Hearing Preservation in Observed Sporadic Vestibular Schwannoma: A Systematic Review

Prospective Symptom Changes in Sporadic Vestibular Schwannoma: A Comparison of Observation, Microsurgery, and Radiosurgery

OBJECTIVE

To compare differences in sporadic vestibular schwannoma (VS)-associated patient-reported symptom scores among patients receiving observation, microsurgery, or radiosurgery.

STUDY DESIGN

Prospective longitudinal survey.

SETTING

Tertiary referral center and the national Acoustic Neuroma Association.

PATIENTS

Adults with sporadic VS.

INTERVENTION

Observation, microsurgery, or radiosurgery.

MAIN OUTCOME MEASURE

Baseline and follow-up surveys on patient-reported severity of tinnitus, dizziness/imbalance, and headaches scored on a 10-point numeric scale, with higher scores indicating more severe symptoms; changes of 2 or more points from baseline were considered clinically important.

RESULTS

A total of 455 patients were eligible for study with a mean (SD) follow-up of 4.5 (2.4) years, including 122 (27%) managed with observation, 226 (50%) undergoing microsurgery, and 107 (23%) undergoing radiosurgery. Changes in tinnitus severity scores differed significantly among management groups ( p = 0.006), with severity scores increasing significantly in the radiosurgery (+0.8, p = 0.005) group but not in the observation (+0.2, p = 0.5) or microsurgery (-0.2, p = 0.18) groups. The changes in dizziness/imbalance and headache severity scores did not differ significantly among management groups. When comparing clinically important improvements (decrease of 2 or more points), the microsurgery and observation cohorts had a greater proportion of patients experiencing a clinically important improvement in tinnitus compared with the radiosurgery cohort; no other clinically important changes were significantly different among management groups.

CONCLUSIONS

In this prospective study of 455 patients comparing patient-reported symptoms after VS management, radiosurgery was associated with worsening tinnitus severity scores overall and resulted in fewer patients reporting clinically important improvements in tinnitus compared with observation and microsurgery. As there was substantial variability in the effect of management modality on changes in symptom severity scores, possible treatment effects on subjective symptoms, including tinnitus, dizziness/imbalance, and headache, should not be used in isolation to inform clinical decision-making for management of sporadic VS.

Vestibularisschwannom – diagnostikk og behandling

Vestibular schwannoma is a benign tumour originating from Schwann cells in the vestibular nerve. Each year, up to 250 patients in Norway are diagnosed with the condition. Treatment options are surgery, gamma knife radiosurgery or observation. The best treatment modality remains a topic of debate, and there are few high-quality comparative studies. With the ageing population and increasing access to MRI scans, the number of patients diagnosed with vestibular schwannoma is expected to rise. This clinical review article focuses on the diagnosis and treatment of vestibular schwannoma.

Hypofractionated Versus Single-Session Radiosurgery to Preserve Hearing in Patients Affected by Sporadic Vestibular Schwannoma: The ACOUNEU Randomized Clinical Trial

PURPOSE

During the last decades, in addition to tumor control, hearing preservation has become an important priority in the treatment of vestibular schwannoma (VS). Given that the potential advantages of hypofractionated radiosurgery (hRS) over single-session radiosurgery (RS) in terms of improved hearing outcomes remain unclear, this randomized trial aims to provide a robust answer to this question.

METHODS AND MATERIALS

The present is a double-arm randomized clinical trial. The study started in 2011 and the last patient was enrolled in 2020. The minimum follow-up was 36 months. The trial involved patients with a diagnosis of sporadic VS with preserved hearing. One hundred and eight patients were enrolled. Participants were randomized to receive either hRS (18 Gy/3 consecutive fractions) or RS (most commonly 12 Gy/1 fraction). At each follow-up, clinical assessment, volumetric magnetic resonance imaging, and audiometry were evaluated. The primary endpoint was hearing sparing 36 months after RS or hRS. The maintenance of a serviceable hearing was defined according to the American Academy of Otorhinolaryngology Head and Neck Surgery classification.

