Management of Vestibular Schwannoma: Dependence on Stakeholder's View for Small and Medium-Sized Tumors

Management options for patients with vestibular schwannoma include observation and active treatment, namely surgical resection, gamma knife stereotactic radiosurgery or fractionated radiation therapy. Although for large tumors microsurgery remains the mainstay of treatment, management of the small- and medium-sized vestibular schwannomas has been the matter of considerable controversy. Computerized clinical decision support systems have been developed to assist clinicians in this demanding task. Nonetheless, the complexity of the problem requires adaptation of the decision strategy to specific circumstances arising within a particular clinical scenario which can not always be modeled with adequate precision or addressed adequately within a mathematical framework. We present a set of clinical, neurophysiologic and radiologic parameters and the respective evidence which may guide carers’ decisions. These parameters include the size, growth rate and localization of the tumor, the age, general medical condition, facial nerve function, hearing and hearing deterioration rate, balance, vestibular and trigeminal nerve function of the affected individual, the estimated risk of malignant transformation and radiation-induced tumors, the health-related quality of life measures, the patient’s and surgeon’s preference and the issue of cost-effectiveness. A complex decision analysis, guided by evidence and tailored to each individual patient is required.