Estadísticas

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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Pseudoprogression and treatment success&#46; Tumor in 67-year-old female patient with severe hearing loss &#40;Gardner&#8211;Robertson IV&#41;&#46; History of subtotal surgical resection of left VS one year earlier and ventriculoperitoneal shunt for post-surgical hydrocephalus&#46; &#40;A&#41; Treatment with LINAC-RS in 2012 of the rest of the tumor after surgery &#40;initial TV 3&#46;2<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; &#40;B&#41; Post-RS control MRI after 9 months of treatment&#44; compatible with pseudoprogression &#40;TV 4&#46;2<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; &#40;C&#41; Progressive regression in control MRI at 24 months &#40;TV 3&#46;2<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; &#40;D&#41; Control MRI at 36 months post-RS &#40;TV 0&#46;75<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; TV&#58; tumor volume&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vestibular schwannomas &#40;VS&#41; represent 6&#8211;10&#37; of intracranial neoplasms<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">1</span></a> and 80&#8211;90&#37; of cerebellopontine angle tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">2</span></a> The therapeutic option &#40;expectant behavior&#44; surgery&#44; or radiosurgery &#8211; RS&#41; varies depending on the characteristics of the patient and the radiological features of the tumor&#46; RS is a radiotherapy technique first used by Lars Leksell in 1951&#46; Local control rates are similar for surgery and RS &#40;95&#37;&#41;&#44; with the latter described as offering better hearing preservation &#40;60&#37;&#41; and facial nerve preservation &#40;98&#37;&#41;&#46; However&#44; this technique is not without complications&#46; Treatment with a linear electron accelerator &#40;LINAC&#41; with a micro-multileaf collimator is an RS modality described in 1984 that has shown similar results compared to other types such as GammaKnife&#44; proton beam or Cyberknife and has been used in our center since 2010&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The objectives of our study were to evaluate tumor response in a series of patients with VS treated using LINAC-RS&#44; describe complications after the procedure and analyze variables related to response to treatment and complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patient cohort</span><p id="par0015" class="elsevierStylePara elsevierViewall">This was a retrospective descriptive study of patients diagnosed with VS&#44; treated in our center using LINAC-RS between 2010 and 2016&#44; whose minimum follow-up time was 12 months&#46; Patients with neurofibromatosis were excluded&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Indication for treatment and description of the technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">Our study was conducted in the skull base unit of the neurosurgery service at a tertiary hospital in which there are two neurosurgeons specialized in radiosurgery&#46; In bulky schwannomas &#40;Koos grade III in young patients or cystic tumors and Koos grade IV&#41;&#44; and in patients with trigeminal neuralgia due to the compressive effect of the lesion&#44; surgery is considered the first therapeutic option&#46; With the intention of preserving facial nerve function&#44; less radical surgeries are currently performed and radiosurgery treatment is used as an adjuvant treatment or at progression&#44; depending on each case&#46; In tumors with Koos grades III and IV in elderly patients with an excessive surgical risk or who refuse surgical treatment&#44; radiosurgery or fractionated stereotactic radiotherapy is proposed&#44; respectively&#46; The follow-up option is offered to patients with schwannomas smaller than 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in maximum diameter that are paucisymptomatic and with no evidence of accelerated growth&#44; especially older patients &#40;lower potential risk of growth&#41;&#46; All potential candidates for treatment with radiosurgery are evaluated by a multidisciplinary committee &#40;neurosurgery&#44; radiotherapeutic oncology&#44; medical physics and radiology&#41; to determine if it is ultimately the best option for the patient&#46; The main limiting factor for RS treatment is the dose tolerance for the adjacent organs at risk &#40;cochlea&#44; brainstem&#44; cranial nerves V and VII&#41;&#46; Radiosurgical treatment was performed with a Varian 600DBX linear electron accelerator with 6<span class="elsevierStyleHsp" style=""></span>MV photons&#44; coupled with a Brainlab M3 micro-multileaf collimator&#46; A Brainlab iPlan 4&#46;5 planning system was used for clinical dosimetry calculation&#46; For immobilization&#44; an invasive stereotactic frame was placed onto the skull after injection of local anesthetic at the four fixation points&#46; 3D planning was conducted using computed tomography under stereotactic conditions combined with a previous contrast-enhanced axial T1- and T2-weighted brain MRI with 1-mm slice thickness&#46; The prescribed dose in all cases was 12<span class="elsevierStyleHsp" style=""></span>Gy at 90&#37; isodose &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0025" class="elsevierStylePara elsevierViewall">The following variables were recorded&#58; age &#40;grouped as&#58; &#60;41 years&#44; 41&#8211;60 years&#44; &#62;60 years&#41;&#44; sex&#44; symptomatology at treatment &#40;such as cranial nerve V or VII involvement&#44; headache&#44; tinnitus&#44; dizziness&#44; nausea&#44; and instability&#41;&#44; degree of hearing loss according to the