Same-Day Preventive Embolization and Surgical Excision of Carotid Body Tumor

Preoperative Embolization Followed by Tumor Resection Without Time Interval in Advanced Juvenile Nasopharyngeal Angiofibroma

PURPOSE

This study explored the feasibility and security of the clinical application of preoperative embolization and tumor resection for advanced juvenile nasopharyngeal angiofibroma (JNA) without a time interval, performed on the same date, and under the same general anesthesia (GA).

MATERIALS AND METHODS

Between December 2020 and December 2023, patients with JNA underwent embolization and resection at our hospital. All patients underwent preoperative embolization using liquid embolic material under GA with partial coil assistance; the tumor was removed immediately under the same GA. Both embolization and resection were performed on the same date in the same hybrid operating room without a time interval. Outcome measures included adverse events, blood loss, residual disease, and recurrence.

RESULTS

Complete tumor embolization and complete tumor resection (R0) were achieved in 27 patients under a single GA. 1/27 patient (3.7%) experienced adverse events related to nontarget embolization of the cerebral vessels. However, due to timely detection and treatment, no functional disability occurred after delayed tumor resection and active treatment for cerebral infarction. During a mean follow-up of 12 months, 25/27 patients (92.6%) had no residual tumor seen on imaging or endoscopic evaluation, while residual tumor was observed in 2/27 patients (7.4%). No further treatments were performed. The mean blood loss in tumor resection was 911 mL (100-3400 mL).

CONCLUSION

No interval between preoperative embolization and tumor resection is a feasible and safe treatment modality in patients with advanced JNA.

Bilateral carotid body tumor management: tips, tricks, strategies, and problems

PURPOSE OF REVIEW

Carotid body tumors (CBTs) are rare neuroendocrine tumors with an annual incidence of 1 : 30 000. Bilateral carotid body tumors (BCBTs) account for 3-5% of all CBTs and are more frequently linked to familial syndromes and potential malignancy. BCBT management is still not universally standardized and depends on multiple factors, including patient's age, risk of malignancy, location, growth rate, size, and related Shamblin and Mehanna classifications.

RECENT FINDINGS

Options of treatment include active surveillance, external beam radiation, and surgery. Surgery is the first-choice treatment, but it may not always be performed especially in elderly patients. Simultaneous BCBT resection is not suggested due to high intra-operative and postoperative risks. The decision to operate on the larger or smaller tumor first is still debated. Whenever feasible, treatment of the larger tumor first to reduce the tumor burden should be preferred but with higher risks of neurovascular injury. Conversely, starting with the smaller tumor first offers a lower risk at initial surgery but may complicate the management of the larger tumor later.

SUMMARY

Surgery for BCBTs, whenever feasible, remains the most indicated treatment but poses a significant risk of neurovascular complications. Resection of the larger, often more symptomatic, and potentially problematic or malignant tumor, reduces the overall disease burden and mitigates risks of rapid progression but involves a higher immediate complication hazard. Multidisciplinary evaluation is essential for balancing surgical risks and long-term outcomes, prioritizing neurovascular preservation and reducing morbidity.

Surgical Management of Carotid Body Tumors: Experience of Two Centers

BACKGROUND

Carotid body tumors (CBTs) are rare but require surgical resection given their potential for growth and malignancy. For some surgical teams, tumor hypervascularity justifies preoperative embolization to facilitate resection and limit complications. The objective of our study was to evaluate 2 different practices of surgical resection with or without preoperative embolization in a 2-center cohort.

METHODS

A consecutive series of patients who underwent CBT surgery, from January 2011 to June 2019, were divided into 2 groups, as to whether they were (embolized CBT [ECBT]) or not (nonembolized CBT [NECBT]) preoperatively embolized. Both groups were compared specifically according to the duration of operation, postoperative complications, and length of stay.

RESULTS

Twenty-two patients with a mean age of 48.5 ± 14.3 years were included. In the series, 23 CBTs were resected: 13 were embolized preoperatively; the mean time between embolization and surgery was 2.62 ± 1.50 days. Both groups were comparable based on characteristics of population and tumor, with a mean size of 33.2 ± 11.9 mm. We noted a significant increase in operation duration in the ECBT group: 151 min (±40.9) vs. 87.0 min (±21); P < 0.01. There was no difference between the 2 groups regarding cranial nerve (50% vs. 46%; P = 1), sympathetic nervous system (20% vs. 23%; P = 1), or vascular nerve (20% vs. 23%; P = 0.18) complications. No cerebrovascular accident was identified. The length of stay was 3.60 days (±1.78) vs. 3.73 days (±1.19; P = 0.44).

