Current concepts for the surgical management of carotid body tumor

Pediatric carotid body tumors: A case report and systematic review

Carotid body tumors (CBTs), or chemodectomas, are rare, especially in the pediatric population. They often present with minimal symptoms, making timely diagnosis challenging. This case report and systematic review highlights a distinctive presentation and summarize the current evidence on pediatric CBTs. We report a case of a 13-year-old girl presenting with neck pain and a left-sided neck mass. After extensive evaluation, a Shamblin type III tumor was identified and removed surgically. Postoperatively, the patient experienced transient hypertension and significant dysphagia, both of which resolved within a few weeks with no permanent sequelae. Histology confirmed a benign paraganglioma. A systematic literature review of PubMed identified 29 cases from 23 published studies spanning from 1968 to 2024. The average age at diagnosis was 12.6 ± 3.6 years. The most common symptom was a neck mass or swelling, reported in 75% of cases (n = 21). Tumor sizes ranged from 1.3 to 8.0 cm, with Shamblin III being the most frequent classification. Gross total resection (n = 25 [89.3%]) alone or in combination with preoperative embolization (n = 10 [35.7%]) were the most common methods of management. In 62.1% of cases, there were no permanent complication or sequelae. The proximity to vital neurovascular structures and high vascularity in pediatric patients necessitates careful perioperative interdisciplinary management. Owing to their rarity and nonspecific presentation, CBTs often remain undiagnosed for years. They respond well to treatment, but can be fatal if untreated, underscoring the importance of including CBTs in the differential diagnosis of pediatric neck masses.

Carotid body tumor: characteristics and surgical outcome

BACKGROUND

Carotid body tumors are uncommon neuroendocrine growths near the carotid bifurcation. While some advocate preoperative embolization to minimize bleeding, others avoid it due to complications. This study shares the experience of a single center in managing patients with carotid body tumors without practicing preoperative embolization.

METHODS

This was a cross-sectional study of patients with carotid body tumors managed between 2020 and 2024. Data were collected from the hospital's registry. When necessary, routine blood tests, neck ultrasonography, and computed tomography scans were conducted. The tumors were categorized according to Shamblin's classification. The average duration of follow-up was 20 months.

RESULTS

The study involved 25 patients, 22 (88%) females and 3 (12%) males. Their ages ranged from 27 to 85 years old. Twenty (80%) cases presented with neck swelling, and six (24%) had a positive medical history. Tumors were mainly on the right side (52%), with 20 (80%) showing ill-defined neck masses. Tumor sizes ranged from 1.5 to 7 cm, with Shamblin type II tumors being discovered in the majority of cases (72%). Types of tumors were significantly associated with the tumor size (p-value < 0.05). Blood transfusion was required in five cases (20%), three from type III and two from type II, with none from type I (p-value = 0.001). Temporary neurological deficits occurred in 3 cases (12%). No functional impairment or mortality was recorded.

CONCLUSIONS

Carotid body tumors are rare tumors with an unknown etiology. Operation without practicing preoperative embolization may be feasible with an acceptable outcome.

Paragangliomas of the Head and Neck: A Review of the Latest Diagnostic and Treatment Methods

Background and objectives: Paragangliomas of the head and neck are rare, slow-growing neuroendocrine tumors, benign in their vast majority, but with a possibility of developing distant metastases. They show great inheritable character, and their behavior has proven to be unpredictable; therefore, they are considered malignant. Material and methods: This article aims to offer a more comprehensive presentation of the pathogenesis, epidemiology, diagnostic methods, imaging development, and treatment guidelines. We tried to bring together all the necessary data that, in our opinion, a head and neck practitioner should know when managing this type of tumor. Our main focus is on the most recent studies, with the purpose of a homogenous presentation of all current guidelines and approaches to this pathology. Results: Paragangliomas of the head and neck are still a disputed topic. One of the main reasons for that is their low incidence of 0.3 to 1 per 100,000 every year. The most frequent locations are the carotid body, the temporal bone, the jugular and mastoid foramen, and the vagal nerve. Their clinical presentation usually involves a painless lateral mass associated with symptoms such as hoarseness, hearing loss, tinnitus, and cranial nerve deficits. Up to 40% of them are inherited, mostly linked with mutations of succinate dehydrogenase complex. Imaging evaluation consists of CT and MRI, and new functional explorations such as 18F-FDA and 18F-FDG PET/CT, 18F-DOPA PET, 123I-MIBG, and 68Ga-DOTATE PET/CT. Measuring the catecholamine levels in the plasma and urine is mandatory, even though paragangliomas of the head and neck rarely display secretory behavior. Treatment mainly consists of surgery, with different approaches and techniques, but conservative management methods such as wait and scan, radiotherapy, proton therapy, and chemotherapy have proven their efficiency. The therapeutical decision lacks consensus, and current studies tend to recommend an individualized approach. Guidelines regarding long-term follow-up are still a matter of debate.

Surgical outcomes for carotid body tumour resection without preoperative embolization: a 10-year experience

Background

Carotid body tumours (CBTs) are neoplasms originating from the paraganglionic cells of the carotid body. Excision is the main route of treatment. This study sought to assess the surgical outcomes of post-carotid body tumour resection without preoperative embolization and discern any underlying relationships between modified Shamblin classes (MSC) and related complications.

Methods

A retrospective medical record review of prospectively collected data is performed at Sulaymaniyah Teaching Hospital between 2008 and 2019, for 54 patients. Presurgical and postsurgical variables such as comorbidities and complications were noted, respectively.

Results

Patient ages ranged between 26 and 60 years (x̄=40.06) with a minimal female predominance (57.4%). Complications included one minor stroke. MSC and postoperative complications were significantly related (P≤0.001). Our analyses also suggested a significant relationship between intraoperative blood loss and the incidence of postoperative complications (P=0.001, χ²=25). The MSC III subtype was significantly associated with intraoperative blood loss (P=0.000), length of stay (P=0.000), and operating time (P=0.001).

