Carotid body tumor

Prevalence, characteristics, evaluation, and management of carotid body tumors: Systematic analysis based on available evidence

OBJECTIVE

Although carotid body tumors (CBTs) are rare, they attract particular attention because of their propensity for malignant transformation and the high surgical risk. Because data are scarce and as it is difficult to achieve a large sample size, no study has yet comprehensively analyzed the characteristics, management, or operative complications of CBTs. Therefore, we collected and analyzed all currently available information on CBTs and used the pooled data to derive quantitative information on disease characteristics and management.

METHODS

We systematically searched PubMed, Embase, the Cochrane Library, and the Web of Science up to December 1, 2022, for studies that investigated the characteristics and management of CBTs. The primary objective was to identify the prevalence of the various characteristics and the incidence of complications. The secondary objective was to compare patients who underwent preoperative embolization (PE) and those who did not (non-PE), as well as to compare patients with different Shamblin grades and those with and without succinate dehydrogenase (SDH) mutations in terms of CBT characteristics and complications. Two reviewers selected studies for inclusion and independently extracted data. All statistical analyses were performed using the standard statistical procedures of Review Manager 5.2 and Stata 12.0.

RESULTS

A total of 155 studies with 9291 patients and 9862 tumors were identified. The pooled results indicated that the median age of patients with CBT was 45.72 years, and 65% were female. The proportion of patients with bilateral lesions was 13%. In addition, 16% of patients had relevant family histories, and the proportion of those with SDH gene mutations was 36%. Sixteen percent of patients experienced multiple paragangliomas, and 12% of CBTs had catecholamine function. The incidence of cranial nerve injury (CNI) was 27%, and 14% of patients suffered from permanent CNI. The incidence rates of operative mortality and stroke were both 1%, and 4% of patients developed transient ischemic attacks. Of all CBTs, 6% were malignant or associated with metastases or recurrences. The most common metastatic locations were the lymph nodes (3%) and bone (3%), followed by the lungs (2%). Compared with non-PE, PE reduced the estimated blood loss (standardized mean difference, -0.95; 95% confidence interval [CI], -1.70 to -0.20) and the operation time (standardized mean difference, -0.56; 95% CI, -1.03 to -0.09), but it increased the incidence of stroke (odds ratio, 2.44; 95% CI, 1.04-5.73). Higher Shamblin grade tumors were associated with more operative complications. Patients who were SDH gene mutation-positive were more likely to have a relevant family history and had more symptoms.

CONCLUSIONS

CBT was most common in middle-aged females, and early surgical resection was feasible; there was a low incidence of serious operative complications. Routine PE is not recommended because this may increase the incidence of stroke, although PE somewhat reduced the estimated blood loss and operation time. Higher Shamblin grade tumors increased the incidence of operative complications. Patients who were SDH gene mutation-positive had the most relevant family histories and symptoms.

A Global Bibliometric Analysis of the Top 100 Most Cited Articles on Carotid Body Tumors

The carotid body, situated at the common carotid artery bifurcation, comprises specialized glomus cells responsible for sensing blood oxygen, carbon dioxide, pH, and temperature changes, crucial for regulating breathing and maintaining oxygen homeostasis. Carotid body tumors (CBTs), arising from these cells, are rare, representing only 0.5% of head and neck tumors, often presenting as benign, slow-growing, vascularized masses. In February 2023, this bibliometric analysis was conducted, which involved screening 1733 articles from the Web of Science database. The screening process was based on citation count, and articles were selected for inclusion based on specific criteria that focused on CBTs located within the carotid bifurcation. Rigorous selection involved independent screening and data extraction by four authors. The top 100 articles, published between 1948 and 2019, totaled 6623 citations and were authored by 98 unique first authors from 22 countries and 77 institutions, spanning 42 journals. Treatment articles were the predominant category, comprising 49% of the literature. This analysis offers insights into publication trends, identifies literature gaps, and outlines areas of research focus, providing a valuable resource to guide future studies on CBTs.

Non-Functional Carotid Body Tumors in Patients Without Somatic Mutations May Be Considered for Non-Operative Management

BACKGROUND

Carotid Body Tumors (CBT) are rare neuroendocrine paragangliomas which are typically asymptomatic and benign, with a low rate of biochemical functionality. Historically, early surgical excision was recommended to prevent development of CBT-related complications. Yet, CBT resection can result in significant cranial nerve and vascular injuries. Recent work has shown successful primary observation without resection of non-carotid body, cranial paragangliomas with slow growth and low rate of neuropathies. We hypothesize that primary observation of CBT is safe and may be considered for majority of CBT.

METHODS

Retrospective cohort study of patients at a multi-hospital healthcare system with radiologic identification and/or diagnostic or procedural billing codes for CBT (2000-2019). Tumor size (greatest diameter), associated symptoms, and interventions were recorded at the initial evaluation and throughout follow-up. Multivariable logistic regression investigated the risk of initial surgical resection.

