization than a specific response in decibels in a given frequency band).
Lest I be misunderstood, SBI's work is of great interest to me and I would consider choosing them for my surgery should I ever have to go under the knife for an AN or other brain tumor. All I'm saying is I want to see more stringently worded details in their report. As it reads in the linked article, the wording is too broad and generalized to get me overly excited.
Nevertheless, I really appreciate Eve posting the link to the article. I'm excited to learn more when the full report comes out.
Sincerely,
TW
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I have a PDF of the study but its too long to copy and paste to the forum and looses formating for the charts, etc. If someone can tell me how to post a PDF file, I would be glad to do so. Might have to upload it to a hosting site and create a link. I can also e-mail it to someone that can post a link.
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TW,
I am of exactly the same opinion as you but before I comment on the results, I would like to take a look at the study itself because medicalnewstoday could have misinterpreted the results.
Captoats,
I will PM you with my e-mail address so that you can send me the study. I will then cut and paste some extracts of the study on the forum and will not call SBI on Monday.
Eve
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Hi Eve, I sent you the PDF. Let me know how you can post something like that
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Hi everybody,
Captoats e-mailed me the 9-year old study from SBI and here are the excerpts:
Population: The subjects consist of 527 patients with unilateral VS who have undergone fully endoscopic surgical resection of their tumors from October, 2001 to July, 2010. Patients with NFT2 were excluded from this study. This series included 44 cases that had undergone previous Gamma Knife radiosurgery and 61 cases with purely intracanalicular VS(s).
Note: VS stands for vestibular schwannoma, another name for AN (Eve)
Age: 30-71 Tumor Size: 0.3 – 5.8cm Completeness of removal: 94%
Methods: Assessment was based upon clinical, radiological, and audiometric examinations. Pre- and postoperative data was collected and evaluated in a database for patients who have undergone fully endoscopic VS resections at the Skull Base Institute in Los Angeles, California.
Facial Nerve Preservation: Anatomical preservation of the facial nerve was achieved in 527/527 (100%) cases. One year after tumor removal, facial nerve function was re-assessed. Out of 527 patients with anatomically preserved facial nerves, 491/527 (93%) showed excellent facial nerve function (H-B grade 1/2); while 21/527 (4%) showed intermediate function (H-B grade 3/4); and 15/527 (3%) showed poor function (H-B grade 5/6).
Hearing Preservation: Functional hearing preservation, being defined as measurable hearing (serviceable/some), was possible in 213/374 (57%) of the same group.
Post operative complications: CSF leak from the wound occurred in 17 cases, either re-suturing of the wound or bone waxing air cells stopped the leak (lumbar drain was not required) in all but one patient who required a subtotal petrosectomy.
One patient developed postoperative ventricular dilatation on the second day of surgery and was obtunded; a temporary ventricular catheter for diversion of CSF was placed for 5 consecutive days and the condition resolved. Exposure keratitis occurred in 9 patients and was treated with a “gold-weight†placed over the affected eyelid in 3 patients and aggressive ointment and artificial tears in the other 6 patients until facial nerve function eventually improved. Superficial wound infection was encountered in 13 patients and was treated conservatively in 4 patients; the other 9 patients required re-opening of the wound for irrigation, disinfection and overall debridement.
Cerebellar and brain stem injuries are the major and most feared complications of the retrosigmoid approach.30,33 Postoperative complications excluding those related to cranial nerves were minimal (Table 4). Major complications such as postoperative hemorrhage, quadriparesis, hemiparesis, meningitis or death did not occur.
I copied and pasted from the study because it is too big to post in its entirety. There is also a fascinating but very detailed discussion of cochlear nerve preservation. If anybody is interested, I will be happy to post an excerpt dealing with it.
Eve
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Eve:
Thanks so much for taking the time to post this report. It is fascinating!
