Introducing an Evidence-Based Approach to Wait-And-Scan Management of Sporadic Vestibular Schwannoma

Marinelli, John P.; Lohse, Christine M.; Carlson, Matthew L.

doi:10.1016/j.otc.2023.02.006

Cited by 3 publications

(5 citation statements)

References 39 publications

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“…The current work and prior studies illustrate that tumor size within the CPA constitutes the strongest association with poorer postoperative outcomes, with the current study suggesting that every 1-mm increase in CPA tumor size is associated with a 13% increased risk of NTR/STR or long-term facial paresis. When considering continued observation in the setting of growing vestibular schwannoma during wait-and-scan management, this finding suggests earlier intervention for a tumor with CPA extension may be preferable, rather than waiting until the upper limit of SRS of 2.5 to 3.0 cm of CPA extension.…”

Section: Discussionmentioning

confidence: 99%

Salvage Microsurgery Following Failed Primary Radiosurgery in Sporadic Vestibular Schwannoma

Marinelli,

Herberg,

Moore

et al. 2024

JAMA Otolaryngol Head Neck Surg

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ImportanceManagement of sporadic vestibular schwannoma with radiosurgery is becoming increasingly common globally; however, limited data currently characterize patient outcomes in the setting of microsurgical salvage for radiosurgical failure.ObjectiveTo describe the clinical outcomes of salvage microsurgery following failed primary stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) among patients with sporadic vestibular schwannoma.Design, Setting, and ParticipantsThis was a cohort study of adults (≥18 years old) with sporadic vestibular schwannoma who underwent salvage microsurgery following failed primary SRS/FSRT in 7 vestibular schwannoma treatment centers across the US and Norway. Data collection was performed between July 2022 and January 2023, with data analysis performed between January and July 2023.ExposureSalvage microsurgical tumor resection.Main Outcomes and MeasuresComposite outcome of undergoing less than gross total resection (GTR) or experiencing long-term facial paresis.ResultsAmong 126 patients, the median (IQR) age at time of salvage microsurgery was 62 (53-70) years, 69 (55%) were female, and 113 of 117 (97%) had tumors that extended into the cerebellopontine angle at time of salvage. Of 125 patients, 96 (76%) underwent primary gamma knife SRS, while 24 (19%) underwent linear accelerator-based SRS; the remaining patients underwent FSRT using other modalities. Postoperative cerebrospinal fluid leak was seen in 15 of 126 patients (12%), hydrocephalus in 8 (6%), symptomatic stroke in 7 (6%), and meningitis in 2 (2%). Each 1-mm increase in cerebellopontine angle tumor size was associated with a 13% increased likelihood of foregoing GTR (64 of 102 patients [63%]) or long-term postoperative House-Brackmann grade higher than I (48 of 102 patients [47%]) (odds ratio, 1.13; 95% CI, 1.04-1.23). Following salvage microsurgery, tumor growth–free survival rates at 1, 3, and 5 years were 97% (95% CI, 94%-100%), 93% (95% CI, 87%-99%), and 91% (95% CI, 84%-98%), respectively.ConclusionsIn this cohort study, more than half of patients who received salvage microsurgery following primary SRS/FSRT underwent less than GTR or experienced some degree of facial paresis long term. These data suggest that the cumulative risk of developing facial paresis following primary SRS/FSRT by the end of the patient’s journey with treatment approximates 2.5% to 7.5% when using published primary SRS/FSRT long-term tumor control rates.

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Section: Discussionmentioning

confidence: 99%

Salvage Microsurgery Following Failed Primary Radiosurgery in Sporadic Vestibular Schwannoma

Marinelli,

Herberg,

Moore

et al. 2024

JAMA Otolaryngol Head Neck Surg

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“…In this way, selected patients may be safely observed—as long as reliable follow-up can be assured—until tumor growth into a specific size threshold range whereby further tumor growth would predispose the patient to disproportionately elevated risk of poor posttreatment outcomes. We have termed this concept size threshold surveillance , and a systematic outline of the approach can be found published elsewhere . In brief, the size threshold range for microsurgery is around 15 mm of cerebellopontine angle extension (ie, not including the intracanalicular component), and for radiosurgery, this number is likely closer to 20 mm, although investigation surrounding this remains active by the authors .…”