RESULTS

Of the 108 randomized patients, 100 (47 RS and 53 hRS) were included in the analysis (mean age, 55 years; 56% female). No significant differences between hRS and RS were found in terms of hearing preservation (hazard ratio, 1.083; [95% CI, 0.603-1.946], and P = .789), with pretreatment hearing status, age, and dose to cochlea being the only significant predictors. No other parameters, including tumor volume, were associated with hearing preservation. At a median follow-up of 62 months, local control was 92% (95% CI, 84.8%-96.5%). Treatment-related toxicity was mild or moderate, in general not exceeding National Cancer Institute Common Terminology Criteria for Adverse Events grade 2.

CONCLUSIONS

To our knowledge, this is the first randomized clinical trial comparing 2 different radiosurgical regimens while focusing on hearing preservation. The study failed to demonstrate the potential advantages of hRS over RS with respect to hearing preservation. The volumetric analysis confirmed an excellent postradiosurgery tumor control rate for both RS and hRS groups. These results may guide the clinicians in the treatment schedule choice to preserve hearing in patients with VS.

Documented Initial Growth Does Not Necessarily Indicate Treatment for Sporadic Vestibular Schwannomas

OBJECTIVE

To report the natural history of vestibular schwannoma (VS) who elected an initial period of observation and identify prognostic factors. To describe the natural history of growing VS, identify prognostic factors, and review the most recent literature.

STUDY DESIGN

Prospective cohort study and literature review.

SETTING

Tertiary referral center.

PATIENTS

Adult patients diagnosed with a VS between January 1998 and February 2023.

INTERVENTION

Magnetic resonance imaging surveillance.

MAIN OUTCOME MEASURES

Growth-free survival and subsequent growth-free survival considering significant growth as a change in size of ≥2 mm.

RESULTS

Of 430 patients undergoing observation with serial magnetic resonance imaging, 193 (44.9%) demonstrated significant growth at a median of 1.6 years (interquartile range, 0.94-3.51). Of the 193 patients who presented an initial episode of growth, 137 elected to continue to be observed. Of those, 83 (60.6%) presented a second episode of growth at a median of 1.43 years (interquartile range, 1.00-2.49). The subsequent growth-free survival rates (95% confidence interval) at 1, 3, 5, 7, and 10 years were 91.79% (87.26-96.56%), 64.44% (56.56-73.42%), 52.52% (44.23-62.35%), 42.23% (33.92-52.56%), and 36.11% (27.89-46.76%), respectively. Univariate and multivariate Cox regression analyses showed that EC tumor location and initial growth rate were significant predictors of subsequent growth.

CONCLUSIONS

Close observation after documentation of growth is an appropriate management in well-selected cases given that only around 56% of the tumor will continue to grow. Extracanalicular tumor location and initial growth rate are promising prognostic factors to help determine which patient would be a better candidate for close surveillance after initial documentation of growth.

Reduced Cochlear MRI Signal and Hearing Outcomes in Conservatively Managed Vestibular Schwannoma Patients

OBJECTIVE

This study aimed to determine if hypointense cochlear magnetic resonance imaging (MRI) constructive interference in steady-state (CISS) signal correlates with hearing outcomes in conservatively managed vestibular schwannoma (VS) patients.

STUDY DESIGN

Retrospective review of 657 cases from 1992 to 2020.

SETTING

Tertiary academic referral center.

PATIENTS

A retrospective review was performed to identify conservatively managed VS patients with appropriate baseline MRI, audiology, and at least 12-month audiological follow-up. Patients were excluded if they progressed to surgery or radiotherapy in less than 12 months, bilateral tumors, or surgery on the contralateral ear.

INTERVENTION

Conservatively managed patients with CISS imaging studies and audiology testing.

MAIN OUTCOME MEASURES

Primary outcome measure change in pure-tone average (PTA) and word recognition score (WRS). Secondary outcome measures tumor size, presence of lateral fluid cap, or cystic changes.