As the report shows, endoscopic surgery entails more risk than what the article at medicalnewstoday.com inferred. Still, I'd be willing to bet that most of the complications occurred with removal of the larger tumors and older patients.
What is lacking in the report is an accounting of how many patients 1. suffered no degradation whatsoever in facial-nerve function after surgery and 2. did not have their hearing worsen to the degree that they were in a different hearing Class five years after surgery (which period would allow direct comparisons to published five-year studies for patients who had radiosurgery).
Thanks again, Eve.
Best wishes,
TW
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Hi TW,
What is also missing from the study is whether or not recurrences/regrowths were included and if not, how did these people fare. I bet many of these did suffer some complications. The report also does not give any tally of lower cranial nerve damage which can be very disabling because it can lead to voice and swallowing issues. Intubation for a long time can lead to vocal cord damage but during endoscopic surgery this risk is minimized because the surgery times are so short.
I will post everything the article contains on hearing. Maybe, it will answer your questions.
Eve
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Excerpts from the study on everything that concerns hearing preservation:
Cochlear nerve (hearing) preservation
Cochlear nerve preservation has been reported by many authors10,11,18,29,30 in the recent past, but there is a lot of ambiguity on the criteria for useful hearing. In addition, there are some who believe that the goal of gross total tumor removal cannot be achieved with cochlear nerve preservation.31
In this report, our rate of functional hearing preservation (213/374) (57%) reflects the better outcome associated with better visualization by the angled and zero-degree high-definition endoscopes. The fact that most tumors in this series were less than 4 cm in diameter and presented early with minimal symptoms also has a direct impact on the surgical outcome and prognosis.
Functional hearing preservation, being defined as measurable hearing (serviceable/some), was possible in 213/374 (57%) of the same group. One patient with a right sided intracanalicular VS, 10 mm in diameter and with a small portion of it protruding into the CPA, initially had “some†hearing and regained a “serviceable†hearing one week postoperatively. Another patient had an improvement of > 20 db in his hearing postoperatively
Table 3 : Cochlear Nerve (Hearing) Preservation
Serviceable/Some Total Deafness
Preoperative 374 153
Postoperative 213 314
More regarding facial nerve function:
In this series, at the time of discharge from the hospital, most of the patients had satisfactory facial nerve function with complete eye closure. After one year, 491/527 (93%) showed excellent facial nerve function (H-B grade 1/2), and 21/527 (4%) showed intermediate function (H-B grade 3/4).
In spite of the high rate of facial nerve preservation in this study, anatomical preservation of the facial nerve with complete tumor removal, especially in patients with large tumors, is still a challenge. Facial nerve monitoring has greatly aided separation of the facial nerve from the tumor.10,11,28-30
Hope it helps.
Eve
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There is a lot of evidence emerging that radiation is a better option for small AN's than traditional surgery.
I wonder what their results would look like if they combined technolgies, debulked the AN with endoscopic surgery and then left the last little bit to radiation?
Could this potentially provide the best outcome of all for patients with large AN's?
Thanks Jerseygirl for the info....
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Very interesting report.... thanks JerseyGirl for posting. I've got a few years before the big decision on surgery vs radiation so keeping my fingers crossed that new treatments like this will have provden themselves by then.
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Thanks a lot for the additional excerpts, Eve. So my suspicions about the report's interpretation of "hearing preservation" are confirmed. What it comes down to is this: 57% of the patients retained some useful hearing, while 43% of those who had useful hearing prior to surgery were left completely deaf on the AN side following the operation. This again confirms that surgical resection -- no matter what the approach -- is less likely to preserve hearing than the various forms of radiation treatment.
The SBI report also infers that (at least) 4% of the patients suffered decreased function of the facial nerve (the report is a bit vague here). This is at least 4x worse outcome than with CK on average.
If I had a large tumor that couldn't be treated with radiation, I would seriously consider endoscopic surgery at SBI. But from a purely statistical point of view, radiation presents a far lesser chance of damage to hearing (at least in the short term) and especially facial-nerve function for small and medium-size tumors.
