Facial Nerve Toxicity Research Articles

THREE FRACTION STEREOTACTIC RADIOTHERAPY (SRT) FOR VESTIBULAR SCHWANOMMA: THE WESSEX EXPERIENCE

Abstract AIMS Retrospective review of SRT for vestibular schwannoma. University Hospital Southampton treat tumour vol umes max 2.5cm in diameter without brainstem compression with 21Gy/3#. This reviews the experience of local control and toxicity profile in our centre and the impact of limiting dmax. METHOD Retrospective analysis of patients treated for radiologically diagnosed vestibular schwannoma from 2019 to present. Patient notes, audiograms, imaging and radiotherapy planning system were reviewed for data collection. No patients were removed from analysis due to missing data. RESULTS 36 patients have been treated with three fraction SRT. Median age 68 (47-83). PTV volume from 1.03cm3 to 5.52cm3 (median 2.37cm3). All patients have radiologically stable disease to date, with 14 patients (38.9%) having objective tumour response on imaging. 9 patients had serviceable hearing at baseline and 1 remained serviceable at follow up. 7 (19.4%) patients experienced treatment-related toxicity. 6 patients reported facial nerve toxicity in which 4 (66.7%) this was self-limiting with full recovery. 2 patients had persistent facial nerve symptoms (House-Brackmann score 2, and 3 respectively). Those with dmax <26Gy (n=15) experienced this less with only 1 patient experiencing facial nerve toxicity (House-Brackmann score 2). CONCLUSIONS Three fraction SRT provides excellent local control with high levels of objective radiological response in tumours up to 4cm3, however, long term follow-up is required. This treatment has acceptable toxicity with most symptoms resolving spontaneously. Permanent facial nerve toxicity was seen in 2 (5.6%) of patients. By limiting dmax to <26Gy the rate of facial nerve toxicity is reduced significantly.

P11.35.B STEREOTACTIC RADIOTHERAPY FOR VESTIBULAR SCHWANOMMAS: THE WESSEX EXPERIENCE

Abstract BACKGROUND Review of SRT for vestibular schwannoma (VS) within Wessex region led by University Hospital Southampton (UHS). UHS treat tumour volumes max 2.5cm in diameter without brainstem compression with 21Gy/3#. We reviewed the experience of local control and toxicity profile in our centre comparing with 1 and 5 fraction SRT schedules. We present three fraction SRT as an appropriate fractionation schedule. MATERIAL AND METHODS This is a retrospective analysis of patients treated for radiologically diagnosed vestibular schwannoma from 2019 to present. Patient notes, audiograms, imaging and radiotherapy planning system were reviewed for data collection. No patients were removed from analysis due to missing data. RESULTS 84 patients have been treated with SRT for VS. Median age 66 (39-94). 12Gy/1# (1#) in 36 patients, 21Gy/3# (3#) in 36 patients, 25Gy/5# (5#) in 12 patients. In the 1# group PTV volume 0.31cm3-4.44cm3 (median 1.12cm3), in the 3# group PTV volume from 1.03cm3 to 5.52cm3 (median 2.37cm3), in the 5# group 2.05cm3-5.44cm3 (median 4.12cm3). All patients have radiologically stable disease to date. Objective radiological response noted in 14 patients (38.9%) in 3# group this is higher than any other group and statistically significant (p=0.016). Pre-treatment serviceable hearing only in a minority of patients. Treatment related toxicity was seen in 27% in the 1# group, 19% of patients within the 3# group, and 33% in the 5# group. This was mostly mild and self-limiting. Facial nerve toxicity was seen in 8.3% of the 1# group, 16.7% of 3# group, and 33.3% of the 5# group. However, this was only persistent in 2 patients in 1# group (5.6%), 2 patients in the 3# group (5.6%), and 1 (8.3%) in the 5# group. There is no statistical difference in toxicity between any group using Chi squared test. In 3# group, when Dmax limited to <26Gy (n=15), the frequency of facial nerve toxicity reduces to 1 (2.78%). CONCLUSION Three fraction SRT provides excellent local control with high levels of objective radiological response in tumours up to 4cm3, however, long term follow-up is required. This treatment has acceptable toxicity which is not significantly different from alternative fractionation schedules and is improved by limiting Dmax to <26Gy.

