From the Guidelines
Monoclonal antibodies should not be used as a first-line treatment for schwannoma in patients at risk of syncope, as the current evidence does not support their efficacy in this context. The use of monoclonal antibodies, such as bevacizumab, has been studied in the treatment of vestibular schwannomas, particularly in patients with neurofibromatosis type 2 (NF2) 1. However, the evidence for their use in patients at risk of syncope is limited, and the potential benefits must be weighed against the risks of side effects, such as hypertension, proteinuria, and impaired wound healing.
The European Association of Neuro-Oncology guideline on the diagnosis and treatment of vestibular schwannoma recommends that treatment decisions be based on clinical presentation, tumor size, and expertise of the treating center 1. For patients with NF2-associated schwannomas, bevacizumab has shown promise in reducing tumor size and improving hearing, but its use is not without risks and should be carefully considered on a case-by-case basis 1.
In terms of managing syncope in patients with schwannoma, the guidelines on management of syncope emphasize the importance of identifying and treating the underlying cause of syncope, rather than simply treating the symptoms 1. In patients with structural cardiac or cardiopulmonary disease, treatment goals should focus on preventing symptom recurrence and reducing mortality risk, rather than relying on monoclonal antibodies as a primary treatment.
Key considerations in the management of patients with schwannoma at risk of syncope include:
- Careful evaluation of the underlying cause of syncope
- Consideration of the potential benefits and risks of monoclonal antibody therapy
- Regular monitoring of blood pressure, urine protein, and cardiac function during treatment
- Management by specialists familiar with both schwannomas and syncope management to ensure comprehensive care addressing both the tumor and syncope symptoms.
From the Research
Monoclonal Antibodies for Schwannoma
- There is limited evidence on the use of monoclonal antibodies (mAbs) for the treatment of schwannoma, particularly in relation to syncope risk.
- A study published in 2015 2 reported the use of bevacizumab, a humanized monoclonal antibody, in a patient with neurofibromatosis type 2 and vestibular schwannoma, resulting in hearing improvement and tumor shrinkage.
- However, this study did not specifically address the risk of syncope associated with mAbs treatment for schwannoma.
Schwannoma Treatment Options
- Current treatment options for schwannoma include surgery, radiotherapy, and observation, depending on the tumor size, location, and patient symptoms.
- A review of recent literature on radiotherapy for vestibular schwannoma 3 highlighted the effectiveness of stereotactic radiosurgery and fractionated stereotactic radiotherapy in achieving local control and preserving functional outcomes.
- Surgical excision is also a common treatment approach, as reported in cases of intraparotid facial nerve schwannomas 4 and intraosseous schwannomas 5.
Syncope Risk and Schwannoma
- There is no direct evidence linking monoclonal antibodies treatment for schwannoma to an increased risk of syncope.
- However, patients with schwannomatosis, a rare tumor syndrome characterized by multiple schwannomas, may be at risk for developing symptoms such as paresthesias, pain, or weakness, which could potentially contribute to syncope 6.
- Further research is needed to investigate the potential relationship between mAbs treatment for schwannoma and syncope risk.