Comparing Management Options for Acoustic Neuroma Patients

(For physicians seeking CME credits, please see Gamma Knife Radiosurgery for Acoustic Neuromas: Sorting Out Treatment Options, an online course sponsored by the University of Pittsburgh and the Department of Neurological Surgery.)

A patient with acoustic neuroma has several treatment options including observation, surgical resection, stereotactic radiosurgery, and fractionated radiotherapy. Many patients choose between radiosurgery 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 the patient. These include discussions with surgeons and other physicians, written material from peer-reviewed medical journals, handouts from support groups, internet based reports (of variable reliability), and discussions between patients with acoustic neuromas.

We believe that acoustic neuroma information provided from the peer-reviewed medical literature is the most reliable for patient education. Nevertheless, some acoustic neuroma patients become confused by what they perceive as conflicting opinions amongst physicians. Many such physicians provide only one kind of treatment and may appear to be biased toward their own approach.

(Please see: A Survey of Neurosurgeons' Preferences: Radiosurgery, Resection or Observation for Patient's with Acoustic Neuromas.)

Resection is indicated for patients with larger tumors which have caused major neurological deficits from brain compression. Surgeons perform stereotactic radiosurgery for small or medium-sized tumors with the goals of preserved neurological function and prevention of tumor growth. The long-term outcomes of radiosurgery, particularly with gamma knife technique, have proven its role in the primary or adjuvant management of this tumor. Fractionated radiotherapy has been suggested as an alternative for selected patients with larger tumors for whom microsurgery may not be feasible, or for some patients in an attempt to preserve cranial nerve function. Most such centers do not offer conformal radiosurgery. Patients with neurofibromatosis type 2 pose specific challenges, particularly in regard to preservation of hearing and other cranial nerve function.

The primary clinical issues include avoiding tumor-related or treatment-related mortality, prevention of further tumor-related neurologic disability, minimizing treatment risks such as spinal fluid 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. All acoustic neuroma treatment choices should strive to meet all of these goals.

Acoustic neuroma patients have several options available to them. Large tumors with significant brainstem compression usually require surgical resection. For patients with small or medium sized tumors, radiosurgery has become a common treatment with excellent long-term results reported.

Acoustic neuroma patients must be comfortable with the concept of tumor control rather than tumor removal. Most seem to be satisfied with this concept, if it allows them to avoid brain surgery.

Surgeons should strive to educate their patients with information from the peer-reviewed literature. Confusion amongst patients exist because the information from internet sources, newsletters, support groups, and physicians has not always been validated and supported by outcomes data. Although we are asked to provide our opinions, our comments should not be based on myth, conjecture, training bias, or socioeconomic concerns.

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