Gardner&#8211;Robertson Classification&#44; reason for treatment and history of previous surgery&#46; Radiological variables were&#58; tumor laterality&#44; location &#40;intracanalicular or intra-extracanalicular&#41; and Koos grade&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">3</span></a> Two-dimensional tumor volume was calculated by measuring the lesion in the three axes of space on contrast-enhanced T1 MRI sequences &#40;anteroposterior &#91;A&#93;&#59; mediolateral &#91;B&#93;&#59; craniocaudal &#91;C&#93;&#41; and applying the simplified version of the ellipsoidal volume formula &#40;&#91;A<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>B<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>C&#93;&#47;2&#41;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">4&#8211;6</span></a> initially and subsequent to treatment observed in controls at 6&#44; 12&#44; 24 months and from 36 months&#46; Tumor volume was divided in different size ranges&#58; &#60;0&#46;50<span class="elsevierStyleHsp" style=""></span>cc&#44; 0&#46;51&#8211;1&#46;99<span class="elsevierStyleHsp" style=""></span>cc&#44; 2&#8211;5&#46;99<span class="elsevierStyleHsp" style=""></span>cc and &#62;6<span class="elsevierStyleHsp" style=""></span>cc&#46; Follow-up in months was calculated from treatment to the last revision in consultation&#46; We recorded the clinical results of treatment&#44; acute complications &#40;during the first 3 months&#41;&#44; chronic complications &#40;from 3 months&#41;&#44; and the number of patients with resolution of these&#46; Complications were defined as new symptoms after treatment or worsening of already known symptoms&#46; Treatment success was considered to be those cases in which radiological follow-up showed a regression &#40;&#62;10&#37; decrease compared to the pre-RS volume&#41; or stabilization of the lesion with respect to the initial volume &#40;&#60;10&#37; change&#41;&#46; Treatment failure was defined as findings consistent with progression &#40;&#62;10&#37; increase&#41; beyond 20&#8211;24 months&#46; Pseudoprogression was defined as a transitory growth &#40;&#62;10&#37; compared to the initial volume&#41; after treatment followed by tumor stability or regression with a minimum follow-up of 24 months&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">For the analysis of quantitative variables&#44; Student&#39;s <span class="elsevierStyleItalic">t</span>-test was used&#44; considering normality criteria&#46; For qualitative variables&#44; the Chi-Pearson test and the Fisher test were used &#40;if the value of the expected event was less than 5&#41;&#46; <span class="elsevierStyleItalic">p</span> values &#60;0&#46;05 were considered statistically significant&#46; IBM SPSS Statistics version 22&#46;00 was used for the statistical analysis&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 64 patients were included and their clinical characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The mean age at treatment was 53 years&#44; and 56&#37; were women&#46; Ninety-eight percent of the patients had hearing loss at the commencement of treatment&#44; with Gardner&#8211;Robertson Classification grade III being the most frequent &#40;71&#37;&#41;&#46; The tumor location was predominantly intra-extracanalicular &#40;80&#37;&#41;&#44; with no differences regarding lateralization&#46; The distribution according to Koos grade is shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; The mean tumor volume at treatment was 2&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;95<span class="elsevierStyleHsp" style=""></span>cc &#40;0&#46;092&#8211;14&#46;94&#41; and the mean at follow-up was 40&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;63 months &#40;14&#8211;86&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> describes tumor control in three groups of patients at the completion of follow-up&#46; The overall therapeutic success was 90&#37; &#40;58&#47;64&#41; reaching 100&#37; at 12 and 24 months&#44; in 3 and 17 patients respectively&#46; Treatment success from 36 months on was 86&#37; &#40;a total of 44 patients completed this follow-up&#41;&#46; No loss to follow-up was reported&#46; Transient tumor growth followed by regression or stabilization compatible with pseudoprogression was observed in 20 &#40;31&#37;&#41; patients&#46; Patients with radiological results consistent with progression had a mean follow-up of 48 months &#40;36&#8211;72&#41;&#44; verified with at least two consecutive MRIs&#46; Tumor control was analyzed at the conclusion of follow-up&#44; revealing a statistically significant relationship with pre-RS tumor volume&#44; finding a greater decrease in lesions with volumes between 0&#46;51 and 5&#46;99<span class="elsevierStyleHsp" style=""></span>cc &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;037&#41;&#46; No association was found between radiological control and sex&#44; age&#44; Koos classification&#44; tumor location or clinical improvement&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Twenty-four patients &#40;37&#46;5&#37;&#41; experienced complications &#40;eight had acute and chronic complications&#41;&#46; Fifty-eight percent of the complications were related to vertigo&#44; nausea or instability &#40;14&#47;24&#41;&#46; The following acute complications were found in 18 patients&#58; dizziness and nausea in six &#40;self-limited in four&#41;&#44; transient headache in two and instability in six &#40;three with no subsequent improvement&#41;&#46; There was one case each of trigeminal neuralgia&#44; hearing loss&#44; facial hemispasm and tinnitus&#44; and these complications were permanent&#46; Fifty percent of the acute complications &#40;9&#47;18&#41; were