Paraganglioma surgery: complications and treatment

Intracapsular Enucleation of Cervical Sympathetic Chain Schwannoma

OBJECTIVES

Schwannoma arising from cervical sympathetic chain (CSC) is a rare clinical entity. CSC is hard to preserve in CSC schwannoma (CSCS) surgeries, resulting in Horner's syndrome (HS) and first bite syndrome (FBS). This article aims to explore our experience in successful preservation of CSC in CSCS surgeries.

METHODS

This is a retrospective review of CSCS cases treated at our tertiary medical institution between Apr 2018 and March 2022. Only cases with successful intraoperative preservation of CSC were included.

RESULTS

In total, 3 cases were included. There were 2 male patients and 1 female patient. Their age was between 38 years old and 66 years old (average and median age was 52 and 51 years old, respectively). Presenting symptom was neck mass for all them, 2 of which were on the left side, while 1 was on the right. Intracapsular enucleation of the CSCS was attempted and achieved in all 3 cases. Hemorrhage from the inner surface of capsules was diffuse and heavy. Constant saline irrigation, suction, and bipolar coagulation were needed to achieve hemostasis. Postoperative HS presented between 4 hours and 14 hours after surgery for all 3 patients, which took 1 month to 3 months to recover, whereas FBS did not occur in any patient. Median duration of follow-up was 6 months. No recurrence was observed.

CONCLUSIONS

Intracapsular enucleation should be attempted in CSCS surgeries, although hemorrhage might be diffuse and hard to control. When intracapsular enucleation was achieved, postoperative FBS can be avoided, while postoperative HS could occur, but its recovery was satisfactory.

Management of Abdominal Paraganglioma: A Single Center's Experience

Background and Objectives: Paragangliomas (PGLs) are rare neuroendocrine extra-adrenal tumors that could be secreting mass. The symptoms are the typical triad of paroxysmal headache, hypertension and sweating, but could also be accompanied by symptoms involving multiple organs. Surgery is the gold standard treatment for both PGLs and pheochromocytomas (PHEOs). Material and Methods: We used a computerized endocrine surgery registry to record the demographic and clinical data of 153 patients who underwent surgery for PPGL between 2010 and 2023 at our hospital. Results: Thirteen patients (8.43%) with paragangliomas underwent surgery at our institute. Five patients presented symptomatic syndrome. Preoperative investigations included enhanced abdominal CT (nine patients) and enhanced MRI (seven patients). In cases of suspicious mass, we performed 131I-MIBG scans (two patients) or 68GA-DOTATOC PET-CT scans (11 patients). Laparoscopic approach was used in four cases (30.7%) and abdominal laparotomy in the other nine (69.3%). Biochemical tests were performed on all patients. Conclusions: In this retrospective study, we discuss the multidisciplinary management in our institute of this rare disease, from its challenging diagnosis to the surgical strategy for PGLs. Laparoscopic surgery is the gold standard, but a tailored approach should be adopted for each patient.

Paraganglioma at the cerebellopontine angle: A case report and review of literature

Paragangliomas (PGLs) are rare neuroendocrine tumors. Sometimes, these tumors secrete excessive catecholamines, which results in the manifestations of various signs and symptoms, usually with a triad of hypertension, tachycardia, and headache. We report the case of a 42-year-old woman presenting with uncontrolled hypertension, right facial palsy, vomiting, and disturbed gait. Diagnosis for PGL was confirmed on postoperative histological examination of the excised mass and correlated with preoperative clinical and radiological findings. Tumor excision was done via a suboccipital craniotomy approach. Our case presents the typically severe features of a jugulotympanic PGL, but most importantly, it highlights the necessity of biochemical diagnosing, thorough probing of the causes of hypertension, and a multi-disciplinary approach in dealing with these tumors. Moreover, the case emphasizes necessitating the use of preoperative embolization in vascular tumors of the head and neck to avoid a hemorrhagic crisis during surgery. Unfortunately, due to a lack of adequate hospital funds, the surgeon had to proceed without preoperative embolization. Despite such a risk, the excision was a success.

