Stereotastic radiosurgery for glomus jugulare tumors

OBJECTIVES/HYPOTHESIS

Surgery is considered to be the mainstay of treatment for glomus jugulare tumors. A subset of patients are poor surgical candidates based on age, medical problems, tumor size, or prior treatment failure. The purpose of this study was to review our results with stereotactic radiosurgery (gamma knife treatment) in this group of patients, with particular attention to adverse reactions and symptom relief.

STUDY DESIGN

Retrospective review and phone survey.

METHODS

Charts were reviewed for size and location of tumor, history of previous treatment, symptoms before and after treatment, amount of radiation received, acute and late complications, and functional level before and after treatment. Pre-treatment and posttreatment magnetic resonance imaging scans were also reviewed. Identified patients were then contacted for a phone interview.

RESULTS

Eight patients were identified. Phone interviews were conducted with four patients. Four patients had failed previous treatment. Follow-up ranged from 7 to 104 months. One patient experienced an acute complication: intractable vertigo requiring hospitalization. No patient experienced delayed cranial neuropathies. No patient reported worsening of any of the following symptoms: pulsatile tinnitus, hearing loss, facial weakness, hoarseness, or difficulty swallowing. Three patients reported improvement in their pulsatile tinnitus. Two patients reported improvement in hearing loss, and one patient each reported improvement in vertigo and difficulty swallowing.

CONCLUSIONS

Preliminary results suggest that stereotactic radiosurgery is useful to control symptoms and may be delivered safely in patients with primary or recurrent glomus jugulare tumors who are poor surgical candidates.

Gamma Knife radiosurgery of the glomus jugulare tumour - early multicentre experience

Leksell Gamma Knife was used to treat 66 patients with glomus jugulare tumour at 6 European sites between 1992-1998. The age of the patients ranged between 18-80 years (median 54 years). Gamma Knife radiosurgery was a primary treatment in 30 patients (45. 5%). Open surgery preceded radiosurgery in 24 patients (36.4%), embolisation in 14 patients (21.2%) and fractionated radiotherapy in 5 patients (7.6%). The volume of the tumour ranged 0.5-27 cm(3) (median 5,7 cm(3)). The minimal dose to the tumour margin ranged between 10-30 Gy (median 16.5 Gy). After radiosurgery 52 patients were followed, the follow up period was 3-70 months (median 24 months). Neurological deficit improved in 15 patients (29%) and deteriorated in 3 patients (5,8%), one transient and two persistant. Neuroradiological follow up using MRI or CT was performed in 47 patients 4-70 months (median 24 months) after radiosurgery. Tumour size decreased in 19 patients (40%) while in the remaining 28 patients (60%) no change in the tumour volume was observed. None of the tumours increased in volume during the observation period. Control angiography was performed in 6 patients. Pathological vascularisation completely disappeared in one patient, reduced in two and there was no change in the remaining three. Radiosurgery proves to be a safe treatment for glomus jugulare tumour with no mortality and no acute morbidity. Because of its naturally slow growth rate, up to 10 years of follow up will be necessary to establish a cure rate after radiosurgery for these lesions.

[The biological behavior of jugular glomus tumor and the perioperative management]

OBJECTIVE

Based on our experiences, the biological behavior and perioperative management of the jugular glomus tumor are introduced and discussed in order to prevent the possible mortality and morbidity.

METHODS

Five cases of jugular glomus tumor treated in our institute were reviewed. Laboratory examination, modern imaging techniques such as CT, MRI, 131I-MIBG, DSA, as well as embolization of the blood vessels and/or antihypertensive drugs were selectively used in the preoperative period.

RESULTS

Surgical removal of the tumors was successful in this group.

CONCLUSION

Perioperative management plays an important role in the prevention of surgical complications.

