What drives quality of life in patients with sporadic vestibular schwannoma?: Quality of Life in Vestibular Schwannoma

Quality of Life in Jugular Paraganglioma Following Radiosurgery

OBJECTIVE

The treatment paradigm for jugular paraganglioma (JP) has changed considerably over time with the wider adoption of stereotactic radiosurgery (SRS). To the best of the authors' knowledge, there are no published studies that use validated patient-reported outcome measures to ascertain quality of life (QoL) outcomes following SRS for JP when used in single or combined modality treatment regimens.

STUDY DESIGN

Cross-sectional survey.

SETTING

Tertiary referral center.

PATIENTS

Adult patients with JP treated with primary SRS or SRS following primary surgery between 1990 and 2017.

INTERVENTIONS(S)

Surgery and/or Gamma Knife SRS.

MAIN OUTCOME MEASURES

Global and treatment-related QoL and differences in QoL based on treatment approach.

RESULTS

Sixty-nine surveys were distributed and a total of 26 completed surveys were received (38% response rate). Among respondents, the median age at SRS was 53 years and 16 of the 26 patients (62%) were female. Median follow-up was 97 months. Nineteen patients (73%) were treated with primary SRS or staged SRS following intentional subtotal resection (STR; hereafter referred to as "staged SRS"), while the remainder (n = 7, 27%) were treated with SRS for recurrent JP. Median physical and mental health QoL PROMIS-10 T-scores regardless of treatment strategy were 39.8 and 38.8, respectively, while median SF36 physical and mental component subscores were similar to national averages and non-tumor controls. When comparing general physical and mental health QoL scores, there was no significant difference between patients treated with primary or staged SRS and those treated with SRS for recurrent JP. However, age-adjusted swallowing function among patients treated with primary or staged SRS was better than in those patients treated with SRS for recurrent JP (p = 0.05).

CONCLUSIONS

Patients treated with primary or staged SRS for JP tend to exhibit better swallowing outcomes than those treated with SRS for recurrent JP. However, the majority of overall and disease-specific quality of life measures were not different between groups. Based on the low incidence of new cranial neuropathy following SRS, it is likely that initial surgical morbidity is the primary contributor to this outcome. Disease-specific overall quality of life measures, akin to those already used for other benign skull base tumors, are necessary to better gauge physical and mental health outcomes following treatment for JP. Though limited by small sample size, this represents the first study to gauge QoL outcomes following treatment for JP.

Severity of Tinnitus Distress Negatively Impacts Quality of Life in Patients With Vestibular Schwannoma and Mimics Primary Tinnitus

Objective: Quality of life (QoL) and subjective symptoms are predominantly used to evaluate treatment outcome of patients with vestibular schwannoma (VS). However, for patients undergoing conservative treatment-the most frequently used intervention-the association between QoL and subjective symptoms is unclear. Moreover, it is unknown whether VS-related tinnitus could be associated with the audiological and psychological status of the patient. Our overall aim is to provide objective evidence of this association to better guide treatment of VS. Methods: In a prospective study, we analyzed factors that influence VS-related tinnitus and QoL in 72 patients receiving conservative management of unilateral sporadic VS. This was done through questionnaires that assessed QoL, anxiety, depression, and audiological examinations. We used the SF-36 Short Form to assess QoL; the Tinnitus Handicap Inventory, Dizziness Handicap Inventory, Facial Clinimetric Evaluation Scale, Visual Analog Scale for hearing impairment to assess symptoms subjectively; and pure tone audiometry, the speech discrimination for hearing measurements. For psychological status, we used the Hospital Anxiety and Depression Scale. For analyses, we used Pearson correlation analysis and multiple regression between variables and QoL. Results: Correlation and regression analyses revealed that the severity of tinnitus distress had the largest negative impact on QoL in all domains of SF-36. The severity of tinnitus was significantly associated with subjective hearing impairment and the degree of depression and anxiety. Hearing thresholds had no statistical association with severity of tinnitus. Conclusions: To our knowledge, this is the first study to investigate VS-related tinnitus with respect to both patients' hearing status and psychological condition. Our results suggest that tinnitus distress strongly affects VS patients' QoL and that its characteristics are similar to primary tinnitus. An intervention for VS-related tinnitus, therefore, should assess to what extent tinnitus bothers patients, and it should reduce any unpleasant emotions that may exacerbate symptoms. This approach should improve their QoL.

