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Fancello G, Fancello V, Ehsani D, Porpiglia V, Piras G, Caruso A, Sanna M. Tumor progression in tympanojugular paragangliomas: the role of radiotherapy and wait and scan. Eur Arch Otorhinolaryngol 2024; 281:2779-2789. [PMID: 38184495 DOI: 10.1007/s00405-023-08413-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
INTRODUCTION Tympanojugular paragangliomas (TJ PGLs) are rare tumors characterized by bone infiltration and erosion and a close relationship with critical structures, such as cranial nerves and internal carotid artery. For these reasons, their management represents a tough challenge. Since the fifties, radio-therapy (RT) has been proposed as an alternative treatment aimed at avoiding tumor progression. However, the indolent nature of the tumor, characterized by slow growth, is a crucial factor that needs to be considered before offering radiation. METHODS This study aims to examine tumor progression in RT patients through a systematic review of the literature and in TJ PGL patients who underwent solely wait and scan at our department. RESULTS The rate of tumor progression in the RT group was 8.9%, while in the wait and scan cohort was 12.9%. This data suggests the innate slow growth of PGLs. However, it is not possible to draw certain conclusions because of the wide heterogeneity of the studies. CONCLUSION When complete surgical excision of TJ PGLs is not feasible, appropriate counseling and patient selection, including comprehensive tumor classification, should be performed before proposing RT to control tumor progression, since wait and scan may represent a reasonable option in selected cases.
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Affiliation(s)
- Giuseppe Fancello
- Department of Otology and Skull Base Surgery, Otologic Group, 29121, Piacenza, Italy
- Department of Otorhinolaryngology, Careggi University Hospital, 50134, Florence, Italy
| | - Virginia Fancello
- Department of Otology and Skull Base Surgery, Otologic Group, 29121, Piacenza, Italy.
- Ear Nose and Throat and Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, 44124, Ferrara, Italy.
- ENT Department, Azienda Ospedaliero Universitaria - Sassari, 07100, Sassari, Italy.
| | - Diana Ehsani
- Department of Otology and Skull Base Surgery, Otologic Group, 29121, Piacenza, Italy
- Ear Nose and Throat and Audiology Unit, Department of Neurosciences, University Hospital of Ferrara, 44124, Ferrara, Italy
| | - Vincenzo Porpiglia
- Department of Otology and Skull Base Surgery, Otologic Group, 29121, Piacenza, Italy
- Audiology Unit, Department of Specialistic Surgical Sciences, IRCCS Cà Granda Foundation, Policlinic of Milan, Milan, Italy
| | - Gianluca Piras
- Department of Otology and Skull Base Surgery, Otologic Group, 29121, Piacenza, Italy
| | - Antonio Caruso
- Department of Otology and Skull Base Surgery, Otologic Group, 29121, Piacenza, Italy
| | - Mario Sanna
- Department of Otology and Skull Base Surgery, Otologic Group, 29121, Piacenza, Italy
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Campbell JC, Lee JW, Ledbetter L, Wick CC, Riska KM, Cunningham CD, Russomando AC, Truong T, Hong H, Kuchibhatla M, Kaylie DM. Systematic Review and Meta-analysis for Surgery Versus Stereotactic Radiosurgery for Jugular Paragangliomas. Otol Neurotol 2023; 44:195-200. [PMID: 36728610 DOI: 10.1097/mao.0000000000003781] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Comprehensively analyze tumor control and treatment complications for jugular paraganglioma patients undergoing surgery versus stereotactic radiosurgery (SRS). DATABASES REVIEWED EMBASE, Medline, and Scopus. METHODS The databases were searched for English and Spanish articles from January 1, 1995, to January, 1, 2019, for studies reporting tumor control and treatment side effects regarding patients with jugular paraganglioma treated with surgery or SRS. Main outcome measures included short-term and long-term tumor recurrence, as well as postintervention complications. RESULTS We identified 10,952 original abstracts, 705 eligible studies, and 107 studies for final data extraction. There were 3,498 patients-2,215 surgical patients and 1,283 SRS patients. Bayesian meta-analysis was applied to the extracted data, with tau measurements for study heterogeneity. SRS tumors were larger (3.9 cm 3 versus 8.1 cm 3 ). Meta-analysis results demonstrated low rates of long-term recurrence for both modalities (surgery, 15%; SRS, 7%), with SRS demonstrating lower rates of postintervention cerebrospinal fluid leak, dysphagia, and cranial nerve Vll, lX, X, Xl, or Xll palsies. CONCLUSIONS This study demonstrates excellent control of jugular paragangiomas with both surgery and SRS, with higher rates of lower cranial neuropathies, dysphagia, and cerebrospinal fluid leaks among surgical patients.
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Affiliation(s)
- James C Campbell
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine
| | - Jessica W Lee
- Departments of Radiation Oncology, Duke University Medical Center
| | - Leila Ledbetter
- Medical Center Library, Duke University, Durham, North Carolina
| | - Cameron C Wick
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St. Louis, Missouri
| | | | - Calhoun D Cunningham
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine
| | - Alessandra C Russomando
- Department of Otolaryngology Head and Neck Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - David M Kaylie
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine
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Abstract
BACKGROUND Current treatment strategies for head and neck paragangliomas are moving away from radical resection and toward surgical tumor reduction, in order to preserve function and reduce morbidity. Radiotherapy modalities are alternative primary treatment options. MATERIALS AND METHODS A PubMed search of the relevant literature on genetics and treatment of head and neck paragangliomas was conducted. RESULTS The rapid progress made in genetic research was mainly triggered by two factors: firstly, the establishment of central registries for paraganglioma patients and secondly, the availability of next-generation sequencing methods. Exome sequencing and a gene-panel sequencing approach have already been successfully applied to paraganglioma syndromes. The latter method in particular is rapid and cost-effective, and may soon replace complex genotyping algorithms. The literature provides good evidence that diversified modern treatment options are available to realize individual treatment concepts for almost all paraganglioma manifestations. Generally, small and symptomatic tumors should be completely resected, particularly in younger patients. Considering the patient's age, symptoms, morbidity risk, and comorbidities, larger tumors should be surgically treated in a function-preserving manner. In these cases, primary radiotherapy is an equivalent alternative option. A "wait and scan" strategy is possible in selected cases. DISCUSSION The potential morbidity of surgical treatment must be weighed against the expectable quality of life. Comprehensive consultation with the patient about possible treatment modalities is mandatory. Treatment decision making should involve a multidisciplinary team of experts.
