Acquired Vascular Tumors of the Head and Neck

Fifteen Years of Experience with Surgical Management of Bilateral Non-familial Carotid Body Tumors

BACKGROUND

Bilateral carotid body tumors (CBTs) clinical manifestation is infrequent. We conducted this work to describe our experience in the surgical treatment of bilateral CBT and to analyze our results.

METHODS

A retrospective, observational study. We analyzed the totality of bilateral CBT resections that had been performed in our institution from January 2008 to September 2023. Data was obtained from medical records and anonymized, ethics approval was obtained from our institution committee. As the number of observations was less than those required by the central limit theorem our sample was considered nonparametric. Statistical analysis was performed on Stata 17.

RESULTS

We evaluated 16 patients with a total of 32 CBT; surgical resection was performed in 28 cases (87.50%). Median age of the patients was 60 years (interquartile range [IQR] 46-64). Regarding the Shamblin classification, 9 CBTs (32.14%) were classified as Shamblin I, 11 (39.29%) as Shamblin II, and 8 (28.57%) as Shamblin III. The median Distance to the Base of the Skull (DTBOS) was 3.5 cm (IQR 2.7-5.1), and the median tumor volume was 11.25 cc (IQR 3.4-18.7). The median bleeding volume was 300 ml (IQR 200-500), and the median surgical time was 190 min (IQR 145-240). All surgeries were performed using the Retrocarotid Dissection technique. We documented 9 (32.14%) cases of nerve injuries, all of which were transitory. In the median regression a statistically significant association was found between DTBOS, Shamblin classification and tumor volume with intraoperative bleeding and length of stay.

CONCLUSIONS

Surgical treatment remains safe and should be considered the gold standard for accurate histologic diagnosis. DTBOS and tumor volume, in addition to Shamblin classification, must be considered in preoperative planning to predict bleeding and hospital stay.

Integrated Molecular and Histological Insights for Targeted Therapies in Mesenchymal Sinonasal Tract Tumors

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of mesenchymal sinonasal tract tumors (STTs), a distinct subset of STTs. Despite their rarity, mesenchymal STTs represent a unique clinical challenge, characterized by their rarity, often slow progression, and frequently subtle or overlooked symptoms. The complex anatomy of the sinonasal area, which includes critical structures such as the orbit, brain, and cranial nerves, further complicates surgical treatment options. This underscores an urgent need for more advanced and specialized therapeutic approaches.

RECENT FINDINGS

Advancements in molecular diagnostics, particularly in next-generation sequencing, have significantly enhanced our understanding of STTs. Consequently, the World Health Organization has updated its tumor classification to better reflect the distinct histological and molecular profiles of these tumors, as well as to categorize mesenchymal STTs with greater accuracy. The growing understanding of the molecular characteristics of mesenchymal STTs opens new possibilities for targeted therapeutic interventions, marking a significant shift in treatment paradigms. This review article concentrates on mesenchymal STTs, specifically addressing sinonasal tract angiofibroma, sinonasal glomangiopericytoma, biphenotypic sinonasal sarcoma, and skull base chordoma. These entities are marked by unique histopathological and molecular features, which challenge conventional treatment approaches and simultaneously open avenues for novel targeted therapies. Our discussion is geared towards delineating the molecular underpinnings of mesenchymal STTs, with the objective of enhancing therapeutic strategies and addressing the existing shortcomings in the management of these intricate tumors.

MRI features of sinonasal tract angiofibroma/juvenile nasopharyngeal angiofibroma: Case series and systematic review

BACKGROUND AND PURPOSE

To comprehensively summarize the radiological characteristics of sinonasal tract angiofibroma (STA) (commonly known as juvenile nasopharyngeal angiofibroma).

METHODS

Forty-four lesions from 41 cases provided by 33 study articles identified through a systematic review and 13 lesions from 13 cases from our institution associated with patients with STA who underwent MRI were included in the review study, carried out by two board-certified experienced radiologists.