CONCLUSIONS

This study reflects the experience of 2 centers in the management of CBT which is a rare pathology with no standardized treatment. Our series showed no significant difference between the ECBT and NECBT groups regarding postoperative complications and length of hospital stay. The reduction in operating time in the NECBT group remains to be demonstrated.

Retrospective, multicenter study of surgical treatment for carotid body tumors with or without preoperative embolization

Background

Carotid body tumor (CBT) is the most common head and neck paraganglioma. Whether preoperative embolization benefits CBT patients who will receive surgical resection is still controversial.

Methods

In this multi-center retrospective study, we collected data from patients with CBT who received surgical treatment without (group A) or with preoperative embolization (group B) from 2011 to 2019. The primary outcome was the rate of death or stroke after 3 years of follow-up. The secondary outcomes of the study were length of operation (LOO), intraoperative blood loss (IBL), length of stay (LOS), rate of recurrence, and rate of cranial nerve (CN) injuries. Descriptive statistics were used to analyze the demographics, clinical characteristics, complications, and follow-up results of the patients.

Results

Between January 2011 and October 2019, 261 consecutive patients (107 male and 154 female) entered analysis. After 3 years of follow-up, no patient died in both groups. Only three patients with stroke were detected: 2/226 (0.9%) in group A vs. 1/35 (2.9%) in group B (p = .308). The LOO in group A was 132.6 ± 64.6 min compared with 152.9 ± 40.4 min in group B (p = .072). IBL in group A was 375.4 ± 497.8 ml compared with 448.0 ± 270.8 ml in group B (p = .400). LOS in group A was 8.3 ± 2.0 days compared with 7.4 ± 1.7 days in group B (p = .016). Seventy-two CN injuries were detected: 65/226 (28.8%) in group A vs. 7/35 (20.0%) in group B (p = .281). There were 65 temporary CN injuries (59 in group A vs. 6 in group B) (p = .254) and seven permanent CN injuries (6 in group A vs. 1 in group B) (p = .945). Three most frequently injured cranial nerves were the pharyngeal branch and superior laryngeal nerve (12.3%), recurrent laryngeal nerve (7.7%) and vagus nerve (7.3%).

Conclusion

There was insufficient evidence to support the efficacy of preoperative embolization. CBT resection alone had a similar rate of stoke, recurrence, and CN injuries when compared with CBT resection with preoperative arterial embolization. Meanwhile, CBT resection alone did not increase LOO and IBL.

Carotid paragangliomas. Alternatives for presurgical endovascular management

Carotid paragangliomas (CP) are rare tumors, representing 0.6% of the head and neck tumors. These tumors have their origin in the carotid body located in the adventitia of the vascular wall of the carotid bifurcation. Among their principal characteristics are hypervascularity, primarily dependent on branches of the external carotid artery, the proximity and possible involvement of the cranial nerves IX, X, XI, XII, and extension to the base of the skull. Complete surgical resection is the first line of management; however, this procedure can be a surgical challenge due to the potential risk of bleeding, intraoperative neurovascular injuries, and prolonged surgical time. Tumor embolization, carotid stenting, and tumor embolization with carotid stenting have been developed as alternative presurgical endovascular techniques that decrease tumor vascularity and/or provide structural vascular support, reducing bleeding and facilitating tumor dissection. Two cases of carotid tumors of the same classification, Shamblin II, are presented, one treated by preoperative embolization and the other managed with a carotid stent; the indications, advantages, and possible complications of each one are discussed. Two cases of Shamblin II carotid tumors are presented, one treated preoperatively with a carotid stent and the other with preoperative embolization. A literature review was carried out, with a search in PubMed that includes case reports, case series, review articles, meta-analyses on CP, presurgical tumor embolization, presurgical carotid stent placement, and surgical treatment of carotid body tumor. Hypervascularity and adhesion to the carotid wall are the leading causes of difficulties in surgical resection of CP. Optimal tumor embolization and/or preoperative carotid stent placement reduce intraoperative bleeding and provide vascular structural support, reducing intraoperative and postoperative complications.

Low red blood cell predicts high risk of temporary postoperative complications after carotid body tumor surgical resection

Background

Carotid body tumor (CBT) is a rare paraganglioma located at the carotid bifurcation. The red blood cell count, hemoglobin, and hematocrit are indexes to be evaluated in blood routine tests. The purpose of this study was to clarify their predictive value for temporary postoperative complications in patients that had undergone CBT surgery.

Methods

This retrospective trial included data from 169 patients received surgical treatment for CBT from October 2008 to September 2018 in this retrospective study. Postoperative follow-up was conducted under the guidance of both vascular surgeon and neurologist. The symptoms existed less than 2 years postoperatively were regarded as temporary injuries. The red blood cell count, hemoglobin, and hematocrit were obtained from the complete blood count results of the participants. Analyses of multilevel multivariable regression and descriptive statistics were conducted.