Conclusions

Our study purports a strong relationship between greater MSC and complications of all types. As such, surgeons may benefit from preoperative strategies to minimize complications.

A Global Bibliometric Analysis of the Top 100 Most Cited Articles on Carotid Body Tumors

The carotid body, situated at the common carotid artery bifurcation, comprises specialized glomus cells responsible for sensing blood oxygen, carbon dioxide, pH, and temperature changes, crucial for regulating breathing and maintaining oxygen homeostasis. Carotid body tumors (CBTs), arising from these cells, are rare, representing only 0.5% of head and neck tumors, often presenting as benign, slow-growing, vascularized masses. In February 2023, this bibliometric analysis was conducted, which involved screening 1733 articles from the Web of Science database. The screening process was based on citation count, and articles were selected for inclusion based on specific criteria that focused on CBTs located within the carotid bifurcation. Rigorous selection involved independent screening and data extraction by four authors. The top 100 articles, published between 1948 and 2019, totaled 6623 citations and were authored by 98 unique first authors from 22 countries and 77 institutions, spanning 42 journals. Treatment articles were the predominant category, comprising 49% of the literature. This analysis offers insights into publication trends, identifies literature gaps, and outlines areas of research focus, providing a valuable resource to guide future studies on CBTs.

Hypoxic Signaling Pathways in Carotid Body Tumors

Carotid body tumors (CBTs) are rare tumors with a 1-2 incidence per 100,000 individuals. CBTs may initially present without apparent symptoms, and symptoms begin to arise since tumors grow bigger to compress surrounding tissue, such as recurrent laryngeal nerve and esophagus. Also, the etiology of CBTs remains unclear since it is more likely to occur in those who live in high-altitude areas or suffer from chronic hypoxic diseases such as COPD. SDH mutations and familial inheritance have been reported to be related to CBTs. SDH complexes play crucial roles in aerobic respiration, and SDH mutations in CBTs have been reported to be associated with hypoxia. Hypoxic signaling pathways, specifically hypoxic markers, have attracted more research attention in tumor exploration. However, the existing literature on these signaling and markers lacks a systematic review. Also, therapeutic approaches in CBTs based on hypoxic signaling are rarely used in clinics. In this review, we concluded the role of hypoxic signaling and markers and their potential implications in the initiation and progression of CBTs. Our findings underscore the involvement of the SDH family, the HIF family, VEGFs, and inflammatory cytokines (ICs) in tumorigenesis and treatment. Of particular interest is the role played by SDHx, which has recently been linked to oxygen sensing through mutations leading to hereditary CBTs. Among the SDH family, SDHB and SDHD exhibit remarkable characteristics associated with metastasis and multiple tumors. Besides SDH mutations in CBTs, the HIF family also plays crucial roles in CBTs via hypoxic signaling pathways. The HIF family regulates angiogenesis during mammalian development and tumor growth by gene expression in CBTs. HIF1α could induce the transcription of pyruvate dehydrogenase kinase 1 (PDK1) to inhibit pyruvate dehydrogenase kinase (PDH) by inhibiting the TCA cycle. Then, carotid body cells begin to hyperplasia and hypertrophy. At the same time, EPAS1 mutation, an activating mutation, could decrease the degradation of HIF2α and result in Pacak-Zhuang syndrome, which could result in paraganglioma. HIFs can also activate VEGF expression, and VEGFs act on Flk-1 to control the hyperplasia of type I cells and promote neovascularization. ICs also play a pivotal signaling role within the CB, as their expression is induced under hypoxic conditions to stimulate CB hyperplasia, ultimately leading to CBTs detecting hypoxic areas in tumors, and improving the hypoxic condition could enhance photon radiotherapy efficacy. Moreover, this review offers valuable insights for future research directions on understanding the relationship between hypoxic signaling pathways and CBTs.

MR imaging-based risk stratification scoring system to predict clinical outcomes in carotid body tumors

Objectives

This study aims to evaluate the role of pretherapy MRI in predicting outcomes in carotid body tumors and propose a grading system for high- and low-risk characteristics.

Materials and methods

A retrospective observational study of 44 patients with 51 lesions was carried out from year 2005 to 2020. MR images were reviewed for characteristics of carotid body tumor, and a score was given that was correlated with intra- and postoperative findings. The various other classifications and our proposed Mahajan classification were compared with Shamblin's classification. The area under the curve and ROC curves were used to present the accuracy of different predictive models.

Results

Our scoring system allotted a score of 0 to 15 on the basis of MRI characteristics, with scores calculated for patients in our study ranging from 0 to 13. Lesions with scores of 0-6 were considered low risk (45%), and scores of 7-15 were regarded as high risk for surgery (55%). The Mahajan classification stages tumors into four grades: I (10%), II (20%), IIIa (8%), and IIIb (62%). The frequency of vascular injury was 50% in category I and 64% in category IIIb. The frequency of cranial nerve injury was 50%, 66%, and 27% in categories I, II, and IIIb.

Conclusion

The Mahajan classification of CBTs evaluates high-risk factors like the distance of the tumor from the skull base and the angle of contact with ICA, which form the major predictors of neurovascular damage and morbidity associated with its surgery. Though the Shamblin classification of CBT is the most widely accepted classification, our proposed Mahajan classification system provides an imaging-based alternative to prognosticate surgical candidates preoperatively.

