[Malignant paragangliomas--the results of radiotherapy in 6 patients]

Between February 1984 and May 1989, six patients (four male, two female) with malignant paragangliomas of the carotid body (n = 4) and glomus jugulare (n = 2) were irradiated in the Department of Radiation Oncology at Essen University. All patients had macroscopic (residual) tumor at the start of treatment. Five out of six paragangliomas had to be considered malignant, since histological lymph node involvement or distant metastasis was confirmed. In the sixth case extra- and intracranial tumor growth was observed. Total doses between 40 and 55 Gy using cobalt 60, 10 or 15 MeV photons were administered. Radiation therapy was canceled at 30.6 Gy in one patient because of multiple distant metastasis. Three out of four patients, who received curative treatments, were locally controlled (25 to 91 months). A local recurrence in one patient was detected 18 months after irradiation; this patient died of distant metastasis 23 months after treatment. In one out of two palliatively irradiated patients, local control could be achieved until the patient died of distant metastasis twelve months after treatment. Grade III- or grade IV-treatment toxicity was not observed. Radiation therapy of malignant paragangliomas with doses between 45 and 54 Gy in five to six weeks is an effective treatment with low toxicity and should be preferred to surgery in glomus jugulare and advanced carotid body tumors.

Glomus jugulare tumors. Long-term control by radiation therapy

The records of 49 patients with glomus jugulare tumor seen at the University of Virginia from 1932 to 1985 were retrospectively reviewed with the objective of assessing long-term results of treatment. Follow-up ranged from 5 to 31 years, with a minimum of 10 years in 36 patients (73%). According to McCabe's classification, 17 patients (35%) were Group I, 11 patients (22%) were Group II, and 21 patients (43%) were Group III. Analysis by therapeutic technique revealed that 20 patients received surgery alone (41%), 15 patients received radiation therapy alone (31%), and 14 patients received combined therapy (28%). Only 7 patients (14%) have had clinical or radiologic evidence of disease progression. Three of these patients were treated by surgery alone and three by a combination of surgery and radiation, but the dose was less than 4000 cGy. Only one patient treated by radiation therapy alone or with surgery and radiation to a dose in excess of 4000 cGy demonstrated disease progression. Salvage radiation therapy was given to three of the seven patients when progressive disease was detected. Radiation therapy is an effective treatment for glomus jugulare tumor with minimal late progression of disease in adequately treated patients and no significant long-term complications.

Chemodectoma of the head and neck: results of treatment in 84 patients

Eighty-four patients with chemodectoma of the head and neck presented to the Royal Marsden Hospital between 1949 and 1985. For tumors arising at the skull base (glomus jugulare and glomus tympanicum) 46 were treated with radiotherapy alone resulting in an actuarial local control rate of 73% at 25 years; 13 were treated with surgery plus radiotherapy with no recurrences during a median follow-up of 9 years; 4 had surgery alone but all recurred by 7 years. For tumors of the soft tissues of the neck (carotid body and glomus vagale) 13 were treated with surgery alone with an actuarial control rate of 54% at 15 years; 4 were treated with radiotherapy which resulted in local control at 1, 2, 8 and 11 years; and one patient who received both surgery and radiotherapy remained controlled at 1 year. Although comparison between radiotherapy and surgery in terms of tumor control is not simple, the case is argued for more frequent use of radiotherapy at all sites. This case is strengthened by minimal morbidity from radiotherapy in doses which appear effective: in the range of 45-50 Gy in 25 daily fractions over 5 weeks.

Radiation therapy for paragangliomas of the temporal bone

Treatment of paragangliomas of the temporal bone (glomus jugulare and glomus tympanicum tumors) is controversial, with both surgery and radiation therapy having their advocates. This paper discusses the experience at the University of Arizona Health Sciences Center in treating 10 cases of this uncommon tumor between 1971 and 1988. Seven of 10 cases were initially treated using irradiation and achieved complete tumor control for a mean of 67 months (range = 23-107 months). Two patients, one treated surgically and the other by embolization, had recurrences and were salvaged by radiation, and neither has recurred. The final patient is disease-free 9 months after embolization and surgery. There have been no serious sequelae of treatment. We conclude that moderate-dose irradiation can safely control most temporal bone paragangliomas.

[Radiotherapy of glomus jugulare and tympanicum tumors]

Glomus jugulare tumors are difficult to manage therapeutically due to their localisation. Operation may be successful in small tumors but can be hazardous in larger lesions mainly because of bleeding and palsy of cranial nerves. In these cases there should be used radiation therapy under the condition that it is planned by use of computed tomography. Moreover reproducibility of radiation treatment set-up is vital. In this way tumor regression may be achieved. Four own illustrative cases are demonstrated. According to the stage of disease a modified treatment strategy is presented which integrates surgical procedures, angiographic embolization and radiotherapy.