Results

The baseline data showed no significant difference. Patients were predominantly women (53.8%), with a mean age of 42.6 years. The total incidence of temporary postoperative complications was 22 (13.0%), including transient ischemic attack (8, 4.7%), tongue bias (7, 4.1%), dysphagia (2, 1.2%), hoarseness (4, 1.8%), and eyelid ptosis (1, 2.4%). The univariate and multivariate regression analysis results revealed that the occurrence of temporary postoperative complications was increased with age [odd ratio (OR, 0.09; 95% CI (CI), 0.9–1.0; P = 0.014], length of operation time (OR, 1.0; 95% CI, 1.0–1.0; P = 0.005), Shamblin type II vs. I (OR, 0.1; 95% CI, 0.0–0.5; P = 0.008), red blood cell count postoperative (OR, 0.2; 95% CI, 0.1–0.8; P = 0.026), hemoglobin (OR, 0.9; 95% CI, 0.9–1.0; P = 0.011), and hematocrit (OR, 0.8; 95% CI, 0.7–1.0; P = 0.025). The smooth curve fitting showed that the trend of complications occurrence rate was reduced with the increase of patients’ postoperative red blood cell count, hemoglobin, and hematocrit. Gender, weight, length of operation, Shamblin type, postoperative red blood cell count, hemoglobin, and hematocrit were included in the risk model with AUC = 0.86.

Conclusion

These patients with CBT who received surgical resection with low postoperative red blood cell, hemoglobin, or hematocrit had a high risk of temporary postoperative complications. The risk prediction model established for predicting temporary postoperative complications showed satisfactory prediction effects.

Paragangliomas of the head and neck

Paragangliomas are rare neuroendocrine tumors that can be found from the skull base to the pelvis. Head and neck paragangliomas have been historically treated with surgery. However, surgical resection adds risk of injury to vascular structures and cranial nerves that can lead to morbidity such as hoarseness, dysarthria, dysphagia, or aspiration. Recently, improved understanding of the behavior of these tumors and increasing experience in non-surgical treatments such as observation and radiation therapy, have changed the paradigms of management of this entity. Multiple series now show a trend towards a more conservative management, with a higher percentage of patients being observed or treated with radiotherapy. Several factors should be taken into consideration when deciding the most appropriate treatment for head and neck paragangliomas, starting by differentiating carotid body tumors from non- carotid body tumors. In general, surgical resection is normally recommended for carotid body tumors as the complications from treatment are usually minimal. In contrast, for non- carotid body tumors, surgery is often associated with significant functional impairment due to cranial nerve paralysis. As such, non-surgical treatment is now usually recommended for this subset of head and neck paragangliomas. In young patients with no comorbidities and a small to medium carotid body tumors, surgery should be considered. Moreover, surgery should be offered for secreting tumors, malignant tumors, tumors with rapid growth or increase in symptomatology, and when radiotherapy cannot be performed. Conversely, conservative management with active surveillance or radiotherapy can be offered in the remaining cases in order to avoid unnecessary morbidity while still providing acceptable tumor control.

The Influence of Young Age on Difficulties in the Surgical Resection of Carotid Body Tumors

Simple Summary

The aim of this study was to reveal the factors affecting the complexity and difficulties in performing surgery to resect carotid body tumors (CBTs). We analyzed 20 patients with 21 CBTs. We used the “same day surgery” procedure, including preoperative embolization of the feeding arteries in the morning and resection surgery in the afternoon of the same day. Four patients underwent resection of the carotid artery, followed by reconstruction. These four patients were between 18 to 23 years of age at the time of surgery. The mean blood loss and operative time in these patients differed significantly from those in older patients. These results indicated that young age may influence the difficulties faced in CBT surgery, resulting in an increased risk of carotid artery resection. The results obtained from our study could help surgeons safely and effectively perform resection surgery for CBTs.

Abstract

This study evaluated patient characteristics that affect the complexity and difficulties of performing surgery to resect carotid body tumors (CBTs). We retrospectively reviewed the medical records of 20 patients with 21 CBTs who were enrolled in the study. The median patient age was 46 years and the mean tumor diameter was 37.6 mm. The mean blood loss and operative time were 40.3 mL and 183 min, respectively. Four patients underwent resection of the carotid artery followed by reconstruction. These four patients were between 18 to 23 years of age at the time of surgery. The mean blood loss and operative time in these patients were 166 mL and 394 min, respectively, which differed significantly from those of older patients. Therefore, young age influenced the difficulties faced in surgical resection of CBT, with an increased risk of blood loss and carotid artery resection.