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Abstract
Background Commonly occurring in the head and neck, paragangliomas are typically benign, highly vascular neoplasms embryologically originating from the extra-adrenal paraganglia of the neural crest. Frequently, these tumors are associated with the vagus, tympanic plexus nerve, the carotid artery, or jugular bulb. Their clinical presentation can vary across a wide spectrum of signs and symptoms. Methods We reviewed and compared standard treatment approaches for paragangliomas of the head and neck. Results In general, surgery is the first-line choice of therapy for carotid body tumors, whereas radiotherapy is the first-line option for jugular and vagal paragangliomas. Conclusions Because of the complexity of clinical scenarios and treatment options for paragangliomas, a multidisciplinary algorithmic approach should be used for treating paragangliomas. The approach should emphasize single-modality treatment that yields excellent rates of tumor control, low rates of severe, iatrogenic morbidity, and the preservation of long-term function in this patient population.
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Affiliation(s)
- Kenneth Hu
- Departments of Radiation Oncology (KH) and Otolaryngology-Head and Neck Surgery (MSP), New York University Langone Medical Center, New York, New York
| | - Mark S. Persky
- Departments of Radiation Oncology (KH) and Otolaryngology-Head and Neck Surgery (MSP), New York University Langone Medical Center, New York, New York
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Wanna GB, Sweeney AD, Haynes DS, Carlson ML. Contemporary Management of Jugular Paragangliomas. Otolaryngol Clin North Am 2015; 48:331-41. [DOI: 10.1016/j.otc.2014.12.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Künzel J, Koch M, Brase C, Fietkau R, Iro H, Zenk J. Treatment of cervical paragangliomas: is surgery the only way? Am J Otolaryngol 2014; 35:186-91. [PMID: 24051237 DOI: 10.1016/j.amjoto.2013.08.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/05/2013] [Accepted: 08/12/2013] [Indexed: 12/01/2022]
Abstract
PURPOSE To analyze the results after surgery or stereotactic radiotherapy (SRT) in the treatment of cervical paragangliomas. Against this background, the decision-making algorithm used in the treatment of carotid body tumors (CBTs) and vagal paragangliomas (VPs) was reevaluated relative to the existing literature on the topic. MATERIALS AND METHODS Retrospective study between 2000 and 2012. A total of 27 CBTs and nine VPs in 32 patients were treated. Shamblin class I: 59.3% (n=16); class II: 29.6% (n=8); class III: 11.1% (n=3). Treatment modalities were surgery, radiotherapy, or observation. The end points for analysis were long-term tumor control and integrity of the cranial nerves. RESULTS 21 CBTs and seven VPs underwent surgery; SRT was performed in three CBTs and two VPs. Three CBTs were clinically observed. Permanent nerve paresis followed after surgery for CBTs in five patients (20%) and in all patients with VPs. No impaired cranial nerve function resulted after SRT. The median follow-up period was 4.7 years. The tumor control rate after therapy for CBTs and VPs was 100%. One CBT that received clinical observation showed slow tumor progression. CONCLUSIONS A surgical procedure should be regarded as the treatment of choice in patients with small CBTs. In larger CBTs, particularly in elderly patients with unimpaired cranial nerves, radical surgery should be regarded critically. As surgery for VPs caused regularly impairment of cranial nerves with functional disturbances of various degrees a comprehensive consultation with the patient is mandatory and nonsurgical strategies should be discussed.
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Complex glomus jugulare tumor: management issues. Indian J Otolaryngol Head Neck Surg 2014; 65:676-81. [PMID: 24427738 DOI: 10.1007/s12070-011-0399-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Accepted: 11/24/2011] [Indexed: 10/14/2022] Open
Abstract
Glomus tumors are rare and locally aggressive, vascular paragangliomas of the skull base. Tumors may progress to cause lower cranial nerve palsies and involve the major vascular structure in the skull base, and thus pose very difficult surgical challenges. One such case is presented, the management problems in such "complex glomus jugulare" tumors are discussed, and the literature reviewed.
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de Andrade EM, Brito JR, Mario SD, de Melo SM, Benabou S. Stereotactic radiosurgery for the treatment of Glomus Jugulare Tumors. Surg Neurol Int 2013; 4:S429-35. [PMID: 24349866 PMCID: PMC3858802 DOI: 10.4103/2152-7806.121629] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/13/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The glomus jugulare tumor is a slowly growing benign neoplasm originating from neural crest. There is a high morbidity associated with surgical resection of glomus jugulare. Radiosurgery play a relevant role as a therapeutic option in these tumors and its use has grown in popularity. The authors describe a retrospective series of 15 patients and reviewed the literature about the glomus jugulare tumors. METHODS We reviewed retrospectively the data of 15 patients treated with stereotactic linear accelerator stereotactic radiosurgery (LINAC) radiosurgery between 2006 and 2011. RESULTS The average tumor volume was 18.5 cm(3). The radiation dose to the tumor margin ranged between 12 and 20 Gy. The neurological status improved in three patients and remained unchanged in 12 patients. One patient developed a transient 7(th) nerve palsy that improved after clinical treatment. All tumors remained stable in size on follow-up with resonance magnetic images. CONCLUSIONS The radiosurgery is a safe and effective therapy for patients with glomus jugulare tumor. Despite the short follow-up period and the limited number of patients analyzed, we can infer that radiosurgery produce a tumor growth control with low morbidity, and may be used as a good option to surgical resection in selected cases.