Comparison of balance outcomes according to treatment modality of vestibular schwannoma

OBJECTIVES

We sought to compare balance outcomes according to treatment modality of vestibular schwannoma (VS) via a meta-analysis that divided measuring tools of balance outcomes into three categories based on type.

METHODS

A comprehensive review of the literature from January 1966 to September 2017 was performed, looking for studies about long-term balance outcomes after microsurgery (MS), radiotherapy (RT), or observation for VS. A comprehensive meta-analysis was used to analyze effect sizes, explore possible causes of heterogeneity, and check publication bias with a funnel plot and Egger's regression.

RESULTS

Among 633 references, 34 were included in the meta-analysis. Perceived dizziness improvement rate was significantly higher in the MS group than in the RT group (odds ratio [OR]: 1.61; 95% confidence interval [CI]: 1.08 to 2.40; P < .05, I² = 4.18], but no significant difference was observed between the two groups with regard to validated dizziness questionnaire score (standardized mean difference: 0.04; 95% CI: -0.36 to 0.44; P = .84, I² = 69.61) or dizziness or disequilibrium-related symptom incidence rate (OR: 0.91; 95% CI: 0.50 to 1.68; P = .77, I² = 0). In a subanalysis conducted within the groups after intervention, the MS group demonstrated a lower vertigo incidence rate (P < .001), and the RT group experienced a significant reduction in validated dizziness questionnaire score (P < .05).

CONCLUSIONS

Our results indicate that MS should be considered at least equal to RT in regard to resolving long-term dizziness and improving balance outcomes. Furthermore, well-designed studies are necessary to predict balance outcomes after VS treatment and to choose from among possible treatment options.

LEVEL OF EVIDENCE

2a Laryngoscope, 130:178-189, 2020.

Main Symptom that Led to Medical Evaluation and Diagnosis of Vestibular Schwannoma and Patient-Reported Tumor Size: Cross-sectional Study in 1,304 Patients

Objectives  Although vestibular schwannomas (VS) are known to cause cranial nerve deficits, cerebellar symptoms, and hydrocephalus, the role of these symptoms as the key driver of presentation from the patient's perspective has not been described. Our objective was to survey a large, retrospective VS cohort to document the patient-reported principal initial symptom, and self-reported tumor size, and to study trends in VS patient presentation. Methods  Patients diagnosed with VS at our tertiary referral center and belonging to the Acoustic Neuroma Association (ANA) answered a questionnaire between 2015 and 2017. Demographic data, self-reported tumor size, and symptomatology were analyzed. Results  1,304 patients completed the questionnaire. Tumors were diagnosed from 1966 to 2017 at a mean 51.8 years (range: 8-86 years); 66% were female, and 1.1% had confirmed neurofibromatosis type 2 (NF2). Tumor size was reported using a 6-point scale: 0 to 1 cm (22.9%), 1 to 2 cm (28.7%), 2 to 3 cm (20.5%), 3 to 4 cm (10%), greater than 4 cm (7.2%), and unknown (10.6%). Hearing loss was the most common symptom that led to diagnosis (51.5%), followed by dizziness (17%), tinnitus (11.2%), and incidental diagnosis (10.2%); a fraction that has increased significantly in the last decade ( p  = 0.022). Larger tumors and NF2 were significantly associated with young age ( p  < 0.001). Conclusion  Our large-scale questionnaire-driven review of 1,304 patients confirms that VS presentations are stereotypical, with most individuals recalling hearing loss, dizziness, or tinnitus as their chief complaint. Many tumors were incidentally diagnosed; an expanding population, attributable to increased access to magnetic resonance imaging (MRI). Large tumors were significantly more prevalent among younger patients at diagnosis, excluding NF2 patients, suggesting a more aggressive tumor biology that remains incompletely understood.

A missing piece? Neuropsychiatric functioning in untreated patients with tumors within the cerebellopontine angle

PURPOSE

To date, little is known about neuropsychiatric symptoms in patients with tumors within the cerebellopontine angle (CPA). These, however, might be of clinical relevance. Aim of this study was thus to assess possible impairment in cognition, elevation in mood symptoms, and fatigue in this specific patient group.