Dosimetric predictive factors for facial nerve paralysis after cyberknife® stereotactic radiotherapy for vestibular schwannomas: A single institution experience of 88 patients

PurposeTo identify dosimetric predictive factors of facial nerve paralysis for patients with vestibular schwannomas (VS) treated in a single institution with Cyberknife® (CK) hypofractionated stereotactic radiotherapy (SRT). Methods and materialsEighty-eight patients were treated from 2010 to 2020. Different treatment schedules were used over that period, some prescribed to the 80% isodose line (4 × 5 Gy, 3 × 7 Gy, 3 × 8 Gy and 5 × 5 Gy) and one to the 70% isodose line (3 × 7.7 Gy). Local control tumor and facial nerve toxicity were recorded, as well as various dosimetric indicators. ResultsMedian follow-up 37 months (range, 7–96). Of the 88 stereotactic treatments, 20 patients (23%) developed objectively diagnosed radiation-induced facial nerve paralysis. The 2-year and 5-year local tumor control were respectively 95% and 88%, and the overall 2-year facial nerve preservation was 76%. Prescriptions with a maximum dose point (Dmax) of 33 Gy were at a substantially higher risk of facial paralysis than prescriptions with a Dmax less than or equal to 30 Gy (HR = 4.51, 95% CI = [1.04;19.6], p = 0.045). The 2-years cumulative incidences of facial paralysis were 32% [20%;44%] in the case of a 33 Gy Dmax, against 7% [1%;21%] otherwise. We identified four significative dosimetric predictive factors for radiation-induced facial nerve dysfunction: a GTV minimal dose over 22 Gy (EQD2 = 45.5 Gy, p = 0.019), a GTV mean dose over 29 Gy (EQD2 = 73.5 Gy, HR = 2.84, 95% CI = [1.10;7.36], p = 0.024), a PTV mean dose over 27 Gy (EQD2 = 64.8 Gy, HR = 10.52, 95% CI = [1.39;79.76], p = 0.002) and a PTV maximal dose of 32 Gy (EQD2 = 87.5 Gy,HR = 5.09, 95% CI = [1.17;22.15], p = 0.013). ConclusionWe identified four dosimetric predictive factors for post-treatment facial paralysis. Increasing the doses of hypofractionated stereotactic radiotherapy for vestibular schwannomas leads to higher facial nerve toxicity and may lead to lower local control rates than other published series. Our three-hypofractionated regimens may have also played a role in these results.

Long-term outcome after highly advanced single-dose or fractionated radiotherapy in patients with vestibular schwannomas – Pooled results from 3 large German centers

PurposeTo evaluate long-term clinical outcome and determine prognostic factors for local-control, hearing preservation and cranial nerve toxicity in 449 patients treated for 451 vestibular schwannomas (VS) with radiosurgery (n=169; 38%) or fractionated stereotactic radiotherapy (FSRT; n=291; 62%). Methods and materials245 patients were male (55%), and 204 were female (45%). Median age was 60years (range 17–88years). Median tumor diameter was 15mm. For FSRT, a median dose of 57.6Gy in median single doses of 1.8Gy was applied. For SRS, median dose was 13Gy. The median follow-up time was 67months. ResultsLocal control was 97% at 36months, 95% at 60months, and 94% at 120months with no difference between FSRT and SRS (p=0.39).“Useful hearing” was present 46%. After RT, “useful hearing” was preserved in 85% of the patients. Loss of useful hearing was observed in the FSRT group in 14%, and in the SRS group in 16% of the patients. For patients treated with SRS ⩽13Gy, useful hearing deterioration was 13%. For trigeminal and facial nerve toxicity, there was no difference between FSRT and SRS. ConclusionSupported by this large multicentric series, both SRS and FSRT can be recommended for the treatment of VS. SRS application is limited by tumor size, and is associated with a steep dose–response-curve. When chosen diligently based on tumor volume, pre-treatment characteristics and volume-dependent dose-prescription in SRS (⩽13Gy), both treatments may be considered equally effective.