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Affiliation(s)
| | | | - Susana Dias Mario
- Stereotactic Radiosurgery Service, Hospital Bandeirantes, São Paulo-SP, Brazil
| | | | - Salomon Benabou
- Stereotactic Radiosurgery Service, Hospital Bandeirantes, São Paulo-SP, Brazil
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Lieberson RE, Adler JR, Soltys SG, Choi C, Gibbs IC, Chang SD. Stereotactic radiosurgery as the primary treatment for new and recurrent paragangliomas: is open surgical resection still the treatment of choice? World Neurosurg 2012; 77:745-61. [PMID: 22818172 DOI: 10.1016/j.wneu.2011.03.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 01/16/2011] [Accepted: 03/23/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Paragangliomas (PGs) or glomus tumors are rare, and publications comparing treatment alternatives are few. We sought to analyze our experience with stereotactic radiosurgery (SRS), review the literature, and develop treatment guidelines. METHODS We retrospectively examined the outcomes of 41 PGs in 36 patients treated with SRS at Stanford. Our data from medical records, telephone interviews, and imaging studies were combined with previously reported SRS data and compared to results following other treatments. RESULTS With a median clinical follow-up of 4.8 years (3.9 years radiographic), local control was 100%. Complications included increase in preexistent vertigo in one patient and transient cranial neuropathies in two patients. Published surgical series describe a lower local control rate as well as more frequent and severe complications. Published radiation therapy (RT) series document a slightly lower local control rate than SRS, but SRS can be delivered more quickly and conveniently. Open surgery and other combinations of treatments appear to be required for several subpopulations of PG patients. CONCLUSIONS We feel that SRS should be the primary treatment for most new and recurrent PGs. Even some very large PGs are appropriate for SRS. RT remains an appropriate option in some centers, especially those where SRS is not available. PGs occurring in the youngest patients, catecholamine secreting PGs, and PGs causing rapidly progressing neurologic deficits may be more appropriate for open resection. Metastatic PGs may benefit from combinations of chemotherapy and SRS or RT. Treatment guidelines are proposed.
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Affiliation(s)
- Robert E Lieberson
- Department of Neurosurgery, Stanford Hospital and Clinics, Stanford University, Stanford, California, USA.
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Künzel J, Iro H, Hornung J, Koch M, Brase C, Klautke G, Zenk J. Function-preserving therapy for jugulotympanic paragangliomas: A retrospective analysis from 2000 to 2010. Laryngoscope 2012; 122:1545-51. [DOI: 10.1002/lary.23268] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 01/30/2012] [Indexed: 11/08/2022]
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Moe KS, Li D, Linder TE, Schmid S, Fisch U. An update on the surgical treatment of temporal bone paraganglioma. Skull Base Surg 2011; 9:185-94. [PMID: 17171088 PMCID: PMC1656735 DOI: 10.1055/s-2008-1058145] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In 1982, Fisch described his results for the surgical treatment of 74 paragangliomas of the temporal bone, 5 years after his description of the infratemporal fossa approaches (types A and B). This study reviews the subsequent experience of the Department of Otolaryngology-Head and Neck Surgery of the University of Zürich with more than 136 surgically treated cases of paraganglioma of the temporal bone and discusses our current therapy 20 years after the initial description. One hundred nineteen (90%) of the patients had advanced tumors (Fisch class C or C+D), and 81 (68%) had intracranial extension. Total tumor excision was possible in 109 (82%) patients. Subtotal excision was performed in 22 (17%) patients, 21 of whom had intradural tumor invasion. In these cases, the resection was limited not by actual tumor size but by the degree of intracranial intradural tumor extension. Partial tumor excision was undertaken in only 1 patient with a C4De2Di2 tumor. The success rate in preservation of function of the lower cranial nerves was encouraging. Of the 69 patients whose facial nerve status was followed post-operatively, 81% maintained Fisch grade 76 to 100% (House-Brackman grades I and II). Analysis of follow-up data ranging from 2 to 11 years demonstrated 98% disease-free survival when total tumor extirpation was possible. In the patients who underwent subtotal or partial surgical resection there has been no subsequent tumor growth detected by either clinical or neuroradiological evaluation. We have confirmed after more than 20 years of experience that the infratemporal fossa approaches are a safe, highly effective means of surgical management of paragangliomas of the temporal bone, allowing eradication or arrest of disease with minimal morbidity. Limited intradural surgical resection in cases of very extensive tumors can greatly benefit patients for whom complete excision is not an option.
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Gjuric M, Seidinger L, Wigand ME. Long-term results of surgery for temporal bone paraganglioma. Skull Base Surg 2011; 6:147-52. [PMID: 17170971 PMCID: PMC1656562 DOI: 10.1055/s-2008-1058638] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The only way to resolve the dispute about the effectiveness of surgery versus radiation therapy for glomus tympanicum and jugulare tumors is adequate long-term studies. In a retrospective study with an average follow-up period of 15 years (range 11 to 23 years) we reassessed 11 patients with glomus tympanicum tumors and 11 patients with glomus jugulare tumors. Ten of 11 patients with glomus tympanicum tumor were tumor-free after surgery. A temporary facial palsy and an external meatal wall defect were the only surgical complications. The air-bone gap postoperatively closed to within 10 dB in three patients, to within 20 dB in six patients, and to more than 30 dB in one patient. Nine of 10 patients with glomus jugulare tumor receiving complete resection were tumor-free. Less than half the patients experienced new-onset cranial nerve function loss, and all made satisfactory recovery, eliminating the need for tracheostomy or gastrostomy. In two patients, the hearing could be preserved on the preoperative level, but the majority already presented with deafness. In the long-term, surgery remains a treatment of choice for glomus tympanicum tumors. It is also an extremely effective treatment with low morbidity for glomus jugulare tumors, including those with intracranial extension.
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Gjuric M, Völker U, Katalinic A, Wolf SR. Prognostic Factors Including Proliferation Markers Ki-67, bax, and bcl-2 in Temporal Bone Paraganglioma. Skull Base Surg 2011; 7:175-81. [PMID: 17171028 PMCID: PMC1656651 DOI: 10.1055/s-2008-1058593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Valuable criteria with which to predict the clinical behavior of the temporal bone paraganglioma or the response to treatment are lacking. The analysis of markers of cell proliferation is a possibility to estimate the prognosis. Extensive patient data on 40 temporal bone paragangliomas were gathered over the years and correlated with the data obtained by staining histologic sections with bcl-2, bax, and MIB I markers of cellular proliferation. The immunohistochemistry was in all cases negative for bcl-2, positive for bax, and for Ki-67 positive in 20% of tumors. The scores for Ki-67 did not correlate with the majority of clinical parameters, except for treatment modality, preoperative hearing loss, and cranial nerve involvement. The tendency toward poorer hearing and a higher incidence of preoperative lower cranial nerve palsies was demonstrated in patients with higher Ki-67 scores. Furthermore, the higher rate of subtotal tumor removals in these patients reveals technical difficulties in accomplishing a radical removal, although the incidence of residual tumors was thus not affected. In view of the present information obtained with proliferation markers, the site of tumor origin still remains the most predictive variable for the course of the disease.
