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

A single-session stereotactic radiosurgery for vagal paraganglioma: Effective tumor reduction and innovative treatment option

Background

Vagal paragangliomas (VPs) are rare tumors in the upper cervical region. Although surgical resection is the standard treatment for these tumors, it carries significant risks due to the tumor's high vascularity and proximity to vital structures. Stereotactic radiosurgery (SRS) for skull base paraganglioma could be a minimally invasive alternative.

Case Description

We report the case of a 47-year-old man with a large, asymptomatic VP who was successfully treated with SRS with Gamma Knife Icon, which was performed in the parapharyngeal space (volume: 25.7 mL) using a marginal dose of 14 Gy to the 45% isodose line. This case illustrates the successful treatment of a lesion near the conventional limits (lower limit of C2 vertebral body) using noninvasive mask fixation. Excellent tumor control without neurological deficits was achieved for 25 months after SRS. The tumor volume decreased by 70% (final volume: 7.6 mL).

Conclusion

This study demonstrates the utility of Gamma Knife Icon, which facilitates optimal SRS for upper cervical lesions, including VPs.

Glomus jugulotympanicum tumor treated with radiation therapy: A case report with review of literature

Glomus tumors (or paragangliomas) are rare, benign tumors of neuroendocrine origin that appear in tissues of paraganglionic origin. This clinical entity poses a significant treatment challenge due to its proximity to critical neurovascular structures, thus the potential of morbid functional damage caused by disease progression and/or treatment approach. While surgery remains the standard of care for such cases, there has been an increasing trend toward management with radiotherapy or close observation. Here, we present a case of a large and irregularly shaped glomus jugulotympanicum tumor that was treated with volumetric arc radiotherapy. Given the risk of cranial neuropathy with surgery, radiation was the preferred treatment modality. This case demonstrated the safety and efficacy of volumetric arc radiotherapy in the management of a large glomus tumor with a complex shape.

Head and Neck Paragangliomas: Overview of Institutional Experience

Head and neck paragangliomas (HNPGLs) are rare and have high rates of genetic mutations. We conducted a retrospective review of 187 patients with 296 PGLs diagnosed between 1974 and 2023. The mean age of diagnosis was 48.8 years (range 10 to 82) with 69.0% female and 26.5% patients with multiple PGLs. Among 119 patients undergoing genetic testing, 70 (58.8%) patients had mutations, with SDHB (30) and SDHD (26) being the most common. The rates of metastasis and recurrence were higher among patients with SDHB mutations or SDHD mutations associated with multiple PGLs. Metabolic evaluation showed elevated plasma dopamine levels were the most common derangements in HNPGL. MRI and CT were the most common anatomic imaging modalities and DOTATATE was the most common functional scan used in this cohort. Most patients (81.5%) received surgery as the primary definitive treatment, while 22.5% patients received radiation treatment, mostly as an adjuvant therapy or for surgically challenging or inoperable cases. Systemic treatment was rarely used in our cohort. Our single-center experience highlights the need for referral for genetic testing and metabolic evaluation and for a team-based approach to improve the clinical outcomes of patients with HNPGLs.

Contemporary management of paragangliomas of the head and neck

Head and neck paragangliomas (HNPGLs) are rare neuroendocrine tumors typically arising from nonsecretory head and neck parasympathetic ganglia. Historically thought of as aggressive tumors that warranted equally aggressive surgical intervention, evidence has emerged demonstrating that the vast majority of HNPGLs are slow growing and indolent. It is also now recognized that a large proportion of HNPGLs are hereditary with succinate dehydrogenase gene mutations typically implicated. These recent advances have led to significant changes in the way in which clinicians investigate and treat HNPGLs with most now opting for more conservative treatment strategies. However, a proportion of patients present with more aggressive disease and still require nonconservative treatment strategies. Recent studies have sought to determine in which groups of patients the morbidity associated with treatment is justified. We summarize the recent advances in the understanding and management of these tumors and we provide our recommendations regarding the management of HNPGLs.

Extracranial temporal bone paragangliomas: Re-defining the role of otologic surgery within the scope of function-preserving multimodal concepts

INTRODUCTION

The aim of this study was to present our concept in the management of extracranial temporal bone paragangliomas and demonstrate the outcome after primary surgical management of the middle ear component, with an individualized indication for adjuvant radiotherapy.

MATERIALS AND METHODS

The records of all patients treated for extracranial jugulotympanic paragangliomas by means of primary surgical management between 2010 and 2021 were studied retrospectively.

