When Should We Stop Scanning Older Patients with Vestibular Schwannomas?

Borsetto, Daniele; Gair, Juliette; Kenyon, Olivia; Das, Tilak; Donnelly, Neil; Axon, Patrick; Macfarlane, Robert; Scoffings, Daniel; Bance, Manohar; Tysome, James R.

doi:10.1055/s-0038-1676820

Cited by 14 publications

(8 citation statements)

References 16 publications

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“…From the model, a conditional probability of growth of 1% occurs at 6 years 10 months for a 2-mm growth criteria, and 6 years 8 months for 3-mm growth criteria, or put another way, from 7 years onwards the risk of growth in any subsequent year would be <1%. This 1% cut-off is often used by units in deciding when to discontinue surveillance, and as such the model would have implications for the most appropriate protocol for surveillance; however, this is an ongoing discussion (14)(15)(16) beyond the scope of this article. It would be useful to compare the predictive model presented here with future studies of conditional probability to determine the accuracy of this regression analysis.…”

Section: On-19-302mentioning

confidence: 99%

The Conditional Probability of Vestibular Schwannoma Growth at Different Time Points After Initial Stability on an Observational Protocol

Sethi

Borsetto

Cho

et al. 2020

Otology &Amp; Neurotology

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Objective: The natural history of vestibular schwannomas (VS) is well documented in the literature, with tumour growth being paramount to decision making for both surveillance and treatment of these patients. Most previous studies refer to the risk of VS growth over a given period of time; however, this is not useful for counselling patients at different stages of their follow-up, as the risk of tumour growth is likely to be less following each subsequent year that a tumour does not grow. Accordingly, we investigated the conditional probability of VS growth at particular timepoints, given a patient has not grown thus far. This Bayesian method of risk stratification allows for more tailored and accurate approximations of the risk of growth versus nongrowth of VS. Methods: Retrospective analysis of a prospectively collected database in a tertiary referral skull base unit, containing all patients diagnosed between 2005 and 2014 with sporadic unilateral VS and a minimum of 5-year surveillance. Results: A total of 341 patients met the inclusion criteria. The mean age at diagnosis was 67 years, the sizes of the VS at diagnosis were intracanalicular in 49%, small in 39%, medium in 11%, and large in 1%. Over the entire 5-year surveillance period, a total of 139 tumours were seen to grow (41%) and 202 did not grow (59%). At 1 year, the probability of growth given that the tumour had not grown to date was seen to be 21%, at 2 years 12%, at 3 years 9%, at 4 years 3%, and at 5 years 2%. The conditional probability of growth of extracanalicular VS was significantly higher in the first year when compared with intracanalicular VS (29% versus 13%, p ¼ 0.01), but there was no such difference in years 2, 3, 4 or 5 ( p ¼ 0.60, 0.69, 0.36, 0.39, respectively). Conclusion: This is the first study in the literature concerned specifically with the conditional probability of VS growth. The data presented here can be used to better inform VS patients of their risk of growth at particular time points in their disease-the longer VS have been observed to be stable, the lower the risk of subsequent growth in a given year. Further, an extracanalicular vestibular schwannoma is more likely to grow in the first year compared with an intracanalicular vestibular schwannoma. Our data also adds support to surveillance protocols with increasingly infrequent MRI scans, as after 4 years of not growing, the risk of growth in year 5 falls to <2%.

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Section: On-19-302mentioning

confidence: 99%

The Conditional Probability of Vestibular Schwannoma Growth at Different Time Points After Initial Stability on an Observational Protocol

Sethi

Borsetto

Cho

et al. 2020

Otology &Amp; Neurotology

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“…Many authors suggest the need for personalized counselling on VS management, taking into account age, comorbidities, life expectancy, and the risk of any short- or long-term side effects [ 70 ]. Varieties of demographic factors, especially age, are linked to VS size at diagnosis and to the initial treatment plan offered.…”

Section: Resultsmentioning

confidence: 99%

Factors Influencing Personalized Management of Vestibular Schwannoma: A Systematic Review

Sergi

Settimi

Federici

et al. 2022

JPM

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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.

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“…Ideally, it would be at a point at which the risks of growth-related complications are small enough to accept when balanced against the costs of continued surveillance. 2,3 This is necessarily a somewhat subjective and value-based judgment, and although costs can be assigned to various outcome measures, they are very difficult to validate.…”

mentioning

confidence: 99%

Evidence-based surveillance protocol for vestibular schwannomas: a long-term analysis of tumor growth using conditional probability

Borsetto

Sethi

Clarkson

et al. 2022

Journal of Neurosurgery

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OBJECTIVE The growth characteristics of vestibular schwannomas (VSs) under surveillance can be studied using a Bayesian method of growth risk stratification by time after surveillance onset, allowing dynamic evaluations of growth risks. There is no consensus on the optimum surveillance strategy in terms of frequency and duration, particularly for long-term growth risks. In this study, the long-term conditional probability of new VS growth was reported for patients after 5 years of demonstrated nongrowth. This allowed modeling of long-term VS growth risks, the creation of an evidence-based surveillance protocol, and the proposal of a cost-benefit analysis decision aid. METHODS The authors performed an international multicenter retrospective analysis of prospectively collected databases from five tertiary care referral skull base units. Patients diagnosed with sporadic unilateral VS between 1990 and 2010 who had a minimum of 10 years of surveillance MRI showing VS nongrowth in the first 5 years of follow-up were included in the analysis. Conditional probabilities of growth were calculated according to Bayes’ theorem, and nonlinear regression analyses allowed modeling of growth. A cost-benefit analysis was also performed. RESULTS A total of 354 patients were included in the study. Across the surveillance period from 6 to 10 years postdiagnosis, a total of 12 tumors were seen to grow (3.4%). There was no significant difference in long-term growth risk for intracanalicular versus extracanalicular VSs (p = 0.41). At 6 years, the residual conditional probability of growth from this point onward was seen to be 2.28% (95% CI 0.70%–5.44%); at 7 years, 1.35% (95% CI 0.25%–4.10%); at 8 years, 0.80% (95% CI 0.07%–3.25%); at 9 years, 0.47% (95% CI 0.01%–2.71%); and at 10 years, 0.28% (95% CI 0.00%–2.37%). Modeling determined that the remaining lifetime risk of growth would be less than 1% at 7 years 7 months, less than 0.5% at 8 years 11 months, and less than 0.25% at 10 years 4 months. CONCLUSIONS This multicenter study evaluates the conditional probability of VS growth in patients with long-term VS surveillance (6–10 years). On the basis of these growth risks, the authors posited a surveillance protocol with imaging at 6 months (t = 0.5), annually for 3 years (t = 1.5, 2.5, 3.5), twice at 2-year intervals (t = 5.5, 7.5), and a final scan after 3 years (t = 10.5). This can be used to better inform patients of their risk of growth at particular points along their surveillance timeline, balancing the risk of missing late growth with the costs of repeated imaging. A cost-benefit analysis decision aid was also proposed to allow units to make their own decisions regarding the cessation of surveillance.

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When Should We Stop Scanning Older Patients with Vestibular Schwannomas?

Cited by 14 publications

References 16 publications

The Conditional Probability of Vestibular Schwannoma Growth at Different Time Points After Initial Stability on an Observational Protocol

The Conditional Probability of Vestibular Schwannoma Growth at Different Time Points After Initial Stability on an Observational Protocol

Factors Influencing Personalized Management of Vestibular Schwannoma: A Systematic Review

Evidence-based surveillance protocol for vestibular schwannomas: a long-term analysis of tumor growth using conditional probability

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