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Abstract
ABSTRACT
Paragangliomas or glomus tumors are usually low-grade hypervascular tumors occurring in various sites of the autonomic nervous system including the carotid body, glomus vagale and glomus tympanicum. Although the grading of the tumor suggests a benign clinical course, the tumor can be locally malignant and surgical management is sometimes difficult because of postoperative functional loss and local recurrence. In addition, the operative field is generally very bloody and tissue planes are not always well-defined.
Though the optimal management of paraganglioma occurs in a multidisciplinary setting, considering the excellent local control rates with primary irradiation alone, a nonsurgical definitive approach should initially be considered.
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Chen PG, Nguyen JH, Payne SC, Sheehan JP, Hashisaki GT. Treatment of glomus jugulare tumors with gamma knife radiosurgery. Laryngoscope 2010; 120:1856-62. [DOI: 10.1002/lary.21073] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
OBJECTIVES Paragangliomas are rare neuroendocrine neoplasms of the head and neck. Treatment strategies include resection, definitive external beam radiation therapy (EBRT), stereotactic radiosurgery (SRS), or observation alone. Due to their rarity and indolent clinical behavior, the optimal management for long-term control is unknown. METHODS This Institutional Review Board-approved retrospective study identified all paragangliomas of the head and neck treated with definitive fractionated radiotherapy at Duke University Medical Center from 1963 to 2005 with minimum 2-year follow-up. Local control (LC) was calculated using the Kaplan-Meier method. RESULTS Thirty-one patients were identified and treated with EBRT (median dose: 54 Gy, range: 38-65 Gy). Twelve patients were treated with megavoltage photon; 19 were treated with either cobalt-60 or cesium-137. Fourteen (45%) had undergone resection preceding radiation. Median follow-up was 9 years (range: 2-35 years), with 10 patients having greater than 15-year follow-up. LC at 5, 10, and 15 years was 96%, 90%, and 90%, respectively. There were no failures in the group treated with megavoltage photons, although this was not statistically significant (P = 0.28). There was no difference in LC between salvage radiation therapy (RT) used after surgical failure and definitive RT alone (10-year LC, 73% vs. 100%, respectively, P = 0.31). The incidence of acute toxicity greater than grade 2 was 3%, and there were no late toxicities greater than grade 2. CONCLUSIONS RT is an effective and well-tolerated treatment for paragangliomas of the head and neck.
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Paragangliomas of head and neck: a treatment option with CyberKnife radiosurgery. Neurol Sci 2009; 30:479-85. [PMID: 19774334 DOI: 10.1007/s10072-009-0138-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 08/26/2009] [Indexed: 10/20/2022]
Abstract
Paragangliomas are highly vascular and predominantly benign neoplasms that have traditionally been treated by surgery, embolization and/or external beam radiotherapy (EBRT). The aim of this study is to evaluate the short-term local tumor control and safety of CyberKnife radiosurgery for these lesions. Nine patients, eight with jugular glomus paragangliomas and one with a carotid body paraganglioma, were treated. The target contouring was performed on merged CT and MR images. Eight patients were treated with doses ranging from 11 to 13 Gy (mean 12.5 Gy) in a single fraction and one with 24 Gy in three fractions prescribed to 72-83% isodose line. The mean follow-up was 20 months. One patient died from unrelated causes. There were no local recurrences. All eight patients also demonstrated neurological stability or improvement. Neither cranial nerve palsies have arisen, nor has deterioration beyond baseline been observed. In conclusion, CyberKnife radiosurgery appears to be both safe and effective in the treatment of skull base paragangliomas. Determining whether long-term complications will arise will require further investigation.
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Gamma knife radiosurgery for the treatment of glomus jugulare tumors. J Neurooncol 2009; 97:101-8. [DOI: 10.1007/s11060-009-0002-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Accepted: 08/11/2009] [Indexed: 10/20/2022]
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Gemmete JJ, Ansari SA, McHugh J, Gandhi D. Embolization of vascular tumors of the head and neck. Neuroimaging Clin N Am 2009; 19:181-98, Table of Contents. [PMID: 19442905 DOI: 10.1016/j.nic.2009.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Juvenile nasopharyngeal angiofibromas and paragangliomas are the most common hypervascular tumors of the head and neck that require embolization as an adjunct to surgery. A detailed understanding of the functional vascular anatomy of the external carotid artery is necessary for safe and effective endovascular therapy. Embolization, using a transarterial technique and particulate agents, a direct puncture technique and liquid embolic agents, or both techniques may allow for complete devascularization of hypervascular tumors of the head and neck. Effective embolization of these tumors results in a significant reduction of blood loss during surgery and allows for complete resection of the tumors. Use of meticulous technique and a thorough knowledge of functional anatomy of the head and neck vasculature are essential.
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Affiliation(s)
- Joseph J Gemmete
- Department of Radiology, Division of Interventional Neuroradiology, University of Michigan Health System, Ann Arbor, MI 48109-0030, USA.
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Miller JP, Semaan MT, Maciunas RJ, Einstein DB, Megerian CA. Radiosurgery for Glomus Jugulare Tumors. Otolaryngol Clin North Am 2009; 42:689-706. [DOI: 10.1016/j.otc.2009.04.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kaylie DM, O'Malley M, Aulino JM, Jackson CG. Neurotologic surgery for glomus tumors. Otolaryngol Clin North Am 2007; 40:625-49, x. [PMID: 17544699 DOI: 10.1016/j.otc.2007.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article reviews the important aspects of glomus tumor management. The biology and histology of these tumors are unique and have an impact on treatment strategies. Nonsurgical options, such as radiation therapy, are discussed. Surgical resection can be performed safely only after appropriate diagnostic testing is completed. Imaging and other diagnostic testing are explored. The various resection and reconstructive strategies are discussed.
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Affiliation(s)
- David M Kaylie
- The Otology Group of Vanderbilt, Department of Otolaryngology Head and Neck Surgery, Vanderbilt University Medical Center, 300 20th Avenue North, Suite 502, Nashville, TN 37203, USA.