resolved within one year and most required outpatient management&#46; The rate of acute complications was significantly related to the radiological outcome at completion of follow-up&#44; with fewer complications in patients with regression during follow-up &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;016&#41;&#46; In 13 patients &#40;20&#37;&#41; the following chronic complications were recorded&#58; three with definitive hearing loss&#44; four with chronic instability&#44; one patient developed self-limited headache&#44; three patients developed atypical facial pain with resolution in one case&#44; two patients developed nausea and vomiting and another developed hydrocephalus after 24 months of follow-up&#44; requiring a ventriculoperitoneal shunt&#46; These complications were permanent in 84&#37;&#46; Chronic complications were significantly more frequent in the 41&#8211;60 age group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;040&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Clinical characteristics</span><p id="par0045" class="elsevierStylePara elsevierViewall">The mean age at diagnosis of VS in our study was similar to that of other published studies &#40;55 years&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">7&#44;8</span></a> Hearing loss is a frequent form of presentation in up to 95&#37;&#44; tinnitus in &#62;60&#37;&#44; trigeminal nerve involvement in 12&#8211;19&#37; and facial nerve involvement in 17&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> A higher incidence of schwannomas in Caucasian patients has been described&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> As risk factors for the development of VS&#44; prolonged exposure to noise or abusive use of mobile phones &#40;&#62;2<span class="elsevierStyleHsp" style=""></span>h per day for 10 years&#41; could be associated&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> In our series&#44; there was a predominance of Koos grade II and III lesions&#44; as in other published series&#58; 39&#37; in both cases&#46; Only 3&#37; were grade IV&#44; while in other series the figure was approximately 26&#37;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> or even 44&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a> This difference may be attributable to the fact that the policy of our center was to offer surgical treatment to young patients with Koos grade IV and fractionated stereotactic radiotherapy to older patients or patients who refused surgical treatment&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Treatment</span><p id="par0050" class="elsevierStylePara elsevierViewall">The choice of therapy depends on clinical factors such as age&#44; the functional status and hearing preservation&#44; as well as radiological factors including tumor growth during follow-up&#44; Koos grade or brainstem compression&#44; both indirect indicators of tumor volume&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> Furthermore&#44; personal preference or the medical center may influence therapeutic management&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">7&#44;12</span></a> Within radiotherapy treatment&#44; RS has shown similar results to fractionated radiotherapy &#40;FRT&#41;&#44; the latter being especially useful in large irregular lesions in which surgery is not possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#44;14</span></a> Among the different types of RS&#44; the results of treatment with LINAC are currently similar to those obtained with GammaKnife&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;15&#44;16</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Expectant management&#44; known as &#8220;wait-and-scan&#8221;&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">12&#44;16</span></a> may be indicated in patients with lesions &#60;1<span class="elsevierStyleHsp" style=""></span>cm<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a> with preserved hearing&#44; while in lesions between 1 and 3<span class="elsevierStyleHsp" style=""></span>cm along with comorbidity and advanced age&#44; RS is usually the treatment of choice&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">13&#44;18</span></a> Similarly&#44; in young people with preserved hearing in whom there is no contraindication due to size or compression of vital structures&#44; RS is preferable to surgery for comparable results with respect to tumor control and a lower rate of complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;13&#44;16&#44;18&#8211;22</span></a> Some studies have reported expectant management in Koos grade I lesions because of their low rate of progression to be comparable to Koos I lesions treated with RS&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">19&#44;22&#44;23</span></a> According to current guidelines&#44; observation is indicated in patients with VS<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm or intracanalicular without tinnitus&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> Other authors&#44; however&#44; report that expectant management requires strict follow-up and that 14&#46;5&#37; of these cases will end up requiring treatment&#44; discouraging this measure in young people with signs of hearing loss&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;16&#44;25</span></a> where RS assumes a great therapeutic role&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">2&#44;13&#44;21</span></a> Surgical treatment&#44; currently the most common&#44; is indicated for lesions with mass effect and compression&#44; especially if they are &#62;3<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">1&#44;7&#44;19&#44;25</span></a> Young people with