RESULTS

A total of 108 patients (mean age, 59 ± 19 years; 67% female), with 123 CBT (mean diameter 23 ± 12 mm; 52% right) were initially evaluated by otolaryngologists (51%), vascular surgeons (25%), neurosurgeons (8%), or other (16%) medical providers. Fity-five CBT were initially resected, 63 observed, and 5 irradiated. Initial resection was associated with younger age (adjusted odd ratios aOR, 0.95 [95% confidence intervals CI, 0.92-0.97]), male sex (aOR, 4.82 [95% CI, 1.47-15.75]), and evaluation by a vascular surgeon (aOR, 6.17 [95% CI, 2.04-18.63]). Overall median follow-up was 4.7 (IQR, 2.6-9.1) years. Initially observed CBT were on an average stable in size (mean 1 ± 5 mm/year), none became biochemically active, and 2 patients became symptomatic. At the final follow-up, 63 (51%) underwent surgical resection, 54 (44%) observation, and 6 (5%) radiation therapy. Of the 63 surgically resected CBT, 5 (8%) patients had malignant CBT of which 3 (60%) had known somatic mutations (polymerase epsilon [n = 1], succinate dehydrogenase-D gene [n = 2]). Thirty percent of CBT resections had in-hospital postoperative complications, notably including 1 stroke which occurred in an initially observed patient and 16 cranial nerve complications which all occurred in immediately resected patients. Three resected CBT locally recurred, only 1 of which had malignant pathology.

CONCLUSIONS

Patients with newly diagnosed CBT require biochemical functionality and somatic mutation testing. In the absence of these findings, initial observation of CBTs with annual imaging and symptom monitoring may be considered an alternative to immediate resection which demonstrates a high risk of clinically meaningful postoperative complications.

Results of resection of carotid body tumors with and without lymphnodes' dissection

BACKGROUND

Carotid body tumor (CBT) is a slow-growing tumor arising from the carotid body, a chemoceptor organ lying behind the carotid artery bifurcation. Although rarely, metastases can occur distally through the hematogenous route and through the lymphatic route.to the cervical lymphnodes. The purpose of this study was to assess whether lymphnodes' resection should systematically be associated with the primary resection of a CBT.

METHODS

A retrospective analysis of 82 patients, 52 women of a mean age of 42 years undergoing resection of 88 CBT from 1994 to 2019. CBT were divided into 2 groups. Tumors in group A (n = 23, 26%) were treated by resection of the mass followed by a selective latero-cervical lymphadenectomy; tumors in group B (n = 65, 74%) underwent isolated resection of the mass. The study's primary endpoints were postoperative stroke/mortality rate, disease-specific survival and rate of local and distant recurrence of the disease.

RESULTS

Postoperative stroke-mortality rate was nil. One patient in group A (4.3%) presented a minor weakness of the contralateral arm, completely regressive within 12 h. One patient in group B (1.5%) died of liver and lung metastases 51 months after operation, no patient died of recurrent disease in group A (p = .62). No nodal recurrence was observed in group A, whereas one patient in group B (1.5%) presented nodal recurrence 39 months after primary tumor resection (p = .58) CONCLUSION: Selective lymphadenectomy associated with CBT resection does not increase the overall long-term survival and cannot be considered mandatory. It may help to better define the stage of the disease and to plan eventual adjuvant treatments.

A Systematic Review and Meta-Analysis of the Presentation and Surgical Management of Patients With Carotid Body Tumours

OBJECTIVES

The aim was to determine the mode of presentation and 30 day procedural risks in 4418 patients with 4743 carotid body tumours (CBTs) undergoing surgical excision.

METHODS

This is a systematic review and meta-analysis of 104 observational studies.

RESULTS

Overall, 4418 patients with 4743 CBTs were identified. The mean age was 47 years, with the majority being female (65%). The commonest presentation was a neck mass (75%), of which 85% were painless. Dysphagia, cranial nerve injury (CNI), and headache were present in 3%, while virtually no one presented with a transient ischaemic attack (0.26%) or stroke (0.09%). The majority (97%) underwent excision, but only 21% underwent pre-operative embolisation. Overall, 27% were Shamblin I CBTs; 44% were Shamblin II; and 29% were Shamblin III. The mean 30 day mortality was 2.29% (95% CI 1.79-2.93). The mean 30 day stroke rate was 3.53% (95% CI 2.91-4.29), while the mean 30 day CNI rate was 25.4% (95% CI 24.5-31.22). The prevalence of persisting CNI at 30 days was 11.15% (95% CI 8.42-14.64). Twelve series (544 patients) correlated 30 day stroke with Shamblin status. Shamblin I CBTs were associated with a 1.89% stroke rate (95% CI 0.92-3.82), increasing to 2.71% (95% CI 1.43-5.07) for Shamblin II CBTs and 3.99% (95% CI 2.34-6.74) for Shamblin III tumours. Twenty-six series (1075 patients) correlated CNI rates with Shamblin status: 3.76% (95% CI 2.62-5.35) for Shamblin I CBTs, 14.14% (95% CI 11.94-16.68) for Shamblin II, and 17.10% (95% CI 14.82-19.65) for Shamblin III tumours. The prevalence of neck haematoma requiring re-exploration was 5.24% (95% CI 3.45-7.91). The proportion of patients with a neck haematoma requiring re-exploration was not reduced by pre-operative embolisation (5.92%; 95% CI 2.56-13.08) vs. no embolisation (5.82%; 95% CI 2.76-11.88). Pre-operative embolisation did not reduce drainage losses (639 mL vs. 653 mL).

