Do We Really Still Need Open Surgery?

[PaulW]

A new, rather provocatively titled medical paper

Do We Really Still Need an Open Surgery for Treatment of Patients with Vestibular Schwannomas?
http://www.ncbi.nlm.nih.gov/pubmed/23417455

[Chances3]

Shrinkage rates of 76.4 % - there are some of us who chose surgery because we didn't want to have surgery after GK failed to shrink our tumors - that would be the other 23.6 %.

Having said that, we all know there are many members who want to avoid surgery - I can't blame them.

[FlyersFan68]

 "It results in a tumor control rate similar to that seen with microsurgery" ?

[PaulW]

Shrinkage rates of 76.4 % - there are some of us who chose surgery because we didn't want to have surgery after GK failed to shrink our tumors - that would be the other 23.6 %.

I think you will find most of the 23.6% will shrink beyond 3 years

Many tumours swell for up to 2 years, and remain bigger than their original size, before eventually shrinking.
Most will be smaller than their pretreatment size at 5 years..

Radiation success is related to the size of the tumour, whether its cystic or not, and whether you have NF2, whether the tumour is fast growing and the experience of the team. If you exclude the larger tumours say greater than 2.5cm , NF2, and cystic tumours. Success rates for radiosurgery are not much different from microsurgery, after you exclude the high risk categories

[Jim Scott]

No one really wants to undergo AN removal surgery but many do so on the recommendation of doctors and/or because they want what they consider a conclusive solution to their AN diagnosis by having the tumor physically removed.  Of course total removal is not always possible and even when it is, we all know that even one tumor cell left on the nerve sheathing can eventually trigger re-growth. 

I underwent debulking of a 4.5 cm AN that reduced it to approximately 2.5 cm.  The tumor's blood supply was severed.  Then it was radiated via FSR.  The debulking surgery spared my facial nerve and the radiation accomplished the goal of destroying the remaining tumor's ability to re-grow, "killing it's DNA", as my doctor put it.  Both surgery and radiation were relatively complication free and my recovery was rapid.  I went into surgery SSD and my hearing was never considered salvageable.

I believe that doctors who specialize in radiation treatment for ANs are naturally inclined to see non-invasive radiation as the best approach to smaller tumors.  I'm sure surgeons that specialize in ANs might disagree.  Both approaches have their good and bad points.  Although the numbers in the linked article are impressive, at this time, I don't see that radiation is  inevitably going to be the sole choice for addressing acoustic neuromas.  Endoscopic AN surgery shows promise and may replace conventional 'open' surgery in the near future.  Radiation certainly has a place in AN treatment and I can testify to it's efficacy but I also believe that 'open' surgery is not about to replaced by radiation, although the popularity of 'open' surgery  with doctors may decrease over time.   

Jim

[jbbrown15]

Is it me, or does this link not work anymore?

[Chances3]

If radiation has an excellent result rate for small tumors, than why do doctors surgically remove small tumors?

Why don't they send the patient off to GK ?

[robinb]

The link is no longer working for me either.

In my very, very, personal opinion to the previous post from Chances3:

Surgeons believe in what they do and whether its ego or not wanting to lose the business, they will not prefer to lose a patient to another procedure that they don't perform.

Case in point of my own personal experience; I personally saw Dr. Friedman at House after phone/email/MRI review consults with Dr. Konziolka at NYU and Dr. Lunsford at UPMC (both do GK) and Dr. Chang at Stanford (does CK).

Dr. Friedman strongly believed that surgery was my best option, my tumor was small so surgery relatively easy, since my hearing loss was 50% why would I have a problem w/SSD. He pretty much said Dr. Chang was a quack (seriously) and CyberKnife had no merit in tumor shrinkage or hearing preservation. At the end of the consultation, I told him I had decided on GammaKnife. When he realized he couldnt dissuade me, he offered up a begrudging willingness to perform GammaKnife and said I didnt need to travel across the country for it(they dont even mention they perform GK on their web site). I chose GK w/Dr. Lunsford.

Many speak highly of the practice at House and their experience w/surgery for AN's. I cant comment on that.

The best advise is to make the decision each person feels is the right one for them. However, it saddens me to hear of so many people with small AN's that are led to believe invasive surgery provides the best outcome given the serious risk of complications.

[PaulW]

If radiation has an excellent result rate for small tumors, than why do doctors surgically remove small tumors?

Why don't they send the patient off to GK ?

100 years ago everybody caught a ship to travel overseas, nobody flew.
50-60 years ago it was probably split 50:50.
Who takes a boat from New York to London these days?

Radiation even 20 years ago for an Acoustic Neuroma was a bit "out there"
The medical profession do err on the side of caution.

In the US it appears surgery remains the most popular option, while in Europe it has already gone the other way, with radiosurgery the most popular for small AN's

House Clinic probably are probably part of the reason this happens.
Their development of surgical technique, and research into AN's and their pursuit of excellence in microsurgery, as well as sharing the research and techniques with many others, has helped propogate best practice AN surgery to many.