Gamma knife radiosurgery for glomus jugulare tumours

The aim of this clinical study was to determine the tumour control rate, clinical outcome and complication rate following gamma knife treatment for glomus jugulare tumours. Between May 1992 and May 1998, 13 patients with glomus tumours underwent stereotactic radiosurgical treatment in our department. The age of these patients ranged from 21 to 80 years. The male:female ratio was 2:11. Six patients had primary open surgery for partial removal or recurrent growth and subsequent radiosurgical therapy. Radiosurgery was performed as primary treatment in 7 cases. The median tumour volume was 6.4 cm3 (range: 4.6-13.7 cm3). The median marginal dose applied to an average isodose volume of 50% (30-50%) was 13.5 Gy (12-20 Gy). In 10 patients, a total of 48 MRI and CT follow-up scans were available. The remaining three patients have been excluded from the postradiosurgical evaluation since the observation time (t < 12 months) was too short or patients were lost to follow up. The median interval from Gamma Knife treatment to the last radiological follow-up was 37.6 months (5-68 months). In 4 patients (40%) decreased tumour volumes were observed and in 6 cases (60%) the tumour size remained unchanged. Neurological follow-up examinations revealed improved clinical status in 5 patients (50%), a stable neurological status in 5 patients (50%) and no complications occurred. According to our preliminary experience Gamma Knife radiosurgery represents an effective treatment option for glomus jugulare tumours.

[Management of large bilateral glomus jugulare tumors]

Bilateral glomus jugulare tumors are rare. However, their treatment should preserve not only the function of the facial nerve but also the caudal cranial nerves and the middle ears in order to avoid bilateral hearing losses. Further, venous cerebral drainage has to be ensured in order to avoid cerebral hypertension and hemorrhagic infarction after bilateral jugular ligations. In the case presented bilateral glomus jugulare tumors required super-selective angiography and embolization. Complete tumor removal on both sides was then possible by a transmastoid-transcervical approach without any further functional deteriorations. Middle ear function was preserved on both sides by temporary ventral translocation of the posterior wall of the auditory meatus. As the sigmoid sinus and internal jugular vein had been ligated during initial previous surgery, venous drainage was tested one year later by angiography and compression of the remaining internal jugular vein. A sufficient collateral circulation was found and permitted surgery on the second side.

Facial palsy after glomus jugulare tumour embolization

Facial palsy after pre-operative embolization of glomus tumours is a rare complication. In our case, complete facial palsy occurred within four hours after embolization with polyvinyl alcohol foam. Three days later, embolization material was found in the perineural vessels of the facial nerve in its mastoidal segment. Six months after complete tumour removal, facial decompression with perineural incision, and steroid therapy, facial function recovered completely. In cases of embolization of both stylomastoid and branches of the middle meningeal artery with resorbable material, temporary facial palsy can occur.

Leksell gamma knife radiosurgery of the tumor glomus jugulare and tympanicum

We have treated 14 patients with glomus tumor during the 4 years (of 1993 to 1997) using Leksell Gamma Knife radiosurgery. The male: female ratio was 1:3.7, and the mean age 48.6 years (range 22-75 years). The mean tumor volume was 5.5 cm3 (range 0.7-11.3 cm3). The mean maximum dose was 37.4 Gy (range 20-44 Gy). The mean margin dose was 19.4 Gy (range 10-25 Gy). In 3 patients, infrabasal spread of the tumor could not be delineated on peroperative stereotactic CT scans. As a result, this portion of the tumor was treated in 2 patients at a second stage using stereotactic MRI. Follow-up in 11 patients ranged from 6 to 42 months (mean 20.5 months). Hearing on the affected side was further impaired in 3 patients. Tinnitus, vertigo and ataxia improved in 3 patients, headache and nausea in 2 patients. Angiography after radiosurgery was performed in 3 patients. In one patient 12 months after the radiosurgery, pathological vascularisation had completely disappeared. In another patient pathological vascularisation was still present 22 months after the first stage, despite two-stage radiosurgery, although the tumor volume decreased 30%. In the last patient, vascularisation and tumor volume partially decreased 12 months after radiosurgery. The volume of the tumor decreased in 4 patients. No change in tumor volume has been observed in any of the other patients to date. Radiosurgery proves to be a safe treatment for glomus tumor with no acute morbidity. Because of its naturally slow growth rate, up to 10 years follow-up will probably be necessary to establish the therapeutic effectiveness of radiosurgery for glomus tumor.