CONCLUSIONS

This is the largest meta-analysis of outcomes after CBT excision. Procedural risks associated with tumour excision were considerable, especially with Shamblin III tumours where 4% suffered a peri-operative stroke and 17% suffered a CNI.

Multimodal management of pediatric carotid body tumors: a systematic review and case illustrations

OBJECTIVE Carotid body tumors (CBTs), extraadrenal paragangliomas, are extremely rare neoplasms in children that often require multimodal surgical treatment, including preoperative anesthesia workup, embolization, and resection. With only a few cases reported in the pediatric literature, treatment paradigms and surgical morbidity are loosely defined, especially when carotid artery infiltration is noted. Here, the authors report two cases of pediatric CBT and provide the results of a systematic review of the literature. METHODS The study was divided into two sections. First, the authors conducted a retrospective review of our series of pediatric CBT patients and screened for patients with evidence of a CBT over the last 10 years (2007–2017) at a single tertiary referral pediatric hospital. Second, they conducted a systematic review, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, of all reported cases of pediatric CBTs to determine the characteristics (tumor size, vascularity, symptomatology), treatment paradigms, and complications. RESULTS In the systematic review (n = 21 patients [includes 19 cases found in the literature and 2 from the authors’ series]), the mean age at diagnosis was 11.8 years. The most common presenting symptoms were palpable neck mass (62%), cranial nerve palsies (33%), cough or dysphagia (14%), and neck pain (19%). Metastasis occurred only in 5% of patients, and 19% of cases were recurrent lesions. Only 10% of patients presented with elevated catecholamines and associated sympathetic involvement. Preoperative embolization was utilized in 24% of patients (external carotid artery in 4 and external carotid artery and vertebral artery in 1). Cranial nerve palsies (cranial nerve VII [n = 1], IX [n = 1], X [n = 4], XI [n = 1], and XII [n = 3]) were the most common cause of surgical morbidity (33% of cases). The patients in the authors’ illustrative cases underwent preoperative embolization and balloon test occlusion followed by resection, and both patients suffered from transient Horner’s syndrome after embolization. CONCLUSIONS Surgical management of CBTs requires an extensive preoperative workup, anesthesia, and multimodal surgical management. Due to a potentially high rate of surgical morbidity and vascularity, balloon test occlusion with embolization may be necessary in select patients prior to resection. Careful thorough preoperative counseling is vital to preparing families for the intensive management of these children. ABBREVIATIONS BTO = balloon test occlusion; CBT = carotid body tumor; CN = cranial nerve; ECA = external carotid artery; ICA = internal carotid artery; MIBG = iodine-123-meta-iodobenzylguanidine; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Excision of rare carotid body tumour without preembolisation: Case report and literature review

INTRODUCTION

Carotid body tumors also known as parganglioma or chemodactomas are one of the rare tumors of head and neck which present as slow growing masses in the neck region. We present a case of 40 years female with painless slow growing mass over left side of her neck for 6 months. Diagnosis was made on basis of clinical history, examination and radiological findings. Tumor was graded as Shamblin grade II. She was managed with excision of the tumor without preoperative embolisation. Intraoperative and postoperative periods were uneventful.

CASE PRESENTATION

A forty years female presented with left sided painless neck swelling∼5 × 4 cm² over left anterior triangle for 6 months with no history of dysphagia, odynophagia, change in voice, shortness of breath, palpitations, tremors or syncopal attacks. She underwent USG neck and CT angiogram. Based upon the radiological and clinical findings, she was diagnosed asCarotid body tumor. She was managed with excision of the tumor without preembolisation. Her diagnosis was confirmed with histopathology.

CONCLUSION

Carotid body tumours are rare entities of head and neck region. They are mostly benign in nature. Though mostly bening, increasing size might result in grave complications. Thus, the recommended treatment for carotid body tumors is early excision with or without pre-embolisation. In our case preembolisation was not performed. Though some studies have suggested the use of preoperative embolisation in large sized tumors, more studies are yet required to justify the choice of preembolisation despite the dreaded complications.

Diagnosis and treatment of a carotid body tumor: A case report of a rare bilateral tumor

In the present case report, a rare bilateral carotid body tumor (CBT) and the imaging and pathological features of a CBT are described. In the present report, a rare case of bilateral carotid body tumor, which developed in the bifurcation of the common carotid artery, and the clinical manifestations, imaging and pathological features of this CBT are summarized. The imaging cannot validate the diagnosis; however, imaging identified that the tumor exhibited an intact envelope. Immunohistochemical staining revealed that the tumor cells were strongly positive for cluster of differentiation 56, Syn and protein S-100, moderately positive for transcription factor E3, negative for cytokeratin and epithelial membrane antigen, and partial cells were weakly positive for Desmir (<5%). In view of the clinical and pathological features of the carotid body tumor, surgery is hypothesized to be the optimal treatment and may enable the tumor to be resected completely. Refined surgical techniques provide the security of safe resection and decrease the risk of complications occurring.

