Questions for Treating Physician
NON-OPERATIVE TREATMENT WATCH & WAIT / WATCH & SCAN
If the person chooses the observation / watch and wait approach for a small tumor, periodic imaging is advisable. Following initial diagnosis, a reasonable plan would be to get a new MRI scan in six months. If there is no growth, wait one year, and repeat the scan yearly for five years. Be sure to inform your physician of any changes that may occur such as worsening of hearing, imbalance, or facial numbness. These changes could indicate that the tumor is growing more rapidly. By waiting, there is a slight risk you could lose part or all of your hearing in the involved ear.
If significant growth does occur during the observation period, treatment is indicated and you and your physician may decide to choose between one of two therapies: radiation treatment (for control) or microsurgical removal.
RADIATION TREATMENT FOR ACOUSTIC NEUROMA
The goal of radiation treatment for acoustic neuroma is to stop or control tumor growth. It does not remove the tumor. Radiation is used to treat small and medium-sized acoustic neuromas (<2.5 - 3cm). Using controlled high-energy rays, radiation works by damaging the DNA inside cells and making them unable to divide and reproduce and by reducing blood supply or nutrients to the tumor. The benefits of radiation are not immediate but occur over time. Gradually the tumor may stop growing and in some cases may shrink in size.
Stereotactic radiation therapy, referred to as "radiosurgery" (typically performed in a single session) or "radiotherapy" (typically delivered over an extended period of time in multiple doses of radiation) is a technique based on the principle that radiation delivered precisely to the tumor will arrest its growth while minimizing injury to surrounding nerves and brain tissue. This non-invasive procedure can be performed in general on an outpatient basis.
There are several different ways to deliver the radiation required for effective treatment of an acoustic neuroma. Gamma Knife, LINAC, Novalis, XKnife and CyberKnife are all names of specific machines that deliver radiation. In each case, the beam that radiates the tumor consists of highly charged photons; the differences lie in the way they produce the photons as well as the technology they use to focus the beam(s) to the area of interest. Proton Beam is a different form of radiation therapy. Although proton beam centers are few around the US, there are certain instances when proton radiation has benefits over photon radiation. You should discuss this with your physician.
QUESTIONS FOR THE RADIATION TREATING MEDICAL PROFESSIONALS
If you have opted for radiation treatment of your tumor, you may want to ask some of the following questions of your radiation therapist, nurse, neurosurgeon, neurotologist, radiation physicist, radiation oncologist or neuroradiologist:
- How long have you been performing radiation treatment of acoustic neuromas? Have any problems emerged in any of your patients?
- Have you been certified to do radiation for patients with acoustic neuroma?
- Will this be a one-dose procedure (radiosurgery), or will it consist of several smaller doses (radiotherapy)?
- What type of radiation treatment (e.g., Gamma Knife, LINAC, CyberKnife, Novalis FSR, proton beam, etc.) do you most commonly perform? What are the advantages of this type of radiation over the others that are available?
- Why do you recommend this particular form of radiation treatment over others?
- Do you expect hearing, balance or ringing in the ear could be altered by radiation treatment?
- Do you anticipate that the tumor will swell after treatment? For how long?
- What are the long-term side effects of this treatment? Say 10 years or more? How will I know if something is changing?
- Are physicists involved in the planning of your radiation treatment?
- What symptoms are commonly experienced by your patients after treatment? How do you define "side effects"?
- What are the more serious complications such as malignancy, hydrocephalus and others that can happen with treatment and the relative frequency?
- How many of your patients have experienced continued growth of their tumors following treatment? How many of your patients have you followed long-term to draw your conclusion? If this happens to me, what would be my best follow-up procedure, can I have microsurgery?
- After radiation treatment, may I go about my business as before treatment, or are there any special precautions I should take?
- When and how often should I schedule follow-up MRIs after treatment? Will I get these MRI's for the rest of my life?
- Why would you choose radiation for me?
MICROSURGICAL REMOVAL OF ACOUSTIC NEUROMA
Surgical removal is the most common treatment for acoustic neuromas. Priorities in surgery are: first, the maintenance of facial nerve function; second, the preservation of socially useful hearing in the affected ear; and third, complete tumor removal. Total tumor removal carries a higher risk of hearing and facial nerve problems. During tumor removal, a probe is used to stimulate and monitor the facial and in some cases auditory nerves. Because acoustic tumors grow slowly, new research supports partial or near-total removal, whereby small remnants of tumor capsule are left attached to critical nerves. Partial removal techinques have higher rates of facial functional preservation; however, the long-term results of these techniques are still being investigated. Most studies show that near total removal, leaving less then 5mm, results in excellent long term outcomes (reoccurrence <3%) and facial nerve function. If the tumor remnant grows, radiation may be used.
|NOTE: It's all right to get more then one opinion. Since acoustic neuromas are benign and slow growing (usually developing over several years), surgery should not be considered an emergency in most cases. Be cautious of anyone who tries to convince you to rush into surgery before you have taken the time to make an informed decision.
QUESTIONS FOR THE SURGEON
If you have decided to have your acoustic neuroma surgically removed, you may wish to ask some of the following questions of a potential surgeon:
- How many acoustic tumors have you removed this month/this year and/or what specific training in acoustic tumor surgery have you had?
- What is your total experience in operative cases of acoustic neuroma tumors over what period of time?
- What microsurgical approach do you recommend for my tumor size, location, age, health and level of hearing? What approach do you routinely perform?
- Do you feel the facial nerve results or the hearing results are more important in the long-term outcome? How do you achieve their preservation and what are your success rates?
- Do you electrically monitor the facial nerve during surgery?
- Do you use the newer technique to preserve the facial nerve? In your experience, when leaving in small pieces of residual tumor on the brainstem or facial nerve, does tumor growth usually stop?
- For a tumor the size of mine, what have been your results with respect to facial nerve function, both temporary and permanent?
- What is the likelihood that my remaining hearing will be preserved after this surgery?
- Do you anticipate total tumor removal with a single operation? If not, what are my follow-up options? Surgery? Radiation?
- Will this surgery be done by a team of physicians with more than one specialty?
- What has been your rate of surgical complication with respect to stroke, infection, bleeding, cerebral spinal fluid (CSF) leak and headache?
- When and how often should I schedule follow-up MRIs after treatment? Will I get these MRI's for up to 10 years?
- Does your hospital have a neurological intensive care unit?
- About how many days will I be in the hospital?
- What follow-up care will I need?
- How much discomfort should I expect from headaches and from the incision after this surgery?
- What do you do to minimize post-surgery headaches? NOTE: If you have a history of headaches, discuss with your physician.
- Did you feel comfortable with the surgeon, the information shared, access to a non-biased sample of his/her previous patients?
- All other things being equal, when can the surgery be scheduled?
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