less atrophy may present a greater degree of compression&#44; thus indicating surgical decompression&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> In cases of VS Koos grade IV&#44; the combined approach using subtotal surgical excision with functional monitoring followed by RS treatment reduces the risk of facial nerve damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">12&#44;18</span></a>&#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a><span class="elsevierStyleBold">&#41;</span></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Treatment success</span><p id="par0060" class="elsevierStylePara elsevierViewall">Tumor control after treatment with LINAC-RS varies between 81 and 100&#37; at 3 years&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;15&#44;26</span></a> and up to 90&#37; at 5&#46;8 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;22</span></a> In other studies&#44; the success rate is 88&#37; at 10 years&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> Similar results were found in our series in which tumor control at the end of follow-up was 90&#37;&#46; With GammaKnife&#44; control has also been described to be about 97&#37; at 3 years&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> 92&#37; at 7 years&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> and 84&#46;8&#37; at 10 years<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a>&#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; In our series&#44; 20 patients presented transient growth &#40;31&#37;&#41;&#44; consistent with pseudoprogression&#44; defined as transient growth of &#62;20&#37; followed by stability or reduction&#44; with a 31&#37; rate described in the series&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> Peak incidence is described at around 6&#8211;9 months post-treatment<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;19&#44;27</span></a> decreasing from the fifteenth month&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> Van de Langenberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> reported pseudoprogression in 54&#37; after treatment with LINAC and others of up to 40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> In patients treated with GammaKnife&#44; pseudoprogression is described as between 15 and 30&#37; after a minimum follow-up of 24 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">19&#44;26&#44;27</span></a> In the study by Boari et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> of the 332 patients treated with GammaKnife&#44; 54&#37; showed an increase in volume at 6 months&#44; decreasing to 22&#37; at 3 years&#44; and only 5&#37; showed progression&#46; To date&#44; part of the pathophysiology remains unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> Although risk factors have been described that could be related to age&#44; irradiated dose or tumor volume&#44; more studies are needed to clarify these hypotheses&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a> The recently published study by Breshears et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> reported transient growth of 44&#37; in one year with peak growth in 90&#37; of cases during the first 3&#46;5 years after treatment&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In our study&#44; six patients showed growth &#62;10&#37; with respect to the initial volume during a minimum follow-up of 36 months&#46; The definition of progression according to each study was defined as&#58; increase &#62;10&#37;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">11&#44;16</span></a>&#59; increase &#62;20&#37;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10&#44;26</span></a>&#59; growth &#62;2<span class="elsevierStyleHsp" style=""></span>mm in two planes<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">16&#44;17&#44;19</span></a> and even growth &#8805;3<span class="elsevierStyleHsp" style=""></span>mm&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> in a minimum follow-up of 24 months<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">26&#44;27</span></a> and up to 36 months&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a> A follow up as long as 6&#46;9 years has been described as necessary in order to identify true cases of pseudoprogression&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> The rate of progression in our series could be overestimated due to a short follow-up period&#46; In some studies&#44; treatment failure is defined as progression requiring an alternative treatment&#44; without specifying a clear definition in those cases with evidence of growth not requiring salvage treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;25</span></a> Furthermore&#44; alternative treatment is not currently standardized and there is controversy regarding the management of second-line treatment in these patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;25&#44;28</span></a> with RS being an accepted retreatment option&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> Surgery as a second line after initial treatment with RS presents a greater probability of subtotal resection and seventh cranial nerve involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a> No risk factors related to tumor progression have been found&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">17&#44;19&#44;22</span></a> When monitoring these patients&#44; MRI performed from 24 months onwards would be useful to distinguish pseudo-progression from true progression and avoid unnecessary treatments&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">24</span></a> which should not be considered before 36 months and provided that there