Management Options for Patients with Acoustic Neuromas
Management options for patients with vestibular schwannomas (acoustic neuromas) include observation, tumor resection, stereotactic radiosurgery, and fractionated radiotherapy. In this report the authors review their 15-year experience with radiosurgery and discuss indications and expectations in relation to the different approaches. They conducted a survey of neurosurgeons to determine management preferences in two different cases of intra- and extra-canalicular tumor presentations. Patient decisions must be based on quality information derived from peer-reviewed literature.

For the treatment of patients with acoustic neuromas there are several options including observation, resection, SRS, and fractionated SRT. Many patients choose between SRS and resection based on their own specific goals and their understanding of possible results. The decision can be difficult and depends on the sources and strengths of information given to them. These include discussions with surgeons and other physicians, written material disseminated by peer-reviewed medical journals, brochures from support groups, internet-based reports (of variable reliability), and discussions among fellow patients. We believe that information provided in the peer-reviewed medical literature is the most reliable for patient education. Nevertheless, some patients become confused by what they perceive as conflicting opinions among physicians. Many such physicians provide only one kind of treatment and may appear to be biased toward their own approach.

Resection is indicated for patients harboring larger tumors that have caused major neurological deficits due to brain compression. Surgeons perform SRS for small- or medium-sized tumors, their goals being to preserve neurological function and prevent tumor growth. The long-term outcomes of SRS, particularly GKS, have proven its role in the primary or adjuvant management of this tumor. Fractionated radiotherapy has been suggested as an alternative in selected patients with larger tumors for whom microsurgery may not be feasible, as well as in some patients in whom preservation of cranial nerve function is being attempted. Most such centers do not offer conformal SRS. Cases of NF2 pose specific challenges, particularly the preservation of hearing and other cranial nerve function.

Primary clinical issues include avoiding tumor-related or treatment-related mortality, prevention of further tumor-induced neurological disability, minimizing treatment risks such as CSF leakage, infections, or cardiopulmonary complications, maintaining regional cranial nerve function (facial, trigeminal, cochlear, and glossopharyngeal/vagal), avoiding hydrocephalus, maintaining quality of life and employment, and reducing cost. In choosing any particular therapy, the team should strive to meet all of these goals.