Comparison of Lower Cranial Nerve Function Between Tympanojugular Paraganglioma Class C1/C2 With and Without Intracranial Extension: A Four-Decade Experience

OBJECTIVE

To compare preoperative and postoperative lower cranial nerve (LCN) function between Class C1 and C2 tympanojugular paraganglioma (TJP) with/without intracranial intradural (Di)/extradural (De) extensions, according to the experience of a single surgeon over four decades.

STUDY DESIGN

Retrospective review.

SETTING

Quaternary referral center for otology and skull base surgery.

MATERIAL AND METHODS

A chart review was conducted of all the patients operated for C1/C2 TJPs from September 1983 to December 2018. The tumors were classified as: Limited-Group (C1/C2 without Di/De extensions) and Extended-Group (C1/C2 with Di/De extensions).

RESULTS

Of 159 patients, 107 (67.3%) were women; the mean age at surgery was 46.5 years. The Limited-Group (56.6%) comprised C1 (41.1%) and C2 (58.9%) tumors; the Extended-Group (43.4%) comprised C1+Di/De (14.5%) and C2+Di/De (85.5%) tumors. The prevalence of preoperative LCN palsy was 11.9 times higher in Extended than Limited tumors: 61.9% versus 4.9% (p < 0.05). The risk for postoperative LCN palsy was 4.7 times greater in Extended than Limited tumors: 29.2% versus 12.9%, p = 0.01.

CONCLUSION

Especially in younger patients, complete removal of Limited C1/C2 tumors, before they extend intracranially, reduces the risk of dysfunctionality of LCNs and the burden of residual tumor. The incidence of new tumors increased over four decades. However, new-postoperative LCN palsy did not occur in any Limited C1/C2 tumors operated after the year 2000, and declined to less than 10% of Extended C1/C2 tumors.

Iatrogenic central retinal artery occlusion after carotid body tumor embolization and excision

Objective: To report a case of iatrogenic central retinal artery occlusion after embolization and surgical resection of carotid body paraganglioma. Methods: Case report Results: One adult female patient presented with persistent unilateral visual loss after embolization with Embosphere^® and Contour^® microparticles of carotid body tumor. Fluorescein angiography revealed intraluminal microspheres in the central retinal artery ramifications. OCT revealed intraretinal spherical, hyporeflective particles with posterior shadowing. Conclusions: Central retinal artery occlusion should be assessed as a possible complication after surgical repair of head and neck paragangliomas.

Bilateral carotid paraganglioma: surgery and radiotherapy

BACKGROUND

Paragangliomas are relatively rare vascular tumors that develop from the neural crest cells of carotid bifurcation. They usually present as slow-growing, painless unilateral neck masses; bilateral presentation is rare and is mostly associated with familial forms. Bilateral total resection is not always possible for high-grade bilateral tumors, and radiotherapy is a good alternative, with cure rates similar to surgery.

CASE REPORT

A 35-year-old female patient was admitted with a chief complaint of a bilateral, painless mass located on her neck. Subsequent magnetic resonance imaging (MRI) and angiographic imaging revealed bilateral hypervascular masses surrounding her carotid at 360°, and they were interpreted as stage 3 carotid paragangliomas according to the Shamblin classification protocol. Surgery was carried out on the left carotid paraganglioma and the mass was totally resected. It was thought that the patient could not tolerate bilateral surgery. Primary radiotherapy was planned on the right carotid paraganglioma: 59.8 gray (Gy) conformal, Linac-based multileaf collimator radiotherapy with a 180 cGy daily dosage, and five fractions per week were planned.

RESULTS

Follow-up at 3 months following the conclusion of radiotherapy revealed no significant regression. A follow-up MRI 6 months and 24 months later revealed 59% regression. Grade 2 esophagitis and minimal neck edema were the only complications noted during the course of radiotherapy and during the 24-month follow-up period. No complications or relapse were observed except for edema following neck surgery.