is a clear trend towards growth in successive control MRIs&#46; Early MRI &#40;at 6 or 12 months&#41; facilitates the management of possible complications&#46; An increase in volume in asymptomatic patients treated with RS requires expectant management&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">26&#44;28</span></a> Some studies have reported that tumor stability of at least 5 years indicates that tumor growth is unlikely in later years<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> and that hearing loss is greater in the first few years after diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Radiological tumor control after RS is independent of the clinical response of the patient with respect to pretreatment symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">27</span></a> The primary objective of RS treatment is radiological control&#44; with the lowest rate of complications enabling the stabilization of established symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;22</span></a> In addition&#44; tumor response does not appear to be related to the initial Koos grade&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">10&#44;11</span></a> The response rate was equal in Koos grades I and II vs grades III and IV&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> In our series&#44; although tumor response was not significantly related to the Koos grade&#44; we found statistically significant differences in response to treatment according to pre-RS volume &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;037&#41;&#44; with a greater decrease in lesions with a volume between 0&#46;51 and 5&#46;99<span class="elsevierStyleHsp" style=""></span>cc&#46; The initial tumor size has been described as a factor related to subsequent radiological control<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a> demonstrating greater reduction in volume&#44; especially in macrocystic VS compared to homogeneous and microcystic VS&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a> The tumor volume and tolerance dose for organs at risk are the main limiting factors of RS treatment&#46; For this reason&#44; in large tumors &#40;Koos IV&#41; RS is rejected from the outset and surgical treatment or fractionated stereotactic radiotherapy is chosen&#46; Only two patients in our series presented Koos grade IV at the start of treatment&#46; Both had a personal history of subtotal surgery and sequelae prior to RS treatment &#40;facial palsy&#44; grade IV hearing loss in one&#44; and dizziness and vertigo in the other&#41;&#46; With a follow-up longer than 36 months&#44; the first patient showed tumor regression without clinical improvement and the second showed radiological stabilization but required the implantation of a ventriculoperitoneal shunt at 24 months for chronic hydrocephalus&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Complications</span><p id="par0075" class="elsevierStylePara elsevierViewall">The rate of complications from RS is significantly lower than that from surgical treatment&#46; Hearing preservation with surgical treatment is 5&#37; compared to 65&#37; with RS&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">7&#44;13&#44;18</span></a> Boari et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> report that hearing preservation after RS varies according to age&#44; with 92&#37; in Gardner&#8211;Robertson grade I at &#60;55 years compared to 42&#46;9&#37; at &#62;55 years&#46; Hearing preservation in these patients &#40;grade I&#41; is approximately &#62;75&#8211;100&#37; at 2 years&#44; &#62;50&#8211;75&#37; at 5 years and &#62;25&#8211;50&#37; at 10 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">22&#44;30</span></a> Mulfer<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">16</span></a> showed preservation of 44&#8211;68&#37; in those patients with preserved discrimination prior to treatment&#44; requiring a minimum follow-up of 10 years in order to establish an accurate value&#46; The degree of pretreatment hearing has been considered a prognostic factor for subsequent preservation&#44; and hearing deterioration is less if hearing remains stable after the first 6 months of RS treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a> In addition to age and auditory function prior to treatment&#44; the dose of irradiation is of vital importance in the prognosis<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18&#44;30</span></a>&#59; the Koos grade&#44; however&#44; is not&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a> In our series&#44; a high percentage of patients presented no useful hearing at diagnosis&#46; Nevertheless&#44; no significant differences in hearing prognosis have been found in the literature in patients treated with conservative management compared to those treated with RS&#44; although the latter has demonstrated better local tumor control&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">2&#44;23</span></a> Dizziness&#44; nausea and instability are the most frequent complications found in our series &#40;14 patients&#41;&#46; The presence of tinnitus is not usually resolved with treatment&#44; with an improvement of only 20&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> The incidence of paralysis and temporary facial weakness after surgery is 8&#37; and 14&#37;&#44; respectively&#44; higher than with RS with 7&#46;7&#37; and 4&#46;8&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> An improved radiotherapy technique has considerably reduced the rate of complications<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">22&#44;24</span></a> including those related to facial and trigeminal nerve neuropathy from 19&#37; and 