Wait-and-see strategy compared with proactive Gamma Knife surgery in patients with intracanalicular vestibular schwannomas

Clinical article

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Object

The roles of the wait-and-see strategy and proactive Gamma Knife surgery (GKS) in the treatment paradigm for small intracanalicular vestibular schwannomas (VSs) is still a matter of debate, especially when patients present with functional hearing. The authors compare these 2 methods.

Methods

Forty-seven patients (22 men and 25 women) harboring an intracanalicular VS were followed prospectively. The mean age of the patients at the time of inclusion was 54.4 years (range 20–71 years). The mean follow-up period was 43.8 ± 40 months (range 9–222 months). Failure was defined as significant tumor growth and/or hearing deterioration that required microsurgical or radiosurgical treatment. This population was compared with a control group of 34 patients harboring a unilateral intracanalicular VS who were consecutively treated by GKS and had functional hearing at the time of radiosurgery.

Results

Of the 47 patients in the wait-and-see group, treatment failure (tumor growth requiring treatment) was observed in 35 patients (74%), although conservative treatment is still ongoing for 12 patients. Treatment failure in the control (GKS) group occurred in only 1 (3%) of 34 patients. In the wait-and-see group, there was no change in tumor size in 10 patients (21%), tumor growth in 36 patients (77%), and a mild decrease in tumor size in 1 patient (2%). Forty patients in the wait-and-see group were available for a hearing level study, which demonstrated no change in Gardner-Robertson hearing class for 24 patients (60%). Fifteen patients (38%) experienced more than 10 db of hearing loss and 2 of them became deaf. At 3, 4, and 5 years, the useful hearing preservation rates were 75%, 52%, and 41% in the wait-and-see group and 77%, 70%, and 64% in the control group, respectively. Thus, the chances of maintaining functional hearing and avoiding further intervention were much higher in cases treated by GKS (79% and 60% at 2 and 5 years, respectively) than in cases managed by the wait-and-see strategy (43% and 14% at 2 and 5 years, respectively).

Conclusions

These data indicate that the wait-and-see policy exposes the patient to elevated risks of tumor growth and degradation of hearing. Both events may occur independently in the mid-term period. This information must be presented to the patient. A careful sequential follow-up may be adopted when the wait-and-see strategy is chosen, but proactive GKS is recommended when hearing is still useful at the time of diagnosis. This recommendation may be a main paradigm shift in the practice of treating intracanalicular VSs.

Abbreviations used in this paper: ABR = auditory brainstem response; GKS = Gamma Knife surgery; IAC = internal auditory canal; PTA = pure tone average; SDS = speech discrimination score; TDT = tumor doubling time; TGR diam. = tumor growth rate based on diameter; TGR vol. = tumor growth rate based on volume; VS = vestibular schwannoma.

Article Information

Address correspondence to: Jean Régis, M.D., Service de Neurochirurgie Fonctionnelle et Stereotaxique, Hôpital d'adulte de la Timone, 264 rue Saint Pierre, 13385 Marseille Cedex 05, France. email: jregis@ap-hm.fr.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Graph showing Kaplan-Meier survival curves for patients without treatment failure in both the wait-and-see group (47 patients) and the GKS control group (34 patients). Failure was defined as the necessity of radiosurgery or microsurgery in patients displaying tumor growth and/or hearing deterioration (loss of functional hearing). The rate of failure is significantly higher in the wait-and-see population than in the control group treated proactively by GKS.

  • View in gallery

    Graph showing Kaplan-Meier survival curves for patients with functional hearing whose tumors were managed with the wait-and-see strategy from the time of study inclusion. The probability of long-term functional hearing preservation is very poor (40% at 4 years).

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