Comments on ‘Screening for vestibular schwannoma in the context of an ageing population’

Abstract

Cite this article: Gair J, Borsetto D, Donnelly N, Axon P, Bance M, Tysome JR. Comments on 'Screening for vestibular schwannoma in the context of an ageing population '. J Laryngol Otol 2020;134:275-276. https://doi. Dear Editors,We read with interest the systematic review by Basu et al. 1 entitled 'Screening for vestibular schwannoma in the context of an ageing population'. This correctly noted that there has been an increase in the number of over 70-year-olds presenting with small nongrowing vestibular schwannomas which are followed up with a surveillance scan protocol and never need any active treatment. The authors concluded that a prospective analysis of elderly patients should be undertaken, from both a clinical and cost-benefit perspective, given the finite resources and that benign tumours need no direct clinical input bar symptom management.The paper attempted to systematically review literature published up to the end of 2018, but unfortunately missed our very pertinent paper (Borsetto et al., 2 entitled 'When should we stop scanning older patients with vestibular schwannomas?'), likely because it was published in late 2018. We feel it would be important to alert the authors and readers to our paper, which addresses this exact issue, so that it can be taken into account as well. In our retrospective clinical record review of a 13-year period of data at a tertiary referral skull base unit (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018), we reviewed all patients presenting with a unilateral vestibular schwannoma who were initially managed with a surveillance protocol. A total of 112 patients met the inclusion criteria of being aged 70 years or over at presentation, having at least a 5-year follow up, who received no primary surgical or oncological treatment, with no diagnosis of neurofibromatosis type 2, and who underwent magnetic resonance imaging (MRI) at follow up rather than computed tomography.In our cohort of patients, the median age at diagnosis was 74 years (range, 70-87 years), with 48 per cent presenting at over 75 years and 12 per cent at over 80 years. Overall, 46 per cent of presenting tumours were intracanalicular, 41 per cent were small, 12 per cent were medium and only 2 per cent were large. In this cohort, 71 per cent of patients showed no tumour growth in the entire follow-up period (growth was defined as an increase of at least 2 mm per year in maximal diameter measured from the initial diagnostic scan). Of the patients who did show tumour growth (29 per cent), 23 per cent were managed with active treatment with either radiotherapy or surgery, and 6 per cent received continued surveillance. The likelihood of tumour growth did not change with increasing age when examined in terms of age groups (70-74 years, 75-79 years, and 80 and over years).One of the additional factors we investigated was the time-point of growth. Ninety per cent of tumours that grew showed this growth in the first 30 months after diagnosis, but no tumours showed initial growth af...

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“…3 The detection rate of new vestibular schwannomas was 1.23 per cent, comparable to previously published studies. 4,5 In support of the use of the NICE guidelines, all positive cases of vestibular schwannoma fit the NICE guidelines criteria; three of these could have been missed using other criteria. In addition, of the imaging requests that did not meet the NICE guidelines criteria, 281 revealed no positive results.…”