METHODS

Forty-five patients with an untreated CPA tumor (27 vestibularis schwannoma, 18 meningioma) were tested within a cross-sectional observational study in a single institution prior to neurosurgical treatment. Patients were administered a multifaceted battery comprising of widely-used tests for assessment of neuropsychiatric functioning.

RESULTS

The majority of the included patients (69%) showed neurocognitive impairment, most frequently in the areas of attention and visuo-motor speed (e.g., alertness) (62%) as well as visuo-construction (44%). Impaired structural integrity of the brain stem was accompanied by more serious neurocognitive deficits. About one-third of the sample reported clinically relevant depression and/or anxiety and an even higher proportion (48%) described high levels of fatigue. Cognitive and affective symptoms as well as fatigue contributed significantly to patients' Quality of Life, indicating the clinical relevance of neuropsychiatric symptoms in patients with CPA tumors.

CONCLUSIONS

Although patients with untreated CPA tumors often suffer from devastating and prominent physical symptoms, neuropsychiatric problems are also frequent. Including these aspects in the routine clinical assessment and initiating treatment accordingly might thus improve clinical management of the patients and improve Quality of Life.

Postoperative headache following treatment of vestibular schwannoma: A literature review

Vestibular schwannoma (VS) is a brain tumour arising from Schwann cells that is typically closely associated with the vestibulocochlear nerve. Post-operative headaches (POH) are a potentially common complication of surgery for VS. Greatly differing rates of POH have previously been reported, particularly with different surgical approaches. The aim of this review is to identify and summarise the available peer-reviewed evidence on rates of POH following operative (or radiosurgery) treatment for VS, in addition to information about the treatment and prognosis of POH in these patients. A systematic search was conducted of Pubmed, Medline, Scopus and EMBASE in April 2017 using the medical subject headings (acoustic neuroma OR vestibular schwannoma) AND headache. Eligibility determination and data extraction were performed in duplicate with standardised forms. POH is common following surgery for VS. Differing rates of POH have been reported with different management approaches, patient age and tumour size. There are relatively few studies that have directly compared the rates of POH with different surgical approaches. The retrosigmoid approach with craniotomy appears to have lower rates of POH than when the retrosigmoid approach is performed with craniectomy. Patients under the age of 65 and with tumours <1.5 cm in size appear to have a higher risk of POH. The most commonly documented management of POH involves simple analgesia, although the majority of patients report this treatment is of only minimal benefit. Further prospective studies comparing rates of POH following different surgical approaches and radiosurgery are required.

Long-term Quality of Life Following Vestibular Schwannoma Excision Via the Translabyrinthine Approach

OBJECTIVE

To assess postoperative quality of life (QOL) and other patient-reported outcomes following surgery for vestibular schwannoma.

STUDY DESIGN

Cross-sectional retrospective case review using postal questionnaires.

SETTING

Tertiary referral center.

PATIENTS

Five hundred consecutive patients undergoing surgery for vestibular schwannoma.

INTERVENTION(S)

Patients undergoing surgery via the translabyrinthine approach (excluding neurofibromatosis type 2) under the senior author, with a minimum of 5 years follow-up, were included.

MAIN OUTCOME MEASURE(S)

QOL was assessed using the Short Form 36 (SF-36) questionnaire and a disease-specific survey to assess patients' subjective outcomes.

RESULTS

The SF-36 scores in this group were significantly lower than the general UK population, though 24% of respondents reported a subjective improvement in overall QOL. Tumors larger than 4 cm were related to a reduced SF-36 total mental component score (p = 0.037). Increased age at time of surgery correlated with a reduced physical component of QOL (correlation coefficient = -0.26) and an improved mental component (correlation coefficient = 0.26). Subjective reports of postoperative symptoms and return to work, driving and social activities were similar to other published studies. 35% of patients reported vivid dreams or nightmares following surgery; the first reported incidence of this phenomenon in a large group of vestibular schwannoma patients.

CONCLUSIONS

Generic measures of QOL in patients following translabyrinthine surgery for vestibular schwannoma do not always match subjective reports, reflecting the complexity of QOL assessment and the range of outcomes in this group. Increased time since surgery appears to be associated with an improvement in mental health.

