Introduction
Vestibular schwannomas (VS) are benign skull base tumors with an increasing incidence rate of 34 tumors per million [
1]. Although benign, the tumor has the potential of causing serious symptoms, comprising hearing loss, tinnitus, and balance disturbance. Larger tumors may cause facial paresis, facial numbness or pain, elevated intracranial pressure, and compression of the brainstem [
2]. Patients suffering from neurofibromatosis type 2 (NF2) and schwannomatosis are predisposed to the development of vestibular schwannomas, usually bilaterally [
3]. Treatment options for vestibular schwannoma include surveillance, surgical excision, and radiotherapy. The symptoms and signs induced by the tumor – or the therapy – potentially cause a long-lasting impact on quality of life [
4‐
6]. Proton radiotherapy is suggested to minimize the side effects of radiotherapy by reducing the volume of irradiated healthy tissue surrounding the tumor.
While long-term tumor control rates after VS irradiation are approximately 95%, various neurological functions are still threatened by this benign disease or its treatment [
7,
8]. Hearing loss still occurs in approximately half of the patients after photon radiotherapy, a percentage that continues to increase with longer duration of follow-up [
7,
9‐
12]. In addition, radiotherapy confers a risk of increased balance disturbance or dizziness, tinnitus, and trigeminal and facial neuropathy [
13,
14]. Furthermore, the long-term effects of radiotherapy on cognitive functioning are not yet well evaluated, and there is a very small chance of induction of a secondary tumor and sometimes with malignant tumor transformation [
9‐
12,
15,
16]. To minimize these long-term sequelae of radiotherapy, there is a need for an improvement of treatment strategy, especially as the majority of VS patients present in middle age, in the 4 to 6th decade of life, with several decades of expectant survival [
17].
In proton therapy, a smaller volume of non-targeted tissue can be irradiated compared to photon therapy [
18]. This is a result of the low radiation dose entry and finite Bragg peak, a characteristic radiation dose-deposition peak where protons release most of their radiation energy at the end of its defined path length [
19]. There is an absence of dose beyond the Bragg peak, in contrast to photon radiation where x-rays continue to irradiate the tissue beyond the target. In addition, photons have their highest radiation energy deposit shortly after tissue entry, a problem for which many advanced strategies have purposely diffused this entry dose. However, this increases the volume of the brain that receives radiation. In general, the Bragg peak in proton radiotherapy can result in an approximately 50% dose reduction to the surrounding normal brain tissues [
19,
20]. For vestibular schwannomas, most benefit could potentially be seen in the decrease of (low dose) brain irradiation volume and by using the physical properties of these charged particles to specifically avoid organs at risk (OAR) [
21].
As the organs and tissues at risk include the cochlea, the vestibular organ, and the brainstem, reducing radiation dose is relevant. The risk of hearing loss after radiotherapy seems to be dependent on the dose administered to the cochlea, therefore a reduction of cochlear irradiation may result in better long-term hearing [
22‐
29]. The consequences of low-dose brain irradiation are not well understood; however, it is possible that even small amounts of radiation have an impact on the healthy brain tissue [
30,
31]. The trigeminal nerve or the vestibular organ could be additionally spared, which may influence the risk of facial neuralgia, hypoesthesia, and balance disturbance. Although more conformal than photons, the proton beam dose fall off still entails a margin of dose delivered to the normal tissues around a target. Thus, the part of the facial nerve abutting and most adjacent to the tumor does not benefit from the dosimetric benefit of protons over photons; however the more distant parts of the facial nerve and the nuclei may. Moreover, the slightly greater relative biological effectiveness (RBE) of protons to photons is widely accepted as 1.1, but there are recognized uncertainties in which there could be unrecognized clinical impact [
32].
To evaluate tumor control and toxicity of proton radiotherapy in VS patients, a systematic review of the literature was performed to evaluate whether the existing data support that the theoretical advantages of proton therapy translate into clinical benefit.
