Carotid body paragangliomas and matrix metalloproteinases

Malignant carotid body tumors: What we know, what we do, and what we need to achieve. A systematic review of the literature

Malignant carotid body tumors (MCBT) are rare and diagnosed after detection of nodal or distant metastases. This systematic review (SR) focuses on MCBT initially approached by surgery. Preferred Reporting Items for SR and Meta-Analysis (MA) guided the articles search from 2000 to 2023 on PubMed, Scopus, and Web of Science. Among 3548 papers, 132 (337 patients) were considered for SR; of these, 20 (158 patients) for MA. Malignancy rate was 7.3%, succinate dehydrogenase (SDH) mutation 17%, age at diagnosis between 4th and 6th decades, with a higher prevalence of females. MCBTs were mostly Shamblin III, with nodal and distant metastasis in 79.7% and 44.7%, respectively. Malignancy should be suspected if CBT >4 cm, Shamblin III, painful or otherwise symptomatic, at the extremes of age, bilateral, with multifocal disease, and SDHx mutations. Levels II-III clearance should be performed to exclude nodal metastases and adjuvant treatments considered on a case-by-case basis.

Unilateral synchronous masses of the neck revealing a malignant Carotid Body Tumor: A case report and literature review

INTRODUCTION AND IMPORTANCE

Paraganglioma (PG); also known as Glomus Tumor, is a rare neoplastic entity that originates from neural crest cells. It can manifest in different patterns, chiefly benign but others are locally invasive and malignant in behavior. Due to the prevalence of other more common types of neck masses and Paraganglioma's exceeding rarity, misdiagnoses can easily take place, and this results in higher patient morbidity and mortality rates. Preoperative diagnosis constitutes a major clinical challenge, especially in patients with a previous surgical history in the neck region like our patient.

CASE PRESENTATION

We are hereby presenting the case of a 56-year-old female with a known history of total thyroidectomy, who presented to our department with a progressively growing painful recurring neck mass two years following her total thyroidectomy. The preoperative diagnostic assessment revealed two unilateral synchronous masses encapsulating the Right Common Carotid Artery and occupying the common carotid bifurcation.

CLINICAL DISCUSSION

Complete surgical resection of the lesions after isolation from the surrounding anatomical structures was done. Subsequent histopathological and immunohistochemical analyses of the specimens established the diagnosis of a Carotid Body Tumor (CBT).

CONCLUSION

CBTs are rare vascular neoplasia, and they possess the potential for malignant transformation. This neoplasia warrants investigation and documentation to establish innovative diagnostic parameters and accomplish timely surgical interventions. To the best of our knowledge, this is the first documented case of a unilateral synchronous malignant Carotid Body Tumor from Syria. Surgery remains the treatment of choice, while radio-/chemotherapy is reserved for non-surgical cases only.

Metalloproteases in Pain Generation and Persistence: A Possible Target?

Matrix metalloproteinases (MMPs) are a large family of zinc-dependent proteolytic enzymes associated with extracellular matrix protein turnover and tissue degradation. They participate to many different physiological reactions but are also hyperactivated in several diseases. Various literature studies have documented that MMPs play a role in the modulation of neuropathic and nociceptive pain. The heterogeneity of clinical and pre-clinical data is an important issue in this experimental context. Despite the presence of a good number of studies on MMP inhibitors, these drugs showed scarce efficacy and relevant side effects. In the present manuscript, we reviewed studies in the literature that define a possible role of MMPs in pain and the effects of their modulation.

Two stage, hybrid endovascular and open surgical approach to treat difficult carotid body tumors

OBJECTIVE

Present the feasibility, applicability, clinical effectiveness, and results of complicated Shamblin II or III carotid body tumors treated with a two-stage hybrid surgical approach.