A Contemporary Assessment of Carotid Body Tumor Surgery

Carotid body tumor resection remains a surgical challenge traditionally associated with a 15-30% incidence of cranial nerve injury. The authors reviewed their experience with carotid body tumor surgery to determine whether contemporary awareness of carotid body tumors is leading to earlier detection and operation, resulting in a lower incidence of postoperative cranial nerve injury. Twenty-seven carotid body tumors were resected in 25 patients between 1990 and 2000. No patient died and no patient had postoperative baroreflex failure syndrome. There was 1 stroke (4%) in a patient who required ligation of the internal carotid artery. There were 9 cranial nerve injuries (33%), most commonly to the vagus or hypoglossal nerves, which was not significantly different from the rate of cranial nerve injury (44%) in the 9 patients operated upon between 1984 and 1989 (p = 0.37, Fisher's exact test). Multivariate analysis demonstrated that tumor size was the only significant factor predicting cranial nerve injury (p = 0.045, logistic regression). Since carotid body tumors with large size or higher Shamblin grades had predictably high operative blood loss and rates of postoperative cranial nerve injury, a high index of suspicion and aggressive surgical management may lead to earlier detection and operation on smaller tumors, ultimately reducing the risk of nerve injury. Nevertheless, carotid body tumor surgery appears to be relatively free of mortality and major morbidity in contemporary practice.

Carotid body tumor: retrospective analysis on 22 patients

CONTEXT AND OBJECTIVE

Carotid body tumors, or chemodectomas, are the most common head and neck paragangliomas, accounting for 80% of the cases. They may present minor symptoms; however, they deserve special attention in order to achieve accurate diagnosis and adequate treatment. The objectives of this study were to show the approach towards chemodectomas and evaluate the complications of the patients treated surgically without previous embolization.

DESIGN AND SETTING

Retrospective study on chemodectomas followed up at the Head and Neck Surgery Service, Department of Surgery, Unicamp.

METHODS

Twenty-two patients were evaluated between 1983 and 2009. The diagnosis was based on clinical findings and imaging methods. The epidemiological characteristics, lesion characteristics, diagnostic methods, treatment and complications were analyzed.

RESULTS

The paragangliomas were classified as Shamblin I (9%), II (68.1%) and III (22.7%). Angiography, magnetic resonance imaging and computed tomography confirmed the diagnosis in 20 patients (90.9%). Five (22.7%) had significant bleeding during the surgery, while four (18.1%) had minor bleeding. Four patients (18.1%) developed neurological sequelae. Seven (31.8%) needed ligatures of the external carotid artery. Three patients (13.6%) underwent carotid bulb resection. The postoperative follow-up ranged from 3 months to 14 years without recurrences or mortality.

CONCLUSIONS

In our experience and in accordance with the literature, significant bleeding and neurological sequelae may occur in chemodectoma cases, particularly in Shamblin III patients. The complications from treatment without previous embolization were similar to data in the literature data, from cases in which this procedure was applied prior to surgery.

Carotid body paragangliomas: a systematic study on management with surgery and radiotherapy

The definitive universally accepted treatment for carotid body tumors (CBT) is surgery. The impact of surgery on cranial nerves and the carotid artery has often been underestimated. Alternatively, a few CBTs have been followed without treatment or irradiation. The goal of this study is to summarize the existing evidence concerning the efficacy and safety of surgery and external beam radiotherapy (EBRT) for CBT. Relevant articles were identified using strict criteria for systematic searches. Sixty-seven articles met the criteria which included 2,175 surgically treated patients. On the other hand, 17 articles including 127 patients treated with EBRT were found. Long-term control of the disease was obtained in 93.8% of patients who received surgical treatment and in 94.5% of the radiotherapy group. Surgery resulted in 483 (483/2,175 = 22.2%) new cranial nerve permanent deficits, whereas in the EBRT group, no new deficits were recorded (p = 0.004). The common/internal carotid artery was resected in 271 (12.5%) patients because of injury or tumor encasement, with immediate reconstruction in 212 (9.7%) patients. Three percent (60) of patients developed a permanent stroke and 1.3% (26) died due to postoperative complications. The major complications rates and the mortality after completion of the treatment also were significantly higher in surgical series compared to EBRT series. This systematic analysis highlights evidence that EBRT offers a similar chance of tumor control with lower risk of morbidity as compared to surgery in patients with CBT. This questions the traditional notion that surgery should be the mainstay of treatment.

Malignant Carotid Body Tumor with Systemic Metastases

Carotid body tumors (CBTs) are rare neoplasms of the carotid body. Most CBTs are benign; however, some can show malignant behavior. Malignant CBTs have an unpredictable history; often, there is no correlation between the histologic findings and the clinical behavior. They are usually diagnosed by the development of local recurrence or lymph node metastasis following total resection of the primary mass, or by the detection of distant metastasis. There are few reports of histopathologic confirmation of malignant CBTs. We report a rare case of malignant CBT with distant metastases, in which the diagnosis was confirmed by histopathology, and present a review of the literature.

