Adjunct endovascular interventions in carotid body tumors

Use of the Amplatzer vascular plug to treat carotid body tumors extending to the skull base

BACKGROUND

Carotid body tumors extending to the skull base are hypervascular tumors which are difficult to access using a traditional lateral cervical approach. Preoperative embolization can reduce intraoperative blood loss.

CASE PRESENTATION

We report two patients with a carotid body tumor extending to the skull base who underwent preoperative embolization of the external carotid artery using an Amplatzer vascular plug. Two days after embolization, surgical resection was performed. Embolization was successful in both patients and resection proceeded smoothly. Both were discharged on postoperative day 9 without complications. The tumor in each patient was classified as Shamblin group III. Computed tomography angiography of the neck six months after surgery showed patency of the ipsilateral internal carotid artery and no tumor recurrence.

CONCLUSION

Preoperative embolization of the external carotid artery using the Amplatzer vascular plug is safe and feasible for patients with carotid body tumors extending to the skull base.

Surgical Management of Carotid Body Tumors: Experience of Two Centers

BACKGROUND

Carotid body tumors (CBTs) are rare but require surgical resection given their potential for growth and malignancy. For some surgical teams, tumor hypervascularity justifies preoperative embolization to facilitate resection and limit complications. The objective of our study was to evaluate 2 different practices of surgical resection with or without preoperative embolization in a 2-center cohort.

METHODS

A consecutive series of patients who underwent CBT surgery, from January 2011 to June 2019, were divided into 2 groups, as to whether they were (embolized CBT [ECBT]) or not (nonembolized CBT [NECBT]) preoperatively embolized. Both groups were compared specifically according to the duration of operation, postoperative complications, and length of stay.

RESULTS

Twenty-two patients with a mean age of 48.5 ± 14.3 years were included. In the series, 23 CBTs were resected: 13 were embolized preoperatively; the mean time between embolization and surgery was 2.62 ± 1.50 days. Both groups were comparable based on characteristics of population and tumor, with a mean size of 33.2 ± 11.9 mm. We noted a significant increase in operation duration in the ECBT group: 151 min (±40.9) vs. 87.0 min (±21); P < 0.01. There was no difference between the 2 groups regarding cranial nerve (50% vs. 46%; P = 1), sympathetic nervous system (20% vs. 23%; P = 1), or vascular nerve (20% vs. 23%; P = 0.18) complications. No cerebrovascular accident was identified. The length of stay was 3.60 days (±1.78) vs. 3.73 days (±1.19; P = 0.44).

CONCLUSIONS

This study reflects the experience of 2 centers in the management of CBT which is a rare pathology with no standardized treatment. Our series showed no significant difference between the ECBT and NECBT groups regarding postoperative complications and length of hospital stay. The reduction in operating time in the NECBT group remains to be demonstrated.

Carotid Body Tumor in a 26-Year-Old Male Patient Managed With Preoperative Embolization

Carotid body tumors are rare, highly vascularized neuroendocrine tumors that arise near the bifurcation of the common carotid artery (CCA). Controversy exists in the management of those tumors about whether preoperative embolization facilitates surgical excision and decreases perioperative complication risk. We present the case of a 26-year-old patient with a carotid body tumor manifesting as a painless pulsatile mass in the anterior triangle over the left side of the neck and provide details of the preoperative diagnostic steps. Treatment included preoperative embolization of the tumor followed by surgical excision after 48 hours to safely address this rare pathology, resulting in a favorable outcome for the patient.

Preoperative Embolization in Surgical Resection of Cervical Paragangliomas: Usefulness and Current Evidence

BACKGROUND

Cervical paragangliomas (CPG) are slow-growing tumours, most of which are highly vascular, making surgical resection challenging. Preoperative embolisation of afferent arteries has been recommended to facilitate operative dissection, reduce perioperative blood loss, and shorten the duration of the operation. However, there is conflicting evidence on the benefits of preoperative embolisation on surgical outcomes, operative time, and bleeding.

OBJECTIVES

The objective of this study was to compare the perioperative parameters and outcomes like duration of surgery, blood transfusion, duration of stay in the ICU, cranial nerve injuries, and postoperative stroke between patients who underwent excision of CPGs with and without preoperative embolisation.