[Current aspects of radiotherapy of glomus jugulare tumors]

Small glomus jugulare tumors can be operated on successfully. The intraoperative risk of bleeding may be reduced by preoperative irradiation or angiographic embolisation. Patients with advanced tumors (bone destruction, paralysis or cranial nerves and/or invasion of brain) are at high risk if they are operated on. In these cases radiotherapy is an effective alternative with a fairly low complication rate. Prerequisites for successful irradiation are assessment of treatment volume and treatment planning by CT, sophisticated stereotactic irradiation techniques, application of high energy photons and reliable immobilisation measures. Furthermore it is possible to deliver higher doses, leading to regression of the tumor and its symptoms. The technique is illustrated by two characteristic cases. Although irradiation alone can achieve tumor remission the long term prognosis remains doubtful.

[Glomus jugulare tumor. Apropos of 2 cases]

We present two clinical cases of jugular glomus in which different kinds of treatment have been adopted. In literature we can find a review of the utility and morbidity of the different methods of exploration as well as the results obtained by the different authors according to the kind of treatment. Nevertheless we don't come to definite conclusions due to the fact that the classifications and curing criteria very in the different series.

The histopathological and clinical features of irradiated and nonirradiated temporal paragangliomas

This study was undertaken to determine the effects of radiation on temporal paragangliomas. The histological features were assessed in a blind fashion from 20 surgical specimens obtained from 20 patients, half of whom received radiotherapy. All patients had progressive temporal paragangliomas and were selected on a random basis for this study. The derived data clearly identify the unpredictable response of these tumors to radiation and supports our contention that surgery is the preferred form of treatment for temporal paragangliomas even after radiation therapy. Analysis of clinical histories reveals that previous radiation therapy is associated with a greater operative blood loss and a longer mean postoperative hospital stay due to delayed healing. Despite this, there was no mortality or serious morbidity from surgery.

[Results of radiation and combination therapy of glomus tumors]

Over the period of 1965-1985 radiation and combined therapy for glomus tumors of different sites was provided to 80 patients aged 34 to 79. Radiation therapy alone was given to 51 patients, of them 18 patients had recurrences of malignant tumors. Radiation therapy following surgery was given to 29 patients. Gamma-beam therapy was given from fields, size from 5 X 5 to 8 X 10 cm, using in some cases lattice and wedge-shaped filters, at a single dose of 2-3 Gy up to a total dose of 60-70 Gy. Of 33 patients with primary malignant tumors 30 lived over 5 yrs., of 18 patients with postoperative recurrences 15 lived for 5 yrs. Of 29 patients who had been on combined therapy, 2 died in 3-5 yrs. of causes unrelated to the main disease.

The role of radiation therapy in the management of catecholamine-secreting glomus tumors

The major source of controversy that surrounds the use of radiation for glomus tumors is the finding of persistent chief cells years after completion of the treatment. Questions have been raised as to the viability of the irradiated chief cell and its capacity to proliferate. The radiotherapists consider a stable glomus tumor a radiation "cure," whereas skull base surgeons are fearful that these lesions will continue to slowly grow and cause problems 20 to 30 years later. We have recently managed a patient who was not a candidate for surgery, with a catecholamine-secreting glomus jugulare tumor. After 4750 rad of radiation therapy, no changes in tumor size or in catecholamine secretion have been observed (at 20 months of followup). The implications of the case are discussed.

Radiotherapy in glomus tumours (paragangliomas). A 25 year-review

57 patients have been reviewed. 39 had radiotherapy (28 glomus jugulare, 7 glomus tympanicum and 4 glomus caroticum/vagale tumours). Two patients have died of their tumour and one patient had increasing nerve involvement during two months after irradiation. It is concluded that the results bear comparison with those of surgery and that extensive surgery in tumours with extratympanal growth is not warranted.

Glomus jugulare tumours seen in Oxford 1960-1984

A review of 14 cases of glomus jugulare tumour is presented. Patients with a long delay in diagnosis and those with cranial nerve palsies were found to have a poor prognosis. A dose response effect for local control was not observed with the radiation doses used. Three times weekly fractionation was well tolerated by adjacent normal tissues.

Radiation therapy in the treatment of chemodectomas

Twenty-six patients with chemodectomas were treated with radiation therapy from 1961 to 1983 and followed for at least 4 years. In 16 glomus tympanicum lesions treated primarily with radiation, long-term control was achieved in all (follow-up 4-24 years, mean 10.5). Fifteen of 16 had no clinical evidence of disease at time of death or last follow-up, and one patient had recurrent but stable disease at 10 years and died of an unrelated illness 19 years after treatment. Eight of the glomus tympanicum lesions were referred for radiation therapy with persistent disease after multiple surgical procedures. Two had extensive skull and intracranial involvement at the time of radiation. Six patients with glomus jugulare lesions were treated with radiation. Four achieved long-term control, and two died of their disease. In addition, two glomus vagal and one carotid body tumor were treated with palliative intent. One glomus tympanicum lesion was treated with preoperative radiation and resection. Chemodectoma was the cause of death in 4 of 25 patients--3 from intracranial extension and 1 from lung and mediastinal metastases. All four patients were referred for radiation with metastases or extensive bone involvement at the skull base. Radiation appears to be effective in achieving long-term clinical control of chemodectomas. Adequately treated volume should be determined with arteriography and/or contrast-enhanced computer tomography, allowing for geometric margins. Doses in the range of 4,500 to 5,000 cGy delivered in about 5 weeks are recommended.