Synchronous malignant vagal paraganglioma with contralateral carotid body paraganglioma treated by radiation therapy

Paragangliomas are rare tumors and very few cases of malignant vagal paraganglioma with synchronous carotid body paraganglioma have been reported. We report a case of a 20-year old male who presented with slow growing bilateral neck masses of eight years duration. He had symptoms of dysphagia to solids, occasional mouth breathing and hoarseness of voice. Fine needle aspiration cytology (FNAC) performed where he lived showed a sinus histiocytosis and he was administered anti-tubercular treatment for six months without any improvement in his symptoms. His physical examination revealed pulsatile, soft to firm, non-tender swellings over the anterolateral neck confined to the upper-mid jugulo-diagastric region on both sides. Direct laryngoscopy examination revealed a bulge on the posterior pharyngeal wall and another over the right lateral pharyngeal wall. Magnetic resonance imaging (MRI), 99mTc-labeled octreotide scan and angiography diagnosed the swellings as carotid body paraganglioma, stage III on the right side with left-sided vagal malignant paraganglioma. Surgery was ruled out as a high morbidity with additional risk to life was expected due to the highly vascular nature of the tumor. The patient was treated with radiation therapy by image guided radiation to a dose of 5040cGy in 28 fractions. At a follow-up at 16 months, the tumors have regressed bilaterally and the patient can take solids with ease.

Carotid chemodectomas: long-term results of subadventitial resection with deliberate external carotid resection

The aim of this study was to evaluate the short-term and long-term results of the subadventitial resection of carotid chemodectomas and to validate the importance of deliberate resection of the external carotid artery (ECA). From 1981 to 2006, 39 carotid chemodectomas of the carotid bifurcation or of the neighboring nerves were operated on in our department. There were 14 men and 22 women, with a mean age 44.4 +/- 5 (range 21-78) years. One of these operations was a redo surgery for local recurrence. One female patient presented with a bilateral tumor. Two tumors were secreting catecholamines. All these tumors affected the carotid body; 10 of them were also affecting the vagus nerve, and one among these last 10 affected the sympathetic nerve as well. In 11 cases, the tumor had spread into the subparotidal space and, in one case, into the skull. In two cases, the tumor had been revealed by hemispheric ischemia and in every case by tumoral syndrome. All the patients were followed up by clinical examination, duplex scan, or computed tomographic scan until the end of 2006. In 38 cases, complete resection was performed; an incomplete resection was performed in one case with cranial invasion. Under general anesthesia, and most of the time without pharmaceutical preparation, surgery consisted of a deliberate sacrifice of the ECA followed by subadventitial resection of the tumor. In one case, a previous embolization had been carried out to facilitate the cleavage, which in fact rendered it more complicated. In 22 cases, resection concerned the ECA; in seven cases, it concerned the common carotid artery and the internal carotid artery (ICA): in seven cases the superior laryngeal nerve, in nine cases the vagus nerve, in five cases the sympathetic nerve, and in four cases the jugular vein. In 13 cases, node clearing was associated. In 20 cases, an additional vascular procedure was performed: nine dilatations for spasm of the ICA, five autogenous vein grafts, two prosthetic bypasses, and one endarterectomy associated with a patch angioplasty. All patients were followed up until 2006. At 3 months, the observed complications were the sequelae of a homolateral hemispheric accident due to thrombosis of a vein graft, eight peripheral facial nerve palsies, 12 vocal palsies, seven Claude Bernard-Horner (CBH) syndromes, eight palatal paralyses, and 10 nociceptive pains. Some of these complications did persist: nine vocal cord paralyses that were successfully treated by speech therapy, three mild CBH syndromes, and nociceptive pains in 6% of the cases (15.4%), incapacitating in one case. With a follow-up of 115 +/- 27 (range 1-298) months, three local recurrences were recorded at 6 and 10 years. In two cases, local recurrence occurred when initial resection of the ECA had not been performed. Two patients presented with a contralateral lesion, at 12 and 16 years, respectively. At 40 months, one patient had to be reoperated on for an atheromatous stenosis. At 51 months, a female patient's death was not related to the operation. Subadventitial resection of carotid body tumors with deliberate resection of the ECA is a simple and efficient procedure. It is the preferential treatment for these slow-growing localized tumors.

Current concepts for the surgical management of carotid body tumor

BACKGROUND

Carotid body tumor (CBT) is a rare lesion of the neuroendocrine system. Chronic hypoxia has long been recognized as an etiology of CBT and other paragangliomas. Recent biogenetic discoveries reveal that mutations in oxygen-sensing genes are another etiology, accounting for approximately 35% of cases, and that these 2 etiologies are probably additive.

DATA SOURCES

(1) A retrospective analysis of fifteen cases of CBT in a 6-year period occurring in the mountains of Southern Appalachia; (2) an extensive review of the literature on the surgery of CBT and on the expansive biogenetic understanding of the disease.