MATERIALS AND METHODS

Retrospective, observational, cross-sectional, descriptive study of the successful treatment of 16 cases of difficult Shamblin II or III carotid body tumors, consisting of a two-stage surgical approach. We conducted a retrospective, observational, cross-sectional, descriptive study of a series of patients with complicated Shamblin II or III carotid body tumors, which we treated with a two-stage hybrid surgical procedure, in which we first placed a carotid endoprosthesis and 45 days later performed surgical resection of the tumor, following our originally published technique. This study was conducted from February, 2007 to November, 2019, in a third level care centre.

RESULTS

We treated 16 patients with a mean age of 50.5 years. All resided at more than 2000 meters above sea level. In all 16 a complete resection was performed. The average duration of surgery was 103.9 min, the average intraoperative bleeding was 69 ml. There were three cases of neuropraxia. The ansa cervicalis nerve had to be sectioned in three cases and there was permanent upper laryngeal nerve injury in two cases. There were no permanent cerebrovascular injuries from placement of the endoprostheses. One patient developed transient cerebral ischaemia (TIA) with no long-term sequelae. There were two cases of asymptomatic late occlusion of the endoprostheses. The average initial volume of the tumors was 54.4 cc. The average tumor volume 35 days after implant of the endoprosthesis was 30.9 cc.

SYMPTOMS

Presence of tumors in the neck in all cases and two cases of dysphagia.

CONCLUSION

This two-stage hybrid technique allowed for the complete resection of difficult Shamblin II or III carotid body tumors, with one case of TIA and two with permanent upper laryngeal nerve injuries and without mortality.

Carcinoma del glomus carotideo. Serie de casos

Introducción. El carcinoma del glomus carotideo es infrecuente y se presenta en el 6 % de los paragangliomas carotideos. Suele haber dificultad en su diagnóstico preoperatorio y no se diferencia fácilmente de su contraparte benigna, lo que puede conllevar a complicaciones quirúrgicas. Este trabajo describe la experiencia en su abordaje clínico y quirúrgico en una serie de casos, además de una revisión de la literatura profundizando en su diagnóstico, abordaje terapéutico, sobrevida y mortalidad. Métodos. De los pacientes operados por glomus carotideos durante un periodo de 20 años, se identificaron aquellos llevados a cirugía por carcinoma. Se realizó una búsqueda bibliográfica extensa en PubMed, haciendo énfasis en diagnóstico y tratamiento. Resultados. De un total de 139 pacientes sometidos a cirugía de resección de tumor del cuerpo carotideo, tres pacientes (2,2 %) presentaron carcinoma. Dos tenían metástasis cervicales y uno metástasis hepáticas. Uno presentaba glomus bilateral asociado a trastorno genético de origen familiar. Se realizó cirugía y adyuvancia en todos los casos. Discusión. El diagnóstico diferencial preoperatorio entre glomus benigno y maligno es difícil, por lo cual deben buscarse hallazgos clínicos o factores de riesgo que puedan sugerir malignidad. Las imágenes pocas veces muestran características claras de invasión vascular. Siempre que sea posible, en el tratamiento del cáncer del glomus carotideo, debe realizarse resección quirúrgica, acompañada de un vaciamiento funcional de cuello, dejando la radioterapia, la quimioterapia y la hormonoterapia como terapias adyuvantes.

Surgical Versus Sequential Hybrid Treatment of Carotid Body Tumors

Carotid body tumor (CBT) are slow-growing tumors that develop in the cervical region at the carotid bifurcation. . In a randomized study, 33 patients were treated for CBT excision: 10 patients performed preoperative embolization (PE) and 23 were treated only by isolated traditional surgery (N-PE). The first group includes patients undergoing preoperative embolization. The second group of patients (N-PE) included 11 males and 12 females. Intraoperative complications were lower in patients treated with a hybrid procedure (PE): sections of the cranial nerves were recorded in 7% of cases compared to 12% of the surgical procedure (P-value = 0.72); while the reversible nerve lesions (P value = 0.21) and the permanent ones (P value = 0.46), were instead similar in both procedures. The comparative blood loss during the operative procedure shows a P-value of 0.02. Operating times, reversible damage of the cranial nerves , incidence of stroke (0% vs1%, P value> 0.99) and post-operative hospital stay (4.1 vs. 4.2 days, P value = 0.91) did not show differences in the two groups of patients. The analysis of the results detects pre-operative embolization of CBT in reducing intraoperative blood loss and resection of the cranial nerves..

