Current management of carotid body tumors

Carotid body tumors (CBTs) are neoplasms that occur at the bifurcation of the carotid artery and are pathologically classified as paragangliomas. In the 4th edition of the WHO classification, paragangliomas are categorized as neoplasms with malignant potential. Clinically, about 5% of CBTs present with malignant features such as metastasis. Currently, it is challenging to distinguish between tumors with benign courses and those that present malignantly. Recent advances in genetic testing have elucidated the genetic characteristics of paragangliomas, including carotid body tumors. Over 20 genes have been identified as being involved in tumor development. Particularly in head and neck paragangliomas, abnormalities in genes related to succinate dehydrogenase are frequently observed. Research is ongoing to understand the mechanisms by which these genes contribute to tumor development. The definitive treatment for CBTs is surgical resection. These tumors are prone to bleeding and often adhere firmly to the carotid artery, making intraoperative bleeding control challenging. The risk of lower cranial nerve paralysis is relatively high, and there is a risk of stroke because of manipulation of the carotid artery. Preoperative evaluation with angiography is essential, and a multi-disciplinary surgical team approach is necessary. In cases where the tumor is difficult to resect or has metastasized, radiation therapy or chemotherapy are employed. Clinical trials involving targeted molecular therapies and radiopharmaceuticals have recently been conducted, with some applied clinically. The development of various new treatments is anticipated, providing hope for therapeutic options in refractory cases.

Head and Neck Malignant Paragangliomas: Experience from a Single Institution

Objectives: To summarize the clinicopathological and genetic features of malignant paragangliomas in head and neck cancer and to explore the appropriate treatment options for this rare lesion. Methods: Six patients harboring head and neck malignant paraganglioma from Beijing Tongren Hospital were retrospectively reviewed. The clinicopathological characteristics, gene mutations, and prognosis of these patients were analyzed. Results: Of these 6 patients, 3 were male and 3 were female; 4 patients harbored malignant carotid body tumors, and two had malignant vagal paragangliomas. Three patients had cervical lymph node metastasis, two presented with lung and bone metastasis, and 1 had lung and liver metastasis. Of the 6 patients, four underwent surgical resection, and the other two patients denied surgery and instead received chemotherapy with paclitaxel, ifosfamide, and dacarbazine. These 2 patients with vagal paraganglioma received postoperative radiotherapy. All 6 patients are still alive at the present time, with a median follow-up time of 66 months. Positive Ki-67 expression in tumor tissue ranged from 1% to 40%. Genetic mutations in SDHD, SDHB, ATR, and MAP3K13 were identified in 4 patients. Conclusions: After comprehensive treatment, head and neck malignant paraganglioma can attain a favorable prognosis. Genetic mutations are commonly detected in patients with malignant paragangliomas. This study also identified mutations in ATR and MAP3K13 in these patients.

Resorbable Purified Porcine Skin Gelatin Cross-Linked with Glutaraldehyde Spheres for Preoperative Embolization of Carotid Body Paraganglioma

Chemodectomas are rare neuroendocrine tumors that typically arise at the carotid bifurcation and progressively englobe the internal and external carotid artery. Surgical asportation of the capsulated mass is the elective treatment. Pre-procedural embolization of this high vascular tumors is highly recommended because it has shown to improve surgical outcome by reducing both, mean blood loss and total operation time. Many different embolization techniques have been described in literature. In the here presented case we opted for an endovascular approach using resorbable purified porcine skin gelatin cross-linked with glutaraldehyde microspheres (Optisphere - MEDTRONIC) as an embolic agent. These turned out to be very safe and effective in improving surgical outcome by reducing operative blood loss and thus reducing treatment-related morbidity.

Descending musculospinal branch of the ascending pharyngeal artery as a feeder of carotid body tumors: Angio-architecture and embryological consideration

INTRODUCTION

Although the ascending pharyngeal artery (APhA) is known as a main feeder of carotid body tumors (CBTs), its detailed architecture and embryological consideration have not been described. The objective of this study was to describe the architecture of a descending feeder of the APhA and to consider its origin embryologically through a review of our CBT embolizations.

METHODS

We retrospectively analyzed data from patients with CBTs who underwent transarterial embolization or angiographic examination-only between July 2010 and February 2017. The arterial supply of the tumors, the number of feeder pedicles, the mean tumor size, embolization materials, complication of embolization, and extent of tumor removal were assessed. The embryological origin of feeding artery was considered based on the literature.

RESULTS

Eighteen patients with 20 CBTs underwent preoperative embolization or angiographic examination. The number of feeder pedicles was significantly related to the size of the CBT (P = 0.0002). The main feeding artery was the descending branch of APhA, which was hypertrophied and tortuous (18/20, 90%). Embryologically, this artery originated from the musculospinal branch and is termed the "descending musculospinal branch".

CONCLUSION

The main feeder of the CBTs was the "descending musculospinal branch" of the APhA and needs special consideration such as dangerous anastomosis for embolization.

Diagnostic and Therapeutic Difficulties in Carotid Body Paragangliomas, Based on Clinical Experience and a Review of the Literature

BACKGROUND

Paragangliomas are rare neuroendocrine tumors, representing 0.03% of all tumors. Half of them develop in the head and neck, and among these 50% are sporadic cervical tumors.