RESULTS

The study participants were all male patients with a mean age of 15.6 years at the time of diagnosis. All of them presented with nasal cavity lesions (100%), predominantly in the nasopharynx (98.2%). The sphenopalatine foramen/pterygopalatine fossa was involved in 76.0%, and compressive shift of the posterolateral wall of the maxillary sinus was present in more than half (57.9%). T2-weighted imaging signal intensity was heterogeneous with mixed high and iso intensities as compared to skeletal muscle (100%). T1-weighted imaging showed partial high signal intensity in 61.1% of the cases. Flow void and intense enhancement were present in almost all cases. Cystic/nonenhancement changes on contrast-enhanced MRI were relatively common (40.8%). The mean apparent diffusion coefficient value (2.07 × 10-3  mm2 /second) and some quantitative dynamic contrast-enhanced MRI parameters were high. There was a significant difference in the frequency of residual/recurrent lesions based on the presence of MRI findings of skull base invasion (p = .017) and intracranial extension (p = .003).

CONCLUSIONS

We summarized the MRI findings of STA that can facilitate timely diagnosis and appropriate management.

Association of Tumor Volumetry with Postoperative Outcomes for Cervical Paraganglioma

Objectives: To analyze the association of tumor volume with outcome after surgery for cervical paraganglioma. Materials and Methods: This retrospective study included consecutive patients undergoing surgery for cervical paraganglioma from 2009-2020. Outcomes were 30-day morbidity, mortality, cranial nerve injury, and stroke. Preoperative CT/MRI was used for tumor volumetry. An association between the volume and the outcomes was explored in univariate and multivariable analyses. A receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated. The study was conducted and reported according to the STROBE statement. Results: Volumetry was successful in 37/47 (78.8%) of included patients. A 30-day morbidity occurred in 13/47 (27.6%) patients with no mortality. Fifteen cranial nerve lesions occurred in eleven patients. The mean tumor volume was 6.92 cm³ in patients without and 15.89 cm³ in patients with complications (p = 0.035) and 7.64 cm³ in patients without and 16.28 cm³ in patients with cranial nerve injury (p = 0.05). Neither the volume nor Shamblin grade was significantly associated with complications on multivariable analysis. The AUC was 0.691, indicating a poor to fair performance of volumetry in predicting postoperative complications. Conclusions: Surgery for cervical paraganglioma bears a relevant morbidity with a particular risk of cranial nerve lesions. Tumor volume is associated with morbidity, and MRI/CT volumetry can be used for risk stratification.

A dosimetric comparison of proton versus photon irradiation for paediatric glomus tumour: a case study

Background:

Intensity-modulated radiation therapy (IMRT) has revolutionised the way head and neck cancers can be treated. It allows for a more conformal treatment plan when compared to 3D conformal radiation therapy. In paediatric patients, however, IMRT continues to deliver higher doses than desirable. Proton beam therapy on the other hand has the potential to further spare organs-at-risk.

Methods:

A 16-year-old boy with a left-sided paraganglioma of the left base of skull manifested by headaches, neck pain and tongue cramping was simulated, planned and treated with proton therapy with significant contralateral organ-at-risk sparing.

Results:

For this patient, dosimetric plan comparison between photon and proton plans clearly showed better sparing of contralateral organs-at-risk with protons. The contralateral parotid gland received a mean dose of 386·3 cGy with photons, whereas it received 1·3 cGy (CGE) in the proton plan.

Conclusions:

The dosimetric advantage of proton beam over photon beam therapy has successfully been demonstrated in this case study for a paediatric patient with a head and neck tumour. Sparing of contralateral structures is especially important in paediatric patients who are at a greater risk of secondary malignancies due to possible long life expectancy.

[Modern conceptions on neck paragangliomas]

Neck paragangliomas are orphan diseases with incidence 1:30 000-1:100 000. Life expectancy is poor in patients with distant metastasis (5-year overall survival 11.8%), whereas 5-year overall survival in patients with regional metastasis is 76.8-82.4%. Meanwhile, there is still no any reliable tool for prediction of malignant potential of paraganglioma. Above-mentioned data indicate an importance of early diagnosis and timely treatment of neck paragangliomas. Total resection of tumor in ablastic conditions is a gold standard of treatment. However, surgery is associated with a high risk of neurovascular complications and requires multidisciplinary approach. Nevertheless, new knowledge dedicated to different aspects of pathogenesis of neck paraganglioma, diagnosis and treatment arise every year. This review is devoted to modern data on neck paragangliomas.

Pediatric Neck Masses: Imaging Guidelines and Recommendations

Neck masses commonly present in children and several potential diagnostic and management pathways exist, though with a paucity of evidence-based recommendations. The purpose of this article is to evaluate the current literature and utilization of various diagnostic imaging modalities , with a review of imaging features and management pearls for pediatric neck masses. A comprehensive understanding and practical imaging workflow will guide optimal patient workup and management.

