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Shiferaw MY, Teklemariam TL, Wondimagegnewu EZ, Gebrewahd DT, Yesuf EF, Mekuria BH, Abelti SB. Diffuse subarachnoid hemorrhage following ventriculo-peritoneal shunt insertion for acute obstructive hydrocephalus from large glomus jugulare tumor: case report. Front Surg 2024; 11:1353400. [PMID: 38645509 PMCID: PMC11027019 DOI: 10.3389/fsurg.2024.1353400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
Background Glomus jugulare tumors (GJTs) are rare intra-cranial tumors. Commonly, these lesions present with cranial nerve palsies, headaches, and hydrocephalus. Rarely, GJTs present with spontaneous subarachnoid hemorrhage. However, there has never been a report of diffuse subarachnoid hemorrhage following ventriculoperitoneal shunt insertion in a patient who developed hydrocephalus secondary to any brain tumor in general or glomus jugulare tumors in particular. Observation The authors presented an extremely rare complication of diffuse subarachnoid hemorrhage following the insertion of a ventriculoperitoneal shunt (VPS) in a 61-year-old female patient who was diagnosed to have both clinical and radiologic features of acute obstructive hydrocephalus secondary to a highly vascular huge glomus jugulare tumor. Conclusion Subarachnoid hemorrhage following ventriculoperitoneal shunt insertion for hydrocephalus caused by a mass lesion is an extremely rare complication. Preoperative CT angiography should be strongly considered to look for the associated vascular malformations in extremely vascularized mass lesions. Given the not ubiquitous availability of all therapeutic options for GJTs, especially in low and middle income settings contributes for the poor outcome of GJTs and it fosters a global neurosurgery agenda.
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Affiliation(s)
| | | | | | - Dejen Tekiea Gebrewahd
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ermias Fikru Yesuf
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
| | - Bereket Hailu Mekuria
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sebboona Baisa Abelti
- Department of surgery, Neurosurgery Division, Addis Ababa University, Addis Ababa, Ethiopia
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2
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Garibaldi E, Bresciani S, Panaia R, Delmastro E, Malinverni G, Gabriele P. Hereditary Paraganglioma Syndrome Associated with SDHD Gene Mutations: A Patient with Multicentric Presentation Treated with Radiotherapy. Case Report. TUMORI JOURNAL 2018; 97:214-20. [DOI: 10.1177/030089161109700214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Extra-adrenal paragangliomas are rare tumors arising from neuroendocrine cells. Sporadic and hereditary forms have been recognized. Among the latter, the PGL1 and PGL4 syndromes are associated with a high risk of multiple localizations. The treatment of choice for paragangliomas is surgical resection, but in some cases surgery can be difficult due to particular or multiple tumor sites or may result in severe neurological deficits. In such cases radiotherapy can be an effective alternative. In this paper we describe the case of a patient affected by hereditary paraganglioma syndrome with multicentric presentation who was treated at our center by external radiotherapy. Case report A 55-year-old man presented in April 2008 with multiple paragangliomas: one in the left pontocerebellar angle, two in the middle neck, one mediastinal paraaortic mass, and an abdominal paraaortic lesion. The left pontocerebellar and mediastinal tumors were treated with three-dimensional conformal radiotherapy (3D-CRT) at total doses of 50.40 Gy and 55.80 Gy, respectively. The neck lesions were treated with intensity-modulated radiotherapy (IMRT) at a total dose of 55.80 Gy. The abdominal paraaortic lesion was surgically resected. Results No severe acute or late toxicity as evaluated with the EORTC-RTOG scale was observed. Fourteen months after the end of radiotherapy a whole body CT scan showed that the tumor lesions were stable in size and in their relations to contiguous structures. The arterial pressure was controlled by medical therapy and urine catecholamine levels were within the normal range. Conclusions We believe that in patients affected by unresectable paragangliomas radiotherapy is a safe and effective alternative to surgery. The use of high-dose conformity techniques such as 3D-CRT and IMRT will allow higher local control rates with relatively few side effects thanks to the possibility of dose escalation and reduction of the amount of irradiated healthy tissues.