Best wishes,
TW
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Flsunshine,
I hope you will never have to make a decision regarding AN treatment. That's the best way.
TW,
Short term is the key here. In the short term, radiation stats look better. In the long term (10,15,20) years, the picture is probably not so rosy. Nevertheless, those extra years of perfect hearing and facial function are of enormous value to most people. Now we are down to an argument: radiation vs. surgery! ::) I really think that all forms of AN treatment have value. I am pro- newbie education : know the benefits and risks associated with each type of treatment and make an educated choice that is in one's favor.
Eve
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I agree that hearing preservation with radiation treatments is often short-term. In fact, hearing loss may occur within only 5 years of being treated. For many patients, however, hearing is preserved in the long-term.
No disrespect meant for those who choose surgery. God no. It's just that I have had such an extraordinary outcome with CK that I can't help advocating radiation. Had I undergone surgery, I would've been deaf in one ear and possibly (31% chance) paralyzed on one side of my face. Instead, my hearing is relatively good and I've never had any facial symptoms.
All that said, surgery is the most comfortable (and depending on tumor size, sometimes the only) choice for some people. All I hope for here is to share statistics and my personal experience. Too many people choose one form of treatment without investigating all their options thoroughly. In fact, I was initially completely opposed to receiving radiation; wouldn't even consider it. But as I looked further at all my options -- and the risks associated with each -- I became convinced that CK was the right personal choice for me.
Best wishes,
TW
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Hey jerseygirl,
Thanks for the keyhole info. This might be very interesting; let's keep up the research. When is opur next reunion? I miss you!
jerseyboy
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TW and Eve,
Your dialogue here about radiation versus surgery, including the kehole procedure, is hugely informative. But, what are your views if someone statistically should be treated with radiation (older with a small AN), however, he is highly symptomatic, with dizziness, a wonky head, etc. Does that change the calculation? I understand radiation caps symptoms at current levels but doesn't reduce them. So, you're stuck with the symptoms you have, no better, no worse. If surgery could actually reduce the symptoms, and that was the primary goal, regardless of possible hearing loss, even some facial paralysis, would that change the treatment determination? Thanks.
Jeff
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Jeff,
Sorry I somehow missed your previous post. We did not plan any get together luncheon for fall so far. I guess everybody is really busy! The weather has been really nice after this awfully hot summer, may be that's the reason?
From my conversations with neurosurgeons and neurooncologists, any symptomatic AN, no matter how small, is treated with surgery. This is because radiation can cause an increase of current symptoms, at least temporarily. A lot really depends on you. Can you live with temporary (weeks to months) increase in symptoms or will they make you bedridden and miserable? Or, perhaps, that will make you run to the nearest neurosurgeon's office to get rid of the offender for good at any cost. If the chances are good that you will have surgery at a future date anyway, then why not have it right away and forget about radiation and any hopes that it might miraculously make things better.
This is what I understand but I ,think, it would be best to post this question in the Radiosurgery section (they might not find it here). They might have a different opinion, supported by research and case studies. After all, I spoke to a lot more surgeons than radiation specialists, so my knowledge might reflect that.
Good luck with your search.
Eve
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...what are your views if someone statistically should be treated with radiation (older with a small AN), however, he is highly symptomatic, with dizziness, a wonky head, etc. Does that change the calculation? I understand radiation caps symptoms at current levels but doesn't reduce them. So, you're stuck with the symptoms you have, no better, no worse. If surgery could actually reduce the symptoms, and that was the primary goal, regardless of possible hearing loss, even some facial paralysis, would that change the treatment determination? Thanks.
