Contemporary presentation and evolution of management of neck paragangliomas

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.

Risk Factors for Stroke After Carotid Paraganglioma Surgery

BACKGROUND

The Carotid Paraganglioma Cooperative International Registry (CAPACITY) is an international registry composed of 1,432 patients with carotid body tumors (CBT) from 11 centers from 4 countries. The aim of this study was to identify risk factors for patients who presented stroke after carotid paraganglioma resection.

METHODS

Clinical characteristics and demographics of patients who presented transoperatively and postoperatively stroke from the CAPACITY database were retrospectively gathered. Regression analysis was performed using single logistic regression with Omnibus' test for possible factors that might contribute to present stroke.

RESULTS

Out of 1,432 patients, 8 (0.5%) female patients presented stroke. Median age was 53 years (range: 41-70 years). Six strokes occurred transoperatively, diagnosed clinically in the immediate postoperative period. Of them, none of the patients received any further treatment. Three of them died on postoperative day 2, 3, and 4. Two patients developed stroke during the first 24 postoperative hours, patients showed dysarthria, and aphasia. One of them was reintervened with thrombectomy due to thrombosis of the common carotid artery the other patient was treated conservatively. Median follow-up was 16 months (range: 2-72 months). Single logistic regression analysis revealed a history of diabetes mellitus (odds ratio (OR) 7.62), carotid artery disease (OR 17.51), and vascular lesion (OR 2.37) to have significantly increased odds of stroke during CBT surgery.

CONCLUSIONS

In the present study history of diabetes mellitus, carotid artery disease, and vascular lesion had increased odds of stroke during CBT surgery. Findings are limited by low event rate and even larger cohorts are needed to fully define preventive preoperative strategies for preventing stroke.

Clinicopathological characteristics of patients with carotid body tumor with cervical lymph node metastasis: A retrospective study of 10 cases and review of the literature

Carotid body tumor (CBT), also known as carotid body chemoreceptor tumor or nonchromaffin paraganglioma, originates from the chemoreceptor behind the common carotid artery bifurcation in the carotid sheath. Most CBTs are benign. Malignant CBT (MCBT) is extremely rare, and cervical lymph node metastasis (CLNM) is usually regarded as a manifestation of malignant behavior. The association between CLNM, pathological features of the primary lesion, clinical manifestations, and prognosis deserves further investigation. The clinical materials of 133 patients with CBT who underwent total resection of the primary tumor and concomitant selective neck dissection (SND) from February 2002 to June 2018 in a single center were reviewed. Postoperative histopathology confirmed CLNM in 10 cases (10/133); clinical manifestations, pathological and imaging characteristics, and treatment outcome data were reviewed and analyzed. The average patient age was 50.5 years, with a female sex tendency (7/10). The mean and median follow-up periods of all cases were 6.9 years and 7 years, respectively. Nine patients (9/10) survived; one patient died of multiple systemic metastases 10 months after surgery when the tumor metastasized to the bilateral breast and other organs in an orderly manner. None of the patients had local recurrence, but postoperative residual lesions were detected by computer-aided 3-dimensional (3D) visualization computerized tomography in one (1/10). Most CBT cases with CLNM displayed adverse features, especially in patients without distant metastases. Immunohistochemically, the patient with distant metastases was negative for S-100, synaptophysin (Syn), and succinate dehydrogenase B (SDHB) expression. Most patients with CBT with CLNM have a good prognosis. Breast metastasis is an exceedingly rare manifestation of MCBT. Despite some association between clinical biological and histological malignancies in CBT with CLNM, the association seems to be vague in cases involving distant metastasis. The combination of certain immunohistochemical indicators (S-100, Syn, and SDHB) might be valuable for predicting the occurrence of distant metastasis. Computer-aided 3D visualization technology might be helpful for the diagnosis and postoperative follow-up of MCBT. Simultaneous SND can remove potentially metastatic lymph nodes and facilitate diagnosis and treatment.

Impact of Preoperative Embolization on Carotid Body Tumor Surgery

OBJECTIVES

In this study, investigation of the effect of preoperative carotid body tumor embolization (CBTE) on the amount of bleeding, vascular and neurological complications in carotid body tumors was aimed.