OBJECTIVES

The aim of the study was to carry out an epidemiological and clinical analysis of paraganglioma patients diagnosed and treated at the authors' clinics between 1985 and 2014.

MATERIAL AND METHODS

The medical data of 47 patients were analyzed. All the patients were qualified for surgery. In 43 cases (88%), simple resection of the tumor was performed, including 11 cases (22%) that additionally required vascular suturing, and 5 (10%) that required reconstruction of the internal carotid artery. Carotid vessel repair was performed by shortening the internal carotid artery in 3 cases (6%), using a saphenous vein graft in 2 cases (4%), and by creating an anastomosis between the external carotid artery and the distal portion of the internal carotid artery in one case (2%).

RESULTS

In 40 cases (82%), the course of treatment was uneventful. Three patients (6%) were reoperated because of symptoms of cerebral stroke. Palsy of the hypoglossal nerve occurred in 3 cases (6%), and facial nerve palsy in 2 patients (4%). Six patients (12%) developed postoperative hematomas in the wound. In all the cases, histopathological examinations confirmed carotid paraganglioma.

CONCLUSIONS

Cooperation with an otolaryngologist and vascular surgeon during surgery is recommended due to frequent damage to carotid vessels by carotid paragangliomas. Detection of the tumor in the early stages improves surgical treatment outcomes and reduces the number of complications. Regular postoperative check-ups are necessary due to possible occurrences of multiple tumors.

Experiences in the treatment of patients with multiple head and neck paragangliomas

PURPOSE

To analyze treatment results in the multidisciplinary management of patients with multiple head and neck paragangliomas (HNPs).

METHODS

Retrospective analysis including all patients with multiple HNPs (VP, vagal paraganglioma; JTP, jugulotympanic paraganglioma; CBT, carotid body tumor) treated between 2000 and 2013 at a tertiary referral center.

RESULTS

Ten patients (three men, seven women) had 25 HNPs (two VPs, eight JTPs, and 15 CBTs). The age range at diagnosis was 31-71 years (mean 40.9 years, median 37 years). Nine tumors (four CBTs, three JTPs, two VPs) were treated only with stereotactic radiotherapy (SRT; 50.4-56Gy, mean 55.3Gy) or in one case intensity-modulated radiotherapy (60 Gy). Nine tumors were treated with surgery alone (eight CBTs, one JTP) and three JTPs with subtotal surgery combined with adjuvant SRT. A "wait and scan" strategy was used in three cases (two CBTs, one JTP). The mean follow-up period was 4.3 years (range 0.1-13 years, median 4 years). The rate of tumor control with surgery and/or SRT was 100% (21/21). One patient with a wait-and-scan strategy for CBT had slow asymptomatic progression during a 13-year follow-up.

CONCLUSIONS

The treatment results in this series of patients with multiple HNPs show that a very high rate of long-term tumor control with low morbidity can be achieved using tailored and individualized approaches. All of the different treatment strategies available should be discussed with the patient. In particular, the treatment should involve a multidisciplinary team of experts in the fields of nuclear medicine, genetics, pathology, radiology, radio-oncology, and surgery.

Recurrent carotid body tumors: embolization as a treatment option

INTRODUCTION

We report a clinical case where transcatheter embolization was selected as the primary treatment for a large recurrent carotid body tumor

CLINICAL CASE

A 55 year-old female presented with a painful left cervical mass, with progressive growth, for the past 12 months. She complained of jaw stiffness, odynophagia and dysphonia. She had a former history of bilateral carotid body tumor resection. The patient underwent carotid ultrasound examination that showed a recurrent left carotid body tumor with 7x5 cm in dimension, and occlusion of the left internal carotid artery. Magnetic resonance imaging confirmed the presence of a Shamblin type III tumor. The patient underwent transcatheter embolization of the tumor with 300-500 µm and 500-700 µm Bead-Block®. At 1 year of follow-up, the patient was found asymptomatic.

DISCUSSION

The carotid body is located at the bifurcation of the common carotid artery. With increased size, carotid body tumors can induce significant symptoms and are usually detected by clinical examination. Confirmation of diagnosis is usually given by vascular ultrasound. For highly symptomatic, recurrent and frequently unresectable tumors--in patients unfit for surgery--transcatheter embolization can also be used as an effective palliative treatment.

[Diagnostic and therapeutic analysis of malignant carotid body tumors]

OBJECTIVE

To analyze the diagnosis, treatment and prognosis of the malignant carotid body tumor.

METHODS

The data of pathology, diagnosis, therapy and follow-up of seven patients with malignant carotid body tumor in Peking Union Medical College Hospital from Dec 1949 to Dec 2012 were analyzed retrospectively.

RESULTS

2 cases without the tumor resection. 5 cases were treated with surgical methods, 4 cases with tumor resection and external carotid artery ligation, 1 case with tumor resection and reconstruction of internal carotid artery with saphenous vein. Cranial nerve palsy occurred in 5 cases, of which 3 occurred hypoglossal nerve damage, 2 cases occurred vagus damage, 1 case with hypoglossal, vagus and sympathetic nerve damage. Follow-up was from 2 to 12 years. local tumor recurrence happened in 2-year postoperation and got remote bone and pancreas metastasis in 5-year postoperation in one case, and finally died in 7-year postoperation. 1 case had the internal carotid artery restenosis severely in 1-year postoperation, then performed the stent treatment. 2 cases without operation were still alive. Interestingly, the tumor after radiotherapy was steady in one case. The other received the tumor resection because of the severe syndrome after 8 years.