The Role of MMP8 in Cancer: A Systematic Review

Matrix metalloproteinases (MMPs) have traditionally been considered as tumor promoting enzymes as they degrade extracellular matrix components, thus increasing the invasion of cancer cells. It has become evident, however, that MMPs can also cleave and alter the function of various non-matrix bioactive molecules, leading to both tumor promoting and suppressive effects. We applied systematic review guidelines to study MMP8 in cancer including the use of MMP8 as a prognostic factor or as a target/anti-target in cancer treatment, and its molecular mechanisms. A total of 171 articles met the inclusion criteria. The collective evidence reveals that in breast, skin and oral tongue cancer, MMP8 inhibits cancer cell invasion and proliferation, and protects patients from metastasis via cleavage of non-structural substrates. Conversely, in liver and gastric cancers, high levels of MMP8 worsen the prognosis. Expression and genetic alterations of MMP8 can be used as a prognostic factor by examination of the tumor and serum/plasma. We conclude, that MMP8 has differing effects on cancers depending on their tissue of origin. The use of MMP8 as a prognostic factor alone, or with other factors, seems to have potential. The molecular mechanisms of MMP8 in cancer further emphasize its role as an important regulator of bioactive molecules.

Cell Based Therapeutic Approach in Vascular Surgery: Application and Review

Multipotent stem cells - such as mesenchymal stem/stromal cells and stem cells derived from different sources like vascular wall are intensely studied to try to rapidly translate their discovered features from bench to bedside. Vascular wall resident stem cells recruitment, differentiation, survival, proliferation, growth factor production, and signaling pathways transduced were analyzed. We studied biological properties of vascular resident stem cells and explored the relationship from several factors as Matrix Metalloproteinases (MMPs) and regulations of biological, translational and clinical features of these cells. In this review we described a translational and clinical approach to Adult Vascular Wall Resident Multipotent Vascular Stem Cells (VW-SCs) and reported their involvement in alternative clinical approach as cells based therapy in vascular disease like arterial aneurysms or peripheral arterial obstructive disease.

Overexpression of microRNA-1470 promotes proliferation and migration, and inhibits senescence of esophageal squamous carcinoma cells

MicroRNA-1470 (miR-1470) is overexpressed in esophageal squamous cell carcinoma (ESCC); however, its role and underlying molecular mechanism remain unknown. The aim of the present study was to explore the tumorigenic role and mechanism of miR-1470 overexpression in ESCC. The expression of miR-1470 in ESCC tissues and cell lines was detected using human miRNA microarrays and the reverse transcription-quantitative polymerase chain reaction, respectively. The effects of miR-1470 on cell proliferation, migration and senescence were determined using a Cell Counting Kit-8 assay, Transwell migration assay and β-galactosidase staining kit. Western blotting was used to analyze the expression levels of genes in the apoptosis signaling pathway. An increased expression level of miR-1470 was observed in ESCC tissues compared with that in paracancerous tissues. Knockdown of miR-1470 significantly suppressed proliferation, and down-regulated the cell cycle regulatory gene cyclin E1. It was also revealed that knockdown of miR-1470 significantly inhibited migration, and decreased the expression levels of matrix metalloproteinase 2 (MMP2), MMP13 and MMP14. Western blotting analysis revealed that knockdown of miR-1470 induced apoptosis by increasing B-cell lymphoma 2 (Bcl-2) expression. The results of the present study suggest that overexpression of miR-1470 in ESCC promotes cancer cell proliferation by accelerating the cell cycle and inhibiting apoptosis, and also enhances cancer cell migration by upregulating MMPs.

