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Acta Neurochirurgica Dec 2022Surgery and radiosurgery represent the most common treatment options for vestibular schwannoma. A systematic review and meta-analysis were conducted to compare the... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Surgery and radiosurgery represent the most common treatment options for vestibular schwannoma. A systematic review and meta-analysis were conducted to compare the outcomes of surgery versus stereotactic radiosurgery (SRS).
METHODS
The Cochrane library, PubMed, Embase, and clinicaltrials.gov were searched through 01/2021 to find all studies on surgical and stereotactic procedures performed to treat vestibular schwannoma. Using a random-effects model, pooled odds ratios (OR) and their 95% confidence intervals (CI) comparing post- to pre-intervention were derived for pre-post studies, and pooled incidence of adverse events post-intervention were calculated for case series and stratified by intervention type.
RESULTS
Twenty-one studies (18 pre-post design; three case series) with 987 patients were included in the final analysis. Comparing post- to pre-intervention, both surgery (OR: 3.52, 95%CI 2.13, 5.81) and SRS (OR: 3.30, 95%CI 1.39, 7.80) resulted in greater odds of hearing loss, lower odds of dizziness (surgery OR: 0.10; 95%CI 0.02, 0.47 vs. SRS OR: 0.22; 95%CI 0.05, 0.99), and tinnitus (surgery OR: 0.23; 95%CI 0.00, 37.9; two studies vs. SRS OR: 0.11; 95%CI 0.01, 1.07; one study). Pooled incidence of facial symmetry loss was larger post-surgery (14.3%, 95%CI 6.8%, 22.7%) than post-SRS (7%, 95%CI 1%, 36%). Tumor control was larger in the surgery (94%, 95%CI 83%, 98%) than the SRS group (80%, 95%CI 31%, 97%) for small-to-medium size tumors.
CONCLUSION
Both surgery and SRS resulted in similar odds of hearing loss and similar improvements in dizziness and tinnitus among patients with vestibular schwannoma; however, facial symmetry loss appeared higher post-surgery.
Topics: Humans; Neuroma, Acoustic; Radiosurgery; Microsurgery; Facial Nerve; Tinnitus; Dizziness; Treatment Outcome; Hearing Loss; Vertigo; Retrospective Studies
PubMed: 35962847
DOI: 10.1007/s00701-022-05338-z -
Neurosurgery Jun 2023Stereotactic radiosurgery (SRS) is one of the main treatment options in the management of small to medium size vestibular schwannomas (VSs), because of high tumor... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Stereotactic radiosurgery (SRS) is one of the main treatment options in the management of small to medium size vestibular schwannomas (VSs), because of high tumor control rate and low cranial nerves morbidity. Series reporting long-term hearing outcome (>3 years) are scarce.
OBJECTIVE
To perform a systematic review of the literature and meta-analysis, with the aim of focusing on long-term hearing preservation after SRS.
METHODS
Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we reviewed articles published between January 1990 and October 2020 and referenced in PubMed or Embase. Inclusion criteria were peer-reviewed clinical study or case series of VSs treated with SRS (single dose), reporting hearing outcome after SRS with a median or mean audiometric follow-up of at least 5 years. Hearing preservation, cranial nerves outcomes, and tumor control were evaluated.
RESULTS
Twenty-three studies were included. Hearing preservation was found in 59.4% of cases (median follow-up 6.7 years, 1409 patients). Main favorable prognostic factors were young age, good hearing status, early treatment after diagnosis, small tumor volume, low marginal irradiation dose, and maximal dose to the cochlea. Tumor control was achieved in 96.1%. Facial nerve deficit and trigeminal neuropathy were found in 1.3% and 3.2% of patients, respectively, both significantly higher in Linear Accelerator series than Gamma Knife series ( P < .05).
CONCLUSION
Long-term hearing preservation remains one of the main issues after SRS, with a major impact on health-related quality of life. Our meta-analysis suggests that hearing preservation can be achieved in almost 60% of patients after a median follow-up of 6.7 years, irrespective of the technique.