Proteomics analysis of carotid body tumor revealed potential mechanisms and molecular differences among Shamblin classifications

Carotid body tumors (CBTs) are a rare type of paraganglioma, and surgical resection is the only effective treatment. Because of the proximity of CBTs to the carotid artery, jugular vein, and cranial nerve, surgery is extremely difficult, with high risks of hemorrhage and neurovascular injury. The Shamblin classification is used for CBT clinical evaluation; however, molecular mechanisms underlying classification differences remain unclear. This study aimed to investigate pathogenic mechanisms and molecular differences between CBT types. In Shamblin I, II, and III tumors, differentially expressed proteins (DEPs) were identified using direct data-independent acquisition (DIA). DEPs were validated using immunohistochemistry. Proteomics profiling of three Shamblin subtypes differed significantly. Bioinformatics analysis showed that adrenomedullin signaling, protein kinase A signaling, vascular endothelial growth factor (VEGF) signaling, ephrin receptor signaling, gap junction signaling, interleukin (IL)-1 signaling, actin cytoskeleton signaling, endothelin-1 signaling, angiopoietin signaling, peroxisome proliferator-activated receptor (PPAR) signaling, bone morphogenetic protein (BMP) signaling, hypoxia-inducible factor 1-alpha (HIF-1α) signaling, and IL-6 signaling pathways were significantly enriched. Furthermore, 60 DEPs changed significantly with tumor progression. Immunohistochemistry validated several important DEPs, including aldehyde oxidase 1 (AOX1), mediator complex subunit 22 (MED22), carnitine palmitoyltransferase 1A (CPT1A), and heat shock transcription factor 1 (HSF1). To our knowledge, this is the first application of proteomics quantification in CBT. Our results will deepen the understanding of CBT-related pathogenesis and aid in identifying therapeutic targets for CBT treatment.

Microsurgical treatment of carotid body tumors using periadventitial dissection: Analysis of outcomes and prognostic factors in a neurological referral center

Background:

Surgical resection for carotid body tumors (CBTs) is the gold standard of treatment and continues to be a challenging procedure, commonly associated with high vascular injury rates and neurological complications.

Methods:

It is a retrospective case series study between January 2002 and November 2020, with a mean follow-up of 29 months in a single nationwide referral center. Thirty-one patients diagnosed with a carotid body tumor and treated with microsurgical periadventitial resection were included in the study. Patients’ demographics, comorbidities, clinical, radiological factors, and tumor grade, evaluated by the Shamblin scale, were obtained. Statistical analysis was performed on all collected data.

Results:

In this study, we included 31 patients (32 tumors), 80% of the patients were female, and 20% were male, with a mean age of 53 years. One patient presented with bilateral lesions, while 17 tumors were located on the left side. The most frequent symptom was a painless, slow-growing neck mass in 74% of patients. Using the Shamblin classification, 13% of tumors were Grade I, 53% Grade II, and 34% Grade III. In the postoperative period, 3% of patients presented with permanent cranial nerve deficit, while none had vascular injuries or postoperative stroke. A tumor >5 cm increased the risk for nerve lesion by 11 times (OR 12.6, CI 95% 7.4-11.4, P < 0.001).

Conclusion:

Preoperative embolization followed by periadventitial resection by means of a microsurgical technique is a safe and effective approach to remove CBT, with 3% cranial nerve injury rate and no need for vascular sacrifice or reconstruction.

Carotid body tumor encounters over a two-decade period in an academic hospital

Carotid body tumors (CBTs) are rare and mostly benign. Research outcomes usually arise from single-center data. We conducted this study to present the characteristics and outcomes of patients who underwent surgical resection of CBT at our hospital over the past 20 years. In this retrospective review, the records of CBTs in our hospital were reviewed between 1998 and 2021. All patients who underwent CBT resection were included. The follow-up period was 12 months. A total of 44 CBTs were treated in our hospital. The male-to-female ratio was 1:2.4. Only 4.5% of patients had Shamblin I tumors. Patients with Shamblin II and III tumors were 56.8% and 38.6%, respectively. Duplex scan was used to diagnose CBT in all of the patients. The majority of our patients (97.7%) did not receive any preoperative embolization despite an average tumor size of 4.9 cm. Cranial nerve injuries were observed in 29.5% of cases. Meanwhile, stroke was reported in only two cases (4.5%). No deaths were encountered. Surgery is the definitive treatment for CBT. Size and local extension appear to be the main reasons for adverse events rather than surgical techniques. Our results are consistent with those of previously published studies. Good outcomes are expected in high-volume centers with appropriate preoperative imaging.

Non-Functional Carotid Body Tumors in Patients Without Somatic Mutations May Be Considered for Non-Operative Management

BACKGROUND

Carotid Body Tumors (CBT) are rare neuroendocrine paragangliomas which are typically asymptomatic and benign, with a low rate of biochemical functionality. Historically, early surgical excision was recommended to prevent development of CBT-related complications. Yet, CBT resection can result in significant cranial nerve and vascular injuries. Recent work has shown successful primary observation without resection of non-carotid body, cranial paragangliomas with slow growth and low rate of neuropathies. We hypothesize that primary observation of CBT is safe and may be considered for majority of CBT.

METHODS

Retrospective cohort study of patients at a multi-hospital healthcare system with radiologic identification and/or diagnostic or procedural billing codes for CBT (2000-2019). Tumor size (greatest diameter), associated symptoms, and interventions were recorded at the initial evaluation and throughout follow-up. Multivariable logistic regression investigated the risk of initial surgical resection.

RESULTS

A total of 108 patients (mean age, 59 ± 19 years; 67% female), with 123 CBT (mean diameter 23 ± 12 mm; 52% right) were initially evaluated by otolaryngologists (51%), vascular surgeons (25%), neurosurgeons (8%), or other (16%) medical providers. Fity-five CBT were initially resected, 63 observed, and 5 irradiated. Initial resection was associated with younger age (adjusted odd ratios aOR, 0.95 [95% confidence intervals CI, 0.92-0.97]), male sex (aOR, 4.82 [95% CI, 1.47-15.75]), and evaluation by a vascular surgeon (aOR, 6.17 [95% CI, 2.04-18.63]). Overall median follow-up was 4.7 (IQR, 2.6-9.1) years. Initially observed CBT were on an average stable in size (mean 1 ± 5 mm/year), none became biochemically active, and 2 patients became symptomatic. At the final follow-up, 63 (51%) underwent surgical resection, 54 (44%) observation, and 6 (5%) radiation therapy. Of the 63 surgically resected CBT, 5 (8%) patients had malignant CBT of which 3 (60%) had known somatic mutations (polymerase epsilon [n = 1], succinate dehydrogenase-D gene [n = 2]). Thirty percent of CBT resections had in-hospital postoperative complications, notably including 1 stroke which occurred in an initially observed patient and 16 cranial nerve complications which all occurred in immediately resected patients. Three resected CBT locally recurred, only 1 of which had malignant pathology.