METHODS

This is a retrospective study conducted at the Division of Vascular Surgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. The study included a review of the medical records of 32 patients who underwent excision of CPGs. Patients who underwent surgical resection without preoperative embolisation (SR) were compared with those who underwent surgical resection with embolisation (SREMB). Statistical analysis was done in R statistical software (R Foundation for Statistical Computing, Vienna, Austria). Categorical variables were reported in absolute numbers and percentages continuous variables were compared with an unpaired Mann-Whitney U test. The chi-square test was used to compare the categorical data.

RESULTS

Out of 32 patients included in this study, 13 (40.6%) patients were included in the SREMB group. Between the two groups, there were no significant differences in operative time (120 vs. 150 minutes; p = 0.59), blood transfusion requirement (0.69 vs. 0.37 units; p = 0.39) and ICU stays (1 vs. 1; p = 0.56). Postoperative cranial nerve injury was significantly more in the SREMB group (6 vs 1; p = 0.01) but stroke (0 vs 2; p = 0.50) was not statistically significant between the two groups.

CONCLUSION

In this study, we found that there was insufficient evidence to support routine preoperative embolisation in CPG. Hence, preoperative embolisation should only be used in a very select group of patients.

John M. Multidisciplinary care improves outcomes for patients with carotid body paragangliomas-The UCLA experience

Objective

To evaluate the effects and outcomes of multidisciplinary surgical approaches in the management of carotid body tumors (CBT).

Methods

A single-center retrospective study at the University of California-Los Angeles Medical Center was conducted on patients who presented with CBTs and underwent surgical resections from 1998 to 2020. Statistical analysis was performed using IBM SPSS v27 and Excel.

Results

A total of 75 patients with 79 CBT resections were included. Operating surgical subspecialties included: 41.8% vascular surgery, 24.1% otolaryngology head and neck surgeons (OHNS), and 31.6% combined OHNS and vascular. 68.4% of tumors underwent preoperative embolization. EBL was directly correlated with tumor size. CBT size was similar for OHNS (30 mm) and vascular (31 mm) but was significantly larger for combined OHNS and vascular cases (38 mm). EBL was higher in combined cases (301 mL) compared to OHNS (124 mL) or vascular (203 mL) alone. Incidence of postoperative cranial nerve deficits was 7.8%, with combined OHNS and vascular cases having an incidence of 4.0% when compared to OHNS (5.3%) versus vascular surgery alone (12.1%).

Conclusion

CBTs can be managed effectively by single surgical specialties with similar outcomes between vascular surgery and OHNS. In larger, higher grade tumors, however, a combined vascular and OHNS approach had lower incidence of postoperative cranial nerve injuries when compared to single specialty resections, despite a larger EBL. Thus, a multidisciplinary surgical approach suggests favorable outcomes with fewer incidence of cranial nerve deficits for larger, more complex CBT resections.

Level of Evidence

2b-Individual retrospective cohort study.

An analysis from the CAPACITY database of outcomes of preoperative embolization before carotid body tumor surgery compared with resection alone

OBJECTIVE

There is no definitive consensus on the impact of preoperative embolization on carotid body tumor (CBT) treatment. The objective of this study was to compare surgical outcomes of patients who underwent preoperative embolization before CBT resection vs patients who underwent resection alone.

METHODS

The CAPACITY registry included 1432 patients with CBT from 11 medical centers in four different countries. The group of patients undergoing CBT resection with preoperative embolization was matched in a 1:6 ratio from a pool of patients from the CAPACITY database, using a generated propensity score with patients who did not underwent preoperative embolization.

RESULTS

A total of 553 patients were included for analysis. Mean patient age was 56.23 ± 12.22 years. Patients were mostly female (n = 469; 84.8%). Bilateral CBT was registered in 60 patients (10.8%). Seventy-nine patients (14.3%) underwent preoperative embolization. Embolized patients had larger CBT sizes than non-embolized patients (33.8 mm vs 18.4 mm; P = .0001). Operative blood loss was lower in the embolized group compared with the non-embolized group (200 mL vs 250 mL; P = .031). Hematomas were more frequent in the non-embolized group (0% vs 2.7%; P = .044). Operative time, rates of stroke, cranial nerve injuries, and death were not statistically significant between groups.

