Questions for Treating Physician

OBSERVATION

NON-OPERATIVE TREATMENT WATCH & WAIT / WATCH & SCAN

Acoustic tumors are benign tumors arising from the Schwann cells (the insulating cells) of the balance nerve of the inner ear. A more appropriate term is "vestibular schwannoma" because these tumors arise on the vestibular nerve. While such a diagnosis can only be obtained by a tissue sample, a radiological diagnosis by MRI is highly accurate. The goal of any therapy is to minimize side effects and maximize quality of life. Generally speaking the larger the tumor, the more difficult it is to minimize side effects of treatment. Therefore, early treatment may be advisable. Acoustic neuromas (vestibular schwannomas) usually grow slowly. The average growth rate is about 2mm per year. Typically, they affect hearing and create a sensation of tinnitus. (In rare cases, growing tumors do not affect hearing). With advances in MRI imaging, many patients with small, asymptomatic tumors can be managed with observation alone. This is particularly true of older individuals with small tumors that are smaller than 10 millimeters in size. If the person chooses the observation / watch and wait approach, observation by periodic imaging is advisable. Following initial diagnosis, a reasonable plan would be to get a new MRI scan in six months to a year. If there is no growth, wait one year, and repeat the scan yearly for five years. Be sure to inform your physician of any changes that may occur such as worsening of hearing, imbalance, or facial numbness. These changes could indicate that the tumor is growing more rapidly. By waiting, there is a slight risk you could lose part or all of your hearing in the involved ear. If significant growth does occur during the observation period, treatment is indicated and you and your physician may decide to choose between one of two therapies: radiotherapy (for control) or microsurgical removal (for cure).

RADIATION TREATMENT FOR ACOUSTIC NEUROMA

A treatment option for an acoustic neuroma is radiation. Stereotactic radiation therapy, referred to as "radiosurgery" (typically performed in a single session) or "radiotherapy" (typically delivered over an extended period of time in multiple doses of radiation) is a technique based on the principle that radiation delivered precisely to the tumor will arrest its growth while minimizing injury to surrounding nerves and brain tissue. This non-invasive procedure can be performed in a one-dose treatment on an outpatient basis, or in a multi-dose treatment ranging from several days to over several weeks.

QUESTIONS FOR THE TREATING PHYSICIANS

If you have opted for radiation treatment of your tumor, you may want to ask some of the following questions of your radiation therapist, nurse, neurosurgeon, neurotologist, radiation physicist, radiation oncologist or neuroradiologist:

• How long have you been performing radiation treatment of acoustic neuromas? Have any problems emerged in any of your patients?
• Have you been certified to do radiation for patients with acoustic neuroma?
• Will this be a one-dose procedure (radiosurgery), or will it consist of several smaller doses (radiotherapy)?
• What type of radiation treatment (e.g., Gamma Knife, LINAC, CyberKnife, Novalis FSR, proton beam, etc.) do you most commonly perform? What are the advantages of this type of radiation over the others that are available?
• Why do you recommend this particular form of radiation treatment over others?
• Do you expect hearing, balance or ringing in the ear could be altered by radiation treatment?
• Do you anticipate that the tumor will swell after treatment? For how long?
• What are the long-term side effects of this treatment? Say 10 years or more? How will I know if something is changing?
• Are physicists involved in the planning of your radiation treatment?
• What symptoms are commonly experienced by your patients after treatment? How do you define "side effects"?
• What are the more serious complications such as malignancy, hydrocephalus and others that can happen with treatment and the relative frequency?
• How many of your patients have experienced continued growth of their tumors following treatment? If this happens to me, what would be my best follow-up procedure, can I have microsurgery?
• After radiation treatment, may I go about my business as before treatment, or are there any special precautions I should take?
• When and how often should I schedule follow-up MRIs after treatment? Will I get these MRI's for the rest of my life?

MICROSURGICAL REMOVAL OF ACOUSTIC NEUROMA

NOTE: Since acoustic neuromas are benign and slow growing (usually developing over several years), surgery should not be considered an emergency in most cases. Be cautious of anyone who tries to convince you to rush into surgery before you have taken the time to make an informed decision.

QUESTIONS FOR THE SURGEON

If you have decided to have your acoustic neuroma surgically removed, you may wish to ask some of the following questions of a potential surgeon:

• How many acoustic tumors have you removed this month/this year and/or what specific training in acoustic tumor surgery have you had?
• What is your total experience in operative cases of acoustic neuroma tumors over what period of time?
• What microsurgical approach do you recommend for my tumor size, location, age, health and level of hearing?
• Do you feel the facial nerve results or hearing results are more important in the long-term outcome? How do you achieve their preservation and what are your success rates?
• Do you electrically monitor the facial nerve during surgery?
• Do you use the newer technique to preserve the facial nerve? When leaving in small pieces of residual tumor on the brainstem or facial nerve, tumor growth usually stops as long as the tumor is not connected to the porus.
• For a tumor the size of mine, what have been your results with respect to facial nerve damage, both temporary and permanent?
• What is the likelihood that my remaining hearing will be preserved after this surgery?
• Do you anticipate total tumor removal with a single operation? If not, what are my follow-up options? Surgery? Radiation?
• Will this surgery be done by a team of physicians with more than one specialty?
• What has been your rate of surgical complication with respect to infection, bleeding, CSF leak and headache?
• When and how often should I schedule follow-up MRIs after treatment? Will I get these MRI's for up to 10 years?
• Does your hospital have a neurological intensive care unit?
• About how many days will I be in the hospital?
• What follow-up care will I need?
• How much discomfort should I expect from headaches and from the incision after this surgery?

• It's all right to get more than one opinion.
• Did you feel comfortable with the surgeon, information shared, etc.?
• All other things being equal, when can the surgery be scheduled?