Lower cranial nerves function after surgical treatment of Fisch Class C and D tympanojugular paragangliomas

The aim of this study was to report the postoperative lower cranial nerves (LCNs) function in patients undergoing surgery for tympanojugular paraganglioma (TJP) and to evaluate risk factors for postoperative LCN dysfunction. A retrospective case review of 122 patients having Fisch class C or D TJP, surgically treated from 1988 to 2012, was performed. The follow-up of the series ranged from 12 to 156 months (mean, 39.4 ± 32.6 months). The infratemporal type A approach was the most common surgical procedure. Gross total tumor removal was achieved in 86% of cases. Seventy-two percent of the 54 patients with preoperative LCN deficit had intracranial tumor extension. Intraoperatively, LCNs had to be sacrificed in 63 cases (51.6%) due to tumor infiltration. Sixty-six patients (54.09%) developed a new deficit of one or more of the LCNs. Of those patients who developed new LCN deficits, 23 of them had intradural extension. Postoperative follow-up of at least 1 year showed that the LCN most commonly affected was the CN IX (50%). Logistic regression analysis showed that intracranial transdural tumor extension was correlated with the higher risk of LCN sacrifice (p < 0.05). Despite the advances in skull base surgery, new postoperative LCN deficits still represent a challenge. The morbidity associated with resection of the LCNs is dependent on the tumor's size and intradural tumor extension. Though no recovery of LCN deficits may be expected, on long-term follow-up, patients usually compensate well for their LCNs loss.

Carotid Body Tumor Resection: Does the Need for Vascular Reconstruction Worsen Outcome?

We evaluated outcomes after carotid body tumor resection (CBR) requiring vascular reconstruction. Patients undergoing CBR at an academic medical center between 1990 and 2005 were identified. Medical records were retrospectively reviewed for clinical data, operative details, Shamblin's classification, tumor pathology, complications, and mortality. Comparisons were performed between those undergoing CBR alone and CBR requiring vascular reconstruction (CBR-VASC). Of the 71 CBRs performed in 62 patients, 16 required vascular reconstruction (23%). Although there was no difference in mean tumor size (CBR 29.1 +/- 11.9 mm, CBR-VASC 32.5 +/- 9.9 mm; p = 0.133), carotid body tumors were more commonly Shamblin's I when CBR was performed alone (CBR 53% vs. CBR-VASC 25%, p = 0.045) and Shamblin's II/III when vascular reconstruction was required (CBR 47% vs. CBR-VASC 75%, p = 0.045). There was also a significant difference in malignant tumor pathology when vascular reconstruction was required (CBR 4.4% vs. CBR-VASC 25%, p = 0.034). Cranial nerve dysfunction was higher in patients requiring vascular repair (CBR 27% vs. CBR-VASC 63%, p = 0.012), but there was no difference in baroreflex failure (CBR 7.27% vs. CBR-VASC 0%, p = 0.351), Horner's syndrome (CBR 5.5% vs. CBR-VASC 6.25%, p = 0.783), or first bite syndrome (CBR 7.27% vs. CBR-VASC 12.5%, p = 0.877). There were no perioperative strokes in either group, and one death was unrelated to operation. When required, carotid artery reconstruction at the time of CBR can be performed safely. Although cranial nerve dysfunction is more common when vascular repair is required, this is more likely related to locally advanced disease and tumor pathology rather than operative techniques.

Cervical Sympathetic Chain Schwannoma

OBJECTIVES

Schwannomas are benign, slow-growing tumors that arise from nerves. Those originating from the sympathetic cervical chain are rare. We describe our experience with the clinical presentation, surgical management, and outcomes of patients with this pathology.

STUDY DESIGN

Retrospective chart review of a case series in a tertiary referral center.

METHODS

Four cases of cervical sympathetic chain schwannomas were reviewed. Patients presented with either an asymptomatic neck mass discovered on routine physical examination (1 patient), an enlarging neck mass (2), or an acute onset of a Horner's syndrome (1). All patients underwent preoperative imaging (magnetic resonance imaging, computed tomography, or both).

RESULTS

The location and soft-tissue characteristics of the mass, along with displacement of the carotid sheath vessels, were typical of a cervical sympathetic chain schwannoma. All patients underwent surgical excision of the mass. Postoperative Horner's syndrome was encountered in all patients. First bite syndrome was encountered in two patients.

CONCLUSIONS

Cervical sympathetic chain schwannomas are rare tumors. Preoperative imaging characteristics facilitate the diagnosis. First bite syndrome can occur and may be debilitating postoperatively. Long-term prognosis is excellent.