Topics: Humans; Neuroma, Acoustic; Radiosurgery; Treatment Outcome; Quality of Life; Hearing; Follow-Up Studies; Retrospective Studies
PubMed: 36735500
DOI: 10.1227/neu.0000000000002354 -
Systematic Reviews Dec 2022Vestibular schwannomas are benign tumours for which various treatments are available. We performed a systematic review of prospective controlled trials comparing the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Vestibular schwannomas are benign tumours for which various treatments are available. We performed a systematic review of prospective controlled trials comparing the patient-relevant benefits and harms of single-fraction stereotactic radiosurgery (sfSRS) with microsurgical resection (MR) in patients with vestibular schwannoma.
METHODS
We searched for randomized controlled trials (RCTs) and non-randomized prospective controlled trials in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and study registries (last search: 09/2021) and also screened reference lists of relevant systematic reviews. Manufacturers were asked to provide unpublished data. Eligible studies investigated at least one patient-relevant outcome. We assessed the risk of bias (high or low) at the study and outcome level. If feasible, meta-analyses were performed. We graded the results into different categories (hint, indication, or proof of greater benefit or harm).
RESULTS
We identified three non-randomized prospective controlled trials of generally low quality with evaluable data on 339 patients with unilateral vestibular schwannoma. There was an indication of greater benefit of sfSRS compared with MR for facial palsy (OR 0.06, 95% CI 0.02-0.21, p < 0.001, 2 studies), hearing function (no pooled estimate available, 2 studies), and length of hospital stay (no pooled estimate available, 2 studies). We found no clinically relevant differences for mortality, vertigo, headaches, tinnitus, balance function, work disability, adverse events, and health-related quality of life.
CONCLUSIONS
Our systematic review indicates that sfSRS has greater benefits than MR in patients with unilateral vestibular schwannoma. However, it is unclear whether this conclusion still holds after 2 years, as long-term studies are lacking. It is also unclear whether the effects of sfSRS are similar in patients with bilateral vestibular schwannomas. Long-term prospective studies including patients with this condition would therefore be useful.
SYSTEMATIC REVIEW REGISTRATION
The full (German language) protocol and report (Commission No. N20-03) are available on the institute's website: www.iqwig.de/en/projects/n20-03.html.
Topics: Humans; Microsurgery; Neuroma, Acoustic; Radiosurgery; Treatment Outcome; Controlled Clinical Trials as Topic
PubMed: 36503553
DOI: 10.1186/s13643-022-02118-9 -
Neuro-oncology Practice Dec 2021Differences in long-term outcomes of single-fraction stereotactic radiosurgery (SRS) between gamma knife (GK) and linear accelerator (LINAC) systems for vestibular... (Review)
Review
BACKGROUND
Differences in long-term outcomes of single-fraction stereotactic radiosurgery (SRS) between gamma knife (GK) and linear accelerator (LINAC) systems for vestibular schwannoma (VS) management remain unclear. To investigate differences in safety and efficacy between modalities, we conducted a meta-analysis of studies over the past decade.
METHODS
MEDLINE, EMBASE, and Cochrane databases were queried for studies with the following inclusion criteria: English language, published between January 2010 and April 2020, cohort size ≥30, and mean/median follow-up ≥5 years. Odds ratios (OR) compared rates of tumor control, hearing preservation, and cranial nerve toxicities before and after SRS.
RESULTS
Thirty-nine studies were included (29 GK, 10 LINAC) with 6516 total patients. Tumor control rates were 93% (95% CI 91-94%) and 94% (95% CI 91-97%) for GK and LINAC, respectively. Both GK (OR 0.06, 95% CI 0.02-0.13) and LINAC (OR 0.47, 95% CI 0.29-0.76) reduced odds of serviceable hearing. Neither GK (OR 0.71, 95% CI 0.41-1.22) nor LINAC (OR 1.13, 95% CI 0.64-2.00) impacted facial nerve function. GK decreased odds of trigeminal nerve (TN) impairment (OR 0.55, 95% CI 0.32-0.94) while LINAC did not impact TN function (OR 1.45, 95% CI 0.81-2.61). Lastly, LINAC offered decreased odds of tinnitus (OR 0.15, 95% CI 0.03-0.87) not observed with GK (OR 0.70, 95% CI 0.48-1.01).