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Affiliation(s)
- Elisabetta Garibaldi
- Radiotherapy Unit, Institute for Cancer Research and Treatment – IRCC, Candiolo (Turin), Italy
| | - Sara Bresciani
- Medical Physics Unit, Institute for Cancer Research and Treatment – IRCC, Candiolo (Turin), Italy
| | - Rocco Panaia
- Radiotherapy Unit, Institute for Cancer Research and Treatment – IRCC, Candiolo (Turin), Italy
| | - Elena Delmastro
- Radiotherapy Unit, Institute for Cancer Research and Treatment – IRCC, Candiolo (Turin), Italy
| | - Giuseppe Malinverni
- Radiotherapy Unit, Institute for Cancer Research and Treatment – IRCC, Candiolo (Turin), Italy
| | - Pietro Gabriele
- Radiotherapy Unit, Institute for Cancer Research and Treatment – IRCC, Candiolo (Turin), Italy
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Jansen TTG, Timmers HJLM, Marres HAM, Kaanders JHAM, Kunst HPM. Results of a systematic literature review of treatment modalities for jugulotympanic paraganglioma, stratified per Fisch class. Clin Otolaryngol 2018; 43:652-661. [PMID: 29222838 DOI: 10.1111/coa.13046] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Key for successful jugulotympanic paraganglioma management is a personalised approach aiming for the best practice for each individual patient. To this end, a systematic review is performed, evaluating the local control and complication rates for the different treatment modalities stratified by the broadly accepted Fisch classification. DESIGN A systematic literature review according to the PRISMA statement was performed. A detailed overview of individual treatment outcomes per Fisch class is provided. MAIN OUTCOME MEASURES Local control, cranial nerve damage, complications, function recovery. RESULTS Eighteen studies were selected, resembling 83 patients treated with radiotherapy and 299 with surgery. Excellent local control was found post-surgery for class A and B tumours, and risk of cranial nerve damage was <1%. For class C1-4 tumours, local control was 80%-95% post-surgery (84% post-radiotherapy), and cranial nerve damage was found in 71%-76% (none post-radiotherapy; P < .05). There was no difference in treatment outcomes between tumours of different C class. For class C1-4De/Di tumours, local control was 38%-86% (98% post-radiotherapy; P < .05) and cranial nerve damage/complication rates were 67%-100% (3% post-radiotherapy; P < .05). C1-4DeDi tumours showed lesser local control and cranial nerve damage rates when compared to C1-4De tumours. CONCLUSIONS An individual risk is constituted for surgery and radiotherapy, stratified per Fisch class. For class A and B tumours, surgery is a suitable treatment option. For class C and D tumours, radiotherapy results in lower complication rates and similar or better local control rates when compared to the surgical group.
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Affiliation(s)
- T T G Jansen
- Department of Otolaryngology and Head & Neck Surgery, Radboudumc, Nijmegen, The Netherlands
| | - H J L M Timmers
- Department of Endocrinology, Radboud Skull Base Centre, Radboudumc, Nijmegen, The Netherlands
| | - H A M Marres
- Department of Otolaryngology and Head & Neck Surgery, Radboudumc, Nijmegen, The Netherlands
| | - J H A M Kaanders
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - H P M Kunst
- Department of Otolaryngology and Head & Neck Surgery, Radboudumc Skull Base Centre, Radboudumc, Nijmegen, The Netherlands
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Hafez RFA, Morgan MS, Fahmy OM. An intermediate term benefits and complications of gamma knife surgery in management of glomus jugulare tumor. World J Surg Oncol 2016; 14:36. [PMID: 26879488 PMCID: PMC4753653 DOI: 10.1186/s12957-016-0779-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 01/26/2016] [Indexed: 11/03/2022] Open
Abstract
Glomus tumors are rare skull base slow-growing, hypervascular neoplasms that frequently involve critical neurovascular structures, and delay in diagnosis is frequent. Surgical removal is rarely radical and is usually associated with morbidity or mortality. Gamma knife surgery (GKS) has gained an increasing dependable role in the management of glomus jugulare tumors, with high rate of tumor growth control, preserving or improving clinical status and with limited complications. This study aims to evaluate intermediate term benefits and complications of gamma knife surgery in management of twenty-two patients bearing growing glomus jugulare tumors at the International Medical Center (IMC), Cairo, Egypt, between 2005 and 2011. The mean follow-up period was 56 months (range 36-108 months); there were 3 males, 19 females; mean age was 43.6 years; 15 patients had GKS as the primary treatment; 2 patients had surgical residuals; 2 had previous radiation therapy; and 3 previously underwent endovascular embolization. The average tumor volume was 7.26 cm3, and the mean marginal dose was 14.7 Gy. Post gamma knife surgery through the follow-up period neurological status was improved in 12 patients, 7 showed stable clinical condition and 3 patients developed new moderate deficits. Tumor volume post GKS was unchanged in 13 patients, decreased in 8, and showed tumor regrowth in 1 patient. Tumor progression-free survival in our studied patients was 95.5% at 5 and 7 years of the follow-up period post GKS. Gamma knife surgery could be used safely and effectively with limited complications as a primary management tool in the treatment of glomus jugulare tumors controlling tumor growth with preserving or improving clinical status especially those who do not have significant cranial or cervical extension, elderly, and surgically unfit patients; moreover, it is safe and highly effective as adjuvant therapy as well.