CONCLUSION

the diagnosis of malignant carotid body tumor should base on occurring extensive invasion of adjacent organs, metastasis and pathology. Early stage surgical excision can reduce the recurrence and complication. Radiotherapy can effectively control local size and distant metastasis.

Head and neck paragangliomas

Head and neck paragangliomas (HNPGL) are rare, slowly growing tumours, presenting as a painless mass in the neck. Multiple genetic mutations are associated with HNPGL; screening can have an important role in patients of a young age and/or with a positive family history and/or malignant HNPGL. The choice of treatment should be made individually, based on the patient's condition, the risk of complications and the aim of therapy. Observation can be a logical choice given the low incidence of malignancy. In the case of intervention, surgery and radiotherapy show comparable results for local control. For definitive eradication, surgery would be the treatment of choice, involving however high risks of complications.

Clinical characteristics and remedies in 45 Iranians with carotid body tumors

Carotid body tumors (CBTs) are rare, slow-growing tumors that should be considered in evaluating every lateral neck mass. This single center study was performed to define demographic features, clinical characteristics and remedies of Iranian patients with CBT. A retrospective review of prospectively collected data was done on 45 patients with 50 CBTs who have been referred to Sina Hospital, Tehran, Iran, during a 10-year period, were investigated in this study. The demographic characteristics, clinical and pathologic features, imagings, preoperative treatments, surgical approach and complications were analyzed. The study group predominantly consisted of females (82%). Age of diagnosis was 18 to 75 years old. Five patients had bilateral CBT. Family history of CBT was positive in seven patients. Most of CBTs were ≤ 3cm in size. All of the patients presented with a neck mass, mostly without pain (84%). Other symptoms included vertigo 4%, dysphasia 4% and tinnitus 2%. There was no patient with cranial nerve involvement at presentation. The most common imaging helping the diagnosis was color Doppler sonography. Three patients had preoperative embolization. All patients underwent surgery and seven patients had post-operative cranial nerve injury. Nine cases underwent external carotid artery ligation and four ones had external carotid repair. Post operative mortality rate was one patient. This study provides epidemiological data on patients with CBT in Iran, which could be useful for health care workers in prompt diagnosis and appropriate work ups for patient's families in bilateral CBTs.

A 22-year Northern Irish experience of carotid body tumours

OBJECTIVES

Carotid body tumours (CBTs) are rare vascular neoplasms originating in paraganglionic cells of the carotid bifurcation. The aim of this study was to review all patients diagnosed with CBTs in Northern Ireland.

METHODS

A retrospective review was performed of all patients who had CBTs treated at our institutions between 1987 and 2009. Patient demographics, clinical symptomatology, investigative modality, therapeutic intervention, pathological analysis and long-term outcomes were assessed.

RESULTS

Twenty-nine patients were identified with 33 CBTs and three glomus intravagale tumours (GITs). Six patients had bilateral CBTs (21%), one of whom had a synchronous GIT. Twenty-six patients underwent a total of 30 operative procedures for the resection of 28 CBTs and 3 GITs. Conventional operative treatment included subadventitial tumour excision. A vascular shunt facilitated arterial reconstruction following the removal of seven (23%) tumours and on six of these occasions (19%) continuity was restored with an interposition vein graft. For access the external carotid artery was ligated during the removal of four tumours (13%). Two tumours were considered malignant. No peri-operative mortalities were recorded. Immediate complications included peri-operative stroke secondary to an occluded vein graft (n=1), requirement of tracheostomy (n=2), emergency haematoma drainage (n=2) and transient cranial nerve damage (n=8). Late complications included pseudoaneurysm of vein graft with subsequent stoke (n=1), permanent cranial nerve damage (n=9), Horner's syndrome (n=1) and an asymptomatic vein graft occlusion (n=1). One patient had tumour recurrence two years post-operatively and died due to pulmonary metastases. Two other patients died of unrelated causes. All other patients remain well with no evidence of tumour recurrence at mean followup of 1801 days (range 159-9208 days).

CONCLUSION

Our long-term experience is comparable with other reported case series where surgical intervention conferred a long-term survival advantage despite associated cranial nerve co-morbidities.

Preoperative embolization of carotid body tumor by direct percutaneous intratumoral injection of N-butyl cyanoacrylate glue assisted with balloon protection technique

Substantial intraoperative bleeding during surgical removal of carotid body tumor may be a major problem in the management of these highly vascularized tumors. Traditional preoperative embolization via a transarterial access has proved effective but is often limited by complex vascular anatomy and small feeding vessels that is difficult to catheterize. We report two cases of carotid body tumor treated with direct puncture and intratumoral injection of N-butyl cyanoacrylate glue (NBCA) assisted with balloon protection technique for preoperative devascularization. The result was impressive and minimal bleeding loss during surgery was observed.

Current concepts in the management of carotid body tumours

OBJECTIVE

To review the current management of carotid body tumours and examine our own experience at the Singapore General Hospital.

STUDY DESIGN

Retrospective review.

SUBJECTS AND METHODS

Case note review of patients treated by the Department of Otolaryngology Head and Neck Surgery, Singapore General Hospital over a period of nine years from January 1999 to December 2007.