[Surgical indications and complications management in vestibular schwannoma]

BACKGROUND

Recent surgical treatment concepts for patients with vestibular schwannoma (VS) require an interdisciplinary approach as well as recognition and mastering of complications.

OBJECTIVE

This paper provides an overview of indications, as well as possible options for function preservation and management of complications in the surgical resection of these tumors.

METHODS

Up-to-date treatment concepts and surgical indications were differentiated according to size and extent of tumors. The frequency of important complications was extracted from the literature. Technical options to avoid and correct complications were compiled from personal experience and review of the literature.

RESULTS

Complications unrelated to cranial nerves are not infrequent, particularly in older patients. Small and medium-sized tumors that do not reach the fundus and cochlear fossa can be completely removed with good chances of hearing preservation. As long as these tumors do not grow, patients benefit from observation. Large tumors are overrepresented in surgical series compared to their prevalence. Postoperative facial nerve function correlates to tumor volume. Hearing preservation in these tumors is rare. Intraoperative electrophysiological techniques are valuable for attempted preservation of cranial nerve function. Persistent facial palsies can be remedied by dynamic and static interventions for facial rehabilitation.

CONCLUSION

Mortality and morbidity associated with surgical treatment of VS are very acceptable. Surgical concepts should be custom-tailored to the individual patient in order to ensure high quality of life.

Diagnostics and therapy of vestibular schwannomas - an interdisciplinary challenge

Vestibular schwannomas (VS) expand slowly in the internal auditory canal, in the cerebellopontine angle, inside the cochlear and the labyrinth. Larger tumors can displace and compress the brainstem. With an annual incidence of 1:100,000 vestibular schwannoma represent 6-7% of all intracranial tumors. In the cerebellopontine angle they are by far the most neoplasm with 90% of all lesions located in this region. Magnetic resonance imaging (MRI), audiometry, and vestibular diagnostics are the mainstays of the clinical workup for patients harboring tumors. The first part of this paper delivers an overview of tumor stages, the most common grading scales for facial nerve function and hearing as well as a short introduction to the examination of vestibular function. Upholding or improving quality of life is the central concern in counseling and treating a patient with vestibular schwannoma. Preservation of neuronal function is essential and the management options - watchful waiting, microsurgery and stereotactic radiation - should be custom-tailored to the individual situation of the patient. Continuing interdisciplinary exchange is important to monitor treatment quality and to improve treatment results. Recently, several articles and reviews have been published on the topic of vestibular schwannoma. On the occasion of the 88^th annual meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck surgery a special volume of the journal "HNO" will be printed. Hence this presentation has been designed to deviate from the traditional standard which commonly consists of a pure literature review. The current paper was conceptually woven around a series of interdisciplinary cases that outline examples for every stage of the disease that show characteristic results for management options to date. Systematic clinical decision pathways have been deduced from our experience and from results reported in the literature. These pathways are graphically outlined after the case presentations. Important criteria for decision making are size and growth rate of the tumor, hearing of the patient and the probability of total tumor resection with preservation of hearing and facial nerve function, age and comorbidity of the patient, best possible control of vertigo and tinnitus and last but not least the patient's preference and choice. In addition to this, the experience and the results of a given center with each treatment modality will figure in the decision making process. We will discuss findings that are reported in the literature regarding facial nerve function, hearing, vertigo, tinnitus, and headache and reflect on recent studies on their influence on the patient's quality of life. Vertigo plays an essential role in this framework since it is an independent predictor of quality of life and a patient's dependence on social welfare. Pathognomonic bilateral vestibular schwannomas that occur in patients suffering from neurofibromatosis typ-2 (NF2) differ from spontaneous unilateral tumors in their biologic behavior. Treatment of neurofibromatosis type-2 patients requires a multidisciplinary team, especially because of the multitude of separate intracranial and spinal lesions. Off-label chemotherapy with Bevacizumab can stabilize tumor size of vestibular schwannomas and even improve hearing over longer periods of time. Hearing rehabilitation in NF2 patients can be achieved with cochlear and auditory brainstem implants.