METHODS

50 patients treated for 51 carotid body tumors in 2 clinics, between 2005 and 2020 were evaluated. Polyvinyl alcohol (PVA) embolization of the carotid body tumor was performed in 23 patients before the surgical excision. The results were compared with the remaining 28 patients, whom CBTE was not performed, in terms of neurological complications, requirement of additional vascular interventions, bleeding amount, and length of hospital stay.

RESULTS

Mean bleeding amount was significantly lower in CBTE group (406ml-217ml p<0.05). Median erythrocyte suspension (ES) transfusion was significantly lower in the CBTE group (0.3 units vs. 1.1 units, p<0.05). Neurological deficits developed in a total of 13 patients, 6 of whom were in the CBTE group and 7 in the non-CBTE group, in the early postoperative period (p=0.90). No significant difference was observed between the groups in terms of additional vascular interventions and length of hospital stay (p=0.79 and p=0.61).

CONCLUSIONS

Carotid body tumors are rarely encountered tumors. However, their surgical excision is challenging for surgeons regarding intraoperative and postoperative bleeding. This study demonstrates that preoperative CBTE significantly reduces the amount of bleeding, especially in Shamblin II/III tumors.

Shamblin III Chemodectoma: The vascular surgeon's point of view

Chemodectomas (CBTs) are the most frequently encountered tumours at the carotid bifurcation. Even if rare and commonly benign, their development close to the head and neck structures is often source of morbidity by compression and infiltration. Therefore, in order to avoid permanent neurologic or vascular complications these infrequent lesions need to be early removed. The total excision may be technically challenging and requires extensive expertise in surgical neck anatomy and a cooperative multidisciplinary approach. Almost a quarter of CBTs infiltrate carotid vessels so vascular expertise is pivotal in their resection. The present study aims to give an overview of vascular specificity and procedures required during surgical excision of such tumors to assist and guide treating physicians who encounter CBTs. This overview will particularly emphasize current therapeutic options: we discuss the referral criteria that should guide the decision about what type of preoperative care and surgical procedure should be offered to the affected patients. We also specify the epidemiologic data, screening recommendations and outcomes achieved with the different therapeutic approaches. The clinical, operative and follow-up data about a case of a Shamblin III carotid body tumour surgically removed by a multidisciplinary team at our Institution are also reported.

Carotid Paraganglioma in Adolescence-Clinical Picture-Surgical Technique and Review of the Literature

Paraganglia are clusters of cells originating from the neural crest with histological and cytochemical characteristics of neuroendocrine cells. Paragangliomas of the head and neck represent less than 0.5% of all head and neck tumors and they usually occur between the ages of 40 and 50. Paragangliomas in childhood and in adolescence are extremely rare; only 23 case reports have been reported in the recent literature. In childhood, the estimation of malignant potential is 3–10%; therefore, early diagnosis and treatment of carotid body paragangliomas are mandatory. However, due to the rarity of these lesions in young patients, they are often not included in the differential diagnosis of solid masses in the neck area, a fact that may lead to misdiagnosis or delay in treatment. We present, herein, two extremely rare cases of patients in adolescence who were diagnosed with a carotid body paraganglioma and were treated surgically in our unit. One of the patients was diagnosed and treated at the age of 15 years while the other had a long-standing tumor in the neck that was followed up by a general surgery outpatient service as a branchial cleft cyst at the age of 15 years and was eventually treated surgically 8 years later. Carotid body tumor was not considered in the initial differential diagnosis because of its rarity at this age range.

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.