CONCLUSIONS

Improved imaging, vascular surgical techniques, and understanding of the disease have vastly improved outcomes for patients. The necessities for long-term follow-up and appropriate genetic testing and counseling of patients and their families are documented. Surgeon and institutional competence are critical in achieving maximal outcomes.

Angiofibroma of the larynx: report of a case with clinical and pathologic literature review

BACKGROUND

Angiofibromas are uncommon vascular tumors with a strong predilection for the nasopharynx of adolescent males. Although they are slow growing and histologically benign, they have the potential to cause significant morbidity with laryngeal involvement.

METHODS

We describe the clinical characteristics, histopathologic findings, differential diagnosis, preoperative evaluation, and management of a case of laryngeal angiofibroma.

RESULTS

The patient was initially seen with a 2 1/2-year history of progressive dyspnea and dysphagia. Preoperative evaluation suggested a vascular mass involving the left supraglottic larynx. A partial laryngopharyngectomy was performed without complication. The patient is alive and disease free 3 years postoperatively. Final histopathologic diagnosis is consistent with angiofibroma.

CONCLUSIONS

Laryngeal angiofibroma is an extremely rare entity. Adequate preoperative imaging is necessary to confirm the vascularity of this lesion, because ill-planned biopsy may lead to significant blood loss. The role of preoperative embolization of other laryngeal vascular lesions has been well documented and may be useful in the management of laryngeal angiofibroma.

Outcome of surgical treatment for carotid body paraganglioma

BACKGROUND

The present study reviewed a 30-year experience of managing carotid body paraganglioma (CBP) and analysed clinical findings associated with perioperative morbidity.

METHODS

Clinical records, radiological findings and pathological reports of all patients who presented with CBP between 1966 and 1997 were reviewed. There were 39 consecutive patients with 45 tumours and median follow-up was 10 years. The Shamblin classification was used to define complication rates and long-term surgical results.

RESULTS

Preoperative information derived from magnetic resonance angiography (MRA) and colour Doppler imaging (CDI) was comparable to that from standard four-vessel arteriography. Forty-one CBPs were resected in 35 patients. Six patients had bilateral tumours and seven had multicentric tumours. The median duration of operation and blood loss were substantially higher for Shamblin type III tumours. All major vascular complications (four of 39 patients) and permanent neurological complications (three of 39) were observed in type III tumours.

CONCLUSION

Surgical planning and prediction of perioperative complications can be obtained by staging derived from MRA and CDI. Severe complications occur predominantly in type III CBPs.

Management of carotid body tumors

The carotid body tumor is a rare neoplasm that has generated much literature over the past century, and for which continued controversy exists regarding natural history, biologic behavior, proper technique of excision, and the risk of morbidity and mortality. This article discusses overall management of carotid body tumors.

Carotid body tumors: the role of preoperative embolization

Resection of carotid body tumors (neck paragangliomas) carries inherent risks of injury to the cranial nerves and other structures as well excessive blood loss. Preoperative embolization has been used to lessen the morbidity in tumors that are larger than 2 cm in diameter. Two female patients presented for treatment with large asymptomatic carotid body tumors-one 4 cm and one 5 cm in diameter. Both patients had preoperative angiography the day before surgery that revealed the feeding arterial vessels so that successful embolization could be accomplished with gel. Success was judged by diminution of the angiographic blush. Both patients had an uneventful surgical excision the following day with the carotid body tumors being able to be resected periadventitially without damage to either the external or internal carotid artery. The cranial nerves were preserved in both patients and blood loss was only 200 cc in both cases. We conclude that preoperative embolization is an important adjunct in treating patients with large carotid body tumors. The surgical exploration proceeds much smoother, the blood loss is minimal, and patients have minimal morbidity.

Malignant carotid body tumors: report of three cases

The aim of the current report was to describe 3 cases of malignant carotid body tumor (CBT) and to review the literature. My clinical records of 87 CBTs in 81 patients (6 bilateral) were reviewed, 79 of which were operated on. Three malignant cases were found. The first was in a 40-year-old man who presented with pulmonary metastases 6 years after resection of a CBT. He was treated with chemotherapy and interferon, but died with disseminated disease 2 years later. The second case was in a 56-year-old woman who had a 5-cm, fixed, hard mass in the upper aspect of the neck and a paralysis of the left vocal cord. This lesion was completely resected, and a shunt and reconstruction with a saphenous vein graft were performed. Pathology revealed a malignant chemodectoma with invasion to 2 of the 5 lymph nodes removed. Radiotherapy (50 Gy) was given after the operation. She is well and free of disease 68 months after the resection. The third case was in a 61-year-old woman who presented with an 8-cm nontender, hard, immobile mass in the left upper neck that displaced the left wall of the oropharynx toward the midline. A carotid arteriogram showed a CBT. On computed tomography, the tumor extended to the infratemporal fossa with no bone involvement. The lesion was embolized with a 40% reduction in vascularity. At surgical exploration, the tumor involved the sternocleidomastoid muscle and the lymph nodes at levels II and III, and the internal carotid artery could not be dissected free at the skull base, so only a partial resection was performed. This patient was lost to follow-up. These 3 cases are in agreement with the literature. Locoregional control is usually obtained with complete primary tumor resection and lymphadenectomy and eventual radiotherapy. Surgery with radiotherapy seems to be effective for isolated metastases. Current multidisciplinary treatments have been unsuccessful in controlling disseminated disease.