RESULTS

There were a total of ten patients. Eight patients underwent surgery with no mortality or major surgical morbidity. Mean follow-up was 3 years and 5 months with no evidence of recurrence. One patient had bilateral tumours and is under surveillance. The last patient had inoperable disease and received radiotherapy.

CONCLUSION

Our series has shown that carotid body tumours can be safely removed surgically. If the internal carotid artery needs to be resected, we prefer the use of a Pruitt-Inahara shunt. Radiotherapy is reserved for large inoperable cases or patients not fit for surgery.

[Selective embolization for surgical treatment of carotid body tumor]

OBJECTIVE

To investigate the value of carotid arteriography and selective embolization in surgical treatment of carotid body tumor.

METHODS

Seven patients with carotid body tumor were operated, and four patients were performed with carotid arteriography and selective embolization before operation. All patients were treated by stripping the carotid body tumor from the carotid artery. Treatment effectiveness of the patients with and without selective embolization were compared.

RESULTS

Seven cases were classified as Shamblin III type. The CT scan and digital subtraction angiography (DSA) showed the tumor lesion in the carotid bifurcation, and the tumor and its relation with the surrounding arteries were expressed by CT and three dimensional CT images. All cases of carotid body tumor were resected without any carotid artery ligation. No serious complications occurred after operation. There was average 160 mL blood loss in operation of four patients that had angiograms and were preoperatively embolized, and average 2.5 h were expended. There was average 600 mL blood loss in operation of three patients without preoperatively embolized, and average 4 h were expended. Preoperatively high-selected embolization of the tumor-feeding artery could effectively reduce the intraoperative bleeding. With 1.5-3 years follow-up, none of the carotid body tumor recurred in all the seven cases.

CONCLUSION

Carotid arteriography and embolization therapy may decrease blood loss and higher risk for operation in the patients with carotid body tumor.

[Combined endovascular and surgical management of carotid paraganglioma]

Surgical intervention is the only method of radical treatment of carotid paraganglioma (CP). Intraoperative blood loss may exceed 2 litters. Ligation of the external carotid artery (ECA) is not always possible technically due to tumour invasion to the ECA's walls. Prior to operation, in order to diminish blood loss it is suggested to perform endovascular embolization (EE) of the vessels feeding the tumour. The case report presented herein concerns an 18-year-old male patient with CP after comprehensive diagnosis including ultrasonographic duplex scanning with Doppler colour mapping, enhanced-contrast spiral computed tomography, selective carotid angiography. The patient was subjected to selective. EE of the afferent vessels of CP. Embolization of the branch of the ascending pharyngeal artery travelling to the lower pole of the tumour, and that of the large branches feeding the upper pole of the tumour from the initial portion of the occipital artery with poly vinyl alcohol (PVA-300) and hydrogel "Embox" was followed by surgical intervention: removal of the tumour, closure of the ostia of the tumour's own arteries, ligation of the EC A. The volume of intraoperative blood loss amounted to 350 ml. The postoperative period proved uneventful with nothing to report. During the check-up examinations of the patient, performed 3, 6, 12 and 24 months after the operation, a good postoperative therapeutic outcome was noted to persist.

[Experience of surgical treatment of carotid body tumor after preoperative embolization of feeding vessels]

OBJECTIVE

To evaluate the effect of preoperative embolization of the feeding vessels of carotid body tumor in the treatment thereof.

METHODS

33 patients with carotid body tumors not less than 3 cm in diameter were examined by color Doppler ultrasound. Polyvinyl alcohol particle 250-1000 microm in diameter were suspended in meglumine diatrizoate or Ultravist and then injected via microcatheter into the feeding vessels until detainment or reflux was seen. Operation was performed 1 day later on 23 patients and 4 days later on 10 patients. External carotid artery to internal carotid artery bypass was performed on 1 case, anastomosis of common carotid to internal carotid artery with auto-saphenous vein interposition on 3 cases, and repair of internal carotid artery on 1 case.

RESULTS

One-stage resection was completed on all tumors. One case suffered contralateral hemiplegia two times in the operative day, on the next day the contralateral lower limb could move, but the patient could not speak clearly and his tongue was not in right position, after 3 months he was completely recovered and MRI illustrated cranial infarction.

CONCLUSION

An important adjunct in treating large carotid body tumor, preoperative embolization makes the surgical exploration proceed much smoother, blood loss become less, and morbidity lower.

[Clinical analysis of 19 carotid body tumors]

PURPOSE

To investigate the diagnosis and therapeutic approaches of carotid body tumor (CBT).

METHODS

In this study, the medical records of 19 patients with carotid body tumor were reviewed retrospectively. These patients had been referred to the Department of Oral and Maxillofacial Surgery in Shandong Provincial Hospital from 1999 to 2004.

RESULTS

B ultrasound, DSA, MRI, CTA were used as the modalities of diagnosis for 19 CBT cases. All patients were submitted to surgical resection of the tumor. Among them, preoperative Matas test was carried out in 7 patients. Monitoring retrograde stump pressure of internal carotid artery was performed in all the cases during the operations. 11 patients underwent TCD examination before and during operation. Internal shunt was applied in 5 cases. Postoperatively, paralysis of hypoglossal never occurred in 4 patients, paralysis of pneumogastric never occurred in one patient, no hemiplegia and death occurred.