CONCLUSIONS

Embolization before CBT resection was associated with significantly lower blood loss and lower neck hematomas than patients who underwent resection alone. Operative time, stroke, cranial nerve injuries, and death were similar between groups.

Retrospective analysis of carotid body tumor surgical management: roles of preoperative image investigation and preoperative embolization

OBJECTIVE

To analyze the management of carotid body tumors (CBTs), particularly the use of preoperative embolization (EMB) and image features in minimizing surgical complications.

BACKGROUND

CBT surgery is a challenging procedure, and the role of EMB in CBT surgery has remained unclear.

METHODS

A total of 200 CBTs were identified among 184 medical records involving CBT surgery. Regression analysis was used to explore the prognostic predictors of cranial nerve deficit (CND), including image features. In addition, blood loss, operation times, and complication rates were compared between patients who had surgery only versus patients who had surgery along with preoperative EMB.

RESULTS

Overall, 96 males and 88 females were identified for inclusion in the study, with a median age of 37.0 years. Computed tomography angiography (CTA) showed the presence of a tiny gap adjacent to the encasement of carotid vessels, which could help minimize carotid arterial injury. High-lying tumors that encased the cranial nerve were usually managed with synchronous cranial nerve resection. Regression analysis revealed that the incidence of CND was positively associated with Shamblin Ⅲ, high-lying, and a maximal CBT diameter of ≥ 5cm. Among 146 EMB cases, two cases of intracranial arterial embolization occurred. No statistical difference was found between the EBM and Non-EBM groups in terms of bleeding volume, operation time, blood loss, blood transfusion requirement, stroke, and permanent CND. Subgroup analysis revealed that EMB decreased CND in Shamblin III and low-lying tumors.

CONCLUSIONS

CBT surgery should be performed with preoperative CTA to identify favorable factors for minimizing surgical complications. Shamblin Ⅲ or high-lying tumors, as well as CBT diameter, are predictors of permanent CND. EBM does not reduce blood loss or shorten operation time.

Multidisciplinary management of carotid body tumors: a single-institution case series of 22 patients

OBJECTIVE

Carotid body tumors (CBTs) are rare, slow-growing neoplasms derived from the parasympathetic paraganglia of the carotid bodies. Although inherently vascular lesions, the role of preoperative embolization prior to resection remains controversial. In this report, the authors describe an institutional series of patients with CBT successfully treated via resection following preoperative embolization and compare the results in this series to previously reported outcomes in the treatment of CBT.

METHODS

All CBTs resected between 2013 and 2019 at a single institution were retrospectively identified. All patients had undergone preoperative embolization performed by interventional neuroradiologists, and all had been operated on by a combined team of cerebrovascular neurosurgeons and otolaryngology-head and neck surgeons. The clinical, radiographic, endovascular, and perioperative data were collected. All procedural complications were recorded.

RESULTS

Among 22 patients with CBT, 63.6% were female and the median age was 55.5 years at the time of surgery. The most common presenting symptoms included a palpable neck mass (59.1%) and voice changes (22.7%). The average tumor volume was 15.01 ± 14.41 cm3. Most of the CBTs were Shamblin group 2 (95.5%). Blood was predominantly supplied from branches of the ascending pharyngeal artery, with an average of 2 vascular pedicles (range 1-4). Fifty percent of the tumors were embolized with more than one material: polyvinyl alcohol, 95.5%; Onyx, 50.0%; and N-butyl cyanoacrylate glue, 9.1%. The average reduction in tumor blush following embolization was 83% (range 40%-95%). No embolization procedural complications occurred. All resections were performed within 30 hours of embolization. The average operative time was 173.9 minutes, average estimated blood loss was 151.8 ml, and median length of hospital stay was 4 days. The rate of permanent postoperative complications was 0%; 2 patients experienced transient hoarseness, and 1 patient had medical complications related to alcohol withdrawal.