Malignant carotid body tumor: a case report

Carotid body tumors (CBTs) have an unpredictable history with no correlation between histology and clinical behavior. Of reported cases since 1891, local and distant metastases appear in approximately 10% of cases and remain the hallmark of malignancy. Currently, there are not enough data to support a single treatment regimen for malignant CBTs. The reported case demonstrates some unanswered issues with regard to malignant CBTs to include lymph node dissection, the need for carotid resection, and the role of radiation therapy. A 46-year-old pathologist underwent a resection of a Shamblin I CBT, to include jugular lymph node sampling, without complication. There was lymph node involvement, and tumor cells were found on the margins of the pathologic specimen. Subsequent carotid resection with reversed interposition saphenous vein graft and modified neck dissection were performed again without complication. Follow-up at 4 years has been uneventful. Diagnosis of CBTs with the use of magnetic resonance angiography, magnetic resonance imaging, color flow duplex scanning, and the role of arteriography are reviewed. The current treatment options are discussed with reference to primary lymph node sampling, carotid resection, and neck dissection in malignant cases. This case demonstrates that the unpredictable nature of CBTs and their malignant potential warrant aggressive initial local treatment to include jugular lymph node sampling and complete tumor resection.

Catecholamine-secreting carotid body tumor and intracranial aneurysm: coincidence?

BACKGROUND

An extremely rare case of intracranial aneurysm associated with catecholamine-secreting carotid body tumor is presented.

CASE DESCRIPTION

A 64-year-old woman suffering from hypertensive attacks was admitted first to the Otolaryngology Department with a neck swelling. Right common carotid angiography revealed a hypervascular mass at the carotid bifurcation. On the same angiogram a middle cerebral artery aneurysm was discovered incidentally and the patient was referred to the Neurosurgical Department. Because of her history the tumor was considered to be endocrinologically active and the patient underwent alpha- and beta-blockade to protect intraoperative cardiovascular instability. Despite all precautions, during the operation hypertensive crises developed and the aneurysm was clipped with difficulty.

CONCLUSION

Perioperative management designed to avoid complications in treating this rare association is discussed. Although this is the first reported case of an intracranial aneurysm associated with a functional carotid body tumor, a possible etiopathogenesis of the relationship between the aneurysm and hypertensive attacks due to an acute catecholamine-discharging tumor is presented.

Baroreflex failure syndrome after bilateral excision of carotid body tumors: an underestimated problem

Carotid body tumors (CBTs) are relatively rare paragangliomas that develop from neural crest cells at the bifurcation of the common carotid artery. They are generally slow growing and benign. Excision is currently considered the treatment of choice, although vascular and especially neural injuries are still relatively frequent in patients with large or bilaterally resected tumors. The baroreflex failure syndrome (BFS) has recently been identified as a severe, rarely recognized, and certainly underestimated complication after the bilateral excision of CBTs. The present report describes a case of a bilateral CBT followed by BFS and reviews the experiences reported in the literature. In light of the low incidence of malignancy of these tumors, their biologic behavior, their very high rate of cranial nerve palsy, and the occurrence of BFS in bilaterally resected paragangliomas, the current practice of bilaterally removing these tumors is questioned.

Diagnostic and therapeutic approaches to carotid body tumours: report of three cases and review of the literature

BACKGROUND

Carotid body tumour is a rare neoplasm of the carotid body. Three cases of carotid body tumour presenting as a painless progressive mass in the neck region are reported here. A review of the relevant literature regarding carotid body tumours is also presented.

METHODS

Angiographic features were diagnostic of carotid body tumour and complete surgical excision was done.

RESULTS

There was no mortality and minimum morbidity. There were no malignant tumours. All three patients belong to the high-altitude area of Himachal Pradesh.

CONCLUSIONS

A high degree of clinical suspicion of upper posterior triangle neck masses and an accurate diagnostic work-up are needed for operative planning.

Current trends in the detection and management of carotid body tumors

PURPOSE

Because the natural history of carotid body tumors is believed to be unpredictable, immediate surgical removal has been recommended. The present study reviews our experience in the diagnosis and treatment of these uncommon lesions.

METHODS

The medical records of patients who appeared for treatment with carotid body tumors between 1981 and 1997 were reviewed. Patients demographics, mode of presentation, imaging and treatment modalities, Shamblin classification, and neurologic complications (stroke, cranial nerve injuries) were analyzed.