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Bitaraf MA, Alikhani M, Tahsili-Fahadan P, Motiei-Langroudi R, Zahiri A, Allahverdi M, Salmanian S. Radiosurgery for glomus jugulare tumors: experience treating 16 patients in Iran. J Neurosurg 2006; 105 Suppl:168-74. [DOI: 10.3171/sup.2006.105.7.168] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectGlomus jugulare tumors (GJT) have traditionally been treated by surgery or fractionated external-beam radiotherapy. The aim of this retrospective study was to determine the tumor control rate, clinical outcome, and short-term complications of stereotactic radiosurgery in subsets of patients who are poor candidates for these procedures, based on age, medical problems, tumor size, or prior treatment failure.MethodsThe Leksell Gamma Knife was used to treat 16 patients harboring symptomatic, residual, recurrent, or unresectable GJTs. The age of the patients ranged from 12 to 77 years (median 46.5 years). Gamma Knife surgery (GKS) was performed as primary treatment in five patients (31.3%). Microsurgery preceded radiosurgery in 10 patients (62.5%) and fractionated radiotherapy in three patients (18.8%). The median tumor volume was 9.8 cm3 (range 1.7–20.6 cm3). The median marginal dose applied to a mean isodose volume of 50% (range 37–70%) was 18 Gy (range 14–20 Gy).Neurological follow-up examinations revealed improved clinical status in 10 patients (62.5%), a stable neurological status in six (37.5%), and no complications. After radiosurgery, follow-up imaging was conducted in 14 patients; the median interval from GKS to the last follow up was 18.5 months (range 4–28 months). Tumor size had decreased in six patients (42.9%), and the volume remained unchanged in the remaining eight (57.1%). None of the tumors increased in volume during the observation period.Conclusions According to the authors' experience, GKS represents a useful therapeutic option to control symptoms and may be safely conducted in patients with primary or recurrent GJTs with no death and no acute morbidity. Because of the tumor's naturally slow growth rate, however, long-term follow-up data are needed to establish a cure rate after radiosurgery.
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23
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Abstract
The infratemporal fossa approach type A is the best way to deal with recurrent tympano-jugular paragangliomas because facial nerve rerouting is fundamental to reaching the area of the internal carotid artery, where recurrence is likely to occur. Preservation of lower cranial nerve function is not feasible when there is tumor infiltration of the medial wall of the jugular bulb; any attempt at nerve dissection increases the risk of leaving some tumor remnants. Correct management of the internal carotid artery, including preoperative stent insertion or permanent preoperative balloon occlusion, is usually a fundamental step when dealing with these highly vascularized lesions. Because of the tumor tendency to infiltrate the bony structures, aggressive drilling of the temporal bone is also advised, especially at the level of the petrous apex. Patients affected by uncontrolled recurrences still die of this disease.
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Affiliation(s)
- Mario Sanna
- Gruppo Otologico, via Emmanueli 42, 29100, Piacenza, Italy.
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24
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Krych AJ, Foote RL, Brown PD, Garces YI, Link MJ. Long-term results of irradiation for paraganglioma. Int J Radiat Oncol Biol Phys 2006; 65:1063-6. [PMID: 16682153 DOI: 10.1016/j.ijrobp.2006.02.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Revised: 02/15/2006] [Accepted: 02/16/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE The management of paragangliomas is controversial. Observation, surgery, external-beam radiotherapy (EBRT), and stereotactic radiosurgery (SRS) may, alone or in combination, be appropriate, depending on the size and extent of the tumor, previous treatment, and patient age, general health, and neurologic condition. Few data exist regarding long-term tumor control and late effects after EBRT or SRS. METHODS AND MATERIALS We performed a retrospective review of all patients treated with EBRT or SRS for paraganglioma at our institution between 1967 and 1994. The endpoints of the study were tumor control and late complications. RESULTS The 33 patients in this study had a median follow-up of 13 years (range, 4 months to 36 years). The 10-year tumor control rate was 92% (95% confidence interval, 75-98%). At the last follow-up visit, no patient had developed a radiation-induced malignancy. CONCLUSION External-beam RT and SRS are safe and effective for enlarging and/or symptomatic paragangliomas. The risk of developing a delayed radiation-induced malignancy after EBRT or SRS is low. This risk must be weighed against the significant immediate and permanent risk of cranial nerve deficits if the tumor is untreated or is surgically resected. This risk must also be weighed against the immediate but low risk of surgical mortality.
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Affiliation(s)
- Aaron J Krych
- Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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25
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Kaylie DM, Wittkopf JE, Coppit G, Warren FM, Netterville JL, Jackson CG. Revision lateral skull base surgery. Otol Neurotol 2006; 27:225-33. [PMID: 16436994 DOI: 10.1097/01.mao.0000181186.34034.9a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe functional and reconstructive results after revision lateral skull base surgery with comparison of benign and malignant lesions. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS All patients undergoing revision surgery for benign and malignant lateral skull base tumors. INTERVENTIONS Surgical resection of recurrent lateral skull base tumors and reconstruction of resulting defects. MAIN OUTCOME MEASURES Cranial nerve function postoperative complications. RESULTS Forty operations for recurrent lateral skull base tumors occurred between January 1, 1987, and December 31, 2003, with follow-up of at least 1 year. Thirty-three operations were for benign lesions, 27 of which were glomus tumors. Seven operations were for malignant tumors. Fifty-eight percent of patients had preoperative cranial nerve deficits (66% of benign tumors and 14% of malignancies). The most common preoperative deficit occurred in the Xth cranial nerve. Postoperative cranial nerve deficits were seen in 95% of patients and multiple nerve deficits were seen in 75%. The most common postoperative deficits were observed in the IXth and Xth cranial nerves. Thirty-one patients had one previous procedure, six had two previous procedures, and three had three previous procedures. Abdominal fat and temporoparietal fascia were the most common reconstruction materials. There was one case of meningitis, two cerebrospinal fluid leaks, and one pseudomeningocele. There was one recurrent adenoid cystic tumor resulting in death and two partially resected glomus tumors. Subsequent procedures are discussed. CONCLUSION Postoperative cranial deficits are more common after revision skull base surgery than after primary surgery. Complete resection without recurrence can be expected for revision skull base surgery. Modern reconstruction techniques reduce major postoperative complications and morbidity from cranial nerve deficits.
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Affiliation(s)
- David M Kaylie
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37203, USA.