CONCLUSIONS

This series reveals that endovascular embolization of CBT is a safe and effective technique for tumor devascularization, making preoperative angiography and embolization an important consideration in the management of CBT. Moreover, the successful management of CBT at the authors' institution rests on a multidisciplinary approach whereby endovascular surgeons, neurosurgeons, and ear, nose, and throat-head and neck surgeons work together to optimally manage each patient with CBT.

Carotid Body Tumor: Our Experience with 42 Patients and a Literature Review

To review characteristics, signs, diagnostic methods, and surgical complications in patients with carotid body tumor, in addition to a literature review. This was a cross-sectional study carried out on 42 patients with carotid body tumors referred to Al-Zahra hospital of Isfahan from January 1, 2016, to December 31, 2019. The studied characteristics included age at the onset of symptoms, gender, symptoms, duration of symptomatic status before diagnosis, diagnostic methods, pathological outcome, tumor stage, and surgical complications. The collected data were analyzed using SPSS 21. In this study, 34 patients (80.96%) were female. The mean age at the onset of symptoms was 54.41 years. The mean duration of symptoms before diagnosis was 12.55 months. There was no significant difference between genders for the age and duration of symptoms before diagnosis (p > 0.05). Symptoms were mainly painless mass, hoarseness, coughing, earache, tinnitus, and headache. After surgery, two cases of permanent cranial nerve injuries were found. Thirty-nine patients (93%) were diagnosed by ultrasound imaging and CT scan. We had one case of arterial repair. There was one malignant and one functional tumor. According to the results, carotid body tumor is more common in females especially on the right side. Bilateral tumors are prevalent in females. This mass should be removed by surgery at the time of diagnosis in cases where the patient is not at high risk for surgery due to comorbidities, and the risk of complications following surgery is low.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-021-02453-8.

Operative Technique: Angiomatoid Fibrous Histiocytoma—Unique Case and Management

Objective  We describe the first jugular foramen angiomatoid fibrous histiocytoma (AFH) case and the first treatment with preoperative endovascular embolization. AFH is a rare intracranial neoplasm, primarily found in pediatric patient extremities. With an increase in AFH awareness and a well-described genetic profile, intracranial prevalence has also subsequently increased.

Study Design  We compare this case to previously reported cases using PubMed/Medline literature search, which was performed using the algorithm [“intracranial” AND “angiomatoid fibrous histiocytoma”] through December 2020 (23 manuscripts with 46 unique cases).

Patient  An 8-year-old female presented with failure to thrive and right-sided hearing loss. Work-up revealed an absence of right-sided serviceable hearing and a large jugular foramen mass. Angiogram revealed primary arterial supply from the posterior branch of the ascending pharyngeal artery, which was preoperatively embolized.

Intervention  Gross total resection was performed via a translabyrinthine approach.

Conclusion  The case presented is unique; the first reported AFH at the jugular foramen and the first reported case utilizing preoperative embolization. Preoperative embolization is a relatively safe technique that can improve the surgeon's ability to perform a maximally safe resection, which may decrease the need for adjuvant radiation in rare skull base tumors in young patients.

Outcomes of Carotid Body Tumor Management with Active Surveillance

OBJECTIVES

To assess outcomes of carotid body tumors (CBTs) managed with active surveillance.

METHODS

Retrospective chart review of CBTs managed with active surveillance from 2001 to 2019.

RESULTS

A total of 115 cases were identified during chart review. Sixty-five of these patients were managed with active surveillance, and 11 patients had bilateral tumors for a total of 76 tumors. Follow-up records with symptomatic outcomes were available for 51 patients, and 47 tumors had follow-up imaging. Thirty-one (66%) actively surveilled CBTs remained stable or decreased in size while 16 (34%) increased in size. Patients undergoing active surveillance developed symptoms in 12 cases, 6 of these patients underwent surgical intervention. Nine CBTs managed with active surveillance (18%) were ultimately resected. The majority of patients who did not undergo surgical intervention never developed symptoms (36/42, 86%).

CONCLUSIONS

Active surveillance may be a reasonable approach for a subset of CBTs.

