Vestibular schwannoma: the decisions you may face
4 treatment settings, 4 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Small tumour, stable or good hearing
Observation with MRI and audiometry, typically yearly; treatment on documented growth or hearing decline.
For low-risk prostate cancer, monitoring with PSA, MRI, and repeat biopsy instead of treating, because most such cancers never cause harm.
- Avoids incontinence and erectile dysfunction of treatment in men who would never be harmed
- Level-1 evidence of safety (ProtecT)
MRI uses a strong magnet and radio waves, with no ionising radiation, to picture soft tissue in finer contrast than CT, so it is the standard scan for brain tumours, prostate, rectal cancer staging, liver lesions and breast screening in high-risk women. It is slow, expensive and blurred by movement.
- No ionising radiation
- Best soft-tissue and brain imaging
- Functional sequences (diffusion, perfusion)
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Anxiety and adherence
- Repeat biopsies
- Under-used outside high-income countries
- Slow and expensive
- Motion artefacts
- Gadolinium concerns in renal impairment
- Between Active surveillance and MRI, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (small tumour, stable or good hearing), which of the standard options do you recommend and why?Why: Guideline options include: Observation with MRI and audiometry, typically yearly; treatment on documented growth or hearing decline.
Add these to your appointment list, or take the full question set for this cancer.
Growing small or medium tumour
Stereotactic radiosurgery (Gamma Knife, CyberKnife or linac) at about 12 to 13 Gy, or fractionated stereotactic radiotherapy; microsurgery in younger patients or by preference.
A single very high dose, or a few doses, aimed at a small brain or spine target with millimetre precision, replacing whole-brain radiotherapy for most brain metastases.
- One to five sessions
- Spares healthy brain
- Treats targets surgery cannot reach
The original radiosurgery machine: about two hundred cobalt-60 sources arranged in a shielded helmet whose beams cross at one point inside the brain, so a metastasis or benign tumour a few millimetres across receives a destructive dose in a single visit while the brain around it is spared.
- Sub-millimetre accuracy and steepest fall-off
- Many brain metastases in one session
- Decades of outcome data
A small accelerator on an industrial robot arm that aims hundreds of pencil-thin beams from any direction and follows the tumour as the patient breathes, so brain, spine, prostate, lung and pancreatic tumours can be treated in one to five sessions without a head frame.
- Frameless with real-time tracking of skull, spine and fiducials
- Follows breathing motion without gating
- Non-coplanar beams from almost any angle
IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.
- Conformal dose, fewer side effects
- Hypofractionation saves visits
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Limited to small targets
- Radiation necrosis in a minority
- Needs precise imaging and immobilisation
- Intracranial targets only
- Cobalt sources decay and must be replaced
- Radioactive inventory, shielding and licensing
- Long sessions and low throughput
- Small fields only, not for large volumes
- Fiducial placement is invasive for soft-tissue targets
- Low-dose bath to normal tissue
- Motion management
- Between Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS), Gamma Knife, CyberKnife robotic radiosurgery and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (growing small or medium tumour), which of the standard options do you recommend and why?Why: Guideline options include: Stereotactic radiosurgery (Gamma Knife, CyberKnife or linac) at about 12 to 13 Gy, or fractionated stereotactic radiotherapy; microsurgery in younger patients or by preference.
Add these to your appointment list, or take the full question set for this cancer.
Large tumour with brainstem compression or hydrocephalus
Microsurgical resection with facial nerve monitoring, sometimes deliberately subtotal followed by radiosurgery to the remnant; shunting for hydrocephalus.
A single very high dose, or a few doses, aimed at a small brain or spine target with millimetre precision, replacing whole-brain radiotherapy for most brain metastases.
- One to five sessions
- Spares healthy brain
- Treats targets surgery cannot reach
MRI uses a strong magnet and radio waves, with no ionising radiation, to picture soft tissue in finer contrast than CT, so it is the standard scan for brain tumours, prostate, rectal cancer staging, liver lesions and breast screening in high-risk women. It is slow, expensive and blurred by movement.
- No ionising radiation
- Best soft-tissue and brain imaging
- Functional sequences (diffusion, perfusion)
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Limited to small targets
- Radiation necrosis in a minority
- Needs precise imaging and immobilisation
- Slow and expensive
- Motion artefacts
- Gadolinium concerns in renal impairment
- Between Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS) and MRI, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCCN Guidelines: Central Nervous System Cancers), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (large tumour with brainstem compression or hydrocephalus), which of the standard options do you recommend and why?Why: Guideline options include: Microsurgical resection with facial nerve monitoring, sometimes deliberately subtotal followed by radiosurgery to the remnant; shunting for hydrocephalus.
Add these to your appointment list, or take the full question set for this cancer.