Quality of Life Analysis in Vestibular Schwannoma Patients: to Leave or Not to Leave… Gross Total Vs. Less than Gross Total Resection in an International Cohort of Patients

Introduction: With advancements in surgical techniques and anesthetic care, morbidity and mortality from the surgical removal of vestibular schwannomas (VS) has been markedly reduced in the past several decades. Additionally, stereotactic radiosurgery has been convincingly shown to be safe and effective for small and medium-sized VS, with very low risks of cranial nerve deficits. This has resulted in the priority outcome from surgical resection of VS to become reducing neurologic deficits, rather than removing the tumor in its entirety. The purpose of this analysis was to assess outcomes and long-term quality of life (QoL) in patients undergoing surgical resection of VS <3 cm in posterior fossa diameter who underwent either gross total resection (GTR) versus less than gross total resection (STR).

Methods: Patients operated between 1998 and 2008 at two academic tertiary referral centers, one in northern Europe and one in North America were analyzed. Patients that received microsurgical resection for sporadic VS < 3 cm in posterior fossa diameter were surveyed a mean of 7.7 years following treatment to assess their clinical status and quality of life. Demographic data, hearing, facial function and any additional morbidity were noted and patients were asked to complete the Short Form-36 (SF-36), Patient-Reported Outcomes Measurement Information System short form (PROMIS-10), the Glasgow Benefit Inventory (GBI), and the Penn Acoustic Neuroma Quality of Life analysis (PANQOL).

Results: 122 patients underwent GTR and 21 received STR. There was no difference between these two cohorts with regards to patient age (p = 0.68), hearing outcome (p = 0.20) or facial nerve function at last follow-up (p = 0.097). Patients in the STR group had larger tumors (p < 0.001).

Using multivariable analysis adjusting for age at survey, gender, tumor size, recent ipsilateral hearing, and most recent facial nerve function, at a mean of almost 8 years following surgery, patients that underwent GTR scored better on the SF-36 physical subscale (p = 0.033), SF-36 mental subscale (p = 0.004), PROMIS physical subscale (p = 0.002), PROMIS metal subscale (p = 0.017) and PANQOL total score (p = 0.023) compared with patients that had less than GTR.

Conclusion: Despite attempt to reduce morbidity and improve QoL in patients undergoing surgery for VS, less than GTR did not have any benefit in this study. In fact, GTR resulted in better long-term QoL on a variety of general and disease specific QoL measurements. Most notably, the mental subscales of both the SF-36 and PROMIS-10 showed a highly significant benefit to GTR, indicating to us that likely there is a psychological benefit to removing the entire tumor resulting in potential cure for this benign tumor population.