Stereotactic radiotherapy has an inherent disadvantage in that it does not directly reduce tumor volume. In this increasing environment of cost-containment, however, this modality offers several advantages (see box). Some investigators believe that, over the next generation, stereotactic radiotherapy will be the mainstay of vestibular schwannoma care, with micro-surgery being the exception and being reserved for patients needing urgent decompression and for very young patients . Increasing numbers of patients are undergoing stereotactic radiotherapy as a matter of preference following the provision of sufficient information on the two treatment procedures. When counseling younger patients, it is important to remember that no long-term data about the control rate for stereotactic radiotherapy with the most recent, lower doses are available. Also, surgical salvage, which is necessary in some patients, produces a poor outcome following radiation therapy. Published reports have demonstrated similar facial nerve, hearing preservation, and tumor control rates in the short term only [32, 33]. Data is insufficient to assess the risk for inducing a secondary, treatment-related malignancy. Until long-term results are available, stereotactic radiotherapy should be reserved for medically infirm patients, elderly patients, patients with contralateral deafness or bilateral tumors, and patients who have failed prior microsurgery. Radiotherapy is not the preferred primary treatment modality for vestibular schwannoma based on currently published results.
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