[Quality of life in patients with vestibular schwannoma]

BACKGROUND

Vestibular schwannoma (VS) is a disease which might affect health-related quality of life (HR-QOL) in a negative manner. For many years, only generic quality of life instruments such as SF-36 were available to measure HR-QOL. However, some years ago, the Penn Acoustic Neuroma Quality Of Life (PANQOL) tool, a disease-specific instrument, was developed and validated. It is expected that the application of this instrument will be able to better assess relevant aspects of the HR-QOL of VS patients in the future. A validated German version of the instrument does not exist yet. The disease-specific symptoms most frequently named by patients are headache and dizziness.

RESULTS AND DISCUSSION

The available literature shows that the therapeutic approaches affect HR-QOL differently. In particular, radiation therapy of small and medium-sized tumors has no pronounced negative effects on HR-QOL. However, restrictions after surgery become similar to those after radiotherapy over the course of several years. For large VS with a diameter >3 cm, no guiding data on this aspect are currently available. To clarify the outstanding issues, future prospective studies with long-term follow-up of 10 years and more are desirable.

The Impact of Primary Treatment Strategy on the Quality of Life in Patients with Vestibular Schwannoma

OBJECTIVE

To assess the quality of life (QoL) in a representative sample of patients with vestibular schwannoma and to ascertain the differences in outcomes associated with distinct management strategies.

PATIENTS AND METHODS

Patients with vestibular schwannoma attending a tertiary referral center were asked to complete the Functional Assessment of Chronic Illness Therapy-Brain Questionnaire, which assesses QoL in 5 domains: physical, social, emotional and functional, and a brain cancer-specific domain. Results were analyzed in the overall cohort and in surgery, stereotactic radiosurgery, and conservative management subgroups. The relationship between patient clinical characteristics and QoL outcome also was analyzed by univariable and multivariable logistic regression.

RESULTS

There were 83 survey respondents with an average age of participants of 57 years and a mean follow-up of 4.9 years. QoL was statistically significantly lower in the surgery subgroup within the Physical QoL domain (P = 0.039); however, there was no significant difference in overall QoL between the 3 subgroups of surgery, radiosurgery, and conservative management (P = 0.17). A poor QoL outcome was associated with the number of symptoms at diagnosis, greater tumor size, and a surgical management strategy.

CONCLUSIONS

The QoL within this patient cohort was extremely variable in each management group, mirroring the heterogeneous natural history of this disease process. QoL in patients with vestibular schwannoma cannot be predicted based on management strategy alone, but a poor QoL outcome is more likely in patients with larger, symptomatic tumors that are treated surgically.

Quality of Life in 807 Patients with Vestibular Schwannoma: Comparing Treatment Modalities

Objective In vestibular schwannoma treatment, the choice among treatment modalities is controversial. The first aim of this study was to examine the quality of life of patients with vestibular schwannoma having undergone observation, radiation therapy, or microsurgical resection. The second aim was to examine the relationship between perceived symptoms and quality of life. Last, the association between quality of life and time since treatment was studied. Study Design Cross-sectional study. Setting Tertiary referral center. Subjects and Methods A total of 1208 patients treated for sporadic vestibular schwannoma between 2004 and 2014 were mailed the disease-specific Penn Acoustic Neuroma Quality of Life (PANQOL) questionnaire and additional questions on symptoms associated with vestibular schwannoma. Total and domain scores were calculated and compared among treatment groups. Propensity scores were used, and results were stratified according to tumor size to control for potential confounders. Correlations were calculated to examine the relationship between self-reported symptoms and quality of life, as well as between quality of life and time since treatment. Results Patients with small tumors (≤10 mm) under observation showed a higher PANQOL score when compared with the radiation therapy and microsurgical resection groups. A strong negative correlation was found between self-reported symptoms and quality of life, with balance problems and vertigo having the largest impact. No correlation was found between PANQOL score and time since treatment. Conclusion This study suggests that patients with small vestibular schwannomas experience better quality of life when managed with observation than do patients who have undergone active treatment.

[Vestibular schwannoma - management and microsurgical results]

BACKGROUND

The experience of the medical team, interdisciplinarity, quality of the physician-patient relationship, sensible use of modern technology, and a sound knowledge about the long-term results of observation and interventions all influence treatment quality in patients with vestibular schwannomas.

OBJECTIVES

Compilation of findings regarding the results of observation and microsurgical treatment of patients with these tumors. Deduction of strategies for the medical management from these data.