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26
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Willen SN, Einstein DB, Maciunas RJ, Megerian CA. Treatment of Glomus Jugulare Tumors in Patients with Advanced Age: Planned Limited Surgical Resection Followed by Staged Gamma Knife Radiosurgery: A Preliminary Report. Otol Neurotol 2005; 26:1229-34. [PMID: 16272947 DOI: 10.1097/01.mao.0000176170.41399.fd] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To minimize treatment comorbidities in glomus jugulare tumor patients with advanced age while reducing pulsatile tinnitus and preserving or improving residual hearing using a limited middle ear/mastoid tumor resection and postoperative gamma knife radiosurgery to tumor remnants in the jugular foramen region. STUDY DESIGN Retrospective consecutive case review of five patients. SETTING Tertiary referral, academic medical center. PATIENTS Patients with advanced age (mean, 69.6 yr; range, 61-78 yr) harboring symptomatic glomus jugulare tumors. INTERVENTION All patients were treated with resection of middle ear and mastoid portions of tumor and subsequent gamma knife radiosurgery to jugular foramen portion of tumor. MAIN OUTCOME MEASURES Length of hospitalization; hearing, pulsatile tinnitus, cranial nerve, and tumor control status. RESULTS All patients were treated on an outpatient surgical basis without the need for blood transfusion. There were no incidents of a change in cranial nerve status (Cranial Nerves VII, IX, X, XI, and XII) in the immediate postoperative period. All patients had improvement or resolution of pulsatile tinnitus with preservation or improvement of preoperative hearing levels. Tumor volume was stable or reduced in all patients at mean follow-up of 19 months (range, 11-24 mo). Gamma knife radiosurgery (mean peripheral dose of 15 Gy) was not associated with any significant immediate or delayed complications. CONCLUSION Short-term data reveals that staged microsurgical and radiosurgical therapy for glomus jugulare tumors in the symptomatic patient with advanced age is safe and yields favorable results regarding tinnitus, hearing, and cranial nerve status. Long-term data are needed to further evaluate the effectiveness of this treatment algorithm before extrapolating this treatment option to younger patients.
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Affiliation(s)
- Seth N Willen
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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27
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Abstract
The use of skull base techniques in the treatment of benign skull base tumors has allowed access to areas of the brain once considered inaccessible. The most common benign skull base tumors encountered in neurosurgical practice are benign meningiomas, schwannomas, and glomus jugulare tumors. Gross total resection of these lesions gives patients the best possible chance of a cure. In this paper, we review the rationale for the use of skull base surgery techniques for benign skull base tumors.
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Affiliation(s)
- Ketan R Bulsara
- Department of Neurosurgery, University of Arkansas Medical Sciences, Little Rock, AR 72205, USA
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28
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Gottfried ON, Liu JK, Couldwell WT. Comparison of radiosurgery and conventional surgery for the treatment of glomus jugulare tumors. Neurosurg Focus 2004; 17:E4. [PMID: 15329019 DOI: 10.3171/foc.2004.17.2.4] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The optimal management of glomus jugulare tumors remains controversial. Available treatments were once associated with poor outcomes and significant complication rates. Advances in skull base surgery and the delivery of radiation therapy by stereotactic radiosurgery have improved the results obtained using these treatment options. The authors summarize and compare the contemporary outcomes and complications for these therapies. METHODS Papers published between 1994 and 2004 that detailed the use of radiosurgery or surgery to treat glomus jugulare tumors were reviewed. Eight radiosurgery series including 142 patients and seven surgical studies including 374 patients were evaluated for neurological outcome, change in tumor size (radiosurgery) or percent of total resection (surgery), recurrences, tumor control, need for further treatment, and complications. The mean age at treatment for patients who underwent surgery and radiosurgery was 47.3 and 56.7 years, respectively. The mean follow-up duration was 49.2 and 39.4 months, respectively. The surgical control rate was 92.1%, with 88.2% of tumors totally resected in the initial surgery. A cerebrospinal fluid leak occurred in 8.3% of patients who underwent surgery and recurrences were found in 3.1%; the mortality rate was 1.3%. Among patients who underwent radiosurgery, tumors diminished in 36.5%, whereas 61.3% had no change in tumor size, and subjective or objective improvements occurred in 39%. Despite the presence of residual tumor in 100% of radiosurgically treated patients, recurrences were found in only 2.1%, the morbidity rate was 8.5%, and there were no deaths. CONCLUSIONS Death and recurrences after these treatments are infrequent, and therefore both treatments are considered to be safe and efficacious. Although surgery is associated with higher morbidity rates, it immediately and totally eliminates the tumor. The radiosurgery results are very promising, although the incidence of late recurrence (after 10-20 years) is unknown.
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Affiliation(s)
- Oren N Gottfried
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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29
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Al-Mefty O, Teixeira A. Complex tumors of the glomus jugulare: criteria, treatment, and outcome. Neurosurg Focus 2004. [DOI: 10.3171/foc.2004.17.2.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Tumors of the glomus jugulare are benign, slow-growing paragangliomas. Their natural history, surgical treatment, and outcome have been well addressed in the recent literature; however, there remains a subgroup of complex tumors—multiple, giant, malignant, neuropeptide-secreting lesions, and those treated previously by an intervention with an adverse outcome—that is high risk, presents surgical challenges, and is associated with treatment controversy. In this article the authors report on a series of patients with complex glomus jugulare tumors and focus on treatment decisions, avoidance of complications, surgical refinements, and patient outcomes.
Methods
In this retrospective study, the patient population was composed of 11 male and 32 female patients (mean age 47 years) with complex tumors of the glomus jugulare who were treated by the senior author within the past 20 years. These include 38 patients with giant tumors, 11 with multiple paragangliomas (seven bilateral and four ipsilateral), two with tumors that hypersecreted catecholamine, and one with a malignant tumor. Six patients had associated lesions: one dural arteriovenous malformation, one carotid artery (CA) aneurysm, two adrenal tumors, and two other cranial tumors.
All but one patient presented with neurological deficits. Cranial nerve deficits, particularly those associated with the lower cranial nerves, were the prominent feature. Twenty-eight patients underwent resection in an attempt at total removal, and gross-total resection was achieved in 24 patients. Particularly challenging were cases in which the patient had undergone prior embolization or CA occlusion, after which new feeding vessels from the internal CA and vertebrobasilar artery circulation developed.
