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|NI FEATURE: THE EDITORIAL DEBATE-- PROS AND CONS
|Year : 2016 | Volume
| Issue : 3 | Page : 372
Vestibular schwannoma: A benign tumor in a “malignant” location
Neurosurgery Clinic, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
|Date of Web Publication||3-May-2016|
Neurosurgery Clinic, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Turel K. Vestibular schwannoma: A benign tumor in a “malignant” location. Neurol India 2016;64:372
Cerebellopontine angle (CPA) is the deadliest corner of Neurosurgery. A vestibular schwannoma (VS) is a benign tumor in this 'malignant' location. The problems in the management of these tumors are manifold. Being a benign lesion, their complete removal is obligatory for achieving a cure. But while achieving this, there are obstacles in the way. These include encountering vital cranial nerves, blood vessels and the brain stem in the vicinity of the tumor. If any of these vital structures are disturbed, the event can damage the patient's life or quality of life (QOL). These tumors come in all sizes, and their growth pattern, though generally slow, can be unpredictable. Size is certainly an important consideration; so is the pre-operative neurological status of the patient. The consistency, vascularity and arachnoidal planes are other variables influencing the surgical outcome.
Our strategy of treatment has evolved significantly over the last 3 decades, ranging from the enthusiasm of complete removal, which is often fraught with facial disfiguration and hearing loss, to the current philosophy of tailoring the operation to such an extent so as to minimize the tumor size. The latter strategy enables preservation of these nerves, leaving the remnant behind for radiosurgery (RS) to control. Thanks to RS, neurosurgeons have found a comfort zone in which they do not tax either themselves or their skills to achieve total excision without damaging any other structures. Unfortunately, although RS controls tumor growth in most instances, it is not entirely noninvasive and has the potential to inflict radiation damage to these very nerves, one is aiming to preserve; worse still, it can cause distressing trigeminal dysaesthesia for which there are no answers.
Secondly, a tumor more than 3 cm in size is not amenable to RS. The neurosurgeon is, therefore, obligated to operate upon these tumors, and to do it safely. If most neurosurgeons become accustomed to removing only small tumors, and that too partially or subtotally, how will they be able to handle the larger ones efficiently? On the one hand, we are doing our best to save the patient's life and function; on the other hand, with the presence of increasingly demanding patients and the high frequency of litigations encountered in current clinical practice, surgeons are becoming wary and even timid, defensive and 'self- preserving.' We are indeed skating on thin ice!
So what is the current 'best' treatment and what should we advise our young neurosurgeons? How are we expected to council our patients? The ego of neurosurgeons tends to be high, but surgery for a vestibular schwannoma has indeed humbled it.
Everybody cannot be Madjid Samii, I guess one should follow to the letter, the advocated technical nuances as much as one's ability allows, thus striking a balance between maximal safe removal and ensuring a good quality of life. If one is not doing enough number of these tumors each year, one must allow them to be pooled in a Centre of Excellence where higher volumes are being done on a regular basis with best possible results, as has been the protocol followed in Denmark.
The second issue is that of the preoperative status. If hearing is preoperatively preserved and the tumor is less than 2.5 cm in size, it may be logical to offer radiosurgery. But if it is larger than 3 cm, irrespective of the hearing status, one needs to operate.
| » References|| |
Turel MK, D'Souza WP, Chacko AG, Rajshekhar V. Giant vestibular schwannomas: Surgical nuances influencing outcome in 179 patients. Neurol India 2016;64:478-84.