Jeff
Jeff, the "statistics" you refer to are antiquated. It was (and still is, by some people) feared that radiation could cause malignancy several decades after treatment. Hence, the preference used to be that only older people should take that risk, as they would be dead from natural causes long before malignancy could develop in later years. However, this viewpoint was based on the use of much higher doses of radiation, applied with far less accuracy, than is the case today. In fact, statistics show that the chance of getting a malignant tumor as a result of having radiosurgery (one treatment) or radiotherapy (two or more treatments, in smaller doses) is virtually no greater than the risk to the general population (i.e., it's a statistically insignificant difference, amounting to a fraction of a percent).
Radiation is a viable option for more than just small tumors, too. In most cases, an AN up to 3 cm in size (ANs are typically categorized as a medium-size tumor below that size) can be safely treated with radiation.
There is no guarantee that radiation will "cap symptoms at current levels," as you put it, but that is almost always the case in the long term. Around 25% of CK patients actually notice gratifying improvement in their balance, as I did beginning roughly six months after I was treated. Many radiation patients suffer through an increase in the severity of their symptoms for up to a year or so after treatment, but the increase is almost always transient (resolving over time, returning to the "level" they were at immediately before treatment). With CK at least, you are only likely to have an increase in the intensity of symptoms you already had right before getting treated. For example, if you haven't had vertigo lately, CK is not likely to cause vertigo for you -- even if you had vertigo years ago when the tumor first started becoming symptomatic. In exceedingly rare cases, a patient who has received radiation will see an increase in symptoms that persists; no type of treatment is without risk.
To my knowledge, no surgeon will promise you that surgical resection will abate your symptoms. Just because a tumor that has been removed is no longer putting pressure on cranial nerves it was previously impacting, that doesn't mean that the damage it has already caused will be reversed. But around 20-25% of CK patients who were treated at Stanford also see "gratifying shrinkage" of their tumor over a 5-year period after treatments. In my case, my AN swelled 33% in volume after treatment but then shrank 59% during months 5-11 post-treatment -- a very unusually high rate of shrinkage. This probably explains why my balance has improved so remarkably following CK (and I also regained a little bit of hearing in my bass frequencies, although I lost a little in my midrange at the same time). The bottom line is that you should not expect your current symptoms to abate as a result of any type of treatment, including surgery. If it happens that you are one of the lucky ones who do see symptoms improve, count that as icing on the cake (the cake itself is tumor control).
From your last comment, I assume you meant "balance problems" when you referred to "symptoms" that might possibly improve, notwithstanding possible hearing loss and facial paralysis due to surgery (your inference). Even if one could predict such a tradeoff was likely (again, you can't), the value of trading one symptom for another (a complication from treatment) would be a very personal choice that one cannot possibly cast in broad terms for everyone. For example, a professional musician might value their hearing over their balance, whereas a gymnast might place higher value on retaining their balance. Personal preferences aside, Dr. Chang (esteemed neurosurgeon and CK practitioner at Stanford University Medical Center) generally places the goals of treatment in the following order of importance:
1. Control the tumor's growth (it should be noted that recurrence can happen with either surgical resection or radiation, but it is rare -- roughly 2% chance, when treated by the best doctors of either discipllne).
2. Preserve facial-nerve function
3. Preserve balance
4. Preserve hearing
I hope this info helps.
Best wishes to all,
TW
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Thank you both, Eve and TW,
Your observations are filled with much wisdom and concern for others. I honestly get tears in my eyes reading your posts, as you both are so genuinely trying to be helpful. My big issue is that I frequently have a wonkly head. It feels like a fullness, exacerbated by fast walking, when it feels like my head will explode. (Oddly I can work out on my elliptical machine with no problem.) When I'm not walking somewhat quickly it's very mild, barely noticeable. As I think about treatment, I guess TW's comment summarizes well:
"The bottom line is that you should not expect your current symptoms to abate as a result of any type of treatment, including surgery."
I will wait for my annual MRI in December. Given my age of 64, and tumor size (a year ago) of 0.4mm, I am leaning toward CK. Thank you both so much, again.