CONCLUSIONS

Patients with newly diagnosed CBT require biochemical functionality and somatic mutation testing. In the absence of these findings, initial observation of CBTs with annual imaging and symptom monitoring may be considered an alternative to immediate resection which demonstrates a high risk of clinically meaningful postoperative complications.

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

Background

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

Methods

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

Results

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

Conclusion

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

The value of ultrasound for the preoperative assessment of carotid body tumors

OBJECTIVES

To evaluate the value of ultrasound (US) examination for the preoperative assessment of carotid body tumors (CBTs) and to predict surgical outcomes.

METHODS

A total of 15 CBT lesions in 15 patients were included in this study. CBT measurements determined using US, and included maximal diameter, volume, tumor distance to base of skull (DTBOS), and carotid wall infiltration. A correlation analysis was conducted to determine the correlation between US measurements and surgical outcomes, including estimated blood loss (EBL), cranial nerve injury, surgical time, and hospital length of stay (HLOS).

RESULTS

EBL showed a high level of correlation with the maximal dimeter (r = 0.596, p < .05) and the volume of the tumor (r = 0.864, p < .05). Surgical time was positively correlated with tumor volume (r = 0.592, p < .05) and negatively correlated with DTBOS (r = -0.554, p < .05). There was no significant correlation (p > .05) shown between cranial nerve injury and US variables. HLOS showed the high degree of correlation with the maximal dimeter (r = 0.658, p < .05), and was also negatively correlated with DTBOS (r = -0.620, p < .00).

CONCLUSIONS

US examination allows for the visualization of features of CBTs, which is a useful and safe tool to be used to predict surgical outcomes. Further research is necessary to validate this exploration method for the preoperative assessment of CBTs.

Diagnosis and outcomes of surgical treatment of carotid bifurcation tumors

Objective

To retrospectively review our experience with the diagnosis and treatment of carotid bifurcation tumors (CBFT).

Methods

This was a retrospective study of 60 patients with CBFT who underwent surgical and conservative treatment. The patients’ clinicopathological features, imaging examination findings, treatment strategy, and prognosis were analyzed. The surgical grade, blood loss, tumor size, operative time, and postoperative complications were analyzed by Spearman’s correlation.

Results

Resection was performed in 52 patients with 53 tumors. The mean tumor volume, operative time, estimated blood loss, and follow-up time was 47.62 ± 65.28 cm³, 176.1 ± 86.55 minutes, 231.3 ± 354.0 mL, and 44.42 ± 29.30 months, respectively. Pathological examination showed that the number of carotid body tumors (CBT; paraganglioma), neurilemmoma, mesenchymal tissue tumor, and angioleiomyoma was 42, 8, 1, and 1, respectively. Of the CBT group, the rate of Shamblin Type I, II, and III was 11.9%, 59.5%, and 28.6%, and three cases were malignant CBT with lymph node metastasis. Spearman’s correlation analysis showed that complication grade was significantly related to surgical difficulty grade and operative time.

Conclusion

CBT is the most frequent lesion in CBFT, and CBT may be treated safely by surgical management. The severity of surgical complications is significantly correlated with surgical difficulty.

Imaging criteria to predict Shamblin group in carotid body tumors - revisited

PURPOSE

This study aims to compare the imaging findings of carotid body tumors on contrast-enhanced computed tomography (CT) with the intraoperative Shamblin grade and to evolve an imaging-based scoring system that can accurately predict the Shamblin grade.

METHODS

Preoperative contrast-enhanced CT scans of 40 patients who underwent surgical excision of carotid body tumors in our institution between 2004 and 2017 were retrospectively reviewed. The angle of contact with the internal carotid artery (ICA), tumor volume, presence of peritumoral tuft of veins, loss of tumor adventitia interface and distance from the skull base were assessed and compared with the intraoperative Shamblin grades of the tumor. Ordinal logistic regression was used to determine which parameters could be predictors of the Shamblin grades. Receiver operator characteristic (ROC) curves were used to score the tumor volumes.

RESULTS

Among the 42 tumors evaluated, 6 (14.3%) were surgically classified as Shamblin I, 15 (35.7%) as Shamblin II, and 21 (50%) as Shamblin III tumors. Pairwise comparison between the three Shamblin groups showed a statistically significant difference for angle of contact with ICA, maximum tumor dimension, presence of peritumoral tuft of veins and loss of tumor adventitia interface (p = 0.001, p = 0.001, p = 0.038 and p = 0.003, respectively). However, tumor volumes and distance from skull base were not significantly different between the Shamblin groups (p = 0.136 and p = 0.682). A scoring system, including four of the above mentioned parameters (angle of contact with ICA, tumor volume, presence of peritumoral tuft of veins, and loss of tumor adventitia interface) was developed with a maximum score of 8 and a minimum of 2. A statistically significant difference was found between the final scores among the three Shamblin groups (p < 0.001). Using ROC curves, a final score of ≥6 was found to separate Shamblin grade III tumors from grade I and II tumors (sensitivity, 95.24%; specificity, 71.43%). All patients with documented intraoperative estimated blood loss of >1000 mL had Shamblin grade III tumors. Postoperative complications like stroke, ICA thrombosis and lower cranial nerve palsies were seen only with Shamblin grade II and III tumors.

CONCLUSION

The simple scoring system we have proposed correlates well with the Shamblin grade and helps in identifying patients who have a higher risk of developing complications.