16&#37; to 1&#46;5&#37; and 1&#46;2&#8211;3&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">8&#44;9&#44;13&#44;15&#44;18&#44;25</span></a> Other related complications are hydrocephalus &#40;4&#46;4&#37;&#41; and malignant transformation &#40;&#60;1&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">7&#44;16&#44;24</span></a> According to the Common Terminology Criteria for Adverse Events Classification&#44; the complications described in our study varied between grades 1 and 3&#44; similar results to other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> with no complications requiring urgent intervention or involving a short-term life-threatening risk &#40;grade 4&#41;&#44; nor deaths related to adverse effects of treatment &#40;grade 5&#41;&#46; The rate of acute complications was significantly related to the radiological result at completion of follow-up and was lower in patients with regression &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;016&#41;&#46; This could be a spurious result given the small sample size of our series&#46; Moreover&#44; chronic complications were significantly more frequent in the 41&#8211;60 age group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;040&#41;&#46; This could be due to the fact that elderly patients suffer from a degree of cerebral atrophy that could avoid adverse effects derived from the mass effect on the brainstem&#46; Younger patients&#44; in contrast&#44; may have greater functional and recovery capacity&#46; More studies would be needed to confirm this&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Little information has been reported about the functional impact and quality of life in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">19&#44;20&#44;31</span></a> Health scale scores show poorer outcomes in elderly patients with systemic disease and associated neurological deficit&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a> Measures should be taken to improve the support of these patients with regard to expectations concerning the course of the disease&#44; possibly with psychological support being the most important factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">20&#44;31</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Limitations</span><p id="par0085" class="elsevierStylePara elsevierViewall">The retrospective nature of our series as well as the recent implementation of this technique in our center has so far only allowed for the analysis of the series with a short follow-up time and a small sample size&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Radiosurgery is a consolidated treatment option for VSs that are not free of complications&#44; although they are generally well tolerated and transitory&#44; demonstrating in our series a tumor control in accordance with other published series&#46; The radiological result at the completion of follow-up was significantly related to the volume at the start of treatment&#46; The rate of acute complications was significantly related to the radiological outcome at the end of follow-up&#44; with fewer complications in patients with evidence of regression during follow-up&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">Informed consent was obtained from all participants included in the study&#44; which was approved by the Hospital Ethics Committee&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Variables"
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              "titulo" => "Statistical analysis"
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              "titulo" => "Clinical characteristics"
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              "titulo" => "Treatment success"
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              "titulo" => "Complications"
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          "titulo" => "Limitations"
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          "titulo" => "Conclusion"
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          "titulo" => "Informed consent"
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          "identificador" => "sec0085"
          "titulo" => "Conflicts of interest"
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          "identificador" => "xack413463"
          "titulo" => "Acknowledgements"
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        14 => array:1 [
          "titulo" => "References"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-11-18"
    "fechaAceptado" => "2018-12-21"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
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          "identificador" => "xpalclavsec1126400"
          "palabras" => array:4 [
            0 => "Stereotactic radiosurgery"
            1 => "Linear accelerator"
            2 => "LINAC-RS"
            3 => "Vestibular schwannoma"
          ]
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      ]
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          "identificador" => "xpalclavsec1126401"
          "palabras" => array:4 [
            0 => "Radiocirug&#237;a estereot&#225;xica"
            1 => "Acelerador lineal"
            2 => "Rc-LINAC"