Imaging findings of malignant bilateral carotid body tumors: A case report and review of the literature

Carotid body tumors (CBTs) are a rare type of extra-adrenal paraganglioma, which originate from the carotid body. A 29-year-old woman was admitted to the Department of Head and Neck Surgery, Beijing Tongren Hospital (Capital Medical University, Beijing, China) with hoarseness of the throat, which had progressively worsened over seven months. The patient had a family history of CBTs. Computed tomography and ultrasound imaging revealed multiple well-enhanced masses located at the bilateral carotid bifurcation and in the left parapharyngeal space. Surgery and pathological examination confirmed that the patient had developed regional lymph node metastasis. Significantly enhanced multiple pulmonary and hepatic lesions indicated that the patient had also developed distal metastasis. A genetic analysis performed on the family members of the patient revealed that the family carried a mutated succinate dehydrogenase D gene. In the present study, a systemic review of the literature indicated that extra vigilance is required in familial forms of CBT, in order to increase the standard of treatment for CBT patients.

An uncommon case of arterial aneurysms association with high plasma levels of Matrix Metalloproteinase-9 and Neutrophil Gelatinase-Associated Lipocalin

The association of an axillary artery aneurysm and an abdominal aortic aneurysm is extremely rare. In this study, we describe this association in a 69 year-old-man. We measured this patient’s metalloproteinases (MMPs) and Neutrophil Gelatinase – Associated Lipocalin (NGAL) levels over a three years period before the abdominal aortic aneurysm rupture. We speculate that high serium levels of MMPs and NGAL may have a prognostic role and may predict aneurysm rupture in patients with an uncommon association of arterial aneurysms.

Cell Therapy in Patients with Critical Limb Ischemia

Critical limb ischemia (CLI) represents the most advanced stage of peripheral arterial obstructive disease (PAOD) with a severe obstruction of the arteries which markedly reduces blood flow to the extremities and has progressed to the point of severe rest pain and/or even tissue loss. Recent therapeutic strategies have focused on restoring this balance in favor of tissue survival using exogenous molecular and cellular agents to promote regeneration of the vasculature. These are based on stimulation of angiogenesis by extracellular and cellular components. This review article carries out a systematic analysis of the most recent scientific literature on the application of stem cells in patients with CLI. The results obtained from the detailed analysis of the recent literature data have confirmed the beneficial role of cell therapy in reducing the rate of major amputations in patients with CLI and improving their quality of life.

Adult vascular wall resident multipotent vascular stem cells, matrix metalloproteinases, and arterial aneurysms

Evidences have shown the presence of multipotent stem cells (SCs) at sites of arterial aneurysms: they can differentiate into smooth muscle cells (SMCs) and are activated after residing in a quiescent state in the vascular wall. Recent studies have implicated the role of matrix metalloproteinases in the pathogenesis of arterial aneurysms: in fact the increased synthesis of MMPs by arterial SMCs is thought to be a pivotal mechanism in aneurysm formation. The factors and signaling pathways involved in regulating wall resident SC recruitment, survival, proliferation, growth factor production, and differentiation may be also related to selective expression of different MMPs. This review explores the relationship between adult vascular wall resident multipotent vascular SCs, MMPs, and arterial aneurysms.

Biomarkers in post-reperfusion syndrome after acute lower limb ischaemia

Ischaemia reperfusion (I/R) injury refers to tissue damage caused when blood supply returns to the tissue after a period of ischaemia. Matrix metalloproteinases (MMPs), neutrophil gelatinase-associated lipocalin (NGAL) and cytokines are biomarkers involved in several vascular complications. The aim of this study was to evaluate the role of MMPs, NGAL and inflammatory cytokines in I/R syndrome. We conducted an open label, multicentric, parallel group study, between January 2010 and December 2013. Patients with acute limb ischaemia were enrolled in this study and were divided into two groups: (i) those subjected to fasciotomy and (ii) those not subjected to fasciotomy, according to the onset of compartment syndrome. Plasma and tissue values of MMPs and NGAL as well as plasma cytokines were evaluated. MMPs, NGAL and cytokine levels were higher in patients with compartment syndrome. Biomarkers evaluated in this study may be used in the future as predictors of I/R injury severity and its possible evolution towards post-reperfusion syndrome.

