Surgical Salvage of Acoustic Neuroma after Failed Radiation Treatment

Objectives: The purpose of this study was to determine if a more conservative management scheme for surgical salvage after failed radiation leads to better facial nerve outcomes.

Study Design: This study was an Institutional Review Board (IRB)-reviewed retrospective review using a prospectively planned database.

Setting: The study took place at a private practice tertiary neurotology/neurosurgery referral center.

Patients: A total of 108 patients from our institution have undergone surgical salvage after failed radiation for tumors of the posterior fossa. Included in this study were the 73 patients in this group with vestibular schwannoma who had undergone primary radiosurgery with no other intervention followed by tumor removal using the translabyrinthine approach.

Intervention: Translabyrinthine craniotomy was performed for vestibular schwannoma salvage surgery after failed radiation, with either gross total or partial tumor removal.

Main Outcome Measures: Long-term (1 year) House-Brackmann (HB) facial nerve grades were measured pre- and postoperatively, and changes in facial nerve grades pre- and postoperatively were noted.

Results: Of the 73 patients, 79.5% had gross total removal; 5.5% had planned partial resection (subtotal or near total); and 15.1% had intraoperatively elected partial removal, with the vast majority of these being near total removal. At 1-year follow-up, 50% of patients who underwent gross total removal had good facial nerve function (H-B I/II) compared with 85.7% in those with partial removal (P ≤ 0.03). HB grade remained the same or improved postoperatively in 45.8% of the total removal group compared with 78.6% of the partial removal group (P ≤ 0.037), with 21.7% of the total removal group having unsatisfactory outcomes (HB V or VI). In contrast, only 7.1% of patients managed conservatively with partial or near total removal had such poor outcomes. To date, no patient has required additional treatment.

Conclusions: Currently, failed radiosurgery is the most common indication for salvage surgery at our institution, with an ever-increasing population. Taking a conservative approach with a willingness to perform partial and near total tumor removals leads to better facial nerve outcomes with no current evidence of treatment compromise.