            3 => "Schwannoma vestibular"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aims of our study were to evaluate tumour response in a series of patients with vestibular schwannoma &#40;VS&#41; treated with linear accelerator stereotactic radiosurgery &#40;LINAC-RS&#41;&#44; to describe the complications and to analyze the variables associated with the response to treatment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This retrospective descriptive study included 64 patients treated from 2010 to 2016 with a minimum follow-up of one year&#44; excluding patients with neurofibromatosis&#46; Clinical&#8211;radiological parameters were evaluated&#46; The treatment was performed using LINAC-RS&#46; The prescribed dose was 12<span class="elsevierStyleHsp" style=""></span>Gy at 90&#37; isodose&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean age at treatment was 53 years&#44; 56&#37; were women&#46; Ninety-eight percent of the patients had hearing loss&#44; 71&#37; with grade III according to the Gardner&#8211;Robertson Classification&#46; The mean volume at treatment was 2&#46;92<span class="elsevierStyleHsp" style=""></span>cc and the mean follow-up&#44; 40&#46;95 months&#46; The overall therapeutic success was 90&#37;&#44; reaching 100&#37; at 12 and 24 months&#44; and 86&#37; after 36 months of follow-up&#46; The radiological result was significantly related to the initial tumour volume &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;037&#41;&#46; In 20 patients there was evidence of transient tumour growth compatible with pseudoprogression&#46; Acute complications were present in 37&#46;5&#37;&#44; and transitory complications in 50&#37;&#46; Chronic complications were found in 20&#37;&#44; with 84&#37; being permanent&#46; The rate of acute complications was lower in patients with regression &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;016&#41;&#46; Chronic complications were more frequent in the 41&#8211;60 year old age group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;040&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our study&#44; the overall tumour control was in accordance with other published series&#46; The radiological result significantly related to the tumour volume at the commencement of treatment&#46; The rate of acute complications was lower in patients with regression&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
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            "identificador" => "abst0015"
            "titulo" => "Results"
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            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los objetivos del estudio fueron evaluar la respuesta tumoral en una serie de pacientes con schwannoma vestibular &#40;SV&#41; tratados con radiocirug&#237;a &#40;RC&#41; mediante acelerador lineal de electrones &#40;LINAC&#41;&#44; describir las complicaciones y analizar las variables relacionadas con la respuesta al tratamiento&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo de 64 pacientes tratados entre 2010-2016 con seguimiento m&#237;nimo de un a&#241;o&#44; excluyendo pacientes con neurofibromatosis&#46; Se evaluaron par&#225;metros cl&#237;nico-radiol&#243;gicos&#46; El tratamiento se realiz&#243; mediante RC-LINAC&#46; La dosis prescrita fue de 12<span class="elsevierStyleHsp" style=""></span>Gy al 90&#37; de isodosis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La edad media al tratamiento fue de 53 a&#241;os&#44; 56&#37; mujeres&#46; El 98&#37; de los pacientes presentaban hipoacusia&#44; el 71&#37; grado <span class="elsevierStyleSmallCaps">iii</span> seg&#250;n la clasificaci&#243;n Gardner-Robertson&#46; El volumen medio al tratamiento fue de 2&#44;92<span class="elsevierStyleHsp" style=""></span>cc&#44; y la media de seguimiento 40&#44;95 meses&#46; El &#233;xito terap&#233;utico global fue del 90&#37; siendo del 100&#37; a los 12 y 24 meses y del 86&#37; a partir de los 36 meses de seguimiento&#46; El resultado radiol&#243;gico se relacionaba con el volumen tumoral inicial &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;037&#41;&#46; En 20 pacientes se evidenci&#243; un crecimiento tumoral transitorio compatible con seudoprogresi&#243;n&#46; El 37&#44;5&#37; tuvieron complicaciones agudas siendo transitorias el 50&#37;&#46; Se recogieron complicaciones cr&#243;nicas en el 20&#37;&#44; siendo permanentes en el 84&#37;&#46; La tasa de complicaciones agudas era menor en pacientes con regresi&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;016&#41;&#46; Las complicaciones cr&#243;nicas fueron m&#225;s frecuentes en el grupo de 41-60 a&#241;os &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;040&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestra serie&#44; el control tumoral global obtenido es acorde con otras series publicadas&#46; El resultado radiol&#243;gico estaba relacionado con el volumen tumoral inicial al tratamiento&#46; La tasa de complicaciones agudas fue menor en pacientes con regresi&#243;n&#46;</p></span>"
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            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">LINAC-RS treatment planning&#46; &#40;A&#41; Cranial scout of the patient with placement of the stereotactic frame&#46; &#40;B&#41; Contrast-enhanced T1-sequence brain MRI &#40;tumor with homogeneous uptake in right cerebellopontine angle&#41; during therapeutic planning&#46; Organs at risk are contoured&#44; including cochlea&#44; brainstem and tumor lesion&#46; &#40;C&#41; 3D view after planning&#46; &#40;D&#41; Relationship of the tumor &#40;purple color&#41; with the organs at risk&#46; &#40;E&#41; Isodose curves in an irradiated volume in axial and &#40;F&#41; coronal slices&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Koos classification&#46; Radiological findings of the series according to Koos classification&#58; Koos I &#40;0&#8211;10<span class="elsevierStyleHsp" style=""></span>mm intrameatal&#41;&#58; 19&#37;&#59; Koos II &#40;&#60;2<span class="elsevierStyleHsp" style=""></span>cm intra-extrameatal&#41;&#58; 39&#37;&#59; Koos III &#40;&#60;3<span class="elsevierStyleHsp" style=""></span>cm