CONCLUSIONS

DSA CTA, MRI are more effective modalities to diagnose CBT. The way of choosing local anaesthesia firstly and then general anaesthesia is preferable. Monitoring of TCD, retrograde stump pressure of internal carotid artery and internal shunt application are the keys for successful Surgery.

Stroke from delayed embolization of polymerized glue following percutaneous direct injection of a carotid body tumor

A 52-year-old male with right carotid body tumor underwent direct percutaneous glue (n-butylcyanoacrylate [NBCA]) embolization. Several hours later, he developed left hemiparesis from embolization of the polymerized glue cast. Migration of glue during percutaneous tumor embolization is presumed to occur only in the liquid state, which may lead to stroke or cranial nerve deficits. To the best of our knowledge, this is the first report of delayed glue embolization from a treated hypervascular tumor of the head and neck.

Absence of the Contralateral Internal Carotid Artery: A Challenge for Management of Ipsilateral Glomus Jugulare and Glomus Vagale Tumors

OBJECTIVE

Extensive involvement of the internal carotid artery (ICA) by jugular and vagal paragangliomas represents a challenging problem for skull-base surgeons: radical tumor resection and preservation of the vessel often cannot be achieved in these cases. The aim of this article was to report the management of a complex case of right ipsilateral jugular and vagal paragangliomas in a patient with absence of the contralateral ICA due to a previous removal of a left carotid body tumor. Surgical removal of the lesions was performed after stenting of the cervical and intratemporal segment of the ICA.

METHODS

The charts and all the examinations of the patient were retrospectively reviewed. The patient, a 40-year-old man, was treated at the Gruppo Otologico, a private quaternary referral center for neurotology and skull-base surgery.

RESULTS

The tumors were completely resected during surgery and manipulation of the ICA was greatly facilitated by the stent. No complication occurred during or immediately after surgery; after a follow-up period of 24 months there was no sign of recurrence and imaging studies demonstrated patency of the stented vessel.

CONCLUSION

This report suggests that placement of endovascular stents in the cervical and temporal segments of the ICA has the potential of changing the whole therapeutic management in cases of temporal and vagal paragangliomas that surround and invade the vessel, especially in those cases in which permanent balloon occlusion of the ICA is not feasible.

A multidisciplinary approach to carotid paragangliomas

The surgical management of carotid paragangliomas can be problematic. A multidisciplinary approach was used to include vascular surgery, otolaryngology, and neuroradiology to treat these patients over 9 years. From January 1992 to July 2001, a multidisciplinary team evaluated patients with carotid paragangliomas. Analyzed patient data included age, gender, diagnostic evaluation, tumor size, preoperative tumor embolization, operative exposure, need for extracranial arterial sacrifice/reconstruction, postoperative morbidity including cranial nerve dysfunction, and long-term follow-up. Twenty-five carotid paragangliomas in 20 patients underwent multidisciplinary evaluation and management. Average age was 51 years (range, 28-83 years), and 52% were male. Diagnostic evaluation included computed tomography in 76%, magnetic resonance imaging/magnetic resonance angiography in 52%, catheter angiography in 60%, and duplex ultrasonography in 16%. An extended neck exposure was required in 11 cases (44%), mandibulotomy was used once (4%), and mandibular subluxation was never required. The external carotid artery (ECA) was sacrificed in 8 cases (32%). The carotid bifurcation was resected in 1 patient (4%) requiring interposition reconstruction of the internal carotid artery. Preoperative tumor embolization was performed for 13 tumors (52%). Operative blood loss for patients undergoing preoperative embolization (Group I) was comparable to the nonembolized group (group II): group I lost 365 +/-180 mL versus 360 +/- 101 mL for group II (P = .48). This occurred despite larger tumors (group I - 4.2 cm versus group II - 2.1 cm, P = .03) and a higher mean Shamblin class (group I - 2.5 versus group II - 1.45, P = .001) for group I. There were no perioperative mortalities. Transient cranial nerve dysfunction occurred in 13 CBTs (52%), 2 (8%) of which remained present after 4 months. Patients with carotid paragangliomas benefit from a multidisciplinary team approach. Neuroradiology has been used for selective preoperative embolization, which has decreased estimated blood loss during excision of larger complex tumors. A combined surgical team of otolaryngology and vascular surgery provides for exposure of the distal internal carotid artery as high as the skull base, limited permanent cranial nerve dysfunction, and selective early division and excision of the external carotid artery for complete tumor resection.

[Head and neck paragangliomas: imaging diagnosis and embolization]

OBJECTIVES

To review imaging features of paragangliomas. To determine the usefulness of pre-operative embolization.

MATERIAL AND METHOD

From January 1994 to December 2004, 30 patients at our institution were found to have 33 paragangliomas of the head and neck. They were evaluated with US, CT, MRI, and angiography.

RESULTS

Location distribution was: 16 carotid (1 case of bilateral and 2 of multi-centric presentation are reported), 14 in temporal bone, and 3 vagal. Embolization was performed in 22 cases. It was palliative in 2 cases and adjuvant to surgery (18) or to surgery and radiation therapy (2), resulting in a reduction of surgical complications. Eight patients were operated on and 3 rejected any treatment.

CONCLUSIONS

Imaging studies are essential in the differential diagnosis of head and neck masses. Pre-operative embolization is a major advance in the surgical management of paragangliomas because it decreases potential intra-operative bleeding.