Linear Accelerator Stereotactic Radiosurgery for Vestibular Schwannomas: A UK Series

AimsTo evaluate non-auditory toxicity and local control after linear accelerator stereotactic radiosurgery (SRS) for the treatment of vestibular schwannomas. Materials and methodsThe institutional policy was to use SRS for radiologically progressing vestibular schwannomas. Case notes and plans were retrospectively reviewed for all patients undergoing SRS for vestibular schwannomas between September 2002 and June 2012. All patients were surgically immobilised using a BrainLab stereotactic head frame. The treatment plan was generated using BrainLab software (BrainScan 5.03). The aim was to deliver 12 Gy to the surface of the target with no margin. Patients with a minimum of 12 months of follow-up were included for toxicity and local control assessment. Radiological progression was defined as growth on imaging beyond 2 years of follow-up. Overall local control was defined in line with other series as absence of surgical salvage. ResultsNinety-nine patients were identified. Two patients were lost to follow-up. After a median follow-up interval of 2.4 years, the actuarial radiological progression-free survival at 3 years was 100% and overall local control was also 100%. However, two patients progressed radiologically at 3.3 and 4.5 years, respectively. Twenty-one of 97 (22%) evaluable patients suffered trigeminal toxicity and this was persistent in 8/97 (8%). Two of 97 (2%) suffered long-term facial nerve toxicity (one with associated radiological progression causing hemi-facial spasm alone). One of 97 (1%) required intervention for obstructive hydrocephalus. No statistically significant dosimetric relationship could be shown to cause trigeminal or facial nerve toxicity. However, 7/8 patients with persistent trigeminal nerve toxicity had tumours in contact with the trigeminal nerve. ConclusionsSRS delivering 12 Gy using a linear accelerator leads to high local control rates, but only prospective evaluation will fully establish short-term toxicity. In this study, persistent trigeminal toxicity occurred almost exclusively in patients whose tumour was in contact with the trigeminal nerve.

Single institution experience treating 104 vestibular schwannomas with fractionated stereotactic radiation therapy or stereotactic radiosurgery

The pupose of this study is to assess the long-term outcome and toxicity of fractionated stereotactic radiation therapy (FSRT) and stereotactic radiosurgery (SRS) for 100 vestibular schwannomas treated at a single institution. From 1993 to 2007, 104 patients underwent were treated with radiation therapy for vestibular schwannoma. Forty-eight patients received SRS, with a median prescription dose of 12.5 Gy for SRS (range 9.7-16 Gy). For FSRT, two different fraction schedules were employed: a conventional schedule (ConFSRT) of 1.8 Gy per fraction (Gy/F) for 25 or 28 fractions to a total dose of 45 or 50.4 Gy (n = 19); and a once weekly hypofractionated course (HypoFSRT) consisting of 4 Gy/F for 5 fractions to a total dose of 20 Gy (n = 37). Patients treated with FSRT had better baseline hearing, facial, and trigeminal nerve function, and were more likely to have a diagnosis of NF2. The 5-year progression free rate (PFR) was 97.0 after SRS, 90.5% after HypoFSRT, and 100.0% after ConFSRT (p = NS). Univariate analysis demonstrated that NF2 and larger tumor size (greater than the median) correlated with poorer local control, but prior surgical resection did not. Serviceable hearing was preserved in 60.0% of SRS patients, 63.2% of HypoFSRT patients, and 44.4% of ConFSRT patients (p = 0.6). Similarly, there were no significant differences in 5-year rates of trigeminal toxicity facial nerve toxicity, vestibular dysfunction, or tinnitus. Equivalent 5-year PFR and toxicity rates are shown for patients with vestibular schwanoma selected for SRS, HypoFSRT, and ConFSRT after multidisciplinary evaluation. Factors correlating with tumor progression included NF2 and larger tumor size.

Hearing preservation after radiotherapy for vestibular schwannomas is comparable to hearing deterioration in healthy adults and is accompanied by local tumor control and a highly preserved quality of life (QOL) as patients’ self-reported outcome

PurposeTo evaluate long-term results and patients’ self-reported outcome of high-precision photon radiotherapy for the treatment of patients with vestibular schwannoma (VS). Methods and materialsWe treated 246 patients with 248 VS with fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS). For FSRT, a median total dose of 57.6Gy was prescribed in median single doses of 1.8Gy, for SRS, a median dose of 13Gy/80% isodose was applied. Of all patients, 51 patients died during follow-up. To evaluate long-term toxicity and QOL, we sent out a questionnaire to all living patients; of these, 81 patients (42%) sent back the questionnaire. ResultsMedian local control was 84months, actuarial local control rates for both groups (SRS and FSRT) were 98% after 2, 95% after 5, and 93% after 10years; there was no statistical difference between FSRT and SRS. Hearing deterioration was significantly higher in the SRS group than the FSRT group. However, when comparing FSRT to SRS with doses⩽13Gy, hearing preservation is comparable. In patients with useful hearing, hearing preservation was 89.7% at 1 year, 84.7% at 3years, 76.5% at 5years, and 68.6% at 10 years. After 10years of follow-up, hearing deterioration can be observed in both subgroups. In the FSRT group, facial nerve toxicity rate was 1.6%.Trigeminal nerve toxicity was observed in 2.1% after FSRT. Overall QOL was unchanged in 47% of the patients after RT, and 31% reported an improvement in QOL during follow-up. ConclusionPatients’ self-reported outcome confirms good results with respect to tumor control and QOL after FSRT or SRS in patients with VS. SRS can be associated with higher side effect following a dose-dependency. In long-term follow-up, hearing deterioration is most likely attributed to normal aging, but not treatment-related.