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confidence: 99%

“…We have termed this concept size threshold surveillance , and a systematic outline of the approach can be found published elsewhere . In brief, the size threshold range for microsurgery is around 15 mm of cerebellopontine angle extension (ie, not including the intracanalicular component), and for radiosurgery, this number is likely closer to 20 mm, although investigation surrounding this remains active by the authors . Importantly, we are neither suggesting that every tumor should be observed, nor should every person undergoing observation be observed until 15 mm of cerebellopontine angle extension; instead, we believe these data simply support a more flexible approach to care and must be viewed within the full context of patient goals and disease.…”

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confidence: 99%

Size Threshold Surveillance—A Revised Approach to Wait-and-Scan for Vestibular Schwannoma

Marinelli

Link

Carlson

2023

JAMA Otolaryngol Head Neck Surg

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“…In 2018, a survey study showed that 91% of the members of the North American Skull Base Society would observe a small tumor (<15 mm cerebellar pontine angle [CPA]) until growth was detected 15 . Since then, several papers have been published arguing for observation in small but progressive tumors (CPA < 15 mm), and a size threshold for active treatment was introduced, based on extrameatal tumor diameters, emphasizing the complementary value of tumor diameters to tumor volume measurements 16,17 …”

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confidence: 99%

“…15 Since then, several papers have been published arguing for observation in small but progressive tumors (CPA < 15 mm), and a size threshold for active treatment was introduced, based on extrameatal tumor diameters, emphasizing the complementary value of tumor diameters to tumor volume measurements. 16,17 Therefore, this study aimed to validate an algorithm to measure extrameatal tumor diameters as an addition to a previously reported automated volume measurement algorithm. 13 Combining automated 2-dimensional (2D) and tumor volume (3D) measurements in 1 algorithm would result in a robust tool suited to support treatment decisions in current clinical practice.…”

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confidence: 99%

Automated 2‐Dimensional Measurement of Vestibular Schwannoma: Validity and Accuracy of an Artificial Intelligence Algorithm

Neve,

Romeijn,

Chen

et al. 2023

Otolaryngol.--head neck surg.

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ObjectiveValidation of automated 2‐dimensional (2D) diameter measurements of vestibular schwannomas on magnetic resonance imaging (MRI).Study DesignRetrospective validation study using 2 data sets containing MRIs of vestibular schwannoma patients.SettingUniversity Hospital in The Netherlands.MethodsTwo data sets were used, 1 containing 1 scan per patient (n = 134) and the other containing at least 3 consecutive MRIs of 51 patients, all with contrast‐enhanced T1 or high‐resolution T2 sequences. 2D measurements of the maximal extrameatal diameters in the axial plane were automatically derived from a 3D‐convolutional neural network compared to manual measurements by 2 human observers. Intra‐ and interobserver variabilities were calculated using the intraclass correlation coefficient (ICC), agreement on tumor progression using Cohen's kappa.ResultsThe human intra‐ and interobserver variability showed a high correlation (ICC: 0.98‐0.99) and limits of agreement of 1.7 to 2.1 mm. Comparing the automated to human measurements resulted in ICC of 0.98 (95% confidence interval [CI]: 0.974; 0.987) and 0.97 (95% CI: 0.968; 0.984), with limits of agreement of 2.2 and 2.1 mm for diameters parallel and perpendicular to the posterior side of the temporal bone, respectively. There was satisfactory agreement on tumor progression between automated measurements and human observers (Cohen's κ = 0.77), better than the agreement between the human observers (Cohen's κ = 0.74).ConclusionAutomated 2D diameter measurements and growth detection of vestibular schwannomas are at least as accurate as human 2D measurements. In clinical practice, measurements of the maximal extrameatal tumor (2D) diameters of vestibular schwannomas provide important complementary information to total tumor volume (3D) measurements. Combining both in an automated measurement algorithm facilitates clinical adoption.

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Introducing an Evidence-Based Approach to Wait-And-Scan Management of Sporadic Vestibular Schwannoma

Cited by 3 publications

References 39 publications

Salvage Microsurgery Following Failed Primary Radiosurgery in Sporadic Vestibular Schwannoma

Salvage Microsurgery Following Failed Primary Radiosurgery in Sporadic Vestibular Schwannoma

Size Threshold Surveillance—A Revised Approach to Wait-and-Scan for Vestibular Schwannoma

Automated 2‐Dimensional Measurement of Vestibular Schwannoma: Validity and Accuracy of an Artificial Intelligence Algorithm

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