Frischer Josa M, Gruber Elise, Schöffmann Verena, Ertl Adolf, Höftberger Romana, Mallouhi Ammar, Wolfsberger Stefan, Arnoldner Christoph, Eisner Wilhelm, Knosp Engelbert, Kitz Klaus, Gatterbauer Brigitte
Departments of1Neurosurgery.
2Institute of Neurology, Medical University Vienna; and.
J Neurosurg. 2018 Mar 2;130(2):388-397. doi: 10.3171/2017.8.JNS171281. Print 2019 Feb 1.
The authors present long-term follow-up data on patients treated with Gamma Knife radiosurgery (GKRS) for acoustic neuroma.
Six hundred eighteen patients were radiosurgically treated for acoustic neuroma between 1992 and 2016 at the Department of Neurosurgery, Medical University Vienna. Patients with neurofibromatosis and patients treated too recently to attain 1 year of follow-up were excluded from this retrospective study. Thus, data on 557 patients with spontaneous acoustic neuroma of any Koos grade are presented, as are long-term follow-up data on 426 patients with a minimum follow-up of 2 years. Patients were assessed according to the Gardner-Robertson (GR) hearing scale and the House-Brackmann facial nerve function scale, both prior to GKRS and at the times of follow-up.
Four hundred fifty-two patients (81%) were treated with radiosurgery alone and 105 patients (19%) with combined microsurgery-radiosurgery. While the combined treatment was especially favored before 2002, the percentage of cases treated with radiosurgery alone has significantly increased since then. The overall complication rate after GKRS was low and has declined significantly in the last decade. The risk of developing hydrocephalus after GKRS increased with tumor size. One case (0.2%) of malignant transformation after GKRS was diagnosed. Radiological tumor control rates of 92%, 91%, and 91% at 5, 10, and 15 years after GKRS, regardless of the Koos grade or pretreatment, were observed. The overall tumor control rate without the need for additional treatment was even higher at 98%. At the last follow-up, functional hearing was preserved in 55% of patients who had been classified with GR hearing class I or II prior to GKRS. Hearing preservation rates of 53%, 34%, and 34% at 5, 10, and 15 years after GKRS were observed. The multivariate regression model revealed that the GR hearing class prior to GKRS and the median dose to the cochlea were independent predictors of the GR class at follow-up.
In small to medium-sized spontaneous acoustic neuromas, radiosurgery should be recognized as the primary treatment at an early stage. Although minimizing the cochlear dose seems beneficial for hearing preservation, the authors, like others before, do not recommend undertreating intracanalicular tumors in favor of low cochlear doses. For larger acoustic neuromas, radiosurgery remains a reliable management option with tumor control rates similar to those for smaller acoustic neuromas; however, careful patient selection and counseling are recommended given the higher risk of side effects. Microsurgery must be considered in acoustic neuromas with significant brainstem compression or hydrocephalus.
作者展示了接受伽玛刀放射外科手术（GKRS）治疗听神经瘤患者的长期随访数据。
1992年至2016年期间，维也纳医科大学神经外科对618例听神经瘤患者进行了放射外科治疗。本回顾性研究排除了患有神经纤维瘤病的患者以及因治疗时间过近而未达到1年随访的患者。因此，呈现了557例任何库斯（Koos）分级的自发性听神经瘤患者的数据，以及426例至少随访2年患者的长期随访数据。在GKRS治疗前及随访时，根据加德纳 - 罗伯逊（GR）听力量表和豪斯 - 布拉克曼面神经功能量表对患者进行评估。
452例患者（81%）仅接受了放射外科治疗，105例患者（19%）接受了显微手术 - 放射外科联合治疗。虽然联合治疗在2002年前特别受欢迎，但自那时起，仅接受放射外科治疗的病例百分比显著增加。GKRS后的总体并发症发生率较低，且在过去十年中显著下降。GKRS后发生脑积水的风险随肿瘤大小增加。诊断出1例（0.2%）GKRS后恶变病例。无论库斯分级或治疗前情况如何，GKRS后5年、10年和15年的放射学肿瘤控制率分别为92%、91%和91%。无需额外治疗的总体肿瘤控制率甚至更高，为98%。在最后一次随访时，GKRS治疗前被归类为GR听力I级或II级的患者中，55%的患者保留了功能性听力。观察到GKRS后5年、10年和15年的听力保留率分别为53%、34%和34%。多变量回归模型显示，GKRS治疗前的GR听力分级和耳蜗的中位剂量是随访时GR分级的独立预测因素。
对于中小型自发性听神经瘤，放射外科应被视为早期的主要治疗方法。虽然将耳蜗剂量降至最低似乎有利于听力保留，但作者与之前的其他人一样，不建议为了低耳蜗剂量而对管内肿瘤治疗不足。对于较大的听神经瘤，放射外科仍然是一种可靠的治疗选择，肿瘤控制率与较小听神经瘤相似；然而，鉴于副作用风险较高，建议仔细选择患者并进行咨询。对于有明显脑干压迫或脑积水的听神经瘤，必须考虑显微手术。
