Differing Opinions - Retrosigmoid vs. Middle Fossa

[HRG]

I was recently diagnosed with a 1 cm AN. I live outside Chicago and was referred to Dr. Leonetti. He is recommending a retrosigmoid approach for tumor removal. I was able to have a phone consultation with Dr. Friedman this afternoon and he feels strongly that I should have a middle fossa based on my age (38), tumor size and location, and my level of hearing, which is only slightly deficient in the high frequencies. I spoke with Dr. Friedman's patient navigator at length today. My concerns about Keck are mostly related to the logistics of being so far from home. I have 3 children and I would want them to be there. Luckily, I have family in the Los Angeles area that can help with that, but it seems like an awful lot to deal with on top of the surgery. Any input is greatly appreciated.

[Greece Lover]

Might I suggest you check into the University of Iowa Hospitals and Clinics?  They are one of the higher-volume AN surgery centers in the country, and were among the pioneers in the middle fossa approach.  I had middle fossa there on May 9 and had pretty much a perfect outcome (not that it was easy!). 

Dr. Ganz is more well known, but I can not say enough good things about Marlan Hansen, who did my surgery.  For you, would probably be a 3-4 hour drive.  Might be worth checking out.  From what I know, there are not as many places that do Middle fossa; more surgeons are familiar with retrosig.  Also, from my research, Mid fossa tends to have few complications, especially fewer headaches.  Also much better for hearing retention if that's a possibility for you.  I'm to answer any other questions you have.

[HRG]

Thank you! I will look into the University of Iowa Hospital.

I got another opinion today from another local surgeon, and he advised watch and wait. He agreed that it will probably have to come out eventually, but he seemed to think I should wait until I lose my hearing and then go translab for the fewest complications.

My hearing is quite good, and while that's not my top priority, it would be nice to preserve it if that's an option.

Can you tell me a little more about your middle-fossa recovery? I spoke with one of Dr. Leonetti's patients that was 4 weeks post-op for the retrosig. She was doing great, so that gave me a little bit of comfort.

I have a call with Dr. House tomorrow, so I'll see what he says.

[Greece Lover]

This is just my opinion and how I navigated the process, so obviously take it with a grain of salt.  Not all places are comfortable with middle fossa, or don't do it as much, and I think sometimes they advise patients away from that particular approach. 

If House thinks you're a good candidate for middle fossa, then I would strongly consider it.  The way I looked at it, all options have risk, and you have to weigh those risks against the potential outcomes.  I could have done W and W.  But I felt like choosing surgery right away gave me the best possible chance at the best possible outcome.  Maybe it was more important to me that I keep my hearing than it is for some, and I"m lucky that I did.  My tumor was 1.2 cm, and I was told about a 65% chance they could save serviceable hearing.  It came out that I hear just like I did before the surgery.

The recovery is tough for a few weeks.  Fatigue, the dizziness can be pretty bad.  I also had some anxiety problems.  But, by 4 weeks I was doing pretty well.  Now, I feel great.  I do long bike rides.  I walk to work every day.  I do still notice some off-balance symptoms when I turn my head quickly and in certain directions, but that should continue to improve.  I really could not be happier with my outcome and thus my decision. 

[Citiview]

I found this journal article about Retrosigmoid vs. Middle Fossa in relation to hearing outcomes and facial nerve outcomes. Two of the authors are Drs. Schwartz and Wilkinson from House. Unfortunately this link provides an abstract, but full access will cost you $45.

Stats are specific to institutions mentioned. It is a retrospective study.

https://www.ncbi.nlm.nih.gov/pubmed/27441159

This next link is about an endoscopic tool they use to gain better access to the cochlea if the tumor is located next to it. One of the authors is Dr. Lekovic at House. You can read this article for free at DeepDyve with a trial subscription.

https://www.ncbi.nlm.nih.gov/pubmed/26929894

I hope this helps you and others as well.

[Greece Lover]

My understanding is that Middle Fossa is the rarest of the surgeries for two reasons.  1. It only works for smaller tumors when hearing preservation is desired.  and 2. because of point 1, fewer surgeons are comfortable doing it.  I think it's generally clear that Translab usually has the best results, but they are not far off from Middle fossa. Here is a link I found helpful and helped me make my decision:

http://link.springer.com/article/10.1007/s40136-014-0062-9

[michellef08]

I had Middle Fossa at House 3+ years ago with Dr. Schwartz and Dr. Friedman and they were able to preserve my hearing! I had only lost about 10% post-op and that is what I have today! I also didn't have a single balance or facial nerve issue! My tumor was on the larger side of the Middle Fossa threshold (1.4cm) and I just wanted my tumor out ASAP before it took anymore of my hearing. I know I am one of the lucky ones with a great outcome, but it does happen!

[Citiview]

To Michelle
Congratulations on your expected baby. I know you did well with Friedman/Schwartz back when they were a team. Sounds like you had the right team at the right time, gambled and it paid off.
My problem is the location of the tumor is right next to the cochlea so I get phrases like "hearing preservation is difficult, but not impossible" or "we can try to save your hearing". Nothing that sounds that hopeful. Enjoy your new baby when he or she arrives.

To Greece lover
That was a good article. It confirms that both approaches give limited views of the tumor next to the cochlea. It doesn't make me feel any better however.

I guess the issue is quality of life issues regarding both approaches and radiation. It's hard to tell.

[Greece Lover]

My understanding is that the Cochlea is not always an issue--it depends on precisely where the tumor is in the IAC.  I'm pretty sure that for me (1.2 CM) that the cochlea was not a concern at all.  When they can't preserve hearing its because the tumor is too close to the auditory nerve. 

Anyway, you're right.  We all have to make a bad choice.  I'm not sure I would agree with your gambling analogy, because we are forced to make a choice.  I like to say I played the percentages.  With a small tumor, the chances of a  serious complication are quite low, and I was told a 65% chance of saving my hearing.  Well, maybe that is gambling!

[ANGuy]

I think one of the advantages of MF is that there is no dural penetration.  I'm not sure if this is with all MF, or just some, and I might be wrong about it all together.

This aspect of it interests me and if anyone knows a little about it, please post on it.

[Greece Lover]

That's correct.  They do not open the dura at all, (except I think there is dura they open within the IAC).  They do have to retract the brain a bit to get to the IAC.  Thus, very low instances of CSF leak. It's really not brain surgery with MF.

[Greece Lover]

Ride it as long as you can!