MATERIALS AND METHODS

Review of the pertinent literature concerning the course of the disease with observational management and microsurgical treatment with respect to tumor growth and symptoms.

RESULTS

Reported annual growth rates of vestibular schwannoma vary between 0.3 and 4.8 mm. Vertigo is the symptom that is most influential on quality of life regardless of the medical management strategy. Up to 75 % of patients are treated within 5 years of the primary diagnosis. Independent of the approach, reported resection rates are higher than 95 %, even with preservation of function as the primary goal. Recurrence rates after subtotal removal are three times higher than after complete removal. Facial nerve preservation is accomplished in more than 90 % of cases. With functional hearing before surgery and small tumors, the chance of hearing preservation exceeds 50 %.

CONCLUSIONS

Quality of life is primarily defined by symptoms caused by the tumor itself and only secondarily by the medical interventions. Treatment should be directed towards the preservation of the patient's quality of life from the beginning. Results of medical treatment should be superior to the natural course of the disease.

A Patient-Assessed Morbidity to Evaluate Outcome in Surgically Treated Vestibular Schwannomas

OBJECTIVE

Outcome after treatment of vestibular schwannomas can be evaluated by health providers as mortality, recurrence, performance, and morbidity. Because mortality and recurrence are rare events, evaluation has to focus on performance and morbidity. The latter has mostly been reported by health providers. In the present study, we validate 2 new scales for patient-assessed performance and morbidity in comparison with different outcome tools, such as quality of life (QOL) (European Quality of Life-5 dimensions [EQ-5D]), facial nerve score, and work capacity.

METHODS

There were 167 total patients in a retrospective (n = 90) and prospective (n = 50) cohort of surgically treated vestibular schwannomas. A new patient-assessed morbidity score (paMS), a patient-assessed Karnofsky score (paKPS), the patient-assessed QOL (EQ-5D) score, work capacity, and the House-Brackmann facial nerve score were used as outcome measures. Analysis of paMS components and their relation to other outcomes was done as uni- and multivariate analysis.

RESULTS

All outcome instruments, except EQ-5D and paKPS, showed a significant decrease postoperatively. Only the facial nerve score (House-Brackmann facial nerve score) differed significantly between the retrospective and prospective cohorts. Out of the 16 components of the paMS, hearing dysfunction, tear dysfunction, balance dysfunction, and eye irritation were most often reported. Both paMS and EQ-5D correlated significantly with work capacity.

CONCLUSIONS

Standard QOL and performance instruments may not be sufficiently sensitive or specific to measure outcome at the cohort level after surgical treatment of vestibular schwannomas. A morbidity score may yield more detailed information on symptoms that can be relevant for rehabilitation and occupational training after surgery.

The Changing Landscape of Vestibular Schwannoma Management in the United States--A Shift Toward Conservatism

OBJECTIVE

To characterize the evolving management of vestibular schwannoma (VS) in the United States.

STUDY DESIGN

Retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) database.

SETTING

SEER database.

SUBJECTS AND METHODS

All patients with a diagnosis of VS were analyzed. Data were described and compared using trend analyses and univariate and multivariable logistic regression.

RESULTS

A total of 8330 patients (average age 54.7 years, 51.9% female) were analyzed. The mean incidence was approximately 1.1 per 100,000 per year and did not vary significantly across time; however, from 2004 to 2011, there was a statistically significant decrease in tumor size category at time of diagnosis (P < .01). Overall, 3982 patients (48%) received primary microsurgery, 1978 (24%) radiation therapy alone, and 2370 (29%) observation. Within the microsurgical cohort, 732 (18%) underwent subtotal resection, and of those, 98 (13.4%) received postoperative radiation therapy. Multivariable regression revealed that surgical treatment was more common in younger patients and larger tumor size categories (P < .05). Management trend analysis revealed that microsurgery was used less frequently over time (P < .0001), observation was used more frequently (P < .0001), and the pattern of radiation therapy remained unchanged. Linear regression was used to create an equation that was applied to predict future management practices. These data predict that by 2026, half of all cases of VS will be managed initially with observation.

CONCLUSION

While the incidence of VS has remained steady, tumor size at time of diagnosis has decreased over time. Within the United States there has been a clear, recent evolution in management toward observation.