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Scalzitti and Pfannenstiel, J Otol Rhinol 2014, 3:3

http://dx.doi.org/10.4172/2324-8785.1000155

Case Report

Journal of
Otology & Rhinology
a SciTechnol journal

Spontaneous Size Regression of


a Vestibular Schwannoma
Nicholas J Scalzitti1*, and Travis J Pfannenstiel1

Abstract
Vestibular schwannomas are the most commonly occurring
skull base tumors. Increasing availability of magnetic resonance
imaging has allowed early recognition of these tumors and better
characterization of their natural course. Recently, several series
have presented data with regard to the slow growth of these tumors
and challenged the need for tumor resection or radiation in cases
involving small to medium-sized tumors. This is a case report of
spontaneous regression of a medium-sized vestibular schwannoma
occurring after initial slow tumor growth.

Keywords
Skull base tumor; Vestibular schwannoma; Tumor resection; Serial
high-resolution MRI

Introduction
Vestibular schwannoma (VS), also called acoustic neuroma, is a
common benign tumor of the supporting cells of the eighth cranial
nerve axons. VS accounts for as much as 6% of all intracranial tumors,
representing about 13 cases per 1 million people per year [1]. With
the increased use and improved resolution of magnetic resonance
imaging (MRI), smaller and more commonly asymptomatic tumors
are being discovered, and the medical and surgical paradigms for their
management continue to evolve. Treatment options for vestibular
schwannoma include: observation, stereotactic radiosurgery,
stereotactic radiotherapy, and microsurgical resection. Conservative
management with serial imaging has become more common for
small and medium-sized tumors, as data demonstrating the slow
growth and limited morbidity of observing these tumors over
extended periods has become available. The growth rate of vestibular
schwannoma has been studied extensively, and a recent meta-analysis
defined the range of growth as 0.3-4.8mm per year, with a mean of 1-2
mm per year [2].
We present a patient whose vestibular schwannoma exhibited
initial growth before diminishing in size over several years of
observation. Previously published case series estimate from 4% to
13% of vestibular schwannomas may regress spontaneously [3].
Unique to this case is a period of slow or typical growth followed by
dramatic regression in tumor size.

part of an evaluation for unilateral profound deafness. The patients


only symptoms relative to the VS were right sided profound hearing
loss and tinnitus. He denied any imbalance, vertigo, facial nerve
dysfunction, or other cranial nerve deficit. The patients medical
history was significant for several existing comorbidities: peripheral
vascular disease, chronic obstructive pulmonary disease, carotid
artery stenosis, and hypertension. The three primary treatment
options were presented to the patient, including: observation,
microsurgical resection, and radiotherapy. He was found at the
time of initial presentation to be a poor candidate for microsurgical
resection secondary to his failing general health status. He declined
stereotactic radiotherapy and stereotactic radiosurgery in favor of
observation.
During the initial four years following diagnosis, the tumor was
surveyed with serial high-resolution MRIs (Figures 1 and 2). The
patient presented with and maintained a profound hearing loss on the
affected side with no significant change in his contralateral hearing
thresholds or discrimination. During the initial observation period,
the tumor showed mild growth without brainstem compression. The
patient continued to decline radiation as a treatment modality, and
his health status worsened to requiring supplemental home oxygen
therapy. Due to more pressing medical and social issues, the patient
was lost to follow-up for a period of 4 years. The patient presented
back to the Neurotology clinic due to a new symptom of infrequent
right sided headache. An interval MRI examination was ordered and
demonstrated a significantly smaller tumor (Figure 3).
The change in tumor size over its 8 year clinical history is
demonstrated in Table 1. Two separate linear measurement methods
for tumor size were used. The first technique measures the largest
extrameatal diameter in a direction parallel to the petrous ridge,
and the second employs the measurement guideline endorsed by the
American Academy of Otolaryngologys Committee on Hearing and
Equilibrium in 1995 [4,5]. As seen in Table 1, the tumor exhibited
mild growth from the time of its initial identification in 2004 to a
follow-up MRI in 2006 (15.6% and 7.1% growth by the 2 employed
measurement techniques respectively). Exams subsequent to that
time have shown regression in size to its most recent state. The 2012

Figure 1: High Resolution T1-weighted post-contrast MRI performed at initial


diagnosis in 2004.