Therapeutic profile of single-fraction radiosurgery of vestibular schwannoma: unrelated malignancy predicts tumor control

Radiosurgery has become an accepted treatment option for vestibular schwannomas. Nevertheless, predictors of tumor control and treatment toxicity in current radiosurgery of vestibular schwannomas are not well understood. To generate new information on predictors of tumor control and cranial nerve toxicity of single-fraction radiosurgery of vestibular schwannomas, we conducted a single-institution long-term observational study of radiosurgery for sporadic vestibular schwannomas. Minimum follow-up was 3 years. Investigated as potential predictors of tumor control and cranial nerve toxicity were treatment technology; tumor resection preceding radiosurgery; tumor size; gender; patient age; history of cancer, vascular disease, or metabolic disease; tumor volume; radiosurgical prescription dose; and isodose line. Three hundred eighty-six patients met inclusion criteria. Treatment failure was observed in 27 patients. History of unrelated cancer (strongest predictor) and prescription dose significantly predicted tumor control. The cumulative incidence of treatment failure was 30% after 6.5 years in patients with unrelated malignancy and 10% after ≥15 years in patients without such cancer (P < .02). Tumor volume was the only predictor of trigeminal neuropathy (observed in 6 patients). No predictor of facial nerve toxicity was found. On the House and Brackmann scale, 1 patient had a permanent one-level drop and 7 a transient drop of 1 to 3 levels. Serviceable hearing was preserved in 75.1%. Tumor hearing before radiosurgery, recurrence, and prescription isodose predicted ototoxicity. Unrelated malignancy is a strong predictor of tumor control. Tumor recurrence predominantly predicts ototoxicity. These findings potentially will aid future clinical decision making in ambiguous cases.

LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY FOR BILATERAL VESTIBULAR SCHWANNOMAS IN PATIENTS WITH NEUROFIBROMATOSIS TYPE 2

Patients with neurofibromatosis Type 2 (NF2) patients typically have bilateral vestibular schwannomas (VS) and are at risk for developing bilateral deafness, bilateral trigeminal, and bilateral facial nerve function loss. Previous reports suggested that treatment outcomes in these patients are worse compared with those for patients with sporadic solitary VS. Very few reports, however, have been published on linear accelerator-based radiosurgery (RS) and stereotactic radiation therapy (SRT) in patients with NF2. In particular, in patients with NF2 who already have unilateral hearing loss, avoidance of hearing loss on the opposite side poses a challenge for RS and SRT. We studied our treatment results in patients with NF2 with bilateral VS, treated with linear accelerator-based RS and SRT. In 204 patients with VS treated with RS or SRT in Amsterdam starting from 1992, we identified 25 patients with NF2 who had bilateral tumors. Indications for treatment were either tumor progression on sequential magnetic resonance imaging scans and/or progressive hearing loss. Mean tumor diameter was 2.5 cm. Stereotactic irradiation was administered to all patients using five noncoplanar arcs with a single isocenter to a dose of 10 to 12.5 Gy in a single fraction or 20 to 25 Gy in five fractions in 1 week prescribed to the 80% isodose encompassing the tumor. On the untreated side, all patients showed hearing loss and eight (32%) had ipsilateral deafness. Five patients were followed for less than 1 year. Of the remaining 20 patients, five had ipsilateral deafness before treatment. Consequently, 15 patients were at risk for treatment-related hearing loss. They showed a mean pure tone average (PTA) of 51 dB (8-112 dB) before treatment. After treatment all patients were assessed at yearly intervals including magnetic resonance imaging and pure tone audiometry. Median follow-up time was 51 months (12-109 mo). Local tumor control was obtained in all 20 patients, and no treatment-related trigeminal or facial nerve toxicity was observed. Hearing status was assessed yearly after treatment. This assessment revealed that the mean PTA in the 15 hearing patients dropped from 51 to 77 dB (40-120 dB). In six patients (40%) the additional PTA loss ranged from 0 to 15 dB, in another six (40%) it ranged from 15 to 45 dB, and in three of these patients (20%), it was more than 45 dB. No additional hearing loss was observed beyond 36 months after treatment. In this largest series in the literature of linear accelerator-based RS and SRT for VS NF2 patients, excellent local control rates were found with minimal facial and trigeminal nerve toxicity. Although more than 40% of the patients retained their hearing level or lost less than 15 dB of PTA on the irradiated side, preservation of hearing remains a major concern.