[Combined treatment of embolization followed by surgical resection in carotid paraganglioma]

Carotid body tumors represent a relatively uncommon finding in vascular surgery. We present the case of a 62 years old man with a right carotid paraganglioma diagnosed by cervical ultrasound scanner, magnetic resonance imaging and carotid arteriography. We decided to treat the patient in two times. In a first approach the tumor was percutaneously embolized, later on in a second time the paraganglioma was surgically resected. The patient is doing well without echographic evidence of tumor 3 years after the operation. This modality of treatment, embolization followed by surgical excision is a useful and valuable alternative.

Intratumoral injection of cyanoacrylate glue in head and neck paragangliomas

BACKGROUND AND PURPOSE

Substantial intraoperative bleeding during surgical removal of head and neck paragangliomas may be a major problem in the management of these highly vascularized tumors. Traditional preoperative embolization via a transarterial approach has proved beneficial but is often limited by complex vascular anatomy and unfavorable locations. We report our experience with the preoperative devascularization of head and neck paragangliomas by using direct puncture and an intralesional injection of cyanoacrylate.

METHODS

We retrospectively analyzed nine consecutive patients with head and neck paragangliomas who were referred for preoperative devascularization. Three patients were treated for carotid-body tumors; two for vagal lesions; and four, for jugular paragangliomas. Direct puncture of the lesion was performed by using roadmap fluoroscopic guidance. Acrylic glue was injected by using continuous biplane fluoroscopy. All patients underwent postembolization control angiography and immediate postoperative CT scanning.

RESULTS

Angiograms showed that complete devascularization was achieved in all cervical glomus tumors, whereas subtotal devascularization was achieved in jugular paragangliomas. In this latter location, the injection of acrylic glue was limited by the potential risk of reflux into normal brain territory via feeders from the internal carotid or vertebral artery. The tumors were surgically removed and histologically examined. No technical or clinical complications related to the embolization procedure occurred.

CONCLUSION

Percutaneous puncture of paragangliomas in the head and neck region and their preoperative devascularization by intralesional injection of acrylic glue is a feasible, safe, and effective technique.

Direct percutaneous embolization of a carotid body tumor with n-butyl cyanoacrylate: an alternative method to endovascular embolization

We report ultrasound-guided direct percutaneous injection of n-butyl cyanoacrylate for preoperative embolization of carotid body tumor in a 50-year-old patient. Angiographic road map assistance was used for protection of parent arteries during the injection. After embolization, complete devascularization of the tumor was achieved without complications. The tumor was removed surgically with minimal blood loss. This procedure is effective and promising for preoperative embolization of carotid body tumors.

Glomus tumors: therapeutic role of selective embolization

The primary goals of preoperative embolization of glomus tumors are to reduce the blood loss in the surgical field, minimize the risk of operative complications, and prevent recurrence by contributing to complete resection. Obliteration of a vascular channel may provide additional help in symptomatic relief by decreasing the tumor volume. Selective transarterial embolotherapy outcomes of 17 patients, most of whom had inoperable tumors and were unable to have surgery/radiotherapy because of poor general health, were evaluated to investigate the therapeutic contributions, efficacy, and safety of embolization techniques in the treatment of different glomus tumors and to examine the role of the embolotherapy in the treatment algorithm of such lesions. The pattern of vascular supply of these tumors was also documented. Eleven glomus jugulotympanicum, 4 glomus caroticum, and 2 glomus vagale tumors were embolized for palliative or curative purposes between 1992 and 2000. Coils and combination of coils plus polyvinyl alcohol were used for embolization. Relief of symptoms and patient satisfaction were analyzed within 3 months after the intervention by a questionnaire combined with full ear, nose, and throat and neurological examinations. The results indicate that the use of embolotherapy in the treatment of glomus tumors must be basically preoperative but is not curative.

Paragangliomas of the head and neck

Paragangliomas are neuroendocrine tumors derived from the extra-adrenal paraganglia of the autonomic nervous system. Within the head and neck, they are generally defined and named according to their site of origin, and may be found frequently neighboring vascular structures. Physiologic activity is rare in these neoplasms and they may exhibit patterns of inheritance which predispose their occurrence in families, often with multicentricity. These tumors generally exhibit a slow rate of growth, most often presenting asymptomatically as a space occupying mass lesion noted clinically or radiographically. The most common paraganglioma of the head and neck is the carotid body tumor followed by the jugulo-tympanic and vagal varieties. Other rare sites where this tumor may occur include; the larynx, sinonasal chambers and orbit. Diagnosis is generally made through a combination of clinical findings and radiographic studies. Magnetic resonance represents the most important imaging modality for the evaluation and characterization of suspected head and neck paraganglioma. Definitive management for these lesions should be carefully considered in relation to both tumor and patient-oriented factors, especially in regard to the potential morbidity of treatment. Surgery and radiation therapy represent the main treatment modalities for paraganglioma. The selection of treatment depends on the size, location, and biologic activity of the tumor as well as the overall fitness of the patient. Although radiotherapy may be effective in arresting growth of these tumors, rarely is the neoplasm eliminated without surgical resection. Surgery may be associated with significant morbidity, primarily as a consequence of incurring major cranial nerve injury. Patient selection (relative to age and medical condition) should be carefully considered prior to recommending aggressive surgery for paragangliomas of head and neck, especially in those patients at risk for disabling surgical morbidity.

