Upfront Radiosurgery Compared to Watch-and-Wait Approach for Vestibular Schwannomas: A Systematic Review and Meta-Analysis

Introduction: The ongoing controversy in vestibular schwannoma (VS) management revolves around the decision between early treatment versus a conservative watch-and-wait (WW) approach, with uncertain benefit in hearing preservation, local tumor control, and quality of life. The data is limited to retrospective studies. By incorporating the findings gained from the recently published VREX trial, which compares upfront radiosurgery (SRS) with the WW, this study aims to contribute to the existing medical literature.

Methods: We performed a systematic review with metanalysis adhering to PRISMA guidelines. Searches were conducted on MEDLINE, Embase, and Cochrane. Inclusion criteria included studies comparing upfront SRS with WW for patients with newly diagnosed VS.

Results: Data from 17 studies, and 2641(1488 WW; 1153 SRS) patients with unilateral VS, were included. Baseline pure tone average (PTA) means were 43 and 45dB, for WW and SRS groups respectively. Final PTA values were 56 and 66dB for the WW and SRS groups, respectively (non-significant). In the WW group, tumor growth was observed in 38.5% of patients, with 60% of them requiring further treatment. In the SRS group, growth was observed in 8% of patients, with 43% requiring re-treatment. Meta-analysis demonstrated significant favor for the SRS approach with an (OR=1.61) for tumor control and an (OR=9.02) for the absence of further treatment(p < 0.001). There was no statistical difference between the two groups in terms of hearing preservation.

Conclusion : Our findings align with the results reported in the VREX trial. Upfront SRS does not lead to a significant hearing decline when compared to the WW approach. Patients should be advised about the natural progression of VS and the potential benefits of upfront treatment in certain populations, such as Koos grades 2 and 3 VS or those who present with accelerated growth rates. In these cases, upfront SRS allows targeting a smaller volume, thus sparing possible adverse radiation effects.