intra-extrameatal in contact with brain stem&#41;&#58; 39&#37;&#59; Koos IV &#40;&#62;3<span class="elsevierStyleHsp" style=""></span>cm intra-extrameatal with brainstem compression&#41;&#58; 3&#37;&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Pseudoprogression and treatment success&#46; Tumor in 67-year-old female patient with severe hearing loss &#40;Gardner&#8211;Robertson IV&#41;&#46; History of subtotal surgical resection of left VS one year earlier and ventriculoperitoneal shunt for post-surgical hydrocephalus&#46; &#40;A&#41; Treatment with LINAC-RS in 2012 of the rest of the tumor after surgery &#40;initial TV 3&#46;2<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; &#40;B&#41; Post-RS control MRI after 9 months of treatment&#44; compatible with pseudoprogression &#40;TV 4&#46;2<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; &#40;C&#41; Progressive regression in control MRI at 24 months &#40;TV 3&#46;2<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; &#40;D&#41; Control MRI at 36 months post-RS &#40;TV 0&#46;75<span class="elsevierStyleHsp" style=""></span>cc&#41;&#46; TV&#58; tumor volume&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">VDI&#58; vertigo&#44; dizziness&#44; instability&#59; Pre-RS&#58; prior to radiosurgery treatment&#46;</p>"
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">No&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53 &#91;23&#8211;76&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>41&#8211;60&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29 &#40;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lesion &#62;1&#46;5<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">24 &#40;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rest post-surgery&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Clinical deterioration&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Desire of the patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cranial nerve V involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cranial nerve VII involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hearing loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">63 &#40;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Gardner&#8211;Robertson</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>V&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Headache&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tinnitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35 &#40;55&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VDI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Casual&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intra-extracanalicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Intracanalicular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lateralization&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pre-RS tumor volume</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#46;51&#8211;1&#46;99<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46;00&#8211;5&#46;99<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;6&#46;00<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">SD&#58; Standard Deviation&#59; cc&#58; cubic centimeters&#59; Pre-RS&#58; prior to radiosurgery&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evolution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#62;36 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean follow-up &#40;months&#41; 40&#46;95 &#40;14&#8211;86&#41;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD 15&#46;631</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean tumor volume pre-RS &#40;cc&#41; 2&#46;92 &#40;0&#46;092&#8211;14&#46;94&#41;<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD 2&#46;95</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Progression&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Regression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31&#40;10<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">51&#40;15<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Stability&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#47;3 100&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&#47;17 100&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38&#47;44 86&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">84&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cranial nerve V involvement &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cranial nerve VII involvement &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anderson &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">LINAC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">83&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">97&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Benghiat &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LINAC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Boari &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">379&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GK&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">97&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wangerid &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">128&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GK&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ikonomidis &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LINAC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">91&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                            5 => "D&#46;-K&#46; Lee"
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                            4 => "A&#46;H&#46; Friedman"
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