The earlier, the better: The beneficial effect of different timepoints of the preoperative transarterial embolization on ameliorating operative blood loss and operative time for carotid body tumors

BACKGROUND

To explore the effect of the optimal time interval from preoperative transarterial embolization to surgery of carotid body tumors by analyzing surgery-related indicators.

METHODS

This single-center retrospective review included 103 patients and 108 carotid body tumor resections performed between June 2010 and June 2020. All carotid body tumors were divided into three groups based on interval time between transarterial embolization and surgery: 1-day group (G1), 2-day group (G2), and 3-day group (G3). Demographics, inflammatory biomarkers, periprocedural details, and postoperative outcomes were analyzed.

RESULTS

Among 103 patients, 48.54% were women, and the mean age was 37.07 years. The tumor sizes were 43.83, 44.31, and 42.84 mm in G1, G2, and G3, respectively, and the blood loss and operative time were 163.68, 331.54, and 683.68 mL, and 182.32, 216.31, and 280.79 mins with the prolonged time interval, respectively. Compared with pretransarterial embolization, the expression of white blood cells (10⁹/L) and neutrophils (10⁹/L) were obviously increased post-transarterial embolization in the three groups (G1: white blood cells 6.81 vs 9.32; neutrophils 0.54 vs 0.74, all P < .05. G2: white blood cells 7.19 vs 10.01, P = .118; neutrophils 0.54 vs 0.77, P < .05. G3: white blood cells 7.08 v. 12.37; neutrophils 0.59 vs 0.80, all P < .05), and those in G3 were significantly higher than those in G1. The incidences of revascularization, which was 30.26%, 53.85%, and 42.10%, and adverse events (26.32%, 30.77%, and 21.05%) were not significantly different among G1, G2, and G3.

CONCLUSION

The optimal time interval between preoperative transarterial embolization and surgical resection resulted as 1 day as patients in this group showed obvious lower blood loss and shorter duration of operation than patients in other groups. Both inflammation and recanalization provided support for these results at some extent.

Is Preoperative Embolization Necessary for Carotid Paraganglioma Resection: Experience of a Tertiary Center

PURPOSE

This study was designed to investigate whether preoperative embolization is a useful procedure to decrease blood loss and neurovascular complications for carotid body tumor (CBT) surgery or not.

METHODS

Medical records of our tertiary care center from 2012 to 2019 were scanned for patients who underwent surgery for CBT, retrospectively. Age, gender, complaint and head and neck examination findings at the time of presentation, preoperative complete blood count parameters, imaging records (cervical magnetic resonance imaging and carotid artery angiography), Shamblin classification, tumor size, intraoperative findings, and postoperative complications were noted.

RESULTS

A total of 26 patients were operated due to CBT between 2012 and 2019 in our clinic; preoperative arterial embolization was performed to 15 (57.7%) patients, and 11 (42.3%) patients were operated without embolization. Youngest patient was 24 years old, while oldest was 69 years and mean age was 44.35 ± 12.73. (embolization group: ages ranging between 24 and 64 with a mean of 41.5 ± 11.02 years; in nonembolization group: ages ranging between 26 and 69 with a mean of 48.1 ± 14.3). Embolization status was not significantly related to cranial nerve injury, vascular injury, overall complications, and hematocrit decrease. Arterial injury is more likely to occur with increasing Shamblin class (r = .39; P = .04). Tumor size is not found to be significantly related to cranial nerve injury, vascular injury, overall complications, and hematocrit decrease, but cranial nerve injury and vascular injury were more likely to occur in large tumors (r = .34; P = .089 and r = .34; P = .087, respectively). Age was significantly and negatively correlated to vascular injury (r = -.51; P = .05). Vascular injury was significantly correlated with gender (male predominance: r = -.64; P = .000).

CONCLUSION

Although preoperative arterial embolization is considered to attenuate the complication risk, we found that there was no significant difference among the patients with or without embolization.

Head and neck paragangliomas: 30-year experience

BACKGROUND

We aimed to review our experience and the changing trends in the management of head and neck paragangliomas (HNPG) over the last three decades.

METHODS

We retrospectively reviewed 103 patients with HNPG treated at our center (1986-2017). We included patients treated with surgery, radiotherapy, and patients maintained under active surveillance.

RESULTS

Of the surgically treated patients (n = 79), 20% (12/59) of the carotid body tumors (CBT) had a cranial nerve deficit as sequela compared to 95% (19/20) of the non-CBT. Radiotherapy controlled growth in all tumors treated with this modality (n = 10). Of the initially observed patients, 70% (14/20) remained stable and did not require additional treatment. Stratifying by decades, there was a progressive increase in patients initially attempted to be observed and a decrease in upfront surgery. No deaths attributable to the HNPG were encountered.

CONCLUSIONS

Surgery is an effective treatment for CBT. Nonsurgical treatment should be considered for non-CBT.