Clinical management of vestibular schwannoma - what's the evidence?

Clinical management of vestibular schwannomas (VS) encompasses three main strategies: observation ("wait-and-scan"), stereotactic radiosurgery, and microsurgery. Despite extensive literature, a consensus on the optimal modality is lacking due to the scarcity of high-level evidence.

This narrative review explores the current understanding of the most significant clinical and radiographic outcomes following wait-and-scan, radiosurgery, and microsurgery. This is not a systematic review of the literature.

Observational studies indicate that approximately one-third of tumors demonstrate growth within 3 years, and approximately 40% of patients eventually require active treatment. Radiosurgery achieves high long-term control, with radiological control exceeding 90% and clinical control above 95% at 10 years. However, hearing preservation is variable and time-dependent. Microsurgery can achieve gross total tumor removal and high long-term tumor control, with reported recurrence rates below 2% following gross total resection. However, recurrence estimates vary according to follow-up methodology and definitions of recurrence. Risks of hearing deterioration and facial nerve impairment increase with tumor size and extent of resection. Comparative studies, largely nonrandomized, suggest that radiosurgery offers better hearing and facial nerve outcomes than microsurgery in small- to medium-sized tumors. Quality-of-life assessments show little difference among treatment modalities. The V-REX trial remains the only randomized study to date, showing that upfront radiosurgery reduces tumor volume but does not yield superior clinical outcomes compared with observation.

The current evidence is dominated by retrospective case series with heterogeneous methodologies. Prospective, randomized controlled trials (RCTs) are critically needed to guide superior treatment strategies and enhance patient care.