Successful Resection of a Large Carotid Body Tumor Masquerading Complete Encasement of the Internal Carotid Artery on Preoperative Imaging

A 41-year-old woman presented with a large painful and tender mass of the left side of her neck located just below the angle of the mandible. She was also complaining of frequent attacks of symptoms ranging from dizziness upon resuming the erect position to frank syncope. Color-coded duplex showed a large well-vascularized vascular mass at the level of the carotid bifurcation, suggesting the diagnosis of a carotid body tumor (CBT). A computerized tomographic angiography confirmed the diagnosis of a CBT, which measured 5.7 cm in its craniocaudal axis. The tumor appeared to encase the internal carotid artery (ICA) at the level of its origin, indicating the presence of a Shamblin group 3 tumor. During surgery, the CBT seemingly encased the ICA; however, it was successfully taken off the ICA, by establishing an adventitial dissection place, obviating the need for arterial resection and replacement. A brief intraoperative episode of cardiac arrest was successfully managed. Postoperative course was uneventful, and all symptoms were cured. Pathology confirmed the clinical diagnosis and did not show malignancy. In conclusion, meticulous surgical techniques can spare the ICA from removal or inadvertent injury during CBT surgery and reduce the morbidity often associated with the resection of large or advanced tumors but also cure atypical patient symptoms.

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.

Imaging characteristics of nodal metastases in paraganglioma, ameloblastoma and olfactory neuroblastoma: case reports and literature review

Paraganglioma, ameloblastoma and olfactory neuroblastoma are uncommon primary head and neck tumours. When nodal metastases from these tumours occur, they may present later than and with different imaging characteristics compared with squamous cell carcinoma (SCC), demonstrating appearances similar to the primary tumour type rather than features typical of metastatic nodal SCC. We present three cases in which imaging characteristics of nodal metastases in paraganglioma, ameloblastoma and olfactory neuroblastoma mimicked the primary tumour and discuss their implications for clinicoradiological follow-up.

Resection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat

A 39-year-old man was referred to the vascular surgeons with a right-sided cervical mass, palpitations, headaches and sweating. He had presented with abdominal discomfort 12 months earlier. Investigations had revealed a gastrointestinal stromal tumour (GIST) and left adrenalectomy. CT of the neck with contrast demonstrated a large right carotid paraganglioma, extending superiorly from below the carotid bifurcation to encase the internal carotid artery. Genetic screening confirmed the diagnosis of Carney-Stratakis syndrome, an SDH-D germline mutation leading to GIST and multifocal paragangliomas. Successful surgical excision required considerable multidisciplinary teamwork between neuroendocrinologists, anaesthetists and surgeons. The tumour was highly vascular and involved the right carotid body, hypoglossal and vagus nerves. Access was challenging and maxillofacial surgical expertise were required for division of the mandible. The patient made a good recovery following speech and swallowing rehabilitation.

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.

Symptomatic carotid stenosis in the setting of bilateral disease and coexisting carotid body tumor: management with a carotid stent and staged excision

The aim of the paper is to describe the management of a patient with bilateral carotid artery stenosis, symptomatic on the left, with coexisting left carotid body tumor with left carotid stenting followed by right carotid endarterectomy and excision of carotid body tumor. A 60-year-old man with significant bilateral carotid stenosis was referred to us with symptomatic left carotid disease and concomitant left carotid body tumor. A Precise nitinol carotid stent (Cordis Endovascular, Miami Lakes, FL, USA) was placed in his left carotid artery followed by interval carotid endarterectomy on the right. Excision of the carotid body tumor was then performed. Carotid stenting is a treatment option in patients with carotid stenosis and coexisting carotid body tumor. To our knowledge, this is the first reported carotid stent for symptomatic carotid stenosis in a patient with a concomitant carotid body tumor.

The known unknowns of perioperative stroke during carotid body tumour resection

Carotid body tumour (CBT) surgery has a risk of stroke. A 57-year-old lady presented with lethargy and generalised limb pain secondary to a right parathyroid adenoma. CT scan demonstrated as an incidental finding of a left CBT. Intraoperatively the CBT was infiltrating the vessel wall. The carotid bifurcation was resected and reconstructed using a reversed saphenous vein graft. Postoperatively the patient developed right arm weakness. A CT scan showed a left hemispheric watershed infarct. On discharge (day 8 postoperatively) she had no functional deficit. Reconstruction of the internal carotid artery in patients with CBT is associated with an increased risk of stroke. This index case and literature research highlight the knowns and unknowns on stroke associated with CBT resection.