Efficacy and safety of preoperative embolization in carotid body tumor treatment: A propensity score matching retrospective cohort study

BACKGROUND

To assess the efficacy and safety of preoperative embolization (PE) in patients with carotid body tumor (CBTs).

METHODS

In a single-center retrospective cohort study, 127 patients underwent surgical resection of CBTs from January 2003 to December 2019. One-to-one propensity score matching was conducted between patients with or without PE.

RESULTS

Thirty-two (25.2%) patients received PE. After propensity score matching, no statistically significant differences were found in the baseline characteristics of 28 patients in each group. Compared with NPE group, operative time and estimated blood loss (EBL) were significantly reduced in the PE group. The incidence of stroke, perioperative complications, intraoperative blood transfusion, vascular reconstruction, hospital stay, tumor recurrence, and all-cause mortality were not different between the PE and NPE group.

CONCLUSIONS

Preoperative embolization was efficient and safe with a reduction of intraoperative blood loss and operative time during CBT resection.

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.

The role of combined computed tomographic angiography and digital subtraction angiography in the management of cervico-facial vascular lesions

Background

Cervicofacial vascular lesions are one of the most challenging diseases managed by intervention radiologists and specialized surgeons. These lesions were diagnosed to be vascular in origin by other imaging techniques such as Duplex and/or magnetic resonance imaging (MRI). All patients underwent computed tomographic angiography (CTA) to confirm the diagnosis as well as to decide the most effective choice of management based on multidisciplinary team (MDT). Then, Digital subtraction angiography (DSA) was done as it is offering an accurate vascular map for the vascular lesions which is inevitable for successful super-selective endovascular embolization which can be done at same sitting. Small cases of arteriovenous malformations (AVMs) were sufficiently managed by only embolization, whereas cases of adequately embolized large AVMs as well as juvenile nasopharyngeal angiofibroma (JNA) cases were followed by surgery with the advantage of less blood loss and decreasing operation time as well as complications. This prospective study was done to highlight the role of combined CTA and DSA in cervicofacial vascular lesion management.

Results

Twenty patients were included in our study: 16 patients were males, and 4 were females; 17 of them were under 40 years, and three were above 40 years. Preoperative embolization was done in 12 patients, which were all the cases of JNAs and large AVMs. Four patients were managed by only embolization as a definitive treatment. Complete technical success rate was about 94%, while only 6% (single case) of the partial technical success rate which was due to a very small accessory feeder that could not be catheterized even with repeated trials.

Conclusions

Combined CTA and DSA is the cornerstone for managing vascular lesions in the cervicofacial region, which necessitates a MDT to decide the most beneficial and least complicated way for management.

The effect of preoperative embolization on surgical outcomes for carotid body tumor resection

Objective:

Compare the effects of preoperative embolization for carotid body tumor resection on surgical outcomes to carotid body tumor resections without preoperative embolization.

Methods:

Single-center retrospective review of all consecutive patients who underwent carotid body tumor resection from 2001 to 2019. Surgical outcomes with emphasis on operative time (estimated blood loss and cranial nerve injury) of patients undergoing carotid body tumor resection following preoperative embolization were compared to those undergoing resection alone using unpaired Student’s t-test and Fisher’s exact test.

Results:

Forty-six patients (15% male, mean age 50 ± 15 years) underwent resection of 49 carotid body tumors. Patients undergoing preoperative embolization (n = 20 (40%)) had larger mean tumor size (4.0 ± 0.7 vs 3.2 ± 1 cm, p = 0.006), increased Shamblin II/III tumor classification (18 (90%) vs 22 (76%), p < 0.001), operative time (337 ± 195 vs 199 ± 100 min, p = 0.004), and cranial nerve injuries overall (8 (40%) vs 2 (10%), p = 0.01) compared to patients undergoing resection without preoperative embolization (n = 29 (60%)). In subgroup analysis of Shamblin II/III classification tumors (n = 40), preoperative embolization (n = 18) was associated with increased tumor size (4.1 ± 0.6 vs 3.5 ± 0.9 cm, p = 0.01), operative time (351 ± 191 vs 244 ± 105 min, p = 0.02), and cranial nerve injury overall (8 (44%) vs 2 (9%), p = 0.03) compared to resections alone (n = 19). In further subgroup analysis of large (⩾ 3 cm) tumors (n = 37), preoperative embolization (n = 18) was associated with increased operative time (350 ± 191 vs 198 ± 99 min, p = 0.006) and cranial nerve injury overall (8 (44%) vs 2 (11%), p = 0.03) compared to resections alone (n = 19). There were no significant differences in estimated blood loss, transfusion requirement, or hematoma formation between any of the embolization and non-embolization subgroups.

