Abstract
BACKGROUND: The level of evidence to provide treatment recommendations for vestibular schwannoma (VS) is low. Both Stereotactic Radiosurgery (SRS) and microsurgical resection (SURG) are available as treatment options for VS. There are very few direct comparative studies comparing both treatment modalities in large cohorts allowing detailed subgroup analysis. MATERIAL AND METHODS: This is a retrospective dual-center cohort study. Data was retrospectively collected from two large centers involved in the treatment of solitary vestibular schwannomas for patients between 2005 und 2011 to enable follow-up of up to 10 years. Tumor size was classified by Koos Classification. Clinical state was reported by House and Brackmann (H&B) and Gardner-Robertson (G&R) scale (with H&B and G&R 1-2 considered as good outcome), and Recurrence-free-survival (RFS) was assessed radiographically by contrast-enhanced MR imaging. VS-associated symptoms like trigeminal affection, tinnitus, and vertigo/imbalance were also collected. RESULTS: The study population included N=901 patients, who were treated in both centers. N=559 patients were treated by SRS, and 342 patients by SURG.Treatment-related functional deterioration (e.g. hearing and facial deterioration) was significantly more common in patients treated by SURG. The incidence of complications was similar in both groups (14% and 13%). Secondary VS-related symptoms like tinnitus, vertigo, imbalance and trigeminal symptoms were significantly improved by microsurgery, but not by SRS. This study reported an overall incidence of recurrence in SURG of only 4%, and 11% in SRS respectively. Tumor control was comparable in small tumors (Koos I and II) in both SRS and SURG. Patients treated by SRS had significantly smaller tumors (p<0.001). In large VS (Koos III and IV), SURG is superior to SRS considering tumor control with a risk reduction for incidence of recurrence. CONCLUSION: SRS can achieve similar tumor control compared to SURG in smaller VS (Koos I-II) - with less severe postinterventional morbidities (hearing and facial function loss). In large VS (Koos III-IV), tumor control by SRS is inferior to SURG. Therefore, while SURG is increasing the risk for facial palsy, it reduces the risk for recurrence. Moreover, SURG may improve secondary VS symptoms (e.g. tinnitus, vertigo/imbalance and trigeminal symptoms), even in small VS. Our data on tumor control and tumor size in SRS and SURG suggest that if combination therapy is chosen, the residual tumor for adjuvant SRS should not exceed the size of Koos II.These figures should be considered when deciding on treatment modality.