A Protocol for the Conservative Management of Vestibular Schwannomas

Martín, Timothy; Senthil, Latha; Chavda, Swarapsinh V.; Walsh, Richard; Irving, Richard

doi:10.1097/mao.0b013e31819a8df6

Cited by 69 publications

(65 citation statements)

References 13 publications

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“…Such screening options included hearing tests, which were reported to be equivocal between lesions that grew and those that did not. 9,17,31 Interestingly, in line with the findings of Nikolopoulos et al, 22 Martin and colleagues 16 also suggested that cystic tumors should be followed more closely, as they represented a disproportionate percentage of the tumors that grew, especially in cases in which a solid tumor converted into a cystic one.…”

supporting

confidence: 65%

“…The protocol established by Martin et al 16 contrasts with the one proposed by Strangerup et al, 32 who suggested annual scans for 5 years after treatment and then follow-up scans at 7, 9, and 14 years after treatment. Smouha et al 29 proposed a different strategy, suggesting that those selected for conservative management should undergo MRI studies at 6 months after treatment and ev-ery year thereafter.…”

mentioning

confidence: 63%

“…Martin et al 16 suggested an initial rescan with MRI at 6 months posttreatment followed by scans annually for 2 years and then every 5 years for the remainder of the patient's life. They recommended reassessment if growth > 2 mm occurs at any interval.…”

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confidence: 99%

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Incidental vestibular schwannomas: a review of prevalence, growth rate, and management challenges

Schmidt¹,

Boghani²,

Choudhry³

et al. 2012

FOC

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With the relatively recent increase in the use of MRI techniques, there has been a concurrent rise in the number of vestibular schwannomas (VSs) detected as incidental findings. These incidental VSs may be prevalent in up to 0.02%–0.07% of individuals undergoing MRI and represent a significant portion of all diagnosed VSs. The management of these lesions poses a significant challenge for practitioners. Most incidental VSs tend to be small and associated with minimal symptoms, permitting them to be managed conservatively at the time of diagnosis. However, relatively few indicators consistently predict tumor growth and patient outcomes. Furthermore, growth rates have been shown to vary significantly over time with a large variety of long-term growth patterns. Thus, early MRI screening for continued tumor growth followed by repeated MRI studies and clinical assessments throughout the patient's life is an essential component in a conservative management strategy. Note that tumor growth is typically associated with a worsening of symptoms in patients who undergo conservative management, and many of these symptoms have been shown to significantly impact the patient's quality of life. Specific indications for the termination of conservative management vary across studies, but secondary intervention has been shown to be a relatively safe option in most patients with progressive disease. Patients with incidental VSs will probably qualify for a course of conservative management at diagnosis, and regular imaging combined with the expectation that the tumor and symptoms may change at any interval is crucial to ensuring positive long-term outcomes in these patients. In this report, the authors discuss the current literature pertaining to the prevalence of incidental VSs and various considerations in the management of these lesions. It is hoped that by incorporating an understanding of tumor growth, patient outcomes, and management strategies, practitioners will be able to effectively address this challenging disease entity.

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confidence: 65%

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confidence: 63%

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Incidental vestibular schwannomas: a review of prevalence, growth rate, and management challenges

Schmidt¹,

Boghani²,

Choudhry³

et al. 2012

FOC

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“…Martin et al 34 analyzed 320 patients who underwent observation after an intracanalicular tumor or a tumor smaller than 2 cm in diameter was found. The mean follow-up was 43 months, and 276 patients had at least 1 follow-up image.…”

Section: Observation: the "Wait And Scan" Optionmentioning

confidence: 99%

The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation?

Kondziolka

Mousavi

Kano

et al. 2012

FOC

132

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Object Management recommendations for patients with smaller-volume or newly diagnosed vestibular schwannomas (< 4 cm3) need to be based on an understanding of the anticipated natural history of the tumor and the side effects it produces. The natural history can then be compared with the risks and benefits of therapeutic intervention using a minimally invasive strategy such as stereotactic radiosurgery (SRS). Methods The authors reviewed the emerging literature stemming from recent recommendations to “wait and scan” (observation) and compared this strategy with published outcomes after early intervention using SRS or results from matched cohort studies of resection and SRS. Results Various retrospective studies indicate that vestibular schwannomas grow at a rate of 0–3.9 mm per year and double in volume between 1.65 and 4.4 years. Stereotactic radiosurgery arrests growth in up to 98% of patients when studied at intervals of 10–15 years. Most patients who select “wait and scan” note gradually decreasing hearing function leading to the loss of useful hearing by 5 years. In contrast, current studies indicate that 3–5 years after Gamma Knife surgery, 61%–80% of patients maintain useful hearing (speech discrimination score > 50%, pure tone average < 50). Conclusions Based on published data on both volume and hearing preservation for both strategies, the authors devised a management recommendation for patients with small vestibular schwannomas. When resection is not chosen by the patient, the authors believe that early SRS intervention, in contrast to observation, results in long-term tumor control and improved rates of hearing preservation.

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“…Wait and scan policy consists of consecutive MRIs for a period of up to 5 years. [8][9][10][11] So far, growth in MRI and clinical symptoms are considered decisive in patient management planning.…”

Section: Introductionmentioning

confidence: 99%

Predictive factors of acoustic neuroma growth

Kikidis

Xenellis

Kyrodimos

et al. 2016

Int J Otorhinolaryngol Head Neck Surg

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Background:Since the use of magnetic resonance imaging (MRI) as the gold standard for acoustic neuroma diagnosis, the size of the majority of newly diagnosed acoustic neuromas has decreased. Management strategy is challenging, especially in young patients with small tumors. Therefore, prognostic factors for tumor growth may facilitate physicians to optimize treatment choice.Methods:Patients diagnosed with acoustic neuromas were recruited in this study. Gender, age, side, presence of hearing loss, tinnitus, vertigo, unsteadiness, other symptoms, hearing level in the affected ear and tumor growth at the first follow up MRI were recorded. Two primary endpoints were set: overall acoustic neuroma (AN) growth and growth correlated to treatment plan change (clinically significant growth). Multivariate and survival analysis were conducted to this end. Results:85 patients were finally included in the study. The most prevalent presenting symptoms were hearing loss (76%), tinnitus (56%) and unsteadiness (46%). The tumour grew in size in less than 50% of the cases during the observation period. Clinically significant growth was observed in 27% of the cases. Mean initial diameter was 10.41mm and mean final follow-up diameter (diameter at the end of the observation period) 12.73 mm. Following binary logistic regression analysis, tumour growth during the initial follow up visit was found to be correlated in a statistically significant level to overall tumour growth (p-value 0.023). Regarding clinically significant growth, three factors were found to be statistically significant: growth at the initial visit (p-value 0.02), initial diameter (p-value 0.045) and existence of unsteadiness at diagnosis (p-value 0.02).Conclusions:Acoustic neuroma overall growth is not identical to clinically significant growth. Growth at first visit is a significant prognostic factor and intervention potential should be considered under this perspective.

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A Protocol for the Conservative Management of Vestibular Schwannomas

Cited by 69 publications

References 13 publications

Incidental vestibular schwannomas: a review of prevalence, growth rate, and management challenges

Incidental vestibular schwannomas: a review of prevalence, growth rate, and management challenges

The newly diagnosed vestibular schwannoma: radiosurgery, resection, or observation?

Predictive factors of acoustic neuroma growth

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