As we know ships, got faster, got more entertainment, casinos, swimming pools, stabilisers, got cheaper, but eventually couldnt compete with air travel. 

In 200 years from now everything might be non invasive.

I think radiation on small AN's is just a small step to a non invasive future.
In 30 years from now doctors maybe laughing at how they used to remove small AN's instead of using radiation.

Mind you they might be surgically removing radiation induced tumours from 80 year olds who had radiation 30 years ago too.
Mumbling under their breath... radiation... what were we thinking!
 
I think we are in the period where we have a choice and neither is right or wrong.

The trend towards totally non invasive techniques will continue as technology improves.

[arizonajack]

The link stopped working likely because the article is available for purchase.

I found a summary of the article:

Whether Gamma Knife Radiosurgery Is Really Necessary for Treatment of Patients with Vestibular Schwannomas.

Tomokatsu Hori and Takashi Maruyama
Acta Neurochir Suppl (2013), PMID 23417454

 The present study was directed at establishing the role of Gamma Knife radiosurgery (GKS) in the management of vestibular schwannomas (VSs), particularly those that are large. We analyzed a consecutive series of 222 tumors operated on by a single neurosurgeon (T. Hori) at Tottori University (1981-1998) and Tokyo Women's Medical University (1998-2011). The surgical strategy for sporadic unilateral VSs was typically total or nearly total tumor removal with facial nerve preservation, whereas in some cases of neurofibromatosis type 2 intentional subtotal resection was performed. In all, 15 patients (8.6 %) in the series underwent GKS before (4 cases), after (9 cases), or before and after (2 cases) tumor removal. Overall, 211 patients (95 %) were cured by microsurgery alone. Of note, six patients underwent primary radiosurgery but were operated later on for regrowth of the neoplasm, and in four of them near-total resection led to good long-term tumor control. GKS was required in only 5 % of cases for management of residual VS or, more frequently, its regrowth. Radiosurgery resulted in volume reduction in one-third of these tumors. In other cases it stabilized the lesion, preventing further progression. Thus, GKS is considered a reasonable management option for residual or regrowing small VSs to obtain maximum tumor growth control after initially attempting complete surgical removal.
 
http://pubget.com/paper/23417454/Whether_Gamma_Knife_Radiosurgery_Is_Really_Necessary_for_Treatment_of_Patients_with_Vestibular_Schwannomas

The article appears to read just the opposite of the title originally posted.

[Chances3]

Paul,

What I am trying to discern is if the science for GK is overwhelmingly more successful in the eradication of small ANs' than why did my ENT tell me I needed surgery and give me a list of surgeons ?  And, when I visited these surgeons, why didn't they tell me, your AN is small, your an excellent candidate for GK?  Is it because surgeons just want the business ?  No one ever told me that my outcome would be statistically in my favor with GK.  Yes one surgeon offered it, but not with any discussion of outcomes.  I was frightened of the thought of radiation going into my brain.  I didn't want to have to return to a surgical solution should the GK not have the desired results, so I chose surgery.  Many patients have had great outcomes with the surgeons I selected, but not me.  So I try not to deal with the "what ifs" because I am truly trying to move on with my life.  I will add, the ENT wanted me to have middle fossa for hearing preservation, which they did succeed at - albeit a little muffled, so all in all, I really can't complain on this site, considering what other members have been through.

[grammyslim]

Guess I was the lucky one that found a surgeon that was honest and forthcoming.  I saw the radiation guy first (decided I would go with the SRS) and then saw the surgeon. The surgeon said I could go either way with my choice.  I asked him directly if he had to choose for himself what would he do.  He answered radiation.
Yes I have had a few issues BUT they have cleaned up and I am doing great now.  I am so happy I made the choice that I did - some of these stories about the surgery and recovered are not acceptable to me.

It's been 9 months since my procedure.

Grammyslim

[PaulW]

Paul,

What I am trying to discern is if the science for GK is overwhelmingly more successful in the eradication of small ANs' than why did my ENT tell me I needed surgery and give me a list of surgeons ?  And, when I visited these surgeons, why didn't they tell me, your AN is small, your an excellent candidate for GK?  Is it because surgeons just want the business ?  No one ever told me that my outcome would be statistically in my favor with GK. 

I don't think in general it is a money thing, although in some cases I am sure it is. I think its what they are comfortable with.
Radiation oncologists will probably only recommend radiation.

I guess this is one reason the ANA recommends seeing multiple specialists, because everybody should get the opportunity to explore all options

[PaulW]

Found another copy of the article.

Its actually a chapter in a book

http://books.google.com.au/books?id=Y0RrYZU8G6wC&pg=PA24&source=gbs_toc_r&cad=3#v=onepage&q&f=false

[arizonajack]

Found another copy of the article.

Its actually a chapter in a book

http://books.google.com.au/books?id=Y0RrYZU8G6wC&pg=PA24&source=gbs_toc_r&cad=3#v=onepage&q&f=false

Unfortunately, that's just a preview to get you to buy the book and the priview omits several pages of the article.