Pseudoprogression of Vestibular Schwannoma after Stereotactic Radiosurgery with Cyberknife(®): Proposal for New Response Criteria

SIMPLE SUMMARY: After stereotactic radiosurgery of vestibular schwannomas, there may be a transient increase in tumor volume. Therefore, it is difficult to distinguish between tumor growth and treatment-related volume changes. To address this issue, we developed criteria to assess response by systematic volumetric analysis. We found an early (within the first 12 months after treatment) and a late (beyond 12 months) increase in volume. Consequently, in most cases with unclear volume increase after radiosurgery, longer observation intervals should be implemented to better distinguish between transient and continuous tumor growth. ABSTRACT: (1) Background: Transient increase in volume of vestibular schwannomas (VS) after stereotactic radiosurgery (SRS) is common and complicates differentiation between treatment-related changes (pseudoprogression, PP) and tumor recurrence (progressive disease, PD). (2) Methods: Patients with unilateral VS (n = 63) underwent single fraction robotic-guided SRS. Volume changes were classified according to existing RANO criteria. A new response type, PP, with a >20% transient increase in volume was defined and divided into early (within the first 12 months) and late (>12 months) occurrence. (3) Results: The median age was 56 (range: 20–82) years, the median initial tumor volume was 1.5 (range: 0.1–8.6) cm(3). The median radiological and clinical follow-up time was 66 (range: 24–103) months. Partial response was observed in 36% (n = 23), stable disease in 35% (n = 22) and PP in 29% (n = 18) of patients. The latter occurred early (16%, n = 10) or late (13%, n = 8). Using these criteria, no case of PD was observed. (4) Conclusion: Any volume increase after SRS for vs. assumed to be PD turned out to be early or late PP. Therefore, we propose modifying RANO criteria for SRS of VS, which may affect the management of vs. during follow-up in favor of further observation.