Postoperative secondary aggravation of obstructive sleep apnea-hypopnea syndrome and hypoxemia with bilateral carotid body tumor: A case report

BACKGROUND

Carotid body tumor (CBT) is a chemoreceptor tumor located in the carotid body, accounting for approximately 0.22% of head and neck tumors. Surgery is the main treatment method for the disease.

CASE SUMMARY

We reviewed the diagnosis and treatment of one patient who had postoperative secondary aggravation of obstructive sleep apnea–hypopnea syndrome (OSAHS) and hypoxia after surgical resection of bilateral CBTs. This patient was admitted, and relevant laboratory and imaging examinations, and polysomnography (PSG) were performed. After the definitive diagnosis, continuous positive airway pressure (CPAP) treatment was given, which achieved good efficacy.

CONCLUSION

This case suggested that aggravation of OSAHS and hypoxemia is possibly caused by the postoperative complications after bilateral CBTs, and diagnosis by PSG and CPAP treatment are helpful for this patient.

Differential Diagnosis and Treatment Outcomes of Tumors at the Carotid Bifurcation

Purpose

Primary tumor at the carotid bifurcation is uncommon, which includes paraganglioma, schwannoma, and lymphoma. Due to their rarity, characteristics of these tumors and problems related to their surgical treatment have not been well known. We tried to elucidate different clinical characteristics and surgical complications of these tumors.

Materials and Methods

We retrospectively reviewed 21 patients with carotid bifurcation tumor from the Vascular Surgery division of a Korean tertiary institution from 1995 to 2018. We investigated patients' demographics and clinical features, image characteristics, treatment details, and surgical outcomes.

Results

During the period from January 1995 to January 2018, we experienced surgical resections of 21 carotid bifurcation tumors which included 16 (76.2%) paragangliomas and 5 (23.8%) schwannomas. The most common clinical feature was a non-tender cervical mass. According to Shamblin classification, paragangliomas were classified into class II in 68.8% and class III in 25.0%. On the preoperative computed tomography images, all the paragangliomas showed characteristic splaying of the carotid bifurcation and hypervascularity of the tumors. On the contrary, all the schwannomas showed hypovascularity and splaying sign in 60%. Surgical complications related to cervical nerve injury developed in 50% and 60% of patients with Shamblin class III paraganglioma and schwannoma, respectively. During the mean follow-up period of 25 months (range, 1 to 163 months), distant metastases developed in 2 (12.5%) of paraganglioma patients.

Conclusion

Neurologic complications were more common after surgical resection of Shamblin class III paraganglioma and schwannoma. For patients with paraganglioma, postoperative periodic follow-up examination is advised to detect distant metastasis.

Clinical Outcome of Carotid Body Paraganglioma Management: A Review of 10-Year Experience

Background

Carotid body paragangliomas are rare neoplasms usually benign, however sometimes presenting as highly aggressive tumors. Surgery is the main line of treatment.

Purpose

To study and describe clinical presentations, surgical approaches, postoperative complications, and treatment outcomes.

Materials and Methods

A single-institution retrospective analysis of 19 cases with carotid body paragangliomas who were candidates for surgery from January 2009 through January 2019 with a mean follow-up period of 58.8 months.

Results

The mean age was 46 years with the female predominance of 63%. The mean size of the tumor was 4.3 cm. All cases were presented with a painless pulsating neck lump located anteriorly at the level of the hyoid bone. Neck US was done in all cases as a primary screening investigation. CT scanning was the second main investigation performed in 17 cases (89.5%) revealing tumors attached to the carotid artery at its bifurcation. Urinary catecholamine metabolites were measured in all cases to rule out familial functioning types. 5 cases (26.3%) were malignant. All cases were surgically approached through transcervical transverse incision. 11, 5, and 3 cases were classified as Shamblin's type II, III, and I, respectively. All tumors were R0 resected with nodal neck dissection conducted in the malignant group. Major complications occurred in 4 cases (21%) during tumor dissection from the adventitia of carotid bifurcation. ECA ligation was performed in one case (5.3%). 2 patients (10.5%) suffered XII nerve paralysis. Carotid artery blowout occurred in one patient (5.3%) and was immediately controlled. No operative mortality occurred. All patients were free of disease during the follow-up period. 4 malignant cases (21%) suffered a systemic relapse to bone and lung metastasis justifying adjuvant chemotherapy, radiotherapy, or both.

Conclusions

Surgery is the treatment of choice for carotid body paragangliomas. Complete R0 resection should be justified especially in case of malignancy. Adjuvant chemotherapy or radiotherapy is an option for patients with primary malignancy or relapse.

Management and outcomes of vascular reconstruction in carotid body tumor resection: retrospective analysis of 60 cases

PURPOSE

Carotid body tumors (CBTs) are rare tumors of the head and neck area. We evaluated outcomes after carotid body tumor resection (CBR) requiring vascular reconstruction.

METHODS

We retrospectively reviewed the patients, who underwent CBR in our clinic. Medical records were retrospectively reviewed for clinical data, operative details, Shamblin's classification, complications. Comparisons were performed between those undergoing CBR alone and CBR requiring vascular reconstruction (CBR-VASC).

RESULTS

Of the 60 patients, who underwent CBR, 29 (48.3%) underwent vascular reconstruction after the tumor resection. In patients; who underwent carotid endarterectomy and reconstruction of a kinked carotid artery, the blood flow measurements obtained before and after the vascular reconstruction were significantly different. The blood flow measurement parameters obtained before and after the vascular reconstruction were not significantly different in patients undergoing primary repair surgery, patch graft angioplasty, and the use of reversed saphenous vein graft procedures. The overall complication rate was 25% (n = 60) for at least one perioperative problem (CBR 6.4% vs. CBR-VASC 44.8%, p > 0.05). While most patients with Shamblin's class I and II tumors underwent CBR, CBR-VASC was performed more frequently in patients with Shamblin's class III tumors (p = 0.016). The tumor size ( p = 0.016), the volume of intraoperative blood loss (p = 0.002), and the length of hospital stay (p = 0.006) were significantly different between the two groups. The length of the operation time (p = 0.154) and the volume of the postoperative blood drainage (p = 0.122) were not different between the two groups.