Effectiveness of prostaglandin E1 in patients with mixed arterial and venous ulcers of the lower limbs

Mixed arterial and venous ulcers of the lower limbs are present in around 15-30% of patients with chronic venous ulcers (CVUs) and are considered difficult-to-heal wounds. The aim of this study was to evaluate the results of the treatment of mixed arterial and venous ulcers of the lower limbs with prostaglandin E1 (PGE1) infusion. This study was carried out in 48 consecutive patients. Patients who showed intolerability to PGE1, and patients with peripheral neuropathy, blood or systemic diseases, malignancy and acute wound infections or necrotic tissue on the wound bed were excluded. The patients were separated at random into two main groups: group I (25 patients) received standard treatment and PGE1 infusion. Group II (23 patients) received only standard treatment. Pre-treatment data indicated the area of ulceration. The number of healed ulcers and the variation in the area of ulceration were considered as endpoints. The endpoints were noticed after 120 days from the beginning of treatment. Healing occurred in 80% of limbs of group I and in 52·2% of limbs of group II patients. The average reduction in area was 92% versus 60% in patients of group I and II, respectively. During the whole treatment period, the incidence of adverse events was 8% in group I: there was one case of headache and one case of headache and hypotension combined. No side effects were recorded in patients of group II. In conclusion, PGE1 infusion is a determinant in the reduction of the healing time of mixed ulcers of the lower limbs.

The effects of sulodexide on both clinical and molecular parameters in patients with mixed arterial and venous ulcers of lower limbs

BACKGROUND

Mixed venous and arterial ulcers account for approximately 15%-30% of all venous leg ulcerations. Several studies have shown that matrix metalloproteinases (MMPs) and neutrophil gelatinase-associated lipocalin (NGAL) play a central role in the pathophysiology of venous and arterial diseases. Some studies have shown the efficacy of glycosaminoglycans, such as sulodexide (SDX), in treating patients with leg ulcers. The aim of this study was to evaluate clinical effects of SDX and its correlation with MMPs and NGAL expression in patients with mixed arterial and venous leg ulcers.

METHODS

Patients eligible for this study were of both sexes, older than 20 years, and with a clinical and instrumental diagnosis of mixed ulcer.

RESULTS

Fifty-three patients of both sexes were enrolled and divided into two groups by means of randomization tables. Group A (treated group) comprised 18 females and ten males (median age: 68.7 years) treated with standard treatment (compression therapy and surgery) + SDX (600 lipoprotein lipase-releasing units/day intramuscularly) for 15 days followed by SDX 250 lipase-releasing units every 12 hours day orally for 6 months as adjunctive treatment. Group B (control group) comprised 17 females and eight males (median age: 64.2 years) treated with standard treatment only (compression therapy and surgery). The type of surgery was chosen according to anatomical level of vein incompetence: superficial venous open surgery and/or subfascial endoscopic perforating surgery. In all enrolled patients, blood samples were collected in order to evaluate the plasma levels of MMPs and NGAL through enzyme-linked immunosorbent assay. These results were compared to another control group (Group C) of healthy individuals. Moreover, biopsies of ulcers were taken to evaluate the tissue expression of MMPs and NGAL through Western blot analysis. Our results revealed that SDX treatment is able to reduce both plasma levels and tissue expression of MMPs improving the clinical conditions in patients with mixed ulcers.

CONCLUSION

Inhibition of MMPs could represent a possible therapeutic intervention to limit the progression of leg ulceration. In particular, our findings demonstrate the efficacy of SDX in patients with mixed arterial and venous chronic ulcers of the lower limbs.

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.