RESULTS

A total of 92 individuals (47% male, 58 ± 11.6 yr) met the inclusion criteria, with 36 (39%) of patients demonstrating abnormal cochlear CISS signal. At baseline, abnormal cochlear CISS signal was associated with higher intracanalicular (IC) length (7.9 versus 6.6 mm, p = 0.0177) and lower WRS (55.7 versus 78.8 dBHL, p = 0.0054). During follow-up, individuals with abnormal cochlear CISS signal had significantly higher PTA (62.4 versus 46.4 dBHL, p = 0.0010). After adjusting for baseline covariates, abnormal cochlear CISS signal was consistently associated with a greater increase in PTA of 8.3 dBHL (95% confidence interval, 2.9-13.7; p = 0.0032) from baseline when compared with the normal group.

CONCLUSIONS

Abnormal cochlear signal on MRI CISS sequences is associated with poorer hearing outcomes in conservatively managed VS patients.

Patient Characteristics Impacting Adherence to Serial Observation for Vestibular Schwannomas

OBJECTIVE

To examine patient characteristics that impact serial observation adherence among vestibular schwannoma (VS) patients.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care center.

METHODS

We selected for VS patients from 201 to 2020 who elected for serial observation as initial management. Patients under 18, with previous management, bilateral or intralabyrinthine VS, and neurofibromatosis type 2 were excluded. Demographics, tumor characteristics, and follow-up status were extracted. Single and multiple logistic regression was used to identify patient characteristics impacting follow-up.

RESULTS

We identified 507 VS patients who chose serial observation as initial management. Most were female (56.0%), white (73.0%), and married (72.8%). The mean age was 59.3 and most had private insurance (56.4%). Median Charlson Comorbidity Index was 2.00. Mean pure tone audiometry (PTA) average was 41.7 Hz. Average tumor size was 9.04 mm. Of 507 patients, 358 (70.6%) returned for at least one follow-up. On multiple logistic regression analysis, patients with private insurance (odds ratio [OR]: 0.39, confidence interval [CI]: 0.22-0.68; P = .001), racial minority background (OR: 0.54, CI: 0.35-0.83; P = .005), worse PTA averages (OR: 0.99, CI: 0.98-1.00; P = .044), and older age at diagnosis (OR: 0.97, CI: 0.95-1.00; P = .038) were less likely to follow-up.

CONCLUSION

Private health insurance, racial minority background, worse PTA average, and older age were associated with decreased follow-up among adult VS patients electing serial observation. Patients with these characteristics may require additional support to ensure serial observation adherence.

Comparative analysis of upfront stereotactic radiosurgery and watchful waiting in the management of newly diagnosed vestibular schwannomas: a systematic review and meta-analysis

Vestibular schwannomas (VS) are benign intracranial tumors posing significant management challenges. This study aims to compare the outcomes of stereotactic radiosurgery (SRS) and watchful waiting (WW) in the management of newly diagnosed VS, integrating findings from both retrospective and the pioneering V-REX prospective trial. Adhering to PRISMA guidelines, a systematic review was conducted using MEDLINE, Embase, and Cochrane databases. Studies directly comparing SRS with WW for newly diagnosed VS were included. Primary outcomes focused on hearing preservation assessed through the AAO-HNS or Gardner-Robertson hearing classification scales and tumor progression, with secondary outcomes focusing on neurological symptoms, and the need for further treatment. Thirteen studies encompassing 1,635 patients (WW: 891; SRS: 744) were included.While no significant difference was found in serviceable hearing loss at last follow-up (RR = 1.51, [95%CI: 0.98, 2.32], p = 0.06), significant differences favoring WW were observed in pure tone audiometry (PTA) (MD = -13.51 [95%CI: -22.66, -4.37], p = 0.004) and word recognition score (WRS) (MD = 20.48 [95%CI: 9.72, 31.25], p = 0.0002). Analysis of tumor progression indicated no overall significant difference in risk between SRS and WW (RR = 0.40, [95%CI 0.07, 2.40], p = 0.32), but subgroup analysis suggested a lower risk with SRS in certain contexts. The need for further treatments favored SRS (RR = 0.24, [95%CI: 0.07, 0.74], p = 0.007). No significant differences were found in tinnitus and imbalance between the two groups. This comprehensive analysis suggests no marked difference in functional hearing preservation between SRS and WW in managing VS. However, untreated tumors commonly necessitate additional interventions. These findings highlight the need for individualized treatment decisions and underscore the importance of continued monitoring. The study advocates for further prospective trials to refine management strategies for VS.