CONCLUSION

The decision for surgical reconstruction should be made by evaluating the carotid artery blood flow before and after CBR. The type of the reconstruction method does not cause differences in the duration of the surgery and does not elevate the complication rates.

Plasticity of cardiovascular chemoreflexes after prolonged unilateral carotid body denervation: implications for its therapeutic use

Unilateral carotid body denervation has been proposed as treatment for sympathetic-related human diseases such as systolic heart failure, hypertension, obstructive sleep apnea, and cardiometabolic diseases. The long-term therapeutic effects of carotid body removal will be maintained if the remnant "buffer nerves," that is, the contralateral carotid nerve and the aortic nerves that innervate second-order neurons at the solitary tract nuclei (NTS), do not modify their contributions to the cardiovascular chemoreflexes. Here, we studied the cardiovascular chemoreflexes 1 mo after unilateral carotid body denervation either by excision of the petrosal ganglion (petrosal ganglionectomy, which eliminates central carotid afferents) or exeresis of a segment of one carotid nerve (carotid neurectomy, which preserves central afferents). Cardiovascular chemoreflexes were induced by intravenous (iv) injections of sodium cyanide in pentobarbitone-anesthetized adult cats. After 1 mo of unilateral petrosal ganglionectomy, without significant changes in basal arterial pressure, the contribution of the contralateral carotid nerve to the chemoreflex increases in arterial pressure was enhanced without changes in the contribution provided by the aortic nerves. By contrast, after 1 mo of unilateral carotid neurectomy, the contribution of remnant buffer nerves to cardiovascular chemoreflexes remained unmodified. These results indicate that a carotid nerve interruption involving denervation of second-order chemosensory neurons at the NTS will trigger cardiovascular chemoreflex plasticity on the contralateral carotid pathway. Then, unilateral carotid body denervation as therapeutic tool should consider the maintenance of the integrity of carotid central chemoafferents to prevent plasticity on remnant buffer nerves.NEW & NOTEWORTHY Unilateral carotid body denervation has been proposed as treatment for sympathetic hyperactivity-related human disorders. Its therapeutic effectiveness for maintaining a persistent decrease in the sympathetic outflow activity will depend on the absence of compensatory chemoreflex plasticity in the remnant carotid and aortic afferents. Here, we suggest that the integrity of central afferents after carotid body denervation is essential to prevent the emergence of plastic functional changes on the contralateral "intact" carotid nerve.

Multimodal management of pediatric carotid body tumors: a systematic review and case illustrations

OBJECTIVE Carotid body tumors (CBTs), extraadrenal paragangliomas, are extremely rare neoplasms in children that often require multimodal surgical treatment, including preoperative anesthesia workup, embolization, and resection. With only a few cases reported in the pediatric literature, treatment paradigms and surgical morbidity are loosely defined, especially when carotid artery infiltration is noted. Here, the authors report two cases of pediatric CBT and provide the results of a systematic review of the literature. METHODS The study was divided into two sections. First, the authors conducted a retrospective review of our series of pediatric CBT patients and screened for patients with evidence of a CBT over the last 10 years (2007–2017) at a single tertiary referral pediatric hospital. Second, they conducted a systematic review, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, of all reported cases of pediatric CBTs to determine the characteristics (tumor size, vascularity, symptomatology), treatment paradigms, and complications. RESULTS In the systematic review (n = 21 patients [includes 19 cases found in the literature and 2 from the authors’ series]), the mean age at diagnosis was 11.8 years. The most common presenting symptoms were palpable neck mass (62%), cranial nerve palsies (33%), cough or dysphagia (14%), and neck pain (19%). Metastasis occurred only in 5% of patients, and 19% of cases were recurrent lesions. Only 10% of patients presented with elevated catecholamines and associated sympathetic involvement. Preoperative embolization was utilized in 24% of patients (external carotid artery in 4 and external carotid artery and vertebral artery in 1). Cranial nerve palsies (cranial nerve VII [n = 1], IX [n = 1], X [n = 4], XI [n = 1], and XII [n = 3]) were the most common cause of surgical morbidity (33% of cases). The patients in the authors’ illustrative cases underwent preoperative embolization and balloon test occlusion followed by resection, and both patients suffered from transient Horner’s syndrome after embolization. CONCLUSIONS Surgical management of CBTs requires an extensive preoperative workup, anesthesia, and multimodal surgical management. Due to a potentially high rate of surgical morbidity and vascularity, balloon test occlusion with embolization may be necessary in select patients prior to resection. Careful thorough preoperative counseling is vital to preparing families for the intensive management of these children. ABBREVIATIONS BTO = balloon test occlusion; CBT = carotid body tumor; CN = cranial nerve; ECA = external carotid artery; ICA = internal carotid artery; MIBG = iodine-123-meta-iodobenzylguanidine; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

A Hybrid Approach Towards Successful Resection of a Huge Carotid Body Paraganglioma Using Coil Embolization and Traditional Surgical Techniques

Carotid Body Paraganglioma (CBPGL), is a type of neuroendocrine tumor that should be managed promptly due to their malignant potential and locally aggressive nature making resection at a later stage difficult. The objective of this case report is to explore the benefit of coil embolization and describe the surgical techniques employed in successful resection of a huge CBPGL.

Excision of rare carotid body tumour without preembolisation: Case report and literature review

INTRODUCTION

Carotid body tumors also known as parganglioma or chemodactomas are one of the rare tumors of head and neck which present as slow growing masses in the neck region. We present a case of 40 years female with painless slow growing mass over left side of her neck for 6 months. Diagnosis was made on basis of clinical history, examination and radiological findings. Tumor was graded as Shamblin grade II. She was managed with excision of the tumor without preoperative embolisation. Intraoperative and postoperative periods were uneventful.