CONCLUSIONS
VS tumor control and hearing preservation rates are comparable between GK and LINAC SRS. GK may better preserve TN function, while LINAC decreases tinnitus rates. Future studies are warranted to investigate the efficacy of GK and LINAC SRS more directly.
PubMed: 34777833
DOI: 10.1093/nop/npab052 -
World Neurosurgery Feb 2021Cystic vestibular schwannomas (VS) are associated with unpredictable growth behavior and potentially worse surgical outcomes compared with their solid counterparts....
BACKGROUND
Cystic vestibular schwannomas (VS) are associated with unpredictable growth behavior and potentially worse surgical outcomes compared with their solid counterparts. Growth control and potential adverse effects of radiosurgery for cystic VS have created concerns surrounding this modality. We sought to compare the treatment efficacy and safety profile of radiosurgery between cystic and solid VS through a systematic review.
METHODS
PubMed, EMBASE, Web of Science, and Cochrane were searched for related terms and studies reporting radiosurgical outcomes of cystic and solid VS. A meta-analysis was performed to compare the rates of tumor control. Random-effect models with generic inverse variance method was used to calculate overall pooled estimates. Study quality was assessed with the Newcastle Ottawa Criteria.
RESULTS
In total, 2989 studies were retrieved, and 6 including 1358 VS (79.89% solid; 20.11% cystic, median follow-up range 31.8-150 months) were selected. The median maximal dose was 25 Gy (range, 13-36 Gy) and the median marginal tumor dose was 12 Gy (10-18 Gy). There was no difference between cystic and solid VS (risk ratio, 1.02; 95% confidence interval 0.94-1.10; P = 0.69; I = 78%). Transient enlargement of cystic tumors may be associated with trigeminal or facial neuropathy.
CONCLUSIONS
The evidence collected by this study suggests that radiosurgery for cystic VS exhibits effective tumor control probabilities similar to solid VS. Consensus definitions and standard criteria are needed in the future to better understand the patterns of tumor growth and response to treatment following radiosurgery for cystic VS, as well as long-term neurological and functional outcomes.
Topics: Humans; Neuroma, Acoustic; Radiosurgery; Treatment Outcome
PubMed: 33212274
DOI: 10.1016/j.wneu.2020.11.040 -
Pediatric Neurology Sep 2022The neurofibromatoses comprise three different genetic conditions causing considerable morbidity and mortality: neurofibromatosis type 1 (NF1), neurofibromatosis type 2... (Review)
Review
INTRODUCTION
The neurofibromatoses comprise three different genetic conditions causing considerable morbidity and mortality: neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2), and schwannomatosis (SWN). This review summarizes recent and ongoing clinical trials involving patients with neurofibromatoses to better understand the current state of clinical trial research centered around these conditions and inform areas of need.
METHODS
A search was conducted using the Cochrane Central Register of Controlled Trials and clinicaltrials.gov databases. Inclusion and exclusion criteria were designed to identify clinical trials focused on patients with NF1, NF2, or SWN completed in or after 2010 and in process as of December 31, 2021. Information was collected using standardized guidelines.
RESULTS
A total of 134 clinical trials were included, with 75 (56%) completed and 59 (44%) in process. For completed trials, 74% (n = 56) involved patients with NF1, and of those based on specific tumors (n = 26, 46%), the majority focused on plexiform neurofibromas (PNs) (n = 12, 46%). For ongoing trials, 79% (n = 47) involve patients with NF1, and of those based on specific tumors (n = 29, 61%), the majority are focused on PNs (n = 13, 45%).
CONCLUSION
Both recent and ongoing clinical trials have primarily focused on patients with NF1 and the treatment of PNs. This research has led to the first FDA-approved drug for NF1-PN and has changed management of these tumors, allowing for systemic therapy rather than reliance on only a surgical modality. Trials evaluating comorbid psychiatric conditions and quality of life among patients with any of the neurofibromatoses appear less common. These areas may warrant focus in future studies to improve clinical management.