Jeff
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Hi, Jeff:
I'm glad if I've helped in some way. Btw, I used to have horrible imbalance and oscillopsia when walking. (Oscillopsia can be described as bouncing vision, kinda like what you see in a film or video taken by someone walking with the camera while filming.) Walking is, ironically enough, what cured me of the oscillopsia and improved my balance significantly overall. It is very important that you exercise your vestibular system, especially by walking over uneven ground (as long as you take enough care to do it safely). This will retrain your brain to ignore the aberrant signals being sent by your vestibular system on your AN side and rely more on your vision and propioceptors for sense of balance. Walking, or doing anything that makes you dizzy, will feel lousy at first, but it is what you absolutely must do in order to feel better and improve your balance.
Best wishes,
TW
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Dr. Shahinian (of the keyhole apprach) has been sued for malpractice 17 times in his career, and just lost a huge malpractice case. He is not trained as a neurosurgeon. Please see this link:
http://articles.latimes.com/2010/apr/09/local/la-me-malpractice9-2010apr09
Miriam
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Very interesting article, Miriam.
Thanks for posting it.
Jan
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Interesting article. It sounds like he removed another tumor (the "brown lesion" noted in the article) from the patient's IAC. Odd that that wasn't an AN, despite its location. What else could it have been? A facial-nerve schwannoma? I suspect the author of the article may have been confused in their reporting and the article isn't quite totally accurate. It is also likely misleading in at least one aspect: it reports that the patient in question lost their hearing and has chronic headaches, but that is just as (or more) likely to have occurred as a result of the followup conventional surgery he underwent than from the minimally invasive approach Dr. Shahinian took.
I've seen similar allegations against this doctor before. It's interesting that he has prevailed in most of the suits brought against him. The question is how many has he lost? Everyone makes at least one or two big mistakes over the course of their professional career, no matter what the profession. Did he lose just one case? Two cases? Eight?
I would be very interested to see an informal unbiased (patient-generated) survey started on this forum wherein people who have had surgery performed by Dr. Shahinian report their opinions of how successful their operation was. I would personally not be detered by bad press from having him perform my surgery if the results were overwhelmingly favorable. But this article does raise my eyebrows yet again.
Best wishes,
TW
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I believe this article has been posted here before. It proves two things to me: endoscopic surgery might not work out, just like any other surgery, and it is not a "procedure", like it is sometimes called, but a real brain surgery with far-reaching consequences for a patient. As far as Dr. Sh being sued, ALL neurosurgeons are sued sometime in their careers and that is why they have one of the highest malpractice insurance premiums of any medical profession. Brain surgery is risky business by nature. We just do not hear routinely about lawsuits against other neurosurgeons.
Fear of being sued also keeps doctors from taking complicated cases. Thus, doctors who do not undertake risky surgeries, do not have the necessary skills to operate. I was a very challenging case and some doctors just refused to operate. This doctors are in held in high esteem by both the medical profession and their patients. May be they have less lawsuits against them, but I wouldn't fare very well with their advice. I am glad Dr. Sh exists and, regardless of how many times he is sued, he had the necessary skill to solve my case. The best part of the experience was : NO HEADACHES!
I have to note, though, that I do not like to read about failures, regardless of where they come from.
Eve
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Yes that article is old news from earlier this year. I have researched this doctor and the only judgment against him is this one, and it is under appeal at that. A California doctor friend of mine informs me that brain surgeons get sued all the time as someone else noted. Int restingly, if the award is under $30,000, it's not on the doctors record. I would like to know where the author got the 17 lawsuit number because I haven't been able to find case history's for them.
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Why do you say 31% facial paralysis? did you have a large an. The SBI study says 7% over time. What stats do you have on CK?
I was strongly leaning that way but am going to see SBI next week. Would appreciate any help. Thanks Tom
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Tom, please use the Quote button to quote someone so we know whose quote you are addressing with your followup question. That way we can better understand your question.
Thank you!
TW