CASE PRESENTATION

A forty years female presented with left sided painless neck swelling∼5 × 4 cm² over left anterior triangle for 6 months with no history of dysphagia, odynophagia, change in voice, shortness of breath, palpitations, tremors or syncopal attacks. She underwent USG neck and CT angiogram. Based upon the radiological and clinical findings, she was diagnosed asCarotid body tumor. She was managed with excision of the tumor without preembolisation. Her diagnosis was confirmed with histopathology.

CONCLUSION

Carotid body tumours are rare entities of head and neck region. They are mostly benign in nature. Though mostly bening, increasing size might result in grave complications. Thus, the recommended treatment for carotid body tumors is early excision with or without pre-embolisation. In our case preembolisation was not performed. Though some studies have suggested the use of preoperative embolisation in large sized tumors, more studies are yet required to justify the choice of preembolisation despite the dreaded complications.

An anaesthesia perspective on carotid body tumour (CBT) excision: A twenty-year case series at the Singapore General Hospital

Carotid body tumours (CBT) are extremely rare neoplasms that arise from chemoreceptor cells at the bifurcation of the carotid artery. This rarity poses a challenge for the anaesthetist when dealing with surgeries for the removal of CBT. Reports of associated perioperative morbidity range from twenty to forty percent. This paper reviews the perioperative anaesthetic management of CBT patients and challenges in our institution's 20 year experience on 13 surgical CBT resections.

Malignant Shamblin III Carotid Body Tumors Resected with Use of the Retrocarotid Dissection Technique in 2 Patients

Carotid body tumors are rare neoplasms with malignant potential in 6% to 12.5% of cases, and surgical resection is the only cure. We present the cases of 2 female patients who had expanding, painless, right-sided neck masses; computed tomographic angiograms revealed Shamblin III tumors at the carotid bifurcation. Each patient underwent tumor resection with use of the retrocarotid dissection technique. The tumor specimens were histologically consistent with malignancy, and free margins were achieved. The patients remained free of symptoms, local recurrence, and metastasis 44 and 19 months after their respective procedures. These are the first malignant Shamblin III carotid body tumors that we have resected by means of retrocarotid dissection. In addition to our patients' cases, we discuss carotid body tumors and compare the retrocarotid and standard caudocranial resection techniques.

Carotid Body Tumor Resection: Just as Safe without Preoperative Embolization

BACKGROUND

Carotid body tumors (CBTs) are rare entities for which surgical resection remains the gold standard. Given their hypervascularity, preoperative embolization is often used; however, controversy exists over whether a benefit is associated. Proponents of embolization argue that it minimizes blood loss and complications. Critics argue that cost and stroke outweigh benefits. This study aimed to investigate the impact of embolization on outcomes following CBT resection.

METHODS

Patients undergoing CBT resection were identified using the Healthcare Cost and Utilization Project State Inpatient Database for 5 states between 2006 and 2013. Patients were divided into 2 groups: carotid body tumor resection alone (CBTR) and carotid body tumor resection with preoperative arterial embolization (CBETR). Descriptive statistics were calculated using arithmetic means with standard deviations for continuous variables and proportions for categorical variables. Patients were propensity score matched on the basis of sex, age, race, insurance, and comorbidity prior to analysis. Risk-adjusted odds of mortality, stroke, nerve injury, blood loss, and length of stay (LOS) were calculated using mixed-effects regression models with fixed effects for age, race, sex, and comorbidities.

RESULTS

A total of 547 patients were identified. Of these, 472 patients underwent CBTR and 75 underwent CBETR. Mean age was 54.7 ± 16 years. Mean number of days between embolization and resection was 0.65 ± 0.72 days (range 0-3). When compared with CBTR, there were no significant differences in mortality for CBETR (1.35% vs. 0%, P = 0.316), cranial nerve injury (2.7% vs. 0%, P = 0.48), and blood loss (2.7% vs. 6.8%, P = 0.245). Following risk adjustment, CBETR increased the odds of prolonged LOS (odds ratio 5.3, 95% confidence interval 2.1-13.3).

CONCLUSIONS

CBT resection is a relatively rare procedure. The utility of preoperative tumor embolization has been questioned. This study demonstrates no benefit of preoperative tumor embolization.

Current conception of carotid chemodectoma and efficiency of its treatment methods

The review presents current data from foreign studies of a rare tumor — carotid chemodectoma, particularly, about its prevalence, classification, clinical presentation, applicability of different diagnostics methods, and also on efficiency of treatment of this disease and complications developing after it in terms of described clinical cases. Search for relevant sources was carried out in Medline, US National Library of Medicine, Elibrary systems, in Cochrane Library and peer-reviewed scientific journals. A total of 26 studies were found, 22 of them were included in the review. Carotid chemodectoma is most often characterized by benign course, but, because of its scarce clinical presentation, specific examination methods are required for its accurate diagnosis. Surgical resection is usually used for the treatment of carotid chemodectoma, and in case of contraindications for the surgery, radiotherapy is applied (as a palliative method). The most widespread complications after surgical treatment are cranial nerve damage, intraoperative bleeding and ischemic stroke. Several cases were described in literature, when scientists from different countries (USA, Korea) attempted to decrease risk of complications by use of preoperational embolization, but that led to new complications, particularly, to migration of embolic material. At the same time, scientists from Netherlands noted some decrease of the number of postoperative complications when craniocaudal method was used. To date the only effective method of treatment of carotid chemodectoma is still surgical resection, but it cannot be used in a broad variety of cases. Moreover, the world surgical practice has no effective techniques for prevention of different complications occurring in postoperative period, that reduces possibilities of successful patients’ recovery. Therefore, to decrease the rate of postoperative complications and to increase patients survival rate further studies are required.

Case Report: Managing a giant, high-grade carotid body tumor in a resource-limited setting

Herein we report the management of a giant, high-grade and vascular carotid body tumor in a young woman. She presented with slowly progressive neck swelling. Vascular imaging revealed a left-sided, high-grade giant carotid body tumor (> 8cm).  The tumor was completely excised by caudocranial subadventitial dissection. Histology of the tumor revealed a characteristic Zellballen pattern of the lesion, suggestive of a paraganglioma. The patient made an uneventful recovery. We also discuss newer insights regarding the management of such highly vascular lesions.