Material and methods
Literature search and selection
A systematic search of the literature was performed in March 2018 using MEDLINE (PubMed), EMBASE, Web of Science, Cochrane Library, ScienceDirect, and GoogleScholar. The research term was formulated with a scientific librarian. The search term is available as supplemental data; it consisted of “proton radiotherapy” and “vestibular schwannomas,” as well as more specific search terms, including all VS variants (including “acoustic neuroma” and “cerebellopontine angle tumor”). Translations of VS into German, French, and Dutch were added to the search term. No time frame was used for publication. Reference lists from reviews that came up in the search were screened for additional articles. The inclusion criteria for study selection were (1) patients with a vestibular schwannoma, both sporadic as well as part of NF2; (2) treatment with proton radiotherapy; (3) reported outcomes for tumor control and/or hearing preservation; (4) original data; and (5) a wide range of studies, including meeting abstracts, was accepted to ensure complete literature collection. Exclusion criteria included (1) opinion or editorial paper, (2) within patient radiotherapy technique combinations, (3) animal/laboratory study, (4) studies that only reported on meningiomas (NF2), (5) plan comparison studies, and (6) other languages than English, Dutch, French, and German. Two reviewers (EH, KK) independently viewed the abstracts, after which full-text evaluation was performed. Studies with notable similarities were assessed for overlapping datasets; if this was the case, the paper with the largest inclusion was used. This assessment was based on authors, institutions, and data. After full text evaluation, consensus was reached by the two reviewers on article inclusion.
Quality assessment
The National Institute of Health (NIH) Quality Assessment Tool for case series studies was used to assess the quality of the reports [
33]. The assessment for case series was used, as the eligibility criteria for proton irradiation instead of other treatment modalities were unclear, thus making it impossible to conclude a full inclusion of a cohort. To ensure full bias assessment, the list was extended by four questions from the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies for a more complete assessment (question numbers 8, 13, and 14). The final question is an overall rating of the quality of the report, which is either poor, fair, or good. Two researchers (KK, RW) independently assessed the reports, after which consensus was reached on the results of the assessment.
Data extraction was performed independently by two reviewers (KK, RW). The characteristics of the patient population, intervention, tumor control/size, quality of life, and side effects were tabulated. Side effects included hearing loss, facial and trigeminal nerve impairment, as well as hydrocephalus, death, and a secondary tumor. Tumor control was the primary endpoint and was defined as “not needing salvage treatment” (either surgery or re-irradiation), as this would result in the most reliable measure across the included studies. Because these results were obtained from retrospective reviews, no meta-analysis was performed.
Discussion
This systematic review aimed to assess the tumor control and toxicity rates of proton radiotherapy for vestibular schwannomas. Five retrospective reviews were included. The quality assessment showed two articles as having a low, two as having a fair, and one as having a good quality. Only one paper corrected for confounders and only three analyzed the results in subgroups. All studies were retrospective in design, with inherent limitations of patient selection and outcomes reporting bias. The quality assessment also showed a risk of attrition bias because of the non-consecutive inclusion. Only a small percentage of the patients was reported as lost to follow-up; however the follow-up duration has been varied.
Despite this study’s limitations, VS tumor control rate after proton irradiation, defined as not requiring salvage treatment after irradiation, was a reliable and comparable outcome. It showed similar tumor control rates to other radiotherapeutic modalities (92–100% for photons). A systematic review on photon radiosurgery and fractionated radiotherapy reported a tumor control rate of 95% for both modalities [
7]. No published full reports described 10-year follow-up results, but one conference abstract did approximate this that was excluded for overlapping data [
28,
40]. With a median follow-up time of 9.5 years for 52 patients, tumor control was 98%. The occurrence of pseudo-progression may have played a role in the tumor control results, as large tumors were also included in the reviewed studies, and pseudo-progression is more likely to necessitate symptom management in large tumors [
35,
37]. Indeed, most patients requiring salvage treatment were treated within 2 years after their radiation treatment raising the question on whether these were true treatment failures. Additional factors that influence tumor control are prior surgical excision and explicitly offering proton radiotherapy to patients with larger tumors surgery. These conditions harbor intrinsic selection bias of patients with larger tumors that are subsequently referred for proton therapy, for example, to minimize collateral brain irradiation. This could negatively influence tumor control rates and risk for treatment-related symptoms.
NF2 patients remain a unique subset of VS patients with suspected lower rates of tumor control after radiation therapy. A recent systematic review reported a mean 5-year control rate of 75% after stereotactic radiosurgery in NF2 patients, which is notably lower than for sporadic vestibular schwannoma patients [
47]. Here, our data does not show a decreased efficacy of proton irradiation for NF2-associated VS in the aggregate small group of 15 patients identified. However, with known genetic and clinical differences in NF2 patients as compared to sporadic VS patients, NF2 patients should be separately analyzed to better elucidate potential differences in efficacy of proton therapy between sporadic and NF2 tumors.