Case Report
A 75-year-old male was initially diagnosed via contrast-enhanced
MRI with a right sided medium-sized vestibular schwannoma as
*Corresponding author: Nicholas Scalzitti, 2338 Jarve Valley, San Antonio,
TX 78251, USA, Tel: 630-308-0359 / 210-916-8040; Fax: 210-916-8366;
Email: nicholas.j.sclazitti.mil@mail.mil
Received: February 03, 2014 Accepted: April 21, 2014 Published: April 30,
2014

International Publisher of Science,


Technology and Medicine

Figure 2: High Resolution T1-weighted post-contrast MRI in 2006 showing


initial growth of tumor.

All articles published in Journal of Otology & Rhinology are the property of SciTechnol, and is protected by copyright laws.
Copyright 2014, SciTechnol, All Rights Reserved.

Citation: Scalzitti NJ, Pfannenstiel TJ, (2014) Spontaneous Size Regression of a Vestibular Schwannoma. J Otol Rhinol 3:3.

doi:http://dx.doi.org/10.4172/2324-8785.1000155
Our report further supports the continued need for research
into the growth behavior of these tumors, as growth is often the
determining factor in the decision for treatment. Unfortunately,
identifying which tumors will grow continues to be an elusive task.

Conclusion

Figure 3: High Resolution T1-weighted post-contrast MRI in 2012 showing


tumor regression.
Table 1: Size of tumor measured by two methods at different times. Percentage
in parentheses demonstrates percentage (%) of maximum tumor size.
2004

2006

Largest diameter
(mm)

11.9
(84.4%)

14.1 (100%) 10.9 (77.3%) 8.1 (57.4%)

2008

2012

Size by AAO-HNS
guideline (mm)

13.0
(92.9%)

14.0 (100%) 11.0 (78.6%) 7.5 (53.6%)

MRI (Figure 3) demonstrates a nearly 50% reduction compared to the


tumor at its largest known size in 2006.

Discussion

Size regression of a vestibular schwannoma is not a novel


finding, but this case represents tumor shrinkage to a degree
not previously reported. Further, the reduction in size was seen
after first demonstrating mild growth (~1 mm/year). Increase in
tumor diameter demonstrated on serial MRI has been suggested
as a predictor of future growth; [1,6] although, not all algorithms
would consider the mild growth seen with this tumor justification
for intervention [7]. This initial growth did prompt a discussion
with the patient regarding a need for microsurgical or radiosurgical
intervention to prevent the morbidity associated with large vestibular
schwannomas including: facial nerve injury, facial hyperesthesia, and
other cranial neuropathies.
Few studies of tumor progression have identified reliable
predictive factors. A large retrospective study by Malhotra et al.
found the presenting symptom of disequilibrium, or new-onset
disequilibrium during conservative management, to be significantly
higher in the group requiring further intervention. They also found
initial tumor size to be statistically different between the intervention
and non-intervention groups, but no threshold size could be
identified [8].
Several published studies have compared outcomes of conservative
management of small and medium vestibular schwannomas with
surgical or radiosurgical treatments. Gamma knife radiosurgery has
been shown to reduce the likelihood of tumor growth with minimal
impact on hearing outcomes over time relative to untreated controls
[9]. Two separate studies have found a progression of hearing loss
to be the natural course of vestibular schwannoma, regardless of
tumor growth. This has been hypothesized to result from inner ear
ischemia or protein shedding from the tumor [9,10]. Our patient
did not recover hearing as the tumor regressed in size, but recovery
from profound deafness regardless of cause several years after onset
is extraordinarily rare.
The exact cause of this tumors decrease in size cannot be
determined. Cyst rupture, microvascular compromise, host-immune
response, or a currently undetermined process could have caused
the lesions size regression. Serial magnetic resonance imaging
of this patient did demonstrate bilateral internal carotid artery
atherosclerosis and the sequelae of chronic small vessel ischemic
disease. In the absence of any treatment, it is possible that tumor
growth became compromised due to microvascular ischemia of the
tumor itself.
Volume 3 Issue 3 1000155

Management of patients with vestibular schwannoma requires


an extended informed consent process to provide patients with a
foundation from which to determine their treatment choice. This case
demonstrates a tumor exhibiting dramatic size regression following
a period of slow or typical growth. This is an uncommon but not
isolated phenomenon and should be considered in the informed
consent discussion and as part of the natural history of the disease
when designing studies of treatment efficacy.

Disclaimer

The views expressed herein are those of the authors and do not
reflect the official policy or position of the San Antonio Military
Medical Center, the U.S. Army Medical Department, the U.S.
Army Office of the Surgeon General, the Department of the Army,
Department of Defense or the U.S. Government.

Conflict of Interest
Authors do not have any conflict of interest.
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Author Affiliations

Top

Department of Otolaryngology San Antonio Uniformed Services Health


Education Consortium, San Antonio, Texas, USA

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