New parameter of hemoglobin status as an indicator of efficacy of preoperative angioembolization in extracranial hypervascular tumours

BACKGROUND

Routinely, the standard for measuring the success of preoperative embolization procedure as an adjunct in the management of head and neck vascular tumours has been to evaluate the amount of blood loss, duration of surgery, and intraoperative neurovascular injuries.

OBJECTIVE

We hypothesized that the rate of change in the preoperative hemoglobin status would more accurately and objectively reflect the effectiveness of the embolization technique.

MATERIALS AND METHODS

Twenty-six patients with extracranial vascular tumours were divided into two groups (A and B) of 13. Group A patients had preoperative embolization and group B patients directly underwent surgery. The difference between the preoperative and postoperative hemoglobin levels and the percentage rate of change of hemoglobin status were calculated.

RESULTS

The percentage rate of change of preoperative to postoperative hemoglobin is less in group A (9.43%) when compared with group B (18.27%). The ratio of preoperative to postoperative hemoglobin in the two groups is also statistically significant (1:1.9).

CONCLUSIONS

The percentage rate of change of preoperative to postoperative hemoglobin and the ratio of preoperative to postoperative hemoglobin are more accurate and objective parameters for assessment of success of preoperative embolizations rather than other variables such as intraoperative blood loss or duration of surgery.

[Diagnosis and therapy of carotid body tumors]

OBJECTIVE

To summarize the experience in diagnosis and therapy of carotid body tumor.

METHODS

A retrospective review was performed of 46 patients with carotid body tumors diagnosed and treated between February 1968 and March 2001.

RESULTS

Fine-needle aspiration was performed in 2 cases with the the aspirate consisted of blood cells to undergo cytological examination. Blood pool imaging was performed in 12 cases, among which 10 cases (83%) were considered as carotid body tumor. Digital subtraction angiography was performed in 5 cases, all of which were correctly diagnosed. Fifteen cases underwent ultrasound examination, 14 of which (93%) were considered as carotid body tumor. Seven cases underwent computed tomography, among which 5 cases (71%) were considered as carotid body tumor. Four cases underwent magnetic resonance imaging, all of which were correctly diagnosed and 2 of which underwent magnetic resonance angiography. All 46 cases accepted surgical operation, five of them accepted radiotherapy too. The tumors didn't recur during the follow-up period.

CONCLUSION

Ultrasonography is sufficient for the diagnosis of carotid body tumors. MRI/MRA help to draw out reasonable treatment fashion. Surgery is the first choice among treatments for carotid body tumors. Radiotherapy helps control effectively the aggression of tumors. Intraoperative meticulous dissection may decrease the incidence of postoperative complications.

Temporary balloon occlusion and ethanol injection for preoperative embolization of carotid-body tumor

We report on the preoperative embolization of a carotid-body paraganglioma by temporary balloon occlusion and ethanol injection. Complete devascularization was achieved without complication. Resection after a short postembolization interval required artery sacrifice. Histologic evaluation revealed that the tumor contained diffuse ethanol-induced microemboli. Compared with unembolized and polyvinyl-alcohol-embolized carotid-body paragangliomas, our technique resulted in no greater adverse effects on the tumor-vessel interface. This procedure is an effective and promising method of preoperative embolization of carotid-body tumors and warrants further experience and study. In this article, we also review the literature on carotid-body tumor embolization and ethanol embolization.

Carotid body tumor associated with differentiated thyroid carcinoma

We report a case of a carotid body tumor associated with a primary differentiated thyroid carcinoma. A 44-year-old woman presented with a 10-year history of an asymptomatic mass in her neck. Physical examination revealed a pulsatile submandibular mass in her right neck as well as multiple nodules in the thyroid. Magnetic resonance imaging, computed tomography and, in particular, angiography were diagnostic of the carotid body tumor. Slight changes in serum thyroglobulin levels and thyroid scintigraphy led us to suspect thyroid carcinoma. Embolization of the arteries feeding the carotid body tumor was performed, and was followed by tumor resection 24 h later. At surgery, histopathology confirmed the presence of follicular and papillary carcinomas of the thyroid, resulting in concurrent resection of the gland. There were no residual cranial nerve deficits. The patient subsequently received radiotherapy. Diagnosis and surgical management are discussed, together with pathogenetic factors.

[Three cases of carotid body tumor--the usefulness of preoperative radiological studies and embolization]

We report 3 cases of carotid body tumor, computed tomography (CT), magnetic resonance imaging (MRI), and preoperative embolization were conducted in all cases. Carotid body tumor is best treated by surgical removal to ensure a definitive cure. Carotid artery preservation and bleeding control are critical. Although preoperative diagnosis by CT and MRI is relatively easy, the degree of adhesion between a tumor and the carotid artery cannot be determined precisely. Preoperative superselective embolization of the feeding arteries appears useful in decreasing potential intraoperative bleeding and shortening the time required for resection, facilitating the surgical field.

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.

