Vestibular Schwannomas
Nathan Beucler
Abstract
Vestibular SchwannomasTo the Editor: In their article (April 8 issue), 1 Carlson and Link state that because of surgical risks -in particular, risks to the facial nerve -the practice of intentionally leaving a tumor remnant has gained popularity.Such an approach is usually considered in the case of large vestibular schwannomas but not for small or medium-sized tumors, for which radiosurgery is the treatment of choice (supported by level II evidence), 2 since it offers a high degree of facial and cochlear functional preservation. 3 For large vestibular schwannomas, a "nerve-centered approach" with planned intracapsular resection offers equivalent functional outcomes 4 but may expose patients to further remnant growth.For this reason, we suggest a combined approach, including postoperative radiosurgery aimed at attaining better oncologic control. 5However, tumor remnants render planning for radiosurgery difficult, as a result of complex shapes, variability in residual volume, and difficulties in delineating the target volume.To date, we have had high rates of tumor control with our approach, albeit slightly lower than those obtained with upfront radiosurgery for small and medium-sized vestibular schwannomas.The major advantage of this middle ground we advocate is preservation of facial and cochlear function for patients with large vestibular schwannomas that is equivalent to that achieved with up-front radiosurgery in patients with small or medium-sized schwannomas.