Losartan May Not Prevent Vestibular Schwannoma Growth or Related Hearing Loss During Observation

OBJECTIVE

To evaluate the impact of losartan on vestibular schwannoma (VS) growth and related hearing loss during observation.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

Sporadic VS patients undergoing initial observation with at least two magnetic resonance imaging and audiologic examinations.

INTERVENTION

Losartan.

MAIN OUTCOME MEASURES

Endpoints included VS growth, quantitative audiologic changes, survival free of tumor growth, and survival free of nonserviceable hearing. Patient characteristics and endpoints were compared by losartan use.

RESULTS

Seventy-nine patients were included, of which 33% were taking losartan. Tumor growth was observed in 50% of patients in the losartan group and 36% in the non-losartan group (p = 0.329). Survival analysis failed to show a significant difference in the hazard rate of VS growth between groups (hazard ratio, 1.38; 95% confidence interval, 0.70-2.70; p = 0.346). Throughout observation, mean decreases in normalized pure-tone average were 5.5 and 9.3 dB in the losartan and non-losartan groups, respectively (p = 0.908). Mean decreases in normalized word recognition score were 11.0 and 16.6% in the losartan and non-losartan groups, respectively (p = 0.757). Nonserviceable hearing developed in 19% of patients in the losartan group and 28% in the non-losartan group (p = 0.734). Survival analysis did not demonstrate a significant difference in the hazard rate of developing nonserviceable hearing between groups (hazard ratio, 1.71; 95% confidence interval, 0.56-5.21; p = 0.337).

CONCLUSIONS

Losartan use may not reduce the risk of VS growth or hearing loss during observation. A randomized trial would be ideal to further identify the true effect on growth and hearing.

Temporal lobe injury with middle fossa approach to intracanalicular vestibular schwannomas: a systematic review

There are several surgical approaches for vestibular schwannoma (VS) resection. However, management has gradually shifted from microsurgical resection, toward surveillance and radiosurgery. One of the arguments against microsurgery via the middle fossa approach (MFA) is the risk of temporal lobe retraction injury or sequelae. Here, we sought to evaluate the incidence of temporal lobe retraction injury or sequela from a MFA via a systematic review of the existing literature. This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Relevant studies reporting temporal lobe injury or sequela during MFA for VS were identified. Data was aggregated and subsequently analyzed to evaluate the incidence of temporal lobe injury. 22 studies were included for statistical analysis, encompassing 1522 patients that underwent VS resection via MFA. The overall rate of temporal lobe sequelae from this approach was 0.7%. The rate of CSF leak was 5.9%. The rate of wound infection was 0.6%. Meningitis occurred in 1.6% of patients. With the MFA, 92% of patients had good facial outcomes, and 54.9% had hearing preservation. Our series and literature review support that temporal lobe retraction injury or sequelae is an infrequent complication from an MFA for intracanalicular VS resection.

Natural History of Serviceable Hearing During Active Surveillance of Nongrowing Sporadic Vestibular Schwannoma Supports Consideration of Initial Wait-and-Scan Management

OBJECTIVE

The treatment paradigm of vestibular schwannoma (VS) focuses on preservation of neurologic function, with small tumors increasingly managed with active surveillance. Often, tumor size and hearing outcomes are poorly correlated. The aim of the current work was to describe the natural history of hearing among patients with nongrowing VS during observational management.

STUDY DESIGN

Historical cohort study.