Role of radiation therapy in glomus tumor

Since 1964, we have reported twenty-five cases of glomus tumors. Given the evolution of modern surgical technique, we have divided our cases into two groups. The first group includes patients seen from 1964 to 1975: sixteen cases, of whom eleven underwent successful radiotherapy, with a follow-up after ten years. Since 1975 we have adhered to the following therapeutic principles: We have given radiotherapy (5000 rads in twenty-eight days) to patients older than 65 with glomus tumors that had invaded posterior and medial cranial fossa and carotid canal (type C-D, according to Fisch). We have operated on patients with glomus tumors type A-B. Patients treated since 1975 (N = 9) are in the second group.

The management of glomus jugulare tumours

The treatment details of 58 patients treated for glomus jugulare tumours in Newcastle upon Tyne are examined in the light of other studies reported in the literature. For the group of 55 patients treated by radiotherapy, the 20 year survival is 94% (determined actuarially). The 20 year disease-free survival (determined actuarially) is 77%. This is comparable with other series reported. As no glomus tympanicum tumour has recurred following surgery and there has been no morbidity due to these tumours they have not been included in the series. It is recommended that patients who are fit and have tumours confined to the tympanum should have primary surgical treatment. All other patients should be treated by accurately planned radiotherapy, using a dose of 50Gy in 5 weeks to the tumour volume. The morbidity of this treatment policy will be low.

[Radiologic surveillance of irradiated glomal tumors]

A favorable clinical result was obtained in 10 patients with jugular glomal tumors treated by external radiotherapy (approximately 50 Gy), alone or combined with surgical treatment, and preceded in some cases by embolization. Radiologic review examinations showed complete stability of lesions without bone reconstruction phenomena, in spite of a decrease in tympanic mass and regression of functional symptoms.

Skull base surgery for glomus jugulare tumors

Thirty-six patients with glomus jugulare tumors have been managed over a 13-year period using various combinations of skull base surgery and irradiation therapy. The data resulting from this study are presented; the techniques of diagnosis and treatment are reviewed. We conclude that irradiation therapy alone is a satisfactory form of treatment for elderly and poor-risk patients; preoperative x-ray therapy followed by skull base surgery is an effective treatment for younger patients.

Glomus jugulare tumors revisited: a ten-year statistical follow-up of 231 cases

Glomus jugulare tumors are rather common in the middle ear and temporal bone. They are usually easy to diagnose and surgically remove. However, there are a comparatively large number of these growths which not only cause extensive local destruction, but can spread distally and even have endocrine manifestations. This group is difficult to diagnose and manage despite recent advances in diagnostic procedures and the advent of skull base surgery. There is a void in the literature of a large series of cases being followed for a long period of time. This paper presents a comprehensive detailed statistical ten-year follow-up of 231 glomus jugulare tumors. The results suggest that our present diagnostic procedures often are inadequate in finding small tumors, and our treatment and follow-up are lacking because these tumors tend to recur often at a late date and in a different form. A comprehensive method of approach of diagnosis and treatment is described to manage all cases of glomus jugulare.

Radiotherapy for unusual tumors of the head and neck

The role of radiotherapy is discussed relative to the management of juvenile nasopharyngeal angiofibroma, glomus tumors of the middle ear region, ameloblastoma, extramedullary plasmacytoma of the head and neck, and soft tissue and bone sarcoma. Moderate doses of carefully applied irradiation are effective and can be safely utilized for these conditions.

Radiation therapy in the management of chemodectomas in Nigeria

Chemodectomas constitute a very rare group of tumours. They have been described at various sites in the body and their management, particularly the glomus jugulare tumours is of interest, as surgery in some cases may be hazardous and possibly fatal as a result of severe haemorrhage associated with these tumours. Radiotherapy has been advocated as the treatment of choice particularly for the glomus jugulare tumour. Our experience in the management of this rare group of tumours seen at the only Radiotherapy Unit in Nigeria between 1975 and 1979 is analysed. Radiation therapy techniques, doses given and complications noticed are analysed. There was complete control of the disease in four out of four (100%) of the cases at 1 year and three out of four (75%) at 3 years. Results from other reports in the literature are reviewed.

The treatment of glomus tumors in the temporal bone by megavoltage radiation

Forty-five patients with glomus tumors in the temporal bone region were treated by radiation therapy. Only three patients had recurrence or progression of tumor during the follow-up period of 3 to 23 years (median, 10 years). No patient died from uncontrolled glomus tumor. The majority of patients noted symptomatic relief after radiation, but objective neurologic deficits usually remained unchanged or showed only partial improvement. The most commonly used radiation dose was 3500 cGy tumor dose delivered in 15 fractions in 3 weeks by a homolateral wedge technique from megavoltage radiation apparatus. This dose is less than that usually recommended for glomus tumors. From these results and from review of the literature, it is suggested that a moderate radiation dose of 3500 cGy in 3 weeks is effective treatment for glomus tumors, even if complete tumor involution does not occur.