Topics: Humans; Neurilemmoma; Neurofibroma, Plexiform; Neurofibromatoses; Neurofibromatosis 1; Neurofibromatosis 2; Quality of Life; Skin Neoplasms
PubMed: 35759947
DOI: 10.1016/j.pediatrneurol.2022.06.003 -
Neuro-oncology Practice Aug 2021Large vestibular schwannomas (VS) pose a treatment challenge for both microsurgery (MS) and stereotactic radiosurgery (SRS). Technical developments have allowed for... (Review)
Review
BACKGROUND
Large vestibular schwannomas (VS) pose a treatment challenge for both microsurgery (MS) and stereotactic radiosurgery (SRS). Technical developments have allowed for safer irradiation of large tumors. It remains unclear if SRS can achieve appropriate tumor control and acceptable cranial nerve toxicities. In this study, we assess outcomes of irradiation for large VS.
METHODS
PubMed MEDLINE, EMBASE, Web of Science, and Cochrane were searched for all the studies assessing SRS outcome in large VS. Primary endpoints included clinical and radiographic tumor control, need for salvage surgery, serviceable hearing, cranial nerve V and VII impairment, presence of hydrocephalus requiring shunting, and presence of vertigo/dizziness.
RESULTS
Twenty-two studies were identified that met selection criteria for analysis from an initial pool of 1272 reports. They were evaluated according to treatment protocol: 1) single-dose SRS (13 studies, 483 patients), 2) combination of MS and SRS (7 studies, 182 patients), and 3) fractionated SRS (3 studies, 82 patients). Tumor control was achieved in 89%, 94%, and 91% of patients, respectively. Odds ratios (ORs) of post- over pretreatment serviceable hearing were 0.42 ( < .01), 0.47 ( = .05), and 0.60 ( = .22); for facial nerve impairment, these ORs were 1.08 ( = .69), 3.45 ( = .28), and 0.87 ( = .71), respectively.
CONCLUSIONS
The management of large VS remains challenging. All treatment modalities resulted in high tumor control rates and worsening of pretreatment hearing. None, however, caused significant facial nerve impairment, suggesting that management strategies incorporating focal irradiation can be successful.
PubMed: 34277019
DOI: 10.1093/nop/npab011 -
Acta Otorrinolaringologica Espanola 2024Vestibular schwannoma (VS) is the most common tumour of the cerebellopontine angle. The greater accessibility to radiological tests has increased its diagnosis. Taking...
INTRODUCTION
Vestibular schwannoma (VS) is the most common tumour of the cerebellopontine angle. The greater accessibility to radiological tests has increased its diagnosis. Taking into account the characteristics of the tumour, the symptoms and the age of the patient, three therapeutic strategies have been proposed: observation, surgery or radiotherapy. Choosing the most appropriate for each patient is a frequent source of controversy.
MATERIAL AND METHODS
This paper includes an exhaustive literature review of issues related to VS that can serve as a clinical guide in the management of patients with these lesions. The presentation has been oriented in the form of questions that the clinician usually asks himself and the answers have been written and/or reviewed by a panel of national and international experts consulted by the Otology Commission of the SEORL-CCC.
RESULTS
A list has been compiled containing the 13 most controversial thematic blocks on the management of VS in the form of 50 questions, and answers to all of them have been sought through a systematic literature review (articles published on PubMed and Cochrane Library between 1992 and 2023 related to each thematic area). Thirty-three experts, led by the Otology Committee of SEORL-CCC, have analyzed and discussed all the answers. In Annex 1, 14 additional questions divided into 4 thematic areas can be found.
CONCLUSIONS
This clinical practice guideline on the management of VS offers agreed answers to the most common questions that are asked about this tumour. The absence of sufficient prospective studies means that the levels of evidence on the subject are generally medium or low. This fact increases the interest of this type of clinical practice guidelines prepared by experts.