PATIENTS

Adults with sporadic VS.

INTERVENTION

Wait-and-scan management.

MAIN OUTCOME MEASURE

Maintenance of serviceable hearing (SH) after diagnosis.

RESULTS

Among 228 patients with nongrowing VS, 157 patients had SH at diagnosis. Rates of maintaining SH (95% CI; number still at risk) at 1, 3, and 5 years after diagnosis were 94% (89-98; 118), 81% (74-89; 65), and 78% (71-87; 42), respectively. Poorer hearing at diagnosis (hazard ratio [HR] per 10 dB hearing level increase in pure-tone average of 2.51, p < 0.001; HR per 10% decrease in word recognition score of 1.70, p = 0.001) was associated with increased likelihood of developing non-SH during observation. When controlling for baseline hearing status, tumors measuring 5 mm or greater in the internal auditory canal or with cerebellopontine angle extension were associated with significantly increased risk of developing non-SH (HR, 4.87; p = 0.03). At 5 years after diagnosis, 95% of patients with nongrowing intracanalicular VS measuring less than 5 mm maintained SH.

CONCLUSIONS

Hearing worsens during periods of nongrowth in sporadic VS. Patients with small (<5 mm) intracanalicular tumors demonstrate robust maintenance of SH over time, reinforcing the consideration of initial observation in this patient subset.

Middle Ear Cholesteatoma and Vestibular Schwannoma Resection Followed by Cochlear Implant: Surgical Challenges and Audiological Outcomes

(1) Background: The occurrence of vestibular schwannoma (VS) associated with cholesteatoma is rare. A hearing impairment is one of the most significant issues in such cases. Moreover, the presence of middle and inner ear pathologies combined may represent a surgical challenge. No studies have described a combined surgical approach for these coexisting conditions (VS and cholesteatoma), nor the hearing rehabilitation outcomes of using cochlear implants for these patients. (2) Case Report: This paper is on a female patient who underwent simultaneous surgical treatments for VS and middle ear cholesteatoma in the right ear followed by a cochlear implant, describing the technique and the audiological results. (3) Conclusions: The surgical approach was successful and enabled the resection of lesions with the auditory nerve and cochlea preservation. Cochlear implantation in the right ear showed positive postoperative results, with an improvement in the results with the CI in silent and noisy environments.

Incidence and presentation of vestibular schwannoma: a 3-year cohort registry study

BACKGROUND

Vestibular schwannoma (VS) is the most common benign tumour arising in the lateral skull base. Reported incidence rates of VS vary across geographical locations and over time. There is scarce updated evidence over the past decade on the epidemiology and mode of presentation of VS.

OBJECTIVE

To describe the epidemiology and mode of presentation of VS in the East of England between 2013 and 2016.

METHODS

A retrospective epidemiological analysis of data from a national VS registry and electronic patient records was conducted, including all newly diagnosed adult patients in a UK tertiary referral centre, between April 1st, 2013, and March 31st, 2016.

RESULTS

There were 391 new cases identified resulting in an overall mean incidence of 2.2 VS cases per 100,000 person-year. The incidence rate for all patients in the <40 age group ranged between 0.3 and 0.7 per 100,000 person-year, increasing to a range of 5.7 to 6.1 per 100,000 person-year in the 60-69 age group. The top three combinations of symptoms on presentation per patient were hearing loss and tinnitus (97, 24.8%), hearing loss alone (79, 20.2%) and hearing loss, tinnitus, and balance symptoms (61, 15.6%). The median duration of symptoms was 12 months, with a wide range from 1.4 to 300 months. Age was negatively correlated with tumour size (r = -0.14 [-0.24 to -0.04], p=0.01) and positively correlated with symptom duration (r = 0.16 [0.03-0.29], p=0.02).

CONCLUSIONS

The incidence of vestibular schwannoma has increased compared to previous studies in the UK and is similar to incidence rates reported in other countries during the past decade. It peaks in the seventh decade of life, mainly because of an increase in the diagnosis of small tumours with a long duration of audio-vestibular symptoms in older patients, compared to earlier studies.