RESULTS

Twenty-nine patients made up our study sample (mean age 58.8 years). 15 cases were managed solely by means of surgery. Out of the remaining 14 cases with reduction of the middle ear component, adjuvant irradiation was performed in 11 cases, whereas a wait-and-scan strategy was adopted at the patient's request in three cases. No further growth was detected in our study cases.

CONCLUSION

Our protocol seems to be associated with an acceptable quality of life and a satisfactory oncologic outcome.

Identifying Factors Influencing Decision Making in Patients Diagnosed with Carotid Body Tumors: An Exploratory Study

BACKGROUND

Carotid body tumors (CBTs) are rare highly vascularized and slow enlarging tumors arising from the paraganglionic tissue at the carotid bifurcation. Main treatment options for CBTs are surgical resection or "wait and scan" strategy. The choice for either strategy may be equally good medically in many patients. A structured "shared decision making" (SDM) might be helpful for guiding patients.

OBJECTIVES

To develop an SDM strategy for the surgical treatment, we aim to (1) identify considerations and factors involved in the decision making of patients with CBTs and (2) evaluate the current practice in our clinic and explore the opinions of patients on their treatment.

METHODS

This exploratory study was conducted in patients of the Leiden University Medical Centre (LUMC), The Netherlands. Patients who met the inclusion criteria were invited for a semi-structured interview. All conversations were fully audiotaped and transcripted.

RESULTS

Fifteen patients were included and interviewed. Ten of these patients underwent previously surgical resection of at least one tumor. Five patients underwent the wait and scan policy. The most important factors influencing decision making in CBT treatment are family, fears, co-consultants, and doctor-patient relationship.

CONCLUSIONS

This study has identified the factors influencing decision making in CBT and should be considered during consultations. The decision for surgery or not was mainly influenced by physician preferences and family members' prior experiences.

Active surveillance management of head and neck paragangliomas: case series and review of the literature

Background:

Head and neck paragangliomas are rare. They are usually slow-growing, benign, non-catecholamine secreting tumours, traditionally treated with surgical excision. Complications of surgical excision include lower cranial nerve palsies, stroke and death.

Method:

A retrospective case note analysis was conducted of patients with head and neck paragangliomas treated with a watch-and-scan policy from March 2003 to September 2015, and the relevant literature was reviewed.

Results:

Fifteen head and neck paragangliomas were identified. None of the patients developed a new lower cranial nerve palsy or progression of their presenting hearing loss during the follow-up period. Five patients displayed an increase in maximum linear dimension of 4 mm over an average of 57.4 months. A review of the literature showed that a watch-and-surveillance scan policy is evolving as a treatment option for head and neck paragangliomas without malignant risk factors.

Conclusion:

Readily available surveillance scanning in head and neck paragangliomas enables the monitoring of head and neck paragangliomas, which may allow for avoidance of major surgery.

Stereotactic radiosurgery of glomus jugulare tumors: current concepts, recent advances and future perspectives

Stereotactic radiosurgery (SRS), a very highly focused form of therapeutic irradiation, has been widely recognized as a viable treatment option in the management of intracranial pathologies including benign tumors, malign tumors, vascular malformations and functional disorders. The applications of SRS are continuously expanding thanks to the ever-increasing advances and corresponding improvements in neuroimaging, radiation treatment techniques, equipment, treatment planning and delivery systems. In the context of glomus jugulare tumors (GJT), SRS is being more increasingly used both as the upfront management modality or as a complementary or salvage treatment option. As its safety and efficacy is being evident with compiling data from studies with longer follow-up durations, SRS appears to take the lead in the management of most patients with GJT. Herein, we address current concepts, recent advances and future perspectives in SRS of GJT in light of the literature.

Primary thyroid paraganglioma mimicking medullary thyroid carcinoma: A case report

Primary thyroid paraganglioma (TP) is an uncommon tumor, and in rare cases, this disease tends to mimic medullary thyroid carcinoma (MTC). The present study reports a rare case of primary TP mimicking thyroid carcinoma, accompanied by hyperthyroidism. A 30-year-old female presented with an anterior cervical mass. Pre-operative radiological studies and operative frozen section analysis indicated an atypical MTC. Primary TP was finally diagnosed by pathology and immunohistochemical staining. Laboratory examinations (thyroid hormones tests) and Tc99m emission computed tomography revealed hyperthyroidism. Gene analysis of TP-associated gene mutations was negative. Surgical resection was performed as a curative approach and there is currently no metastasis after 36 months of follow-up. Surgeons must be aware of this disease in order to ensure a correct diagnosis and to prevent them from performing unnecessary procedures. The current study presents a case of primary TP mimicking MTC, discusses the radiographic results and histological characteristics, and provides a review of the associated literature.