[Jugular bulb anomaly]

OBJECTIVE

To differentiate and treat correctly the jugular bulb anomalies, as well as to avoid the unnecessarily enlarged operations.

METHODS

Four cases of jugular bulb anunalies were reported and analysed.

RESULTS

Two of 4 cases were misdiognosed as jugular glomus tumors; One was considered to be jugular bulb anomaly, but was done with an enlarged operation; another one was still accompanied with benign intracranial hypertension syndrome, was inappropriately treated.

CONCLUSION

The jugular bulb anomaly was often misdiagnosed, therefore the anomaly should be differentiated from the jugular glomus tumor carefully.

Dural arteriovenous malformations of the transverse/sigmoid sinus acquired from dominant sinus occlusion by a tumor: report of two cases

OBJECTIVE AND IMPORTANCE

Debate continues regarding the pathogenesis of dural arteriovenous malformations (dAVMs). The prevailing theory is that dAVMs are acquired lesions that occur after thrombosis of the dural venous sinus.

CLINICAL PRESENTATION

We report unique cases of two patients having different tumors (one meningioma and one glomus jugulare paraganglioma) that occluded the ipsilateral transverse and sigmoid sinuses, respectively, and were associated with dAVMs. In each patient, the occluded venous sinus was the dominant sinus.

CONCLUSION

Our experience with these patients supports the hypothesis that dAVMs are acquired and induced lesions that may occur after sinus occlusion. We suggest that the occlusion of the dominant transverse/ sigmoid sinus is a major contributing factor to the development of dAVMs because of the inability of the contralateral (nondominant) sinus to handle the venous flow from the obstructed (dominant) side.

Metastatic carcinoma of the temporal bone presenting as glomus jugulare and glomus tympanicum tumours: a description of two cases

Two cases of metastatic carcinoma of the temporal bone, that simulated glomus tumours on thorough preoperative evaluation are described. Although rare, metastatic spread to this area is recognized, but presentation in this way is unique.

[Extramedullary plasmacytoma--manifestation in petrous bone]

BACKGROUND

Extramedullary plasmocytoma of the temporal bone is a rare neoplastic disorder. Only a very few cases are described in the world literature.

CASE

We report on a patient who presented with the clinical signs of a glomus jugular tumor. Postoperative histological evaluation revealed an extramedullary plasmocytoma of the temporal bone.

CONCLUSION

If a glomus tumor is suspected, histological investigation appears necessary if surgery is not possible or is contraindicated.

Saphenous vein graft bypass of the sigmoid sinus and jugular bulb during the removal of glomus jugulare tumors. Report of two cases

Glomus jugulare tumors always invade the jugular bulb and sigmoid sinus, making it difficult to resect these tumors totally without sacrificing the involved sinus. Although the sinus can be sacrificed safely in most patients, a few patients will have serious consequences. Reconstruction of the jugular bulb using a saphenous vein graft may enable tumor resection in these patients without complications. The authors describe two cases of saphenous vein grafting used to bypass the sigmoid sinus. The first case is that of a 61-year-old man with a glomus jugulare tumor that invaded the dominant sigmoid sinus, which was poorly collateralized. Temporary occlusion of the sinus during surgery caused a 15-mm Hg increase in intrasinus pressure, without brain swelling or changes in evoked potentials. A saphenous vein graft was used to bypass the sigmoid sinus and jugular bulb and to allow for total tumor removal. The patient had a good outcome. The second case is that of a 41-year-old man with a left glomus jugulare tumor and another smaller tumor on the opposite, dominant sinus. The left glomus jugulare tumor was resected via a two-stage procedure. A saphenous vein graft was used to reconstruct the left sigmoid sinus because of the presence of contralateral disease, with the potential for bilateral sigmoid sinus occlusion. An evaluation of the venous collateral circulation during jugular foramen surgery and the prevention of complications are also discussed.