The Course of Hearing Loss in Patients With a Progressive Vestibular Schwannoma

OBJECTIVE

This study evaluates the natural course of hearing loss (HL) prior to treatment in patients with progressive tumors and an indication for active intervention. Evaluating this patient group specifically can put hearing outcomes after vestibular schwannoma therapy into an adequate context.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

METHODS

Inclusion criteria comprised unilateral vestibular schwannomas prior to active treatment, with ≥2 mm extracanalicular (EC) tumor growth and ≥2 audiograms. We performed a comprehensive assessment of hearing using multiple outcome parameters including (the annual decrease in) pure-tone averages (PTAs; an average of 0.5, 1, 2, and 3 kHz). Predictors for HL were evaluated (patient age, tumor size/progression, follow-up duration, baseline hearing).

RESULTS

At presentation, 86% of patients suffered from sensorineural HL on the affected side (≥20 dB PTA) with a median of 39 dB (interquartile rate [IQR]: 27-51 dB). The median follow-up duration was 21 months (IQR: 13-34 months), after which 58% (187/322) of patients experienced progressive HL (≥10 dB), with a median increase of 6.4 dB/year. At the last follow-up, the median PTA was 56 dB (IQR: 37-73). Median speech discrimination scores deteriorated from 90% (IQR: 70%-100%) to 65% (IQR: 35%-100%). Tumor progression (maximal EC diameter) was significantly correlated to the progression of sensorineural HL, corrected for follow-up (F(2,228) = 10.4, p < .001, R2  = 8%).

CONCLUSION

The majority of patients (58%) with radiologically confirmed progressive vestibular schwannomas experience progressive sensorineural HL during observation. Tumor progression rate, EC tumor extension, and longer follow-up are factors associated with more sensorineural HL.

Cochlear Implant Outcomes between Patients with Sporadic and Neurofibromatosis Type 2-Associated Vestibular Schwannoma

OBJECTIVE

Compare cochlear implant (CI) performance between patients with ipsilateral sporadic vestibular schwannoma (VS) and NF2-related schwannomatosis (NF2). Compare CI performance according to VS management modality.

STUDY DESIGN

Historical cohort.

SETTING

Tertiary academic center.

PATIENTS

Forty-nine patients (52 ears) undergoing cochlear implantation in the setting of ipsilateral sporadic (n = 21) or NF2-associated VS (n = 28).

INTERVENTIONS

CI ipsilateral to VS.

MAIN OUTCOME MEASURES

Auditory thresholds, consonant-nucleus-consonant (CNC) word scores, and AzBio sentences in quiet scores.

RESULTS

Among all patients, median post-CI pure tone average was 28 dB HL (interquartile range [IQR], 21-38), CNC word score was 39% (IQR, 6-62), and AzBio sentences in quiet score was 60% (IQR, 11-83) at a median of 12.5 months postimplantation. Despite the NF2 cohort having larger tumors, when comparing patients with sporadic versus NF2-associated VS, there were no statistically significant differences in CNC word (49% [30-70] vs. 31% [0-52]) or AzBio sentences in quiet (66% [28-80] vs. 57% [5-83]) scores. Regardless of NF2 status, all patients managed with observation, and radiosurgery achieved open-set speech. In patients who underwent microsurgery, 6 (46%) of 13 with NF2 achieved open-set speech recognition compared with 4 (67%) of 6 with sporadic disease.

CONCLUSION

Select patients with VS achieve successful hearing rehabilitation with a CI. In this cohort, tumor management strategy significantly influenced CI performance, whereas differences in NF2 status exhibited less effect. Specifically, all patients managed with observation or radiosurgery achieved open-set speech perception, whereas approximately half of people with NF2-related VS and two-thirds of people with sporadic VS achieved this outcome after tumor microsurgery. When disease permits, observation and radiosurgery should be considered in patients who may later pursue a CI.