A role for ipsilateral, selective neck dissection in carotid body tumours

Introduction:

A reliable diagnosis of malignant carotid body tumour can only be made in the presence of metastatic disease, because the histological features of the primary tumour do not correlate with clinical behaviour.

Case report:

We report two cases of malignant carotid body tumour in which regional nodal biopsy at the time of excision of the primary tumour revealed unsuspected metastatic disease.

Discussion:

Reoperation in the neck for recurrent metastatic carotid body tumour is difficult and potentially hazardous. The presence of occult metastatic disease is easily identified if a selective – or sentinel – nodal dissection is performed routinely in cases of carotid body tumour excision. Such an approach adds very little morbidity, effort or time to the primary surgery, and is recommended. This view has been supported by some other authors but is generally overlooked in clinical practice.

Concomitant Surgical Treatment of Symptomatic Carotid Artery Disease With a Coexisting Shamblin I Carotid Body Tumor

Symptomatic carotid artery atherosclerotic disease is an indication for carotid artery endarterectomy. The coexistence of carotid body tumors (CBTs) with symptomatic carotid disease is rarely encountered and adds significant challenges to vascular surgeons, with a reported overall mortality for patients who undergo endarterectomy and tumor excision of 8.8%, as opposed to the 2% for those who had CBT excision only. We describe the case of a 79-year-old female who experienced an acute cerebrovascular accident in the left hemisphere; duplex ultrasound revealed high-grade carotid stenosis in the left side and the presence of a Shamblin I CBT. The risks and benefits of the planned operation were reviewed, and the decision was made to proceed with early carotid endarterectomy and concomitant surgical resection of the tumor using the retrocarotid dissection technique. The patient recovered well, and at 11 months from the combined procedure, her neurological deficits improved significantly.

Carotid Body Paraganglioma: Report of Two Cases and Review of Literature

We report two cases of carotid body paraganglioma – one was Shamblin Level III and the other was Shamblin Level I.

How to cite this article

Matta R, Sahoo K, Jagtap S. Carotid Body Paraganglioma: Report of Two Cases and Review of Literature. World J Endoc Surg 2016;8(2):160-163.

Sclerosing Paragangliomas of the Carotid Body: A Series of a Rare Variant and Review of the Literature

The incidence of carotid body tumors is less than 1 in 30,000. Histologically, they present with a classic pattern of tumor cells arranged in "zellballen" or nests. A new extremely rare sclerosing subtype has been described in the literature with distinct stromal sclerosis and hyalinization, differentiating it from conventional paragangliomata. We present a case series of 3 patients with this rare variant and also discuss the diagnosis and management of carotid body parangliomas.

Carotid body tumors: a review of 25 years experience in diagnosis and management of 56 tumors

OBJECTIVE

To report our experience in the management of CBTs and review the literature.

MATERIALS AND METHODS

56 CBTs were operated upon over a period of 25 years. Surgical intervention was planned according to the Shamblin classification. Thirty-nine of the tumors were in males (69.64%), and 17 of the tumors were in females (30.36%). The average age was 42 (ages ranging between 32 and 47). Twenty-two tumors were diagnosed and treated with Shamblin type I, twenty-eight with type II and eight tumors with type III. All patients were unilateral except two had bilateral carotid tumors. Thirty-five lumps were de novo (group A), while 21 lumps were treated after a prior trial of removal (group B).

RESULTS

The incidence of carotid reconstruction was lower among group A (1/35) compared to group B (9/21). Complications were less in group A than group B (23% vs. 30%). There were 4 cases with suspected malignancy and no recurrences during the follow-up period.

CONCLUSION

There is an increased incidence of major vascular reconstruction in cases not properly investigated or diagnosed and in cases with prior attempts of removal in Primary Hospitals. Proper diagnosis of suspicious lumps is mandatory. Resection of CBTs by surgeons with experience in vascular reconstruction is recommended. Vascular reconstructions have to be performed safely without serious complications. Also today, prior attempts of removal are not so common, with preoperative evaluation using the latest diagnostic tools. Cranial nerves injury (especially the Hypoglossal Nv) continues to be the most common complication.

A patient with a painless neck tumour revealed as a carotid paraganglioma: a case report

Carotid paragangliomas are usually slowly enlarging and painless lateral neck masses. These mostly benign lesions are recognized due to their typical location, vessel displacement and specific blood supply, features that are usually seen on different imaging modalities. Surgery for carotid paraganglioma can be associated with immediate cerebrovascular complications or delayed neurological impairment.We are reporting the case of a 36-year-old man who presented with a painless mass on the right side of his neck 11 months after being treated for testicular cancer. After a fine-needle aspiration biopsy, he was diagnosed with a testicular cancer lymph node metastasis. Neck US and fluorine [F-18]-fluorodeoxy-D-glucose (FDG) PET-CT showed no signs of hypervascularity or vessel displacement. The patient underwent a level II to V functional neck dissection. During the procedure, suspicion of a carotid paraganglioma was raised and the tumour was carefully dissected from the walls of the carotid arteries with minimal blood loss and no cranial nerve dysfunction.The histology report revealed carotid paraganglioma with no metastasis in the rest of the lymph nodes. The patient's history of testicular germ cell tumour led to a functional neck dissection during which a previously unrecognized carotid paraganglioma was removed.Surgery for carotid PG can be associated with complications that have major impact on quality of life. A thorough assessment of the patient and neck mass must therefore be performed preoperatively in order to perform the surgical procedure under optimal conditions.

Submandibular approach and use of Ligasure(®) system in a complex carotid paraganglioma

Carotid paragangliomas are rare tumors of slow growth, progressive, and highly vascularized; surgery is the chosen treatment, and most surgeons perform an approach with a longitudinal cervicotomy.