Functional mapping of glomus tumors reveals underlying embryology

A functional map of cranial nerves was created by the multidimensional scaling (MDS) of adults' symptoms from glomus tumors. Differences between cranial-nerve deficits in eight different subsets of glomus tumors were input to MDS. MDS determines coordinates of points (representing cranial nerves) such that distances between points are related as closely as possible to differences in the observed symptoms. For example, two nerves that are equally likely to be affected by a glomus tumor would be put close together in the calculated map, even though they may be physically distant. The result resembles a stage in the developing nervous system. This correlation provides mathematical confirmation that adults' glomus tumors are related to early embryology. This in turn suggests that functional maps can provide a useful way for computers to depict underlying patterns in medical data.

[Bilateral glomus tumors with a blood pressure regulation disorder due to baroreceptor dysfunction]

HISTORY AND CLINICAL FINDINGS

A 73-year-old woman was admitted because of vertigo of recent onset with a tendency to fall down and progressive hearing impairment with tinnitus over the last 2 years. Neurological examination also revealed right recurrent nerve paresis, facial hemispasm and lingual atrophy, pointing to a lesion involving cranial nerves VII, VIII, IX, X and XII. She was found to have spontaneous nystagmus to the left, due to peripheral vestibular function deficit, without otoscopic abnormalities. She was in atrial fibrillation with a blood pressure of 140/80 mm Hg. The suspected cause was a hormonally active glomus jugulare tumour with intermittent hypertension and involvement of several cranial nerves.

INVESTIGATIONS

Repeatedly measured plasma and urinary catecholamine concentration was normal. Neuroradiology showed a contrast-rich lesion close to the jugular vein and the hypoglossal nerve, as well as a tumour in the left retromandibular fossa with displacement of the left internal carotid artery. The suspected cause of these findings was a neurologically asymptomatic left carotid body tumour with multiple cranial nerve deficits (VII, VIII, IX and XII) due to their compression at the base of the skull. No abnormal catecholamine activity could be demonstrated.

TREATMENT AND COURSE

After complete excision of the right carotid body there were no further hypertensive crises. Later on the left carotid body tumour was embolised because it had continued to grow.

CONCLUSION

The repeated hypertensive crises were probably caused by absent blood pressure regulation, the result of destruction of the afferent fibres. This destruction was due to compression of the hypoglossal nerve by the right jugular glomus, at the same time as the contralateral carotid body had been destroyed by tumour.

The variable relationship between the lower cranial nerves and jugular foramen tumors: implications for neural preservation

Tumors involving the jugular foramen (JF) have a variable relationship to the neurovascular structures (jugular vein, cranial nerves IX-XI) that traverse this conduit through the skull base. The surgeon familiar with the site of origin, growth pattern, and geometry of each of the common lesions affecting this region with respect to surrounding nerves and vessels is at a considerable advantage when undertaking a function-sparing procedure. Anatomically, the JF has two vascular compartments that may be affected by tumor: the jugular bulb laterally and a passage for the inferior petrosal sinus medially. Tumors may also penetrate the JF along the fibro-osseous diaphragm, which divides these two vascular channels. The lower cranial nerves lie on either side of this partition, which is connected to the posterior cranial fossa via a curved, funnel-shaped cone of dura. Tumors that arise within or penetrate the JF lateral to this neural plane displace the nerves medially, a position favorable for their preservation during tumor extirpation. By contrast, medially positioned tumors displace the cranial nerves onto the lateral tumor surface, where they interpose between surgeon and tumor-an unfavorable location. Glomus tumors consistently arise in the lateral aspect of the JF, displacing the lower cranial nerves medially. This positioning accounts for the high rate of neural preservation in small and medium-size glomus tumors that have not invaded the foramen's central partition. Meningiomas that arise lateral to the JF (e.g., the posterior petrous surface, sigmoid sinus) favorably displace the lower cranial nerves medially. By contrast, tumors that originate medial to the JF (e.g., clivus, foramen magnum) are unfavorable, laterally displacing the multiple small rootlets that coalesce into cranial nerves IX-XI into a vulnerable location. Schwannomas arise within the neural plane and have a variable geometry that depends, in part, upon the nerve of origin. Theoretically, tumors that arise from the ninth nerve, which is located on the lateral surface of the neural plane, should be more favorable than those originating from the tenth or eleventh nerves, which lie on its deep surface. The propensity of these three tumor types toward thrombosis of the jugulosigmoid complex also carries important surgical implications. Because glomus tumors arise from the jugular bulb, the jugulosigmoid complex is nearly always occluded. In both meningiomas and schwannomas, however, the jugular system may occasionally remain patent. This is important to recognize through angiography and/or magnetic resonance venography, since sacrifice of a patent, dominant system risks intracerebral venous infarction.

