Original ArticleHow to Address Small- and Medium-Sized Acoustic Neuromas with Hearing: A Systematic Review and Decision Analysis
Introduction
Acoustic neuromas (ANs), or vestibular schwannomas, is a type of benign brain tumor. ANs represent 8% of all primary brain neoplasms and approximately 16% of benign brain tumors (24). These tumors are usually slow growing, and there are even some reports that they may undergo long periods of stasis 14, 19, 21. Most patients with small ANs have slight or imperceptible symptoms. Presently, increasing numbers of ANs are being detected incidentally by magnetic resonance imaging for minor symptoms 14, 19. The treatment of this type of tumor continues to be controversial. Both intervention and wait-and-see strategies have been advocated by different experts 1, 16. Even with the use of intervention strategies, microsurgery and radiosurgery continue to be under debate 16, 27. Some systematic reviews have been performed to determine a suitable treatment 23, 29, 41, even proposing treatment algorithms (31). Because the inclusion criteria for the studies vary widely, and because there is a lack of available high-level evidence, their conclusions are not convincing.
Currently, decision-making has been based primarily on the doctor's experience and the patient's choice. On the basis of the results of previous studies, this study evaluates these treatment strategies using decision analysis in an attempt to determine the appropriate treatment.
Section snippets
Ethical Considerations
This is an analysis primarily using the evaluation of anonymous data obtained from the published literature without requiring additional consideration of ethics. The patients' survey was approved by the institutional review board of the local hospital (KY2014-022-01).
Definition of the Problem
The patient should have useful residual hearing, and the tumors should be no more than 3.0 cm in diameter or stages I, II, or III based on the Koos classification (17). Other than some hearing impairment and tinnitus, the patient
Included Studies and the Results of the Synthesis
Eight studies 1, 6, 8, 10, 21, 32, 33, 37 met the inclusion criteria for the wait-and-scan strategy, as shown in Table 1. Among the 8 studies, 2 articles described different aspects of the same patients 1, 37. Three studies collected data from a national population-base 1, 32, 37 and contributed the greatest number of participants. All of the studies had a mean follow-up time of more than 40 months, except for one study (6), in which the follow-up was 27.1 months. Using the QUADAS tool (38) to
Discussion
Decision analysis is a method for breaking down complex problems into manageable components, analyzing these parts in detail, and then combining them in a logical way to indicate the best course of action (36). Another decision analysis study (39) on small ANs concluded that the worst expected value would be found if the wait-and-scan strategy is selected. The conclusions differ because of how the probabilities are obtained and how the utilities are measured. We believe that our study is more
Conclusion
The evidence in this study suggests that radiosurgery therapy for small ANs should be the preferred treatment option, but further studies, such as a health economics analysis, high-grade evidence and the natural history of ANs, are needed.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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