Systematic review and meta-analysis of the technique of subtotal resection and stereotactic radiosurgery for large vestibular schwannomas: a “nerve-centered” approach

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>During the last decade, the primary objective for large vestibular schwannoma (VS) management has progressively shifted, from tumor excision to nerve preservation by using a combined microsurgical and radiosurgical approach. The aim of this study was to provide a systematic review and meta-analysis of the available literature regarding the combined strategy of subtotal resection (STR) followed by stereotactic radiosurgery (SRS) for large VSs.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a systematic review and meta-analysis in compliance with the PRISMA guidelines for article identification and inclusion using the PubMed, Embase, and Cochrane databases. Established inclusion criteria were used to screen all identified relevant articles published before September 2017 without backward date limit.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The authors included 9 studies (248 patients). With a weighted mean follow-up of 46 months (range 28–68.8 months), the pooled rate of overall tumor control was 93.9% (95% CI 91.0%–96.8%). Salvage treatment (second STR and/or SRS) was necessary in only 13 (5.24%) of 18 patients who experienced initial treatment failure. According to the House-Brackmann (HB) grading scale, functional facial nerve preservation (HB grade I–II) was achieved in 96.1% of patients (95% CI 93.7%–98.5%). Serviceable hearing after the combined approach was preserved in 59.9% (95% CI 36.5%–83.2%).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>A combined approach of STR followed by SRS was shown to have excellent clinical and functional outcomes while still achieving a tumor control rate comparable to that obtained with a total resection. Longer-term follow-up and larger patient cohorts are necessary to fully evaluate the rate of tumor control achieved with this approach.</jats:p></jats:sec>

Facial nerve function and hearing after microsurgical removal of sporadic vestibular schwannomas in a population-based cohort

“…Since total resection of especially large VSs carries a considerable risk of facial nerve injury and hearing defect, a less radical treatment paradigm has been introduced during the recent years. After planned sub-total surgical resection combined with adjuvant radiosurgery, better outcomes have been reported in terms of hearing and facial nerve preservation as well as tumor control [11][12][13]51]. During the current study period, the introduction of CK radiosurgery changed the treatment protocol of VSs also at our institution.…”

The impact of the MIB-1 index on facial nerve outcomes in vestibular schwannoma surgery

“…Only 40% of patients suffering from giant VS had a good HB after 2 years. Our data are in agreement with those presented in other reports about giant VS. Consequently, in the treatment of giant VS, facial nerve preservation should be prioritised over total tumour resection [37,47]. Because of its higher incidence of postoperative poor HB scores, the rate of facial nerve palsy-induced morbidity was much higher in class 3 than in classes 1 and 2 (15.8% vs. 6.3% vs. 0%), and this should be discussed with affected patients.…”

Editorial re: Facial nerve function and hearing after microsurgical removal of sporadic vestibular schwannomas in a population-based cohort by Ismail Taha et al.

“…One of the last articles published by Starnoni 2018 [10], the authors attempt to analyze the existing literature through a systematic review of this questionable policy. They included 9 studies and 248 patients with a mean follow-up of 4.8 years.…”