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.

Assessment of health-related quality of life in patients prior to carotid body tumor resection

Background

Carotid body tumors represent approximately 0.5% of the total head and neck tumors, and the most common presentation form is an asymptomatic cervical mass. Despite of being most of them asymptomatic the quality of life could be impacted; however, the literature remains silent about this matter. The Short Form 36 (SF-36) is a health-related quality of life (HRQoL) instrument that includes eight domains to assess physical and emotional function in different diseases. The aim of this study was to compare HRQoL in preoperative patients with carotid body tumor and a control paired group. The secondary objective was to compare HRQoL between carotid body tumor patients according to the volume tumor and Shamblin classification.

Methods

A cross-sectional study that included 23 patients diagnosed with carotid body tumor prior to resection and 23 control patients paired by age and gender was conducted from January 2017 to December 2018. The SF-36 questionnaire was applied in 46 patients. Three-dimensional volume reconstruction and estimation (3DVR) was obtained from a preoperative computed tomography angiography (CTA). Descriptive statistical analysis was performed for demographics and categorical variables were reported by frequencies and percentages. Continuous variables were summarized using median with interquartile ranges (IQR) with 95% confidence interval (CI) and were compared. Differences between medians were analyzed with the Mann–Whitney U test and all statistical tests were two-sided.

Results

In the carotid body tumor group, the mean age was 55 years, females were more frequently affected 19 (83%). Shamblin I was identified in 9% of patients, Shamblin II in 52% and Shamblin III in 39%. Carotid body tumor laterality were 57% right, 34% left and 9% bilateral tumors. The eight domains that comprise the SF-36 questionnaire were statistically significant when compared to the control group.

Conclusion

Significant differences were found in all SF-36 domains in carotid body tumor patients in comparison to control subjects, confirming that this neoplasm has negative impact in the general HRQoL.

Surgical Management of Bilateral Carotid Body Tumors

BACKGROUND

Carotid body tumors (CBTs) are rare neoplasms located in the carotid bifurcation. The majority of these tumors are unilateral; bilateral CBTs represent approximately 5% of all affected patients, and the recommended treatment is to surgically remove them in staged-planned surgeries. We describe the experience, outcomes, and the surgical management of bilateral CBTs in our institution.

METHODS

A retrospective review of CBTs patients was completed; patient demographics, comorbidities, lesion location, anatomic characteristics, surgical techniques, complications, reinterventions, and other factors that may influence outcomes were evaluated.

RESULTS

A total of 109 patients with CBTs were treated surgically; of these, 8 had bilateral CBTs (7%); the mean age was 56 years, and 7 (87%) were females. Thirteen surgical resections were performed, and in 2 of the cases, the pathology report was malignant (15%). Five were classified as Shamblin I (31%), 5 as Shamblin II (31%), and remaining 6 as Shamblin III (38%). The mean time between the first and second procedure was of 10.7 months. Complications included one case of neck hematoma requiring evacuation and postoperative neurologic complications occurred in three patients (one patient with facial and two with vocal cord palsies). None of the studied individuals had a family history of CBT, and all of them lived in altitude areas higher than 2000 meters above mean sea level (mamsl). The mean tumor size was 3.55 cm and 2.75 cm for right and left CBTs, respectively.

CONCLUSIONS

A better understanding of the clinical characteristics of patients with bilateral CBTs may lead to a more standardized and optimal management with fewer complications and a better quality of life afterward.

Incidental Findings in TMJ Imaging

For years, the conventional imaging modalities are generally used in dental practice routine. They provide precious information about dentomaxillofacial region; they also have some limitations such as superimpositions, magnifications, distortions, and low-image quality. Because of these limitations, some pathologies, calcifications, and anatomical variations may be missed. Any findings on a radiographic image which are not related to the research areas of interest could be a description of “incidental findings.” Calcifications are one of these incidental findings. They are asymptomatic and also common in TMJ images. Although most of the calcifications require no treatment, correct identification will reduce further diagnostic assessments. Incidental findings on TMJ images were rare, while examining images for temporomandibular disorders and associated issues, it is important not only to examine the TMJ structures but also to look at the nearby anatomical features to check for evidence of incidental findings pathologies that may have mimicked signs and symptoms of TMJ disorders.