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Affiliation(s)
- Raef F A Hafez
- Department of Neurosurgery and Gamma Knife center, International Medical Center (IMC), Cairo, Egypt.
| | - Magad S Morgan
- Department of Neurosurgery and Gamma Knife center, International Medical Center (IMC), Cairo, Egypt
| | - Osama M Fahmy
- Department of Neurosurgery and Gamma Knife center, International Medical Center (IMC), Cairo, Egypt
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5
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Martín IT, Ávila RDM, Herrera MZ, Arregui G, Osorio-Ceballos JL, Rojas ES, Almansa ÁH, Arrebola JP, Rull JP, Hernández JE, Ramírez EL. Role of radiosurgery in the management of glomus tumors. Head Neck 2015; 38 Suppl 1:E798-804. [DOI: 10.1002/hed.24103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2015] [Indexed: 01/02/2023] Open
Affiliation(s)
- Isabel Tovar Martín
- Radiation Oncology Department; Virgen de las Nieves University Hospital; Granada Spain
| | | | | | | | | | - Enrique Saura Rojas
- Neurosurgery Department; Virgen de las Nieves University Hospital; Granada Spain
| | | | - Juan P. Arrebola
- Radiation Oncology Department; Virgen de las Nieves University Hospital; Granada Spain
- CIBER en Epidemiología y Salud Pública (CIBERESP); Granada Spain
| | - Jorge Pastor Rull
- Neuroradiology Department; Virgen de las Nieves University Hospital; Granada Spain
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El Majdoub F, Hunsche S, Igressa A, Kocher M, Sturm V, Maarouf M. Stereotactic LINAC-Radiosurgery for Glomus Jugulare Tumors: A Long-Term Follow-Up of 27 Patients. PLoS One 2015; 10:e0129057. [PMID: 26069957 PMCID: PMC4466539 DOI: 10.1371/journal.pone.0129057] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 05/04/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The optimal treatment of glomus jugulare tumors (GJTs) remains controversial. Due to the critical location, microsurgery still provides high treatment-related morbidity and a decreased quality of life. Thus, we performed stereotactical radiosurgery (SRS) for the treatment of GJTs and evaluated the long-term outcome. METHODS Between 1991 and 2011, 32 patients with GJTs underwent SRS using a linear accelerator (LINAC) either as primary or salvage therapy. Twenty-seven patients (median age 59.9 years, range 28.7-79.9 years) with a follow-up greater than five years (median 11 years, range 5.3-22.1 years) were selected for retrospective analysis. The median therapeutic single dose applied to the tumor surface was 15 Gy (range 11-20 Gy) and the median tumor volume was 9.5 ml (range 2.8-51 ml). RESULTS Following LINAC-SRS, 10 of 27 patients showed a significant improvement of their previous neurological complaints, whereas 12 patients remained unchanged. Five patients died during follow-up due to old age or other, not treatment-related reasons. MR-imaging showed a partial remission in 12 and a stable disease in 15 patients. No tumor progression was observed. The actuarial overall survival rates after five, ten and 20 years were 100%, 95.2% and 79.4%, respectively. CONCLUSIONS Stereotactic LINAC-Radiosurgery can achieve an excellent long-term tumor control beside a low rate of morbidity in the treatment of GJTs. It should be considered as an alternative therapy regime to surgical resection or fractionated external beam radiation either as primary, adjuvant or salvage therapy.
