Vestibular Schwannoma Practice Patterns: An International Cross-specialty Survey

Abstract

Objective: To assess vestibular schwannoma (VS) practice patterns among providers. Study Design: Cross-sectional survey. Setting: 8th Quadrennial International Conference on Vestibular Schwannoma and Other CPA Tumors. Subjects: Clinicians who specialize in the management of VS. Main Outcome Measures: Responses to questions on the management and anticipated outcomes of VS for a series of common clinical scenarios were compared by specialty (otolaryngology versus neurosurgery), level of experience, scope of practice (surgery versus radiation and surgery), and geographic location of practice (United States versus international). Results: Responses from 110 participants were analyzed. Overall, 53% of respondents were otolaryngologists, 60% had greater than 10 years of experience, and 57% practiced within the United States. In total, 86% of respondents would pursue initial observation for themselves if diagnosed with a 4 mm distal intracanalicular VS; however, practicing radiosurgeons were more likely to select stereotactic radiosurgery for this scenario compared with providers who solely practice surgery (14 versus 0%; p = 0.032). Otolaryngologists and neurosurgeons alike report that radiosurgery should not be considered a long-term hearing preservation strategy. Otolaryngologists were more optimistic regarding microsurgical hearing preservation outcomes for small distal intracanalicular tumors compared with neurosurgeons (11 versus 3% selected a high likelihood of maintaining class A/B hearing; p = 0.007). Ninety-five percent of respondents prioritized facial nerve outcome over complete disease removal in the context of microsurgical resection of large tumors. Conclusions: Management decision-making and expected outcomes for various clinical scenarios were largely similar among providers; however, variances in several key clinical areas exist. This study points to the feasibility of developing a widely accepted consensus statement among VS experts across specialties.

Natural History of Growing Sporadic Vestibular Schwannomas During Observation: An International Multi-Institutional Study

“…The last century has witnessed a dramatic evolution towards increasingly conservative management of sporadic vestibular schwannoma (VS) (1,2). The trend has continued over the most recent two decades, and observation with serial imaging now constitutes the most common initial strategy employed for most patients with small-or medium-sized tumors (3). Today, among unselected population-based cohorts, roughly 75% of newly diagnosed cases undergo at least an initial period of observation with serial imaging (4,5).…”

Genetic variants of cancer‑associated genes analyzed using next‑generation sequencing in small sporadic vestibular schwannomas

“…Here, we focused on previously resected tumors, but our current strategy for evaluating and treating small VSs is to follow up with serial MRI scans and audiological tests. Serial imaging is the most common initial strategy for slow-growing, especially small-sized VS with a length of less than 2 cm (6,11). Previous reports describing tumor size in the genetically analyzed sporadic VS samples reported that the mean size of their surgically removed tumors ranged from 24.8 to 31.0 mm in length (33)(34)(35)49) (Table III).…”

“…Despite the increasing number of VS patients, the traditional microsurgery treatment for VS via the retrosigmoid, middle cranial fossa, or translabyrinthine approach has decreased (5). Serial imaging is now the most common initial strategy for most patients with small-or medium-sized VS tumors (6).…”

Hearing Preservation Microsurgery in Vestibular Schwannomas: Worth Attempting in “Larger” Tumors?

“…Stemming from a significant evolution in patient presentation and a greater understanding of the natural history of the disease, there has been a shift in the focus of vestibular schwannoma (VS) outcomes from radical tumor removal to preserving function and maintaining quality of life. [1][2][3] Today, many patients are diagnosed with small tumors, good hearing, and minimal to no attributable symptoms. For example, a recent publication encompassing 40-year epidemiological data reported a shift from no intracanalicular tumors being diagnosed in the late 1970s to nearly 50% in 2015, and a mean overall tumor size of 26 mm in 1976 to 7 mm in 2015 for all tumors.…”

“…Stemming from a significant evolution in patient presentation and a greater understanding of the natural history of the disease, there has been a shift in the focus of vestibular schwannoma (VS) outcomes from radical tumor removal to preserving function and maintaining quality of life 1–3 . Today, many patients are diagnosed with small tumors, good hearing, and minimal to no attributable symptoms.…”