Long-term outcome of stereotactic radiosurgery (SRS) in patients with acoustic neuromas

To evaluate the effectiveness and long-term outcome of stereotactic radiosurgery (SRS) for acoustic neuromas (AN). Between 1990 and 2001, we treated 26 patients with 27 AN with SRS. Two patients suffered from neurofibromatosis type 2. Before SRS, a subtotal or total resection had been performed in 3 and in 5 patients, respectively. For SRS, a median single dose of 13 Gy/80% isodose was applied. The overall actuarial 5-year and 10-year tumor control probability in all patients was 91%. Two patients developed tumor progression after SRS at 36 and 48 months. Nineteen patients (73%) were at risk of treatment-related facial nerve toxicity; of these, 1 patient developed a complete facial nerve palsy after SRS (5%). A total of 93% of the lesions treated were at risk of radiation-induced trigeminal neuralgia. Two patients (8%) developed mild dysesthesia of the trigeminal nerve after SRS. The hearing preservation rate in patients with useful hearing before SRS was 55% at 9 years. Stereotactic radiosurgery results in good local control rates of AN and the risk of cranial nerve toxicities is acceptable. As toxicity is lower with fractionated stereotactic radiotherapy, SRS should be reserved for smaller lesions.

Outpatient gamma knife surgery for vestibular schwannoma: definition of the therapeutic profile based on a 10-year experience

Object. The purpose of the study was to define the therapeutic profile of outpatient gamma knife surgery (GKS) for vestibular schwannoma (VS) by using sequential tumor volumetry to quantify changes following treatment. Methods. A total of 111 patients met the inclusion criteria. The median follow-up duration was 7 years (range 5–9.6 years). Thirty-seven patients (33%) had undergone surgery before GKS and 10 (9%) had neurofibromatosis Type 2 (NF2). The median VS volume was 1.6 cm3 (range 0.08–8.7 cm3). The actuarial 6-year tumor control rate after a single GKS treatment was 95%. Tumor swelling was observed in 43 patients (38.7%). Recurrence was significantly associated with NF2 (p &lt; 0.003) and the reduced dose (p &lt; 0.03) delivered to these tumors. The incidence of facial nerve neuropathy was mainly determined by surgery prior to GKS (p &lt; 0.0001). Facial nerve radiation toxicity was mild and transient. No permanent facial nerve toxicity was observed. Trigeminal neuropathy occurred in 13 patients, and this was correlated with the VS volume (p &lt; 0.02). The median hearing loss was −10 dB (range + 20 dB to −70 dB). The risk of hearing loss was correlated with age and transient tumor swelling (p &lt; 0.05) but not with dose parameters or NF2. Conclusions. Outpatient GKS is feasible, effective, and safe. Its therapeutic profile compares favorably with that of microsurgery.

Outpatient gamma knife surgery for vestibular schwannoma: definition of the therapeutic profile based on a 10-year experience

The purpose of the study was to define the therapeutic profile of outpatient gamma knife surgery (GKS) for vestibular schwannoma (VS) by using sequential tumor volumetry to quantify changes following treatment. A total of 111 patients met the inclusion criteria. The median follow-up duration was 7 years (range 5-9.6 years). Thirty-seven patients (33%) had undergone surgery before GKS and 10 (9%) had neurofibromatosis Type 2 (NF2). The median VS volume was 1.6 cm3 (range 0.08-8.7 cm3). The actuarial 6-year tumor control rate after a single GKS treatment was 95%. Tumor swelling was observed in 43 patients (38.7%). Recurrence was significantly associated with NF2 (p < 0.003) and the reduced dose (p < 0.03) delivered to these tumors. The incidence of facial nerve neuropathy was mainly determined by surgery prior to GKS (p < 0.0001). Facial nerve radiation toxicity was mild and transient. No permanent facial nerve toxicity was observed. Trigeminal neuropathy occurred in 13 patients, and this was correlated with the VS volume (p < 0.02). The median hearing loss was -10 dB (range + 20 dB to -70 dB). The risk of hearing loss was correlated with age and transient tumor swelling (p < 0.05) but not with dose parameters or NF2. Outpatient GKS is feasible, effective, and safe. Its therapeutic profile compares favorably with that of microsurgery.

