Aspirin Slows Brain Tumor Growth (Acoustic Neuroma)

Image from Wikipedia

There is a type of benign brain tumor called acoustic neuroma or vestibular schwannoma that causes progressive hearing loss on just one side. This non-cancerous tumor which arises off the balance/hearing nerve (cranial nerve 8) typically grows larger in size over time leading to not only hearing loss, but also dizziness, facial paralysis, and even death if large enough.

Harvard researchers, however, have recently reported that aspirin may appear to slow and perhaps even halt the growth rate of this benign brain tumor. This is exciting news given that the alternative options include either brain surgery or radiation therapy with all its attendant risks.

Their conclusion was determined by looking at 347 patients diagnosed with this tumor who were followed by serial MRI scans. In this group, 81 took aspirin and 266 did not.  Of those who took aspirin, 33 demonstrated tumor growth whereas 48 did not. Of the 266 non-aspirin users, 154 demonstrated tumor growth and 112 did not. These numbers indicate a significant inverse association among aspirin users and tumor growth which was not confounded by age or sex.

It is hypothesized to work by targeting COX-2 which is a key enzyme in prostaglandin synthesis. This enzyme is also found at high levels in most vestibular schwannomas.

Given aspirin is a relatively benign drug, it certainly can't hurt to start aspirin on all patients who are diagnosed with this condition.

However, there are some key answered questions:

1) What dose of aspirin?
2) Is aspirin effective when started at time of diagnosis, or does it help when a patient has already been on it long-term?

As such, larger study groups in prospective clinical trials would be best to answer these questions as well as confirm whether aspirin truly has a therapeutic role in the management of these tumors.

Reference:
Aspirin Intake Correlates With Halted Growth of Sporadic Vestibular Schwannoma In Vivo. Otology and Neurotology: February 2014 - Volume 35 - Issue 2 - p 353-357 doi: 10.1097/MAO.0000000000000189

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Cell Phones Caused Brain Tumor Rules Supreme Court

On October 12, 2012, the Italian Supreme Court ruled that cell phones caused one man's brain tumor. The Court felt that there was a causal link between businessman Innocente Marcolini's brain tumor diagnosis and his phone use which he used up to 6 hours per day for over a decade. Although the brain tumor was a benign trigeminal neuroma, it required surgery and badly affected his quality of life.

This "causal link" between cell phones and brain tumors has been described in a previous blog post.

Though definitive scientific proof that links cell phones with brain tumors (benign or cancerous) is still under debate, apparently this court ruling has set a precedent for possible future lawsuits whether there is a true scientific basis present or not.

Indeed, this court ruling should NOT be confused as conclusive scientific evidence which is still lacking.

However, I forsee that this court ruling will be used in place of scientific evidence.

This association has also been claimed by singer Sheryl Crow who has a brain meningioma.

I'm not sure what is going on within the Italian Court system, but they also recently convicted 7 scientists to jail terms for not accurately predicting the 2009 L'Aquila earthquake. Since when does the Court decide on matters of scientific validity?

Source:
Cell Phones Caused Man's Brain Tumor, Italian Supreme Court Rules. Medical Daily 10/19/12.

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What is Asymmetric Nerve Hearing Loss

Given my last blog article regarding an ENT who got sued for not doing an MRI after audiogram showing an asymmetric hearing loss, the question that should be on everybody's mind is what IS asymmetric nerve hearing loss on a hearing test?

I am sad to report that there is no clear consensus on what is asymmetric nerve hearing loss.

First of all, at its most basic definition, asymmetric nerve hearing loss is when hearing is worse in one ear when compared with the opposite ear due to nerve damage.

Technically, hearing should decrease equally on both sides over time, but when one side gets worse faster than the other, it can cause concern because:

1) A tumor can be pressing against the nerve causing it to slowly fail faster than the other ear's nerve which is not compressed.
2) There is a loud noise history with asymmetric exposure to the ears. One example is hunting with a rifle where the left ear would repetitively get noise-induced damage from the gunshot in a right-handed shooter.
3) Bad luck

The conflict is at what point is an asymmetry considered significant enough to warrant a workup which may include an MRI scan of the head and/or auditory brainstem response (ABR)? Also, for a given patient history, a physician/patient may elect to recheck hearing bi-annually to monitor for asymmetric progression rather than pursue workup immediately (further studies being pursued only if asymmetry progresses over time).

Is asymmetry defined as 1 decibel difference between ears? Is it 50 decibel difference?

Even if the decibel difference is agreed upon, than over what frequencies? All of them or just a few of the frequencies?

So for the purposes of a "medically" significant asymmetric nerve hearing loss, the definition must define not only HOW big the difference in hearing loss is present between ears but also at what frequencies.

In one paper, it is 15 decibels at just 3000 Hz.

In another paper, it is 20 decibels at any two adjoining frequencies (or 15 decibels at two adjoining frequencies between 2000 and 8000 Hz).

Get this... even when criteria is defined, one study found substantial disagreement among five expert judges on what hearing tests they considered showed asymmetry.

Even insurance companies are jumping into the fray in what they considered significant enough to warrant covering the MRI scan. At one point when I ordered an MRI scan of the head for what I thought was a significant asymmetry found in one patient's hearing test, the insurance company denied the test citing "that there needed to be other neurological deficits PLUS the asymmetry seen on hearing test before MRI scan would be authorized".

I personally pursue further workup using the 20 decibel difference at two adjoining frequencies OR 30 decibel at one frequency.

Assuming medically significant asymmetric hearing loss has been defined and is present...

What are the chances of something bad going on (i.e., tumor) when an MRI scan of the head is ordered for asymmetry found on hearing test?

Less than 10% (depending on study, can be as low as 1-4%).

Given such a low positive yield on testing, why even pursue a MRI scan?

Because of defensive medicine to avoid being named in a lawsuit if the affected patient just happens to be within that 10% found to have an acoustic neuroma.

Indeed, in one study, 40% of ENTs stated medico-legal concerns factored into their decision to get an MRI scan of the head.

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Sheryl Crow With Benign Brain Tumor

It was announced yesterday that Sheryl Crow has a benign brain tumor known as a meningioma.

The Grammy award winning singer did not disclose what her symptoms were that led to the discovery of this tumor which often is made by an MRI scan of the head.

From an ENT perspective, such a tumor can be confused with an acoustic neuroma if found in an area of the brain called the cerebellopontine angle (CPA) and patients will often initially present to an ENT with symptoms of:

• Ringing of the ear on just one side (tinnitus)
• Sense of ear fullness on one side that does not go away
• Hearing loss worse on one side (asymmetric sensorineural hearing loss)
• More rarely, balance problems

After a basic exam of the ear, a hearing test is performed. If the hearing test shows a significant asymmetry in NERVE hearing (as opposed to conductive hearing loss which is hearing loss NOT due to a nerve problem), an MRI scan of the head with gadolinium is often ordered.

The tumor can be seen very easily on this type of scan.

Other testing that might be performed include:

• ABR (Auditory Brainstem Response)
• OAE (Otoacoustic Emission)

Depending on the location of the meningioma, the patient may see either a neurosurgeon or a neuro-otologic surgeon (sub-specialized ENT surgeon). Typical options depending on symptoms, location, and size include:

• Monitor
• Surgical excision
• Radiation ("gamma" or "cyber"-knife)

It is unclear what course of treatment she has elected to pursue.

Source:
Sheryl Crow Assures Fans Her Brain Tumor Is Non-Cancerous. People 6/6/12.

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