Role of malignancy and preoperative embolization in the management of carotid body tumors

The purpose of this retrospective study is to present our approach to the management of patients with carotid body tumors (CBTs), emphasizing the role of malignancy and preoperative embolization. Between 1975 and 1998 a series of 18 patients with CBTs were treated, and 16 of them underwent successful excision of the tumor. According to the Shamblin classification, six of the tumors were type I, six type II, and six type III. In three of these patients (two with type II tumors and one with type III) in whom preoperative embolization had been performed, mean intraoperative blood loss was 400 ml, whereas in the remaining 13 cases this loss was 700 ml. Two patients with intracranial tumor spread underwent only radiotherapy. Neither postoperative deaths nor strokes occurred. Temporary cranial nerve injury occurred in four cases (25%). Local lymph node invasion was found in two patients, establishing the diagnosis of malignancy. One of these patients developed distal metastases 3 years after the operation and was treated with radiotherapy and octreotide. Follow-up ranging from 30 months to 23 years (mean 5 years) revealed no local recurrence except for the two patients who were treated with radiotherapy only. In conclusion, surgical excision remains the treatment of choice for CBTs and can be performed without major risks and with low morbidity and mortality. Preoperative embolization is helpful by diminishing intraoperative bleeding, and malignancy, though rare justifies early management.

[Bilateral carotid paraganglioma]

We report an unusual case of bilateral paraganglioma of the carotid. The tumor had been neglected for a long time and increased in volume during pregnancy, inducing compression and requiring surgical treatment. We focus on the therapeutic strategy: devascularization followed by percutaneous sclerosis before total surgical removal in a two-step procedure.

Paraganglioma as a systemic syndrome: pitfalls and strategies

Tumours of the neuroendocrine system in the head and neck region are mostly paragangliomas of the glomus tympanicum or jugulare, or of the carotid body. The majority of these tumours are benign, and the coexistence of multiple paragangliomas seems to be rare. Pre-operative embolization and surgery are regarded as primary therapy for these tumours. The treatment regimen in any patient depends on age, general health, hearing status and the function of the lower cranial nerves. Several presentations are possible in which paragangliomas occur as systemic disease. 1. Paragangliomas may occur bilaterally, or, in rare cases, in multiple areas. Pre-operative bilateral angiography is of utmost importance. In case of multicentricity, it might be necessary to proceed without, or just with, unilateral surgery for preservation of adjacent structures. In surgery of jugular vein paraganglioma, we usually perform a modified transmastoidal and transcervical approach with preservation of middle-ear structures and the ossicles. As an alternative or supplement to surgery, radiotherapy or definitive embolization may be used in the treatment of paragangliomas. 2. Paragangliomas may occur as multiple endocrine neoplasia (MEN) syndrome combined with medullary thyroid gland carcinoma, and, facultatively, pheochromocytoma. In these cases, endocrinological examination and magnetic resonance imaging (MRI) of the adrenal region, the thorax and the neck are required for an adequate therapeutic strategy. As MEN may be inherited, family history should be evaluated. 3. Paragangliomas can became malignant and metastasize. Thus, cervical lymph node metastases or distant metastases may occur. We recommend the removal of all ipsilateral lymph nodes and their histological examination.

Carotid body tumors in inhabitants of altitudes higher than 2000 meters above sea level

BACKGROUND

Carotid body tumors (CBTs) are rare. Diagnosis is usually delayed until the tumors reach a critical volume and a mass appears in the neck, which is often asymptomatic.

METHODS

We reviewed retrospectively the cases with CBT diagnosed from 1965 to 1995 in the Hospital de Oncologia in Mexico City with inhabitants at an altitude higher than 2200 m above sea level to see whether these tumors have the same characteristics as those of inhabitants of countries of lower altitudes. We reviewed the clinical features, diagnostic procedures, therapy, results, and complications.

RESULTS

There were 120 CBT cases, which represent 79% of the parapharyngeal space tumors diagnosed at our hospital; 116 (96%) were benign and 4 (3.3%) were malignant. Women predominated (89%), and the female-male ratio was 8.3:1. Five patients had multiple paragangliomas, and one had a family history of CBT. Eighty patients (66%) underwent surgery. This was done by cervical approach in 78 cases (97%), and 2 (2.5%) required additional mandibulotomy. There were three deaths due to brain ischemia after carotid ligature. Forty-one patients were followed without treatment, due to advanced age, concomitant diseases, or great volume of the tumor. Median follow-up of these patients was 47 months, during which time no patient reported additional symptoms, accelerated enlargement of the tumor, or metastasis. With a median follow-up of 54 months, only one patient developed local recurrence and three patients developed distant metastasis.

CONCLUSIONS

We conclude that cases of CBT in our high-altitude population differ significantly from those cases in inhabitants of cities in the U.S. or Europe of less than 1500 m above sea level. Those of high altitudes have an evident female predominance (8.3:1), low rate of bilaterality (5%), and a family history of 1% versus a discrete female predominance (2:1), bilaterality from 10% to 20%, and family history from 7% to 25% in low altitudes. When adequate criteria are used to determine surgical resectability, a complete resection is achieved in 85% of cases, with low or null mortality and high local control.

Embolization of tumors and vascular lesions in the oral and maxillofacial regions

The embolization was used for the treatment of 10 patients with tumors and vascular lesions in the oral and maxillofacial region. The patients were diagnosed as having vascular deformity, hemangioma, hemangiofibroma and chemodectoma. The selective and superselective target artery embolization were conducted and the satisfactory results were achieved. The procedures, effects and precautions of the embolic therapy were also discussed.

[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.