Radiosurgery and stereotactic radiation therapy for vestibular schwannoma in neurofibromatosis type 2 patients

Neurofibromatosis type 2 (NF2) patients typically suffer from bilateral vestibular schwannoma (VS) and are at risk for developing bilateral deafness, bilateral trigeminal and bilateral facial nerve function loss. Previous reports suggest that treatment outcomes in these patients are worse compared to patients with sporadic solitary VS. Especially in NF2 patients who acquired unilateral hearing loss already, avoidance of hearing loss on the opposite side poses a challenge for stereotactic radiosurgery. We studied our treatment results in NF2 patients treated for VS with linac based radiosurgery (RS) and stereotactic radiation therapy (SRT). In 204 VS patients treated with RS or SRT in Amsterdam starting from 1992, we identified 25 NF2 patients with bilateral tumors. Indications for treatment were either tumor progression on sequential MRI and/or progressive hearing loss. Stereotactic irradiation was administered to all patients using 5 non-coplanar arcs with a single isocenter to a dose of 10–12.5 Gy in a single fraction or 20–25 Gy in 5 fractions in 1 week prescribed to the 80% isodose encompassing the tumor. In the first patients a single round collimator was used for every treatment. In subsequent patients conformal arcs were used. Dynamic conformal arcs application, resulting in superior dose distributions, is used currently. Five patients were followed less than 1 year. Of the remaining 20 patients, 5 were ipsilateral deaf prior to treatment. Consequently 15 patients were at risk for treatment related hearing loss. They showed a mean Pure Tone Average (PTA) of 51 dB (8–112) prior to treatment. On the untreated side, all patients showed hearing loss and 8 (53%) were deaf. After treatment all patients were assessed at yearly intervals including MRI and pure tone audiometry. Median follow-up time was 51 months (12–109). Local tumor control was obtained in all 20 patients and no treatment related trigeminal or facial nerve toxicity was observed. Hearing status was assessed yearly after treatment. This revealed that the mean PTA in the 15 hearing patients dropped from 51 to 77 dB (40–120). In 6 of these patients (40%) the additional PTA loss ranged from 0–15 dB, in another 6 patients (40%) it ranged from 15–45 dB and in 3 of these patients (20%) it was more than 45 dB. No additional hearing loss was observed beyond 36 months after treatment. Excellent local control rates can be obtained with RS and SRT for VS in NF2 patients, with minimal facial and trigeminal nerve toxicity. Hearing preservation, however, remains disappointing with 60% of the patients losing 15 dB or more of PTA on the irradiated side. This seems worse than our previously reported outcomes of SRS and RS in patients with solitary sporadic tumors. Improvements may be expected by application of dynamic conformal beam shaping

Fractionated stereotactic radiation therapy and single high-dose radiosurgery for acoustic neuroma: early results of a prospective clinical study

Purpose: To prospectively assess the local control and toxicity rate in acoustic neuroma patients treated with linear accelerator-based radiosurgery and fractionated stereotactic radiation therapy. Methods and Materials: We evaluated 37 consecutive patients treated with stereotactic radiation therapy for acoustic neuroma. All patients had progressive tumors, progressive symptoms, or both. Mean tumor diameter was 2.3 cm (range 0.8–3.3) on magnetic resonance (MR) scan. Dentate patients were given a dose of 5 × 4 Gy or 5 × 5 Gy and edentate patients were given a dose of 1 × 10 Gy or 1 × 12.50 Gy prescribed to the 80% isodose. All patients were treated with a single isocenter. Results: With a mean follow-up period of 25 months (range 12–61), the actuarial local control rate at 5 years was 91% (only 1 patient failed). The actuarial rate of hearing preservation at 5 years was 66% in previously-hearing patients. The actuarial rate of freedom from trigeminal nerve toxicity was 97% at 5 years. No patient developed facial nerve toxicity or other complications. Conclusion: In this unselected series, fractionated stereotactic radiation therapy and linear accelerator-based radiosurgery give excellent local control in acoustic neuroma. It combines a high rate of preservation of hearing with a very low rate of other toxicity, although follow-up is relatively short.