The toxicity profile of proton radiotherapy is currently difficult to evaluate aside from no unexpected adverse effects. Assessments are further limited by the use of increasingly antiquated scattering proton technology and higher radiation doses than currently commonly used. In addition, studies suffer from selection bias and varying reporting consistency. For example, hearing loss is reported by a binary version of the Gardner-Robertson classification which is deemed insensitive as per AAO-HNS recommendation [
40]. Regardless of the classification used, hearing loss occurs frequently after radiotherapy in VS patients. The crude average hearing loss rate was 24% and 68% for a 2- and 5-year follow-up period, respectively. This seems to be higher than reported in a systematic review on hearing loss after photon radiotherapy (42% at 4-year follow up, range: 14–92%). Previous studies have shown cochlear dose to be related to hearing loss progression [
23‐
29, ]. While none of the included studies provided information on the cochlear doses within their study population, one article did state that efforts were made to reduce the dose to the cochlea to 36 Gy(RBE) (while maintaining target coverage) [
35]. The reported occurrence and severity of hearing loss after proton irradiation are probably dependent on several other factors too: the duration of the follow-up, the radiation dose to various structures (brainstem and/or cochlear nerve), the fractionation strategy, tumor size, the patient’s age, and other comorbidities with possible associated radiation sensitivities such as vascular diseases. In addition, the occurrence of pseudo-progression is previously suggested to be of influence on hearing loss as well [
48]. In this study, we find evidence for increased post-irradiation hearing loss in patients with a longer follow-up and those receiving a higher total irradiation dose; however the observed differences are based upon a small sample and not surprising without significant difference.
The reported prevalence of facial and trigeminal nerve impairment due to proton radiotherapy ranged significantly (0–10% and 0–9%, respectively). The high pre-irradiation prevalence of trigeminal and facial neuropathies in some reports may reflect a selection bias, leading to possible overestimation of proton therapy-induced injury. Although most articles included a standardized follow-up protocol comprising audiometry and MR imaging, assessment of trigeminal and facial nerve function was less consistent. In this study, there is low evidence for a higher incidence of facial and trigeminal neuropathy after single-fraction proton radiosurgery. Other reported predictive factors for facial and trigeminal neuropathy include prior vestibular schwannoma surgery, large tumor size, a higher total radiation dose, advanced patient age, and pre-existing neuropathy [
49‐
51].
Other possible side effects of radiotherapy in vestibular schwannoma patients, such as unsteadiness, vertigo and tinnitus, and long-term sequelae such as impact on cognitive functioning, could not be assessed in this review because of insufficient reporting. These outcomes – which are difficult to measure – could be assessed by disease-specific QoL surveys. However, these are lacking for comparison of these complaints to other treatment modalities. Quality of life is arguably the most important outcome and key factor when weighing between therapeutic modalities for vestibular schwannoma patients. Potential effects of the dosimetric differences to the healthy brain tissue are also missing from this review and could potentially be assessed through QoL surveys and/or neurocognitive testing. As a consequence, an accurate inference of QoL could not be determined by the available data. The necessary data does not yet exist and will be imperative to future guidance of best patient care.
Individualized strategy is best for each vestibular schwannoma patient. These range from observation to a variety of radiotherapy options to a variety of surgical approaches. The challenge is to identify those subgroups that would benefit most from a specific treatment, including the option of proton radiotherapy. The rationale for choosing proton radiotherapy over other radiotherapy modalities is the possible reduction of side effects and sequelae induced by the radiotherapy, such as hearing loss, possibly impaired cognitive functioning, and cranial nerve function loss. Theoretically, reducing the amount of irradiation of surrounding tissues by using proton radiotherapy could result in improved cognitive functioning, decreased risk of cranial nerve neuropathies, and a decreased risk of secondary tumor induction. However, while tumor control rates of proton radiotherapy are comparable to other radiotherapeutic modalities, there is currently insufficient clinical evidence to confirm that proton radiotherapy incurs less or less severe side effects than photon radiotherapy in vestibular schwannoma patients, both in the short and long term. At the moment, it is unclear whether this is due to comparable toxicity profiles, to the limited number and quality of the reports on proton radiotherapy in vestibular schwannoma patients, or to the fact that most reviewed articles did not report on the latest proton radiotherapy techniques.
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