A systematic review and meta-analysis of stereotactic radiosurgery as a primary treatment in fast-growing vestibular schwannomas.

BACKGROUND: Stereotactic radiosurgery has been shown to be an effective method of managing vestibular schwannomas. The primary aim here is to establish the impact of pre-treatment fast-growing vestibular schwannomas on the efficacy of stereotactic radiosurgery. METHODS: PubMed, Medline and Embase databases were used. The ROBINS-I ('Risk Of Bias In Non-randomised Studies - of Interventions') tool was utilised to assess for risk of bias. Proportionate meta-analysis and sub-analysis for fast-growing tumours were performed to explore the success rate of stereotactic radiosurgery in stabilising or decreasing the tumour burden in vestibular schwannomas. RESULTS: Four moderate risk studies were included in the analysis. Overall, 91 per cent (95 per cent confidence interval = 0.83-0.97, p < 0.01, I2 = 80 per cent) of the tumours demonstrated successful size reduction or stabilisation following stereotactic radiosurgery. Nevertheless, the efficacy of stereotactic radiosurgery in reducing or stabilising fast-growing vestibular schwannomas decreased by 79 per cent (95 per cent confidence interval = 0.64-0.91, p = 0.11, I2 = 62 per cent). CONCLUSION: Stereotactic radiosurgery has a statistically significant success rate in stabilising or decreasing the vestibular schwannoma size. This success rate is diminished in fast-growing vestibular schwannomas.

Spontaneous Vestibular Schwannoma Regression: A Case-Control Study.

OBJECTIVE: To explore the nature of spontaneously regressing vestibular schwannomas (VS) and identify possible predictive factors for such behavior. STUDY DESIGN: Retrospective case control study. SETTING: Tertiary referral center, university teaching hospital. PATIENTS: Patients with sporadic VS demonstrating spontaneous regression compared with a control group of patients with growing VS. INTERVENTIONS: Review of serial magnetic resonance imaging of the internal auditory meatus (MRI IAM) and case notes and direct comparison of possible related factors between the two groups using univariate analysis. MAIN OUTCOME MEASURES: Presenting symptoms, VS size and consistency, patients' age and sex, tumor laterality and location, and the neutrophil-to-lymphocyte ratio between the two groups. RESULTS: Of the 540 patients on the database 28 (5.2%) showed spontaneous regression with a mean follow-up of 122 months. Mean absolute and relative regression was 3.9 mm and 25.7%, respectively. 60% of tumors showed gradual regression while 25% showed growth followed by regression. Regressing VS had a significantly larger size than the control group; while the regressing tumors were located further from the fundus than the control group. The remaining examined factors did not reach a statistical level of significance. CONCLUSION: This is, to our knowledge, the first study comparing a cohort of regressing tumors with a control group of growing VS. The finding that the location of tumors around the porous, is more common in regressing VS has implications for patients' counselling.

Endoscopic Stapes Surgery: A Comparison With Microscopic Surgery.

OBJECTIVE: To investigate postoperative audiological outcomes and complication rates for fully endoscopic and microscopic stapes surgery carried out by a single surgeon in one center. PATIENTS: All patients having undergone endoscopic and non-endoscopic stapes surgery for otosclerosis from September 2009 to August 2016 under a single surgeon. INTERVENTION(S): Stapedotomy using either an operating microscope or endoscope for visualization. Stapedotomy was carried out using a standard approach. MAIN OUTCOME MEASURE(S): Pre- and postoperative audiometry and complications. RESULTS: Thirty-four patients who underwent endoscopic stapes surgery and 47 patients who underwent non-endoscopic stapes surgery were included in this study. Seventy-nine percent of both endoscopic and non-endoscopic groups had the average air-bone gap closed to less than 10 dBHL, respectively; the difference was not significant (p = 0.940, χ test). No patients with sensorineural hearing loss, vertigo, or facial nerve paresis were reported. Two of 34 patients (6%) of the endoscopic group had the chorda tympani cut intraoperatively for access compared with 11 of 47 patients (23%) of the non-endoscopic group. Sixteen of 47 patients (34%) required an endaural incision for access in the non-endoscopic group; no endaural incisions were made in the endoscopic group. CONCLUSION: Air-bone gap closure and patient complications did not vary significantly between endoscopic and non-endoscopic groups in this study of 34 endoscopic procedures. There is a requirement for further studies with larger sample sizes and longer follow-up periods to fully gauge the safety and effectiveness of this technique.

Association of Low B Cell Count and IgG Levels With Infection, and Poor Vaccine Response With All-Cause Mortality in an Immunosuppressed Vasculitis Population.

OBJECTIVE: Patients with systemic vasculitis (SV) have an increased risk of all-cause mortality, often due to infection, compared to the healthy population. We investigated whether humoral response to vaccination and biomarkers of immune dysfunction were associated with infection and death. METHODS: Patients with SV in remission were vaccinated with pneumococcal 7-valent conjugate, Haemophilus influenzae type b, and meningococcal group C conjugate vaccine and meningococcal polysaccharide groups A, C, Y, and W135 vaccines. Total IgG and antibody titers against specific antigens and lymphocyte subset analysis were performed before vaccination. Postvaccination antibody titers were measured at 4 weeks and 2 years, from which an antibody response score was calculated. Infections and death following vaccination were collected prospectively following vaccination. RESULTS: A total of 92 patients were safely vaccinated with no increase in disease relapse, median followup 4.6 years (interquartile range [IQR] 3.6-4.8 years). Eighteen patients died at a median of 2 years and the overall infection rate was 0.4 (IQR 0.2-1.3) infections/patient/year. Reduced serum IgG, B cell count, and CD4+ cell counts predicted poor vaccine response and infection but not death. The response rates to individual vaccine antigens was highly variable, with a median response rate of 46% (IQR 39-58%) of patients responding to each individual antigen. Vaccine response, age, and reduced renal function were independent predictors of all-cause mortality in multivariate analysis. CONCLUSION: Total IgG and B cell counts predict infection and response to vaccination. Vaccination in patients with SV in remission is safe and the response predicts all-cause mortality. Vaccine response is a surrogate marker of immune system health.