The surgical technique was tailored to each patient and each tumor. It was modified to preserve facial nerve function, particularly in patients with bilateral tumors. Intrabulbar dissection was performed to increase the likelihood that the lower cranial nerves would be preserved. Each tumor was isolated to improve its resectability and prevent blood loss. No operative mortality occurred. In one patient hemiplegia developed postoperatively due to CA thrombosis, but the patient recovered after an endovascular injection of urokinase. In four patients a cerebrospinal fluid leak was treated through spinal drainage, and in five patients infection developed in the external ear canal. Two of these infections progressed to osteomyelitis of the temporal bone. There were two recurrences, one in a patient with a malignant tumor who eventually died of the disease.
Conclusions
Despite the challenges encountered in treating complex glomus jugulare tumors, resection is indicated and successful. Multiple tumors mandate a treatment plan that addresses the risk of bilateral cranial nerve deficits. The intra-bulbar dissection technique can be used with any tumor, as long as the tumor itself has not penetrated the wall of the jugular bulb or infiltrated the cranial nerves. Tumors that hypersecrete catecholamine require perioperative management and malignant tumors carry a poor prognosis.
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30
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Al-Mefty O. Commentary: Complex tumors of the glomus jugulare: criteria, treatment, and outcome. Neurosurg Focus 2004. [DOI: 10.3171/foc.2004.17.2.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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32
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Pareschi R, Righini S, Destito D, Raucci AF, Colombo S. Surgery of Glomus Jugulare Tumors. Skull Base 2003; 13:149-157. [PMID: 15912172 PMCID: PMC1131844 DOI: 10.1055/s-2003-43325] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The treatment of choice for glomus jugulare tumors is still controversial. High rates of morbidity, incomplete resection, and the aggressive behavior of these tumors are the main arguments for advocates of primary radiotherapy. However, constant refinements in skull base techniques have made complete resection of these lesions a realistic goal. The high probability of achieving local control of these tumors by surgery has convinced us to support this option strongly. Between 1993 and 2000 we diagnosed 52 glomus tumors of the temporal bone. Of these patients, only 42 had a class C lesion (glomus jugulare) and were included in this study; 37 of these patients underwent surgery, 10 of whom had intracranial extension of the disease. The overall resection rate was 96 %. Facial nerve function at 1 year was House-Brackmann grade I to II in 52 % of patients and grade III or better in 84 % of patients. Hospitalization was shorter than 14 days in 33 patients (89 %). All patients with pharyngolaryngeal palsy had sufficient compensation at discharge. Twelve vocal chord Teflon injections were performed after surgery to reduce hoarseness and aspiration. No patient died. No relapse was observed (mean follow-up, 4.9 years).
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Affiliation(s)
- Roberto Pareschi
- Unità Operativa Otorinolaringoiatria, Azienda Ospedale Legnano, Legnano, Italy
| | - Stefano Righini
- Unità Operativa Otorinolaringoiatria, Azienda Ospedale Legnano, Legnano, Italy
| | - Domenico Destito
- Unità Operativa Otorinolaringoiatria, Azienda Ospedale Legnano, Legnano, Italy
| | - Aldo Falco Raucci
- Unità Operativa Otorinolaringoiatria, Azienda Ospedale Legnano, Legnano, Italy
| | - Stefano Colombo
- Scuola di Specializzazione in ORL–Padova, Castellanza (VA), Italy
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33
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Eustacchio S, Trummer M, Unger F, Schröttner O, Sutter B, Pendl G. The role of Gamma Knife radiosurgery in the management of glomus jugular tumours. ACTA NEUROCHIRURGICA. SUPPLEMENT 2003; 84:91-7. [PMID: 12379010 DOI: 10.1007/978-3-7091-6117-3_11] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Glomus jugular tumours are usually managed by microsurgical resection and/or radiotherapy with considerable risk for treatment-related morbidity. The role of Gamma Knife Radiosurgery (GKRS) in the management of these lesions remains to be defined. METHOD Between May 1992 and November 2000, 19 patients with glomus tumours underwent GKRS at our department. Nine patients received radiosurgery for residual or recurrent paragangliomas following microsurgical resection and in 10 cases GKRS was performed as primary treatment. The median tumour volume was 5.22 ccm (range: 0.38-33.5 ccm). Marginal doses of 12-20 Gy (median 14 Gy) were applied to enveloping isodose volume curves (Range: 30-55%, median 50%). FINDINGS Except for an 81-year-old patient who died 9 months after radiosurgery the observation time ranged from 1.5 to 10 years (median 7.2 yrs). The total tumour control rate was 94.7% (7 cases with decreased and 11 with stable tumour size). The only patient with tumour progression (5.3%) underwent repeated radiosurgical treatment 85 months after initial GKRS. A newly diagnosed second lesion in the cavernous sinus was treated radiosurgically as well 53 months after the first Gamma Knife procedure. On clinical examination 10 patients (52.6%) presented with improved and 8 patients (42.1%) with unchanged neurological status. Deterioration in one patient (5.3%) was not related to tumour or radiosurgery. INTERPRETATION As GKRS demonstrated to be a minimally invasive treatment alternative to microsurgery and radiotherapy with no acute or chronic toxicity it should be considered more frequently in the primary or adjuvant strategy for glomus jugular tumours.
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Affiliation(s)
- S Eustacchio
- Department of Neurosurgery, Karl-Franzens University, Graz, Austria
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34
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Abstract
OBJECT Tumors of the glomus jugulare are benign, slow-growing paragangliomas. Their natural history, surgical treatment, and outcome have been well addressed in the recent literature; however, there remains a subgroup of complex tumors--multiple, giant, malignant, neuropeptide-secreting lesions, and those treated previously by an intervention with an adverse outcome--that is high risk, presents surgical challenges, and is associated with treatment controversy. In this article the authors report on a series of patients with complex glomus jugulare tumors and focus on treatment decisions, avoidance of complications, surgical refinements, and patient outcomes. METHODS In this retrospective study, the patient population was composed of 11 male and 32 female patients (mean age 47 years) with complex tumors of the glomus jugulare who were treated by the senior author within the past 20 years. These include 38 patients with giant tumors, 11 with multiple paragangliomas (seven bilateral and four ipsilateral), two with tumors that hypersecreted catecholamine, and one with a malignant tumor. Six patients had associated lesions: one dural arteriovenous malformation, one carotid artery (CA) aneurysm, two adrenal tumors, and two other cranial tumors. All but one patient presented with neurological deficits. Cranial nerve deficits, particularly those associated with the lower cranial nerves, were the prominent feature. Twenty-eight patients underwent resection in an attempt at total removal, and gross-total resection was achieved in 24 patients. Particularly challenging were cases in which the patient had undergone prior embolization or CA occlusion, after which new feeding vessels from the internal CA and vertebrobasilar artery circulation developed. The surgical technique was tailored to each patient and each tumor. It was modified to preserve facial nerve function, particularly in patients with bilateral tumors. Intrabulbar dissection was performed to increase the likelihood that the lower cranial nerves would be preserved. Each tumor was isolated to improve its resectability and prevent blood loss. No operative mortality occurred. In one patient hemiplegia developed postoperatively due to CA thrombosis, but the patient recovered after an endovascular injection of urokinase. In four patients a cerebrospinal fluid leak was treated through spinal drainage, and in five patients infection developed in the external ear canal. Two of these infections progressed to osteomyelitis of the temporal bone. There were two recurrences, one in a patient with a malignant tumor who eventually died of the disease. CONCLUSIONS Despite the challenges encountered in treating complex glomus jugulare tumors, resection is indicated and successful. Multiple tumors mandate a treatment plan that addresses the risk of bilateral cranial nerve deficits. The intrabulbar dissection technique can be used with any tumor, as long as the tumor itself has not penetrated the wall of the jugular bulb or infiltrated the cranial nerves. Tumors that hypersecrete catecholamine require perioperative management and malignant tumors carry a poor prognosis.