Conclusion:

After controlling for tumor Shamblin classification and size, carotid body tumor resections following preoperative embolization were associated with increased operative time and inferior surgical outcomes compared to those tumors undergoing resection alone. Nonetheless, such results remain susceptible to the confounding effects of individual tumor characteristics often used in the decision to perform preoperative embolization, underscoring the need for prospective studies evaluating the utility of preoperative embolization for carotid body tumors.

Preoperative Super-Selective Embolization of Carotid Body Tumor and Multidisciplinary Approach

A carotid body tumor (CBT) is a rare highly vascular tumor. Therefore, the assessment of the tumor's vessels preoperatively is significant to decrease the risk of vascular complications intraoperatively. We report a case of carotid body tumor in a 40-year-old female who presented with a headache and a pulsatile right neck mass. She underwent computed tomography (CT), which demonstrated a well-circumscribed tumor mass measuring 3 X 2.7 X 3.6 cm. Preoperatively, selective embolization was performed in which Onyx 18 (Medtronic, Dublin, Ireland) and precipitating hydrophobic injectable liquid (PHIL) 25% (Microvention Inc, California) were used, and that achieved 95% embolization of tumor blood supply. One day after embolization, complete surgical resection was done by a multidisciplinary team.

Superselective carotid body tumor embolization with platinum-based coils

Resection of Shamblin II and III carotid body tumors can be challenging owing to the potential for significant blood loss. Prophylactic use of liquid embolic agents poses a risk of inflammatory reactions and nontarget embolization. On the other hand, coil embolization has traditionally been limited to cases involving external carotid artery sacrifice. Herein we demonstrate that superselective targeting of tumor-feeding vessels using platinum based, fully detachable packing coils is effective at sustained devascularization of Shamblin II and III carotid body tumors without subsequent inflammation, allowing for a longer interval between embolization and tumor resection, and potentially reducing blood loss without need for ligation or reconstruction of the internal or external carotid artery.

Carotid body tumor resection utilizing a covered stent graft to enable resection of the tumor en bloc with the internal carotid artery

Surgical excision is the primary treatment for carotid body tumors (CBT) and infrequently involves carotid vessels reconstruction. A CBT that extends distally to the level of the skull base makes surgical reconstruction very challenging. We report a case of a 30-year-old man who presented with a CBT (Shamblin III) extending to the base of the skull. A covered stent graft was placed in the internal carotid artery. Subsequently, a successful resection of the tumor with the arterial wall en bloc was performed, leaving the stent graft exposed as a bridge between the two ends of ICA.

A 40-YEAR FOLLOW-UP OF A PATIENT WITH MULTIPLE PARAGANGLIOMAS AND A SDHD MUTATION

Context

Germline mutations in Succinate Dehydrogenase Complex Subunit D gene (SDHD) predispose to predominantly benign head and neck and/or thoracic-abdominal pelvic paragangliomas (PGLs).

Objective

We present the case of a patient carrying a germline SDHD mutation responsible for multiple PGLs, who was followed for 40 years. He was initially diagnosed with a left cervical PGL at the age of 23 years, treated by surgery. Then, he recurred and developed a multifocal disease. The second-line therapeutic option was a three-dimensional conformal radiotherapy performed in 2008. In 2013 the patient had clinical, hormonal, PET- and SPECT-CT data revealing a disease progression. The treatment with the long-acting somatostatin analogue Octreotide Lar was carried out till the patient's death caused by pulmonary embolism in December 2014.

Results

Complex treatment led to a long clinical and biochemical remission and control of tumor growth.