Slow-flow phenomena in magnetic resonance imaging of the jugular bulb masquerading as skull base neoplasms

Enhancement in the region of the jugular foramen on magnetic resonance imaging (MRI) is highly sensitive to the presence of a skull base neoplasm. Unfortunately, this imaging method lacks the specificity to be the sole criterion in the diagnosis of a lesion of the jugular foramen. Although well described in the radiological literature, the phenomenon of gadolinium enhancement of the relatively static blood in the jugular system continues to be erroneously diagnosed as glomus jugulare tumor. Instances of this phenomenon present in patients referred to our practice for surgical opinions before radiation therapy and/or definitive resection will be presented. The purpose of this communication is to bring this potential treatment pitfall to the attention of the neurotology community. Treatment planning for lesions of the lateral skull base cannot singularly be based on MRI findings but requires a healthy skepticism satisfied only by more complete evaluation.

Avascular tympanojugular paraganglioma

The avascular paraganglioma described in this article appears to be the second such tumor reported in the international literature and the first to be reported in the tympanojugular region. Despite a highly suggestive history and clinical appearance, the tumor showed no signs of vascularization on radiologic studies. The pathologic postoperative study confirmed the diagnosis of paraganglioma with extensive stromal fibrosclerosis and without the typical well-vascularized thin fibrous septa. In the authors' opinion, this observation is notable because of the difficulties encountered in the correct diagnostic interpretation of an avascular mass in the tympanojugular region. In such cases, the possibility of a paraganglioma should always be considered.

Intracranial pheochromocytoma--a case of noradrenaline-secreting glomus jugulare tumor

A 43-year-old female was admitted for a labile hypertension and depression. High levels of plasma and urinary noradrenaline strongly suggested a pheochromocytoma. However, clinical investigations revealed a normal adrenal gland and thoraco-abdominal region. Venous samples from multiple sites indicated and increase in noradrenaline in the left jugular vein. Using computed tomography and Gadolinium DTPA (diethylene triamine pentaacetic acid)-enhanced dynamic MR (magnetic resonance) imaging, a tumor was discovered in the cerebello-pontine angle. Carotid angiography showed the feeder arteries clearly. Therefore, the tumor was classified as a noradrenaline-secreting glomus jugulare tumor fed by the carotid artery. After embolization and subsequent medical therapy, blood pressure was well controlled. Twenty cases of intracranial pheochromocytoma have been reported to date. This is the second such case in Japan.

[Pulsatile tinnitus as a key symptom of glomus tumor: diagnostic value of magnetic resonance tomography]

The aim of this study was to evaluate the diagnostic value of modern imaging tools in pulsatile tinnitus, which might be apparent in a variety of different diseases. While computed tomography (CT) and digital subtraction angiography (DSA) have been the methods of choice in the diagnostic management of this symptom and its related diseases, the technical progress in the development of MRI and MRA highly recommends these techniques as additional yet sufficient imaging tools. The authors demonstrate 2 representative cases of pulsatile tinnitus (one patient with glomus tumour, one patient with jugular bulb deformity) and the adequate diagnostic procedure in terms of imaging tools. It is concluded that a routine MRI-examination might allow a diagnosis with high sensitivity and specificity. Still, digital subtraction angiography and computed tomography remain indispensable in the diagnostic management of pulsatile tinnitus.