RESULTS

Over the past 16 years, 31 patients with 32 carotid body tumors have been evaluated, with an average follow-up of 3.2 years. The patients were arbitrarily classified into two groups on the basis of the mode of detection. Seventy percent (23 of 32) of the tumors discovered on clinical or self-examination were classified as Group 1; 28% (9 of 32) of the tumors detected during duplex scanning for carotid artery disease (8) or MRI (1) were classified as Group 2. The mean size of chemodectomas found on palpation (4.3 +/- 1.7 cm) was larger than that of those detected by duplex ultrasound (2.7 +/- 1.0 cm; p < 0.05, by paired t test). Preoperative embolization was successfully performed in 5 of 6 instances of large tumors; the remaining patient suffered a procedure-related stroke. Thirty-one carotid body tumors were resected. In one case, the tumor was felt by the primary surgeon to be too small (0.9 x 0.7 cm on duplex scan) to warrant immediate excision; this patient is being followed by periodic duplex scanning. Five neurologic complications were noted in Group 1, one after preoperative embolization and four after surgery. One cranial nerve injury occurred in Group 2. One patient had a large recurrent chemodectoma with clinical evidence of metastatic disease.

CONCLUSION

The increasing use of sophisticated imaging modalities may allow earlier discovery of carotid body tumors before they can be clinically detected. Resection of carotid body tumors of all sizes in appropriate surgical candidates remains the standard of care. Unfortunately, resection of even small tumors is associated with a low but constant incidence of neurologic complications.

An unusual case of carotid body tumour

Carotid body tumours are uncommon but fascinating lesions, which arise from paraganglionic tissue at the bifurcation of the common carotid artery. We report the case history of a 40-year-old female patient who presented initially with a malignant left-sided tumour, followed by a right-sided tumour 17 years later. Although there is no known family history, it is likely, because of the bilateral tumours and the young age at presentation, that the tumour was inherited in this patient. The literature on carotid body tumours is reviewed, with particular emphasis on malignant and multiple tumours and their treatment. We discuss the recently elucidated mechanism of inheritance and its implications for affected patients and their families.

Fine-needle aspiration diagnosis of carotid body tumor: report of a case and review of experience with cytologic features in four cases

A 45-yr-old female presented with a left upper cervical swelling of 4 yr duration. The clinical suspicion of carotid body tumor (CBT) was confirmed by imaging findings, fine-needle aspiration (FNA) cytology, and histology of the resected tumor. Review of our experience with four cases including the present one during 10 yr (1984-1994) showed that the age of the patients ranged from 35 to 45 yr with a mean of 40.8 yr. All four cases were females and had left-sided upper cervical swelling. Clinically one case was diagnosed as cervical lymphadenopathy and there was clinical suspicion of CBT in two cases. Findings of digital subtraction angiogram in four cases and ultrasonography including Doppler ultrasound vascular imaging in three cases were consistent with CBT. The cytodiagnosis was CBT in three cases and inadequate (blood only) in one case. The analysis of detailed cytologic features in three cases revealed blood-rich aspirate with poor to moderate cellularity, indistinct cell outline, and acinar formation. Giant bare nuclei, spindle-shaped tumor cells, and cytoplasmic granulations were observed in two cases each. Histopathology of the resected tumors in two cases confirmed the cytodiagnosis of CBT. FNA cytology played a useful role in arriving at a tissue diagnosis of this rare neoplasm.

Carotid body tumor with concurrent masticatory pain dysfunction

The serendipitous finding of a mass in the left neck unrelated to the prior masticatory muscle findings brought about prompt angiographic and magnetic resonance imaging studies that confirmed the presence of a carotid body tumor. The presence of an unrelated pathologic entity in the area from which prior complaints and findings had originated can be overlooked if one continues to focus on the initial presenting findings. When a more serious and even life-threatening element emerges during the time of painful dysfunction it may be masked by the ongoing symptoms and signs. Failure to recognize the presence of a new component with presenting symptoms similar to those ascribed to myofascial pain dysfunction is fraught with serious consequences for the patient.

Chemodectomas of the Neck

We report the clinical features and surgical management of 7 cases of cervical chemodectoma. Six patients with unilateral sporadic carotid body tumors and 1 with a unilateral tumor of the glomus jugulare were operated on between 1990 and 1994, without cerebrovascular accidents, mortality, or recurrence. Preoperative tumor embolization was employed in 2 cases. Angiography confirmed the diagnosis in all patients.

Carotid Body Paragangliomas

Three case reports discuss similar ultrasonic appearances of carotid body tumors. Ultrasound findings include a hypoechoic mass with multidirectinal color flow located at the carotid bifurcation. The most common sign of a carotid doby tumor is a palpable painless neck mass.

Management of the internal carotid artery during carotid body tumor surgery

Patients with carotid body tumors require accurate preoperative assessment of vessel involvement and the probable impact of interrupting blood flow through the internal carotid artery. Recent developments in imaging, methods of measuring cerebral blood flow, balloon occlusion testing, and techniques to maintain vascular flow when a graft is required have improved the surgeon's ability to completely resect these tumors with reduced complications. We discuss these methods with respect to our review of 20 carotid body tumors in 18 patients. Twenty-five percent of patients were misdiagnosed, and in four patients injury to the vessel wall required appropriate surgical intervention.