Topics: Humans; Neuroma, Acoustic; Prospective Studies; Magnetic Resonance Imaging; Radiosurgery; Microsurgery
PubMed: 38346489
DOI: 10.1016/j.otoeng.2023.10.005 -
The Journal of Laryngology and Otology Sep 2023To assess whether pre-habilitation with intratympanic gentamicin can accelerate vestibular compensation following vestibular schwannoma resection. (Review)
Review
OBJECTIVE
To assess whether pre-habilitation with intratympanic gentamicin can accelerate vestibular compensation following vestibular schwannoma resection.
METHODS
Seventeen studies were retrieved from the databases Medline, PubMed, Frontiers, Cochrane Library, Cambridge Core and ScienceDirect. Eight of the 17 studies met our criteria; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Heterogeneity, risk of bias and effect on post-operative recovery were assessed.
RESULTS
Four of the eight studies showed a statistically positive effect of pre-habilitation with gentamicin on the post-operative recovery process; the remainder also reported benefits, although not statistically significant. No study reported negative effects. Limitations were linked mostly to the limited number of enrolled patients and the outcome assessment methods.
CONCLUSION
Fifty per cent of the studies found a statistically positive effect of pre-habilitation with gentamicin prior to vestibular schwannoma resection. While the results are promising, due to the limited numbers further prospective studies are required to strengthen the evidence.
Topics: Humans; Gentamicins; Neuroma, Acoustic; Vestibule, Labyrinth; Outcome Assessment, Health Care; Prospective Studies
PubMed: 37185086
DOI: 10.1017/S0022215123000725 -
Clinical Neurology and Neurosurgery May 2023Secondary trigeminal neuralgia is a facial pain in trigeminal nerve dermatome caused by an underlying disease, such as cerebellopontine angle tumours. Treatment options... (Review)
Review
BACKGROUND
Secondary trigeminal neuralgia is a facial pain in trigeminal nerve dermatome caused by an underlying disease, such as cerebellopontine angle tumours. Treatment options to relieve the pains were surgical tumour resection and stereotactic radiosurgery of the tumour or trigeminal nerve. This study aims to review the efficacy of open surgery and stereotactic radiosurgery and recommend the treatment of choice for secondary trigeminal neuralgia due to cerebellopontine angle tumours.
METHOD
The inclusion criteria were studies covering patients with trigeminal neuralgia associated with cerebellopontine angle tumours that were treated with either open surgery or stereotactic radiosurgery and reported pain outcomes after treatment. Non-English articles or studies with a population of less than five were excluded. We systematically searched studies from PubMed, Ebscohost, and Cochrane Library from inception until December 20, 2021. Several works of literature from manual search were also added. Selected articles were appraised using a critical appraisal tool for prognostic studies.
RESULT
Included articles were 26 retrospective studies and one prospective study comprising 517 patients. Of 127 schwannomas, 226 epidermoids, 154 meningiomas, and ten other tumours, 320 cases received surgical tumour excision with or without MVD, 196 had tumour-targeted radiosurgery, and 22 underwent nerve-targeted radiosurgery. In surgical series, 92.2 % gained pain improvement, 2.8 % were unchanged, and 4.5 % had recurrence; none of the patients had worsened outcomes. In cases treated with tumour-targeted radiosurgery, the improvement rate was 79.1 %, unchanged at 14.3 %, recurrence at 26.5 %, and worse symptoms rate after the intervention was 6.6 %. Six patients with recurrent pain after tumour-targeted radiosurgery received secondary nerve-targeted radiosurgery with improved outcomes. Only one patient in our review underwent primary nerve-targeted radiosurgery, and the result was satisfactory. One study treated 15 patients with a single session of tumour-targeted and nerve-targeted radiosurgery, with an improvement rate of 93.3 % and a recurrence rate of 21.4 %.
CONCLUSION
Open surgery releasing the nerve root from compressive lesions is advocated to be the first-line treatment to gain satisfactory outcomes. Total removal surgery is recommended if possible. Nerve-targeted radiosurgery should be reserved as a secondary treatment for recurrent cases.
Topics: Humans; Trigeminal Neuralgia; Neuroma, Acoustic; Radiosurgery; Treatment Outcome; Retrospective Studies; Prospective Studies; Facial Pain; Meningeal Neoplasms
PubMed: 37001475
DOI: 10.1016/j.clineuro.2023.107683