Clinical Staging to Estimate the Probability of Severe Postoperative Complications in Patients With Vestibular Schwannoma

Abstract

ver the past 40 years, the incidence of vestibular schwannoma (VS) has been increasing, according to epidemiologic studies in Denmark as well as a population-based study in Olmsted County, Minnesota. [1][2][3] This change is likely explained by increased access to health care and advances in diagnostic technology. Once discovered, these tumors require careful decision-making about treatment options given the slow rate of tumor growth and morbidity associated with treatment. The decision to pursue surgical management instead of radiotherapy or active surveillance is multifactorial and largely depends on features including age, comorbidity, initial tumor size, rate of growth, hearing status, and patient preference. The mortality rate in patients sur-gically managed is very low and affords the opportunity to shift focus to other relevant clinical outcomes, such as recurrencefree survival, growth-free survival, surgical complications, facial nerve functioning, hearing preservation, and quality of life. [4][5][6] Patient symptom presentation is a fundamental characteristic of the patient with VS and likely relates to the pathophysiologic characteristics of the tumor. Symptoms at presentation include cardinal symptoms, such as hearing loss, vestibular dysfunction, facial numbness, tinnitus, and headaches. Despite their clinical relevance, symptoms at presentation have not been thoroughly investigated in the context of clinical outcomes. Earlier investigations have described the IMPORTANCE Vestibular schwannomas have long been treated as a homogeneous entity. Clinical symptoms at presentation may help elucidate the underlaying pathophysiologic characteristics of tumor subtypes. Describing the heterogeneity of these benign tumors may assist in predicting clinical outcomes associated with their treatment.OBJECTIVE To create a tumor staging system that incorporates symptoms at presentation and tumor size to predict severe surgical complications. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort of patients at a single-center tertiary referral center from January 1, 1998, to October 13, 2020, was studied. Patients diagnosed with sporadic vestibular schwannoma surgically treated at Washington University in St Louis, Missouri, were included. MAIN OUTCOMES AND MEASURESSevere surgical complications within 30 days of surgery as determined by the Clavien-Dindo classification system. Patients experiencing a complication of grade 3 or above were determined to have a severe complication. RESULTSOf 185 patients evaluated, 40 (22%) had severe postoperative complications. Twenty of the 40 patients (50%) were women; mean (SD) age was 46 (13) years. Patients with severe complications were more likely to have large tumors (>2.5 cm in largest diameter), vestibular symptoms, and recent hearing loss at presentation. Using conjunctive consolidation, a 4-stage clinical severity staging system that incorporates clinical symptoms and tumor size at presentation was created to predict severe complications. The clinical severity staging syste...

Identifying Predictors of Treatment Response in Meniere's Disease: A Clinical Severity Staging System

“…These staging systems have previously been used in conditions such as lung cancer, 19 laryngeal cancer, 20 papillary thyroid cancer, 21 prostate cancer, 22 and vestibular schwannoma. 23 Multivariable risk stratification allows for the combination of several clinically important risk factors to be assessed and the integration of this information into a staging system. To date, there has been no attempt to gain therapeutic or prognostic insight for MD through the development of a CSSS.…”

“…Clinical severity staging systems (CSSS) use clinical, comorbid, and objective findings to provide prognostic or therapeutic information. These staging systems have previously been used in conditions such as lung cancer, 19 laryngeal cancer, 20 papillary thyroid cancer, 21 prostate cancer, 22 and vestibular schwannoma 23 . Multivariable risk stratification allows for the combination of several clinically important risk factors to be assessed and the integration of this information into a staging system.…”