2025 Proffered Presentations
S176: HOW BEST TO TREAT MEDIUM SIZED VESTIBULAR SCHWANNOMAS: RADIOSURGERY VERSUS SURGICAL RESECTION FOR 2 TO 2.5CM TUMORS
Emery Monnig; Alex Devarajan; Yehia Elkersh; Megan Tang; Jack Zhang; Rui Feng; Joshua Bederson; Raj Shrivastava; Icahn School of Medicine
Background: Vestibular schwannomas are a common type of benign skull base tumor, often leading to significant morbidities, such as, hearing loss, tinnitus, vertigo, and facial nerve dysfunction. As the tumor expands, these morbidities can progressively worsen over time, eventually increasing the risk for brainstem compression, hydrocephalus, and death. Treatment options for acoustic neuromas vary based on tumor size and symptom severity. Radiosurgery is a less invasive procedure than surgical resection but is limited by its inability to fully penetrate larger tumors, with current guidelines having a recommended tumor dimension limit of 2.5cm to prevent brainstem edema. However, treatment decisions for medium-sized tumors (2 to 2.5 cm) remain ambiguous. In these cases, radiosurgery may control tumor growth while decreasing damage to surrounding tissues, whereas surgery can offer a more definitive cure.
Methods: A single-institution, retrospective cohort study identified all patients undergoing treatment for acoustic neuroma between 2009 and 2020. Data on patient demographics, baseline symptoms and tumor characteristics, radiotherapy and surgery procedure information, post-treatment complications, post-treatment symptoms, and comorbidities were collected. Vertigo, tinnitus, facial palsy, and facial paresthesia were assessed post-treatment for improvement in symptoms. Patients with a maximal tumor dimension between 2.0cm and 2.5cm were included. Univariate analyses using Chi-squared tests for categorical variables and t-tests for continuous variables were performed to identify significant differences between groups.
Results: Of the 62 patients with maximal tumor dimension between 2.0 and 2.5 cm, 46.8% (n=29) underwent surgical resection, while 22.6% (n=14) received radiosurgery. There was no significant differences in preoperative or postoperative symptoms. There is a significant difference between surgery and radiosurgery in hospital length of stay (4.04 vs. 0.33; p<0.001), age of diagnosis (50 vs. 64; p<0.001), and post-operative facial palsy (p<0.001). Among post-intervention symptoms studied, facial palsy had largest increase within the surgical group, with 14 cases of new onset facial palsy. Surgery showed better outcomes in reducing vertigo and tinnitus compared to radiosurgery (81.2% and 45.4% vs. 16.7% and 0%, respectively).
Conclusions: Both radiosurgery and surgical intervention have benefits and drawbacks in the treatment of medium-sized vestibular schwannomas. Surgery is more effective at reducing vertigo and tinnitus symptoms but has higher rates of worsened and new onset of symptoms, including facial paralysis and paresthesia, as well as a longer recovery period in the hospital. In contrast, radiosurgery patients had fewer postoperative complications and onset of symptoms, but it was less effective in symptom control. Further research is needed to clarify optimal treatment pathways for tumors where both options remain viable.