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Affiliation(s)
- Ossama Al-Mefty
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.
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35
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Abstract
The management of vagal paragangliomas is extremely challenging. Treatment of these lesions must be tailored individually for each patient. The best treatment modality depends on the patient's age and health and the size and extent of the tumor. This article discusses clinical presentation, multicentric and malignant vagal paragangliomas, evaluation, embolization, surgical management, and special considerations in the management of vagal paragangliomas.
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Affiliation(s)
- J C Sniezek
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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36
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Abstract
The ideal management of most paragangliomas is complete surgical excision. Because of technical advances, issues of resectability have given way to issues of functional outcome and postsurgical quality of life. This article reviews the surgical strategy for craniocervical paragangliomas. Intracranial extension, defect reconstruction, and cranial nerve rehabilitation are addressed.
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Affiliation(s)
- C G Jackson
- The Otology Group, Nashville, Tennessee 37203-2138, USA.
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37
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Gjuric M, Rüdiger Wolf S, Wigand ME, Weidenbecher M. Cranial nerve and hearing function after combined-approach surgery for glomus jugulare tumors. Ann Otol Rhinol Laryngol 1996; 105:949-54. [PMID: 8973281 DOI: 10.1177/000348949610501204] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In this retrospective study, oncologic and functional results of 46 patients treated for glomus jugulare tumor are reported. The standard surgical approach was the combined transmastoid-transcervical approach, modified according to the individual tumor growth, and eventually combined with a transtemporal or a suboccipital approach. Complete tumor removal resulted in a cure rate of 90%. New-onset cranial nerve palsies developed in less than 22% of patients. In 54% of cases it was possible to retain middle ear function. From a total of 12 patients with incomplete tumor removal and postoperative irradiation, progressive tumor growth was noted in 4 patients, and was controlled by salvage irradiation or surgery. Radical tumor removal by ablative surgery can be modified by efforts to reduce multilating resections. In their place, individually tailored and combined multidirectional surgical approaches may allow total tumor removal with lower morbidity.
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Affiliation(s)
- M Gjuric
- Department of Otorhinolaryngology, University of Erlangen-Nuremberg, Germany
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38
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Abstract
The intravagal paraganglioma is a very rare tumor of the head and neck that accounts for only 5% of the paragangliomas in that area. A painless mass in the high neck with extension into the peripharyngeal space is the most common characteristic of this tumor. Malignant paragangliomas with invasion of the cervical lymph nodes and carotid artery have been reported, but the presence of metastasis, rather than the histological findings, is the only parameter for classifying them as malignant tumors. Despite the numerous descriptions of the efficacy of radiation therapy, the histological findings of irradiated specimens have shown little effect of radiation therapy on the chief cells. The only curative therapy for intravagal paragangliomas is the total resection of the tumor. Using the supra-adventitia dissection plane, we were able to achieve total resections in four cases of complex intravagal paraganglioma. The surgical management of these cases was complex because of the following: 1) misdiagnosis as a carotid body tumor, 2) previous radiation therapy and surgical procedure, 3) association with glomus jugulare, and 4) a giant tumor with invasion of the temporal bone and encasement of the internal carotid artery. We report the surgical management of intravagal paragangliomas and the role of radiation therapy, hormonal secretion, and rehabilitation care.
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Affiliation(s)
- L A Borba
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, USA
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39
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Firlik KS, Kondziolka D, Lunsford LD, Janecka IP, Flickinger JC. Radiosurgery for recurrent cranial base cancer arising from the head and neck. Head Neck 1996; 18:160-5; discussion 166. [PMID: 8647682 DOI: 10.1002/(sici)1097-0347(199603/04)18:2<160::aid-hed8>3.0.co;2-#] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Treatment options for head and neck cancers that recur at the cranial base are limited. METHODS Twelve patients with head and neck cancers recurrent after resection and fractionated radiotherapy (n = 11) at the cranial base had stereotactic radiosurgery using the gamma unit. The median dose to the tumor margin was 16 Gy. Imaging follow-up varied from 3 to 17 months; the longest clinical follow-up was at 35 months. RESULTS Three of 8 tumors studied by postradiosurgery imaging remained unchanged in size, 3 decreased, and 2 were no longer visible. There was no morbidity or worsening of symptoms after radiosurgery. Four patients died between 4 and 8 months and did not have postradiosurgery imaging performed. Mean survival after radiosurgery was 10.5 months, with 7 patients (58%) still living. CONCLUSIONS Radiosurgery proved safe and effective in providing local control for recurrent cranial base cancers arising from the extracranial head and neck. Radiosurgery should be considered for those patients who have failed prior fractionated radiation or surgical resection, those who have tumors in high-risk cranial locations, or those who are poor medical candidates. Although this study shows its potential adjuvant role, longer follow-up and increased clinical experience will be necessary to evaluate the overall role of radiosurgery in head and neck cancer.
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Affiliation(s)
- K S Firlik
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania, USA
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40
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Jackson C. Neurotologic skull base surgery for glomus tumors with intracranial extension. ACTA ACUST UNITED AC 1994. [DOI: 10.1016/1043-1810(94)90044-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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