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Master Thesis

Traitement des schwannomes vestibulaires de gros volume (Koos IV) : les stratégies conservatrices

Abstract : Background: The major burden of the surgical removal of large and giant vestibular schwannomas (VS) is related to the potential risk of postoperative FN palsy responsible of severe functional and social handicap for the patients. The “Functional Sparing Surgery” policy consists in performing an optimal tumor resection while reducing the risk for the FN, underlying the possibility of leaving a minor remnant of tumor. Objective: To assess long term clinical and radiological outcomes in patients harboring large vestibular schwannomas (VS) operated with a facial nerve-sparing technique. Methods: Single center retrospective cohort study about 169 consecutive large VS, defined as KOOS Grade IV, operated between January 2003 and May 2015. The postoperative volume of the tumor residue was assessed by a thin slides MRI six months after surgery and checked sequentially. After resection, patients were allocated to a wait & re-scan (W&reS) or an upfront Gamma-Knife Surgery (GKS) policy. Results: At last follow-up examination, among the 145 patients without preoperative facial nerve palsy, facial nerve function was good (House-Brackmann (HB) Grades I or II) in 84% and moderate (HB Grade III) in 15% of patients. Only 1 (1%) patient presented poor FN function (HB Grade IV). Eleven percent of patients underwent gross total (GTR), 59% near total, 21% subtotal, and 9% partial resection. In the 143 non-GTR patients, the overall median volume of tumor residue was .39cc. Sixty six of them had been allocated to a W&reS policy and 77 underwent upfront GKS. Overall tumor control was achieved in 83% of cases with a mean follow-up of 62 months. Among the 27 cases of regrowth, 16 underwent salvage GKS and one required salvage surgery, which corresponds to a failure rate of 11% in the overall population. Among the non-GTR patients, the 1-, 5- and 7-year PFS were 95%, 82% & 76% respectively in the W&reS, and 99%, 81% & 78% in the GKS group (p=0.57). Conclusion: Our analysis of a large group of operated VS indicates that functional nerve-sparing resection provides satisfactory facial nerve preservation. Considering the low probability of regrowth of small remnants in the long term, W&reS seems reasonable. GKS is a legitimate option as a salvage treatment.
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https://dumas.ccsd.cnrs.fr/dumas-01873587
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Submitted on : Monday, March 18, 2019 - 5:45:17 PM
Last modification on : Monday, July 6, 2020 - 4:46:55 PM
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Lucas Troude. Traitement des schwannomes vestibulaires de gros volume (Koos IV) : les stratégies conservatrices. Sciences du Vivant [q-bio]. 2017. ⟨dumas-01873587⟩

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