Conclusions

Despite their usually benign behavior, multicentric SDHD-related PGLs can require a multimodal approach involving surgery, radiotherapy and medical treatment for providing a long-term control of the disease and maintaining a good quality of life.

[Head and neck paragangliomas: An interdisciplinary challenge]

BACKGROUND

Current treatment strategies for head and neck paragangliomas are moving away from radical resection and toward surgical tumor reduction, in order to preserve function and reduce morbidity. Radiotherapy modalities are alternative primary treatment options.

MATERIALS AND METHODS

A PubMed search of the relevant literature on genetics and treatment of head and neck paragangliomas was conducted.

RESULTS

The rapid progress made in genetic research was mainly triggered by two factors: firstly, the establishment of central registries for paraganglioma patients and secondly, the availability of next-generation sequencing methods. Exome sequencing and a gene-panel sequencing approach have already been successfully applied to paraganglioma syndromes. The latter method in particular is rapid and cost-effective, and may soon replace complex genotyping algorithms. The literature provides good evidence that diversified modern treatment options are available to realize individual treatment concepts for almost all paraganglioma manifestations. Generally, small and symptomatic tumors should be completely resected, particularly in younger patients. Considering the patient's age, symptoms, morbidity risk, and comorbidities, larger tumors should be surgically treated in a function-preserving manner. In these cases, primary radiotherapy is an equivalent alternative option. A "wait and scan" strategy is possible in selected cases.

DISCUSSION

The potential morbidity of surgical treatment must be weighed against the expectable quality of life. Comprehensive consultation with the patient about possible treatment modalities is mandatory. Treatment decision making should involve a multidisciplinary team of experts.

Embolization of Carotid Body Tumors: Revisiting Direct Puncture Technique, Preliminary Experience and Literature Review

Preoperative embolization via transarterial route is an acceptable adjunct to the treatment of carotid body tumors (CBT). Direct tumor puncture for embolization has been previously described as a safe and feasible option. We revisit this technique and present our initial experience treating CBT via direct puncture.

We identified six patients that underwent preoperative embolization of CBT using a direct puncture technique embolized with Onyx (EV3 Micro Therapeutics Inc., Irvine, CA, USA). After defining the angioarchitecture via digital subtraction angiography, the tumor was targeted with Onyx. Using a 21-gauge needle, the tumor was punctured using a fluoroscopic road mask. There were no immediate post-procedural complications following embolization. All patients underwent definitive resection within 24 hours. During surgery, the embolization material did not affect surgical maneuvers. In addition, the estimated blood loss was noted to average 50 ml. 

Although early in our experience, direct percutaneous embolization of CBT appears to be a reproducible and well-tolerated endovascular treatment option. Overall, the reported body of evidence available confirms the safety and efficacy of direct intralesional embolization with Onyx.

Multidisciplinary Management of Carotid Body Tumors in a Tertiary Urban Institution

Objective. Aim of this study is to present the experience of our institution in carotid body tumors (CBTs) treatment. Methods. All cases treated in a Vascular Surgery Department within 2.5 years (03/2013-09/2015) were retrospectively evaluated. Demographics, diagnostic, and treatment strategy were recorded. All patients with known CBT underwent ultrasound and magnetic resonance imaging preoperatively. All cases were classified according to the Shamblin type and evaluated by a radiologist, otolaryngologist, and anesthesiologist before and after surgery. Major outcomes included mortality, stroke, cranial nerve injury, and recurrence. Results. Overall, nine patients (mean age: 59.5 ± 16.3 years) with a total of ten CBTs were treated. There was no gender prevalence and most of the cases (55%) were asymptomatic. There were no functional or familial cases. There was only one bilateral case treated in a staged manner. No preoperative embolization of CBTs was performed. Mortality and stroke rates were null. No severe complication was observed in the early and late setting. No malignancy was recorded. Mean follow-up was 15.6 ± 7.8 months. Conclusions. Multidisciplinary management of patients with CBTs is imperative for optimal results, especially in type III tumors, bilateral or functional cases. After careful treatment planning and intraoperative manipulations, complications could be avoided even without preoperative embolization.