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Affiliation(s)
- Faycal El Majdoub
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Stereotaxy and Functional Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
- * E-mail:
| | - Stefan Hunsche
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Stereotaxy and Functional Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - Alhadi Igressa
- Department of Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | - Martin Kocher
- Department of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - Volker Sturm
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Neurosurgery, University Hospital of Wurzburg, Wurzburg, Germany
| | - Mohammad Maarouf
- Department of Stereotaxy and Functional Neurosurgery, University Hospital of Cologne, Cologne, Germany
- Department of Stereotaxy and Functional Neurosurgery, University of Witten-Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
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Gandía-González ML, Kusak ME, Moreno NM, Sárraga JG, Rey G, Álvarez RM. Jugulotympanic paragangliomas treated with Gamma Knife radiosurgery: a single-center review of 58 cases. J Neurosurg 2014; 121:1158-65. [PMID: 24926654 DOI: 10.3171/2014.5.jns131880] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Jugulotympanic paragangliomas (JTPs) are rare benign tumors whose surgical treatment is usually associated with partial resection of the lesion, high morbidity, and even death. Gamma Knife radiosurgery (GKRS) has been reported as a useful treatment option. The goal of this retrospective study is to analyze the role of GKRS in tumor volume control and clinical outcomes of these patients. METHODS A total of 75 patients with JTPs were treated with GKRS at the authors' center from 1995 to 2012. The authors analyzed those treated during this period to allow for a minimal observation time of 2 years. The MR images and clinical reports of these patients were reviewed to assess clinical and volumetric outcomes of the tumors. The radiological and clinical assessments, along with a group of prognostic factors measured, were analyzed using descriptive methods. The time to volumetric and clinical progression was analyzed using the Kaplan-Meier method. Prognostic factors were identified using log-rank statistics and multivariate Cox regression models. RESULTS The mean follow-up was 86.4 months. The authors observed volumetric tumor control in 94.8% of cases. In 67.2% of cases, tumor volume decreased by a mean of 40.1% from the original size. Of patients with previous tinnitus, 54% reported complete recovery. Improvement of other symptoms was observed in 34.5% of cases. Overall, clinical control was achieved in 91.4% of cases. Previous embolization and familial history of paraganglioma were selected as significant prognostic factors for volumetric response to GKRS treatment in the univariate analysis. In multivariate analysis, no factors were significantly correlated with progression-free survival. No patient died of side effects related to GKRS treatment or tumor progression. CONCLUSIONS Gamma Knife radiosurgery is an effective, safe, and efficient therapeutic option for the treatment of these tumors as a first-line treatment or in conjunction with traditional surgery, endovascular treatment, or conventional fractionated radiotherapy.
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8
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Chun SG, Nedzi LA, Choe KS, Abdulrahman RE, Chen SA, Yordy JS, Timmerman RD, Kutz JW, Isaacson B. A Retrospective Analysis of Tumor Volumetric Responses to Five-Fraction Stereotactic Radiotherapy for Paragangliomas of the Head and Neck (Glomus Tumors). Stereotact Funct Neurosurg 2014; 92:153-9. [DOI: 10.1159/000360864] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/21/2014] [Indexed: 11/19/2022]
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Prouse G, Mazzaccaro D, Settembrini F, Carmo M, Biglioli F, Settembrini PG. Double osteotomy of mandibula in the treatment of carotid body tumors with skull base extension. J Vasc Surg 2013; 58:486-90. [DOI: 10.1016/j.jvs.2012.11.086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 11/08/2012] [Accepted: 11/18/2012] [Indexed: 11/16/2022]
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Lieberson RE, Adler JR, Soltys SG, Choi C, Gibbs IC, Chang SD. Stereotactic radiosurgery as the primary treatment for new and recurrent paragangliomas: is open surgical resection still the treatment of choice? World Neurosurg 2012; 77:745-61. [PMID: 22818172 DOI: 10.1016/j.wneu.2011.03.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 01/16/2011] [Accepted: 03/23/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Paragangliomas (PGs) or glomus tumors are rare, and publications comparing treatment alternatives are few. We sought to analyze our experience with stereotactic radiosurgery (SRS), review the literature, and develop treatment guidelines. METHODS We retrospectively examined the outcomes of 41 PGs in 36 patients treated with SRS at Stanford. Our data from medical records, telephone interviews, and imaging studies were combined with previously reported SRS data and compared to results following other treatments. RESULTS With a median clinical follow-up of 4.8 years (3.9 years radiographic), local control was 100%. Complications included increase in preexistent vertigo in one patient and transient cranial neuropathies in two patients. Published surgical series describe a lower local control rate as well as more frequent and severe complications. Published radiation therapy (RT) series document a slightly lower local control rate than SRS, but SRS can be delivered more quickly and conveniently. Open surgery and other combinations of treatments appear to be required for several subpopulations of PG patients. CONCLUSIONS We feel that SRS should be the primary treatment for most new and recurrent PGs. Even some very large PGs are appropriate for SRS. RT remains an appropriate option in some centers, especially those where SRS is not available. PGs occurring in the youngest patients, catecholamine secreting PGs, and PGs causing rapidly progressing neurologic deficits may be more appropriate for open resection. Metastatic PGs may benefit from combinations of chemotherapy and SRS or RT. Treatment guidelines are proposed.
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Affiliation(s)
- Robert E Lieberson
- Department of Neurosurgery, Stanford Hospital and Clinics, Stanford University, Stanford, California, USA.
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Sheehan JP, Tanaka S, Link MJ, Pollock BE, Kondziolka D, Mathieu D, Duma C, Young AB, Kaufmann AM, McBride H, Weisskopf PA, Xu Z, Kano H, Yang HC, Lunsford LD. Gamma Knife surgery for the management