Decision Analysis Of Treatment Options For Vestibular Schwannoma

Y.K. John Lee1, Robert Whitmore1, Sherman Stein1, Michael Ruckenstein1

1University of Pennsylvania, Philadelphia, USA

Keywords: vestibular schwannoma, radiosurgery, gamma knife, Microsurgery, radiotherapy

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     Widespread use of MRI has contributed to the more frequent diagnosis of vestibular schwannoma. These tumors represent 10% of primary adult intracranial neoplasm and if symptomatic, usually present with hearing loss and tinnitus. Currently, there are three treatment options for vestibular schwannoma:  wait and scan, microsurgery, and radiosurgery. 
     Our purpose is to determine which treatment modality yields the highest quality of life at 5 and 10 year follow up, considering the likelihood of recurrence and various complications.
     Online databases Medline, Embase, and Cochrane were searched for English-language articles published between 1990 and June 2008, containing key words relating to vestibular schwannoma. Data were pooled to calculate the prevalence of treatment complications, tumor recurrence, and quality of life with various complications. For parameters in which incidence varied with time of follow-up, we used meta-regression to determine mean prevalence rates at a specified length of follow-up. A decision-analytic model was constructed to compare five year and ten year outcomes for a patient with a unilateral tumor and partially intact hearing. The three treatment options, wait and scan, microsurgery, and radiosurgery, were compared.
     After screening over 2500 abstracts, we ultimately included 113 articles in this analysis. Recurrence, complication rates and onset of complication varied with the treatment chosen. The relative quality of life at 5-year follow-up was 0.898 of normal for scan-and-follow, 0.953 for microsurgery and 0.97 for radiosurgery. These differences are statistically significant (p < 0.0052). Data were too scarce at 10-year follow-up to calculate significant differences between the microsurgery and radiosurgery strategies.
     This is a retrospective study.
     At 5 years, patients treated with radiosurgery have an overall better quality of life than those treated with either microsurgery or those followed with serial scans. 
     We found the complications associated with wait and scan and microsurgery treatment strategies to negatively impact patient lives more than the complications from radiosurgery. One limitation of this study is that the 10 year follow-up data was too limited to analyze, and more studies are needed to determine if our results are still consistent at 10 years.


Project Roles:

Y. Lee (), R. Whitmore (), S. Stein (), M. Ruckenstein ()