Retrosigmoid Approach for Sporadic Vestibular Schwannoma: Patient Selection, Technical Pearls, and Hearing Results

The retrosigmoid corridor provides the most broadly applied approach for resection of sporadic vestibular schwannoma. It may be utilized for any size tumor and for patients with intact hearing with the intention of hearing preservation. For larger tumors, the skull base surgeon must weigh the benefits the retrosigmoid approach against those of the translabyrinthine route. For smaller tumors where hearing preservation is a goal, the retrosigmoid approach is contrasted to the middle fossa route. Hearing preservation is most likely for patients with small and medially located intracanalicular tumors with minimal extension into the cerebellopontine angle, and excellent preoperative hearing.

Natural History of Hearing Loss in Sporadic Vestibular Schwannoma

Hearing loss is the most common and earliest symptom of sporadic vestibular schwannoma (VS). The most common pattern of hearing loss is asymmetric sensorineural hearing loss. Throughout its natural history, patients with serviceable hearing (SH) maintain SH at 94% to 95% after 1 year, 73% to 77% after 2 years, 56% to 66% after 5 years, and 32% to 44% after 10 years. For patients newly diagnosed with VS, it is likely their hearing will worsen despite small initial tumor size or lack of tumor growth.

Guiding Patients Through Decision-Making in Management of Sporadic Vestibular Schwannoma

Decision-making in management of sporadic vestibular schwannoma aims to identify the most appropriate options based on tumor characteristics, symptoms, health, and goals for each patient. Advances in knowledge of tumor natural history, improvements in radiation techniques, and achievements in neurologic preservation with microsurgery have shifted emphasis toward maximizing quality of life using a personalized approach. To empower patients to make informed decisions, we present a framework to help match patient values and priorities with reasonable expectations from modern management options. Introduced herein are practical examples of communication strategies and decision aids to support shared decision-making in modern practice.

Long-term tumor growth and hearing after conservative management of vestibular schwannomas

BACKGROUND

There has been no report of a detailed long-term study of hearing at defined frequencies.

AIMS/OBJECTIVES

This study aimed to evaluate long-term vestibular shwannoma (VS) growth and long-term changes in hearing thresholds at defined frequencies.

METHODS

We retrospectively retrieved the medical records of 67 VS patients. Cases that were followed up for more than 5 years were analyzed.

RESULTS

Tumor growth was observed in 15 cases (22.4%) and 6 cases underwent gamma knife treatment (9.0%). The longest case of tumor growth and gamma knife treatment was observed 11 years after the initial diagnosis. Hearing thresholds at 500-2000 Hz was significantly different between the no growth and growth group (p < .05). Particularly at 1000 Hz, there was a significant difference between the two groups from an early time-point.

CONCLUSIONS AND SIGNIFICANCE

Even a 10-year or longer follow-up of VS may show an increase in tumor growth. Moreover, hearing thresholds, particularly at 1000 kHz, may predict tumor growth when following-up VS patients.

Factors Influencing Personalized Management of Vestibular Schwannoma: A Systematic Review

Management of vestibular schwannoma (VS) is a complex process aimed at identifying a clinical indication for fractionated stereotactic radiotherapy (sRT) or microsurgical resection or wait and scan (WS). The aim of the review was to clarify which patient and tumor parameters may lead to different therapeutic choices, with a view to a personalized VS approach. A systematic review according to Preferred Reporting Items for Systematic Review and Meta-Analysis criteria was conducted between February and March 2022. The authors defined six parameters that seemed to influence decision-making in VS management: 1-incidental VS; 2-tumor size; 3-tumor regrowth after sRT; 4-subtotal resection; 5-patients' age; 6-symptoms. The initial search yielded 3532 articles, and finally, 812 articles were included. Through a qualitative synthesis of the included studies, management strategies were evaluated and discussed. An individualized proposal of procedures is preferable as compared to a single gold-standard approach in VS decision-making. The most significant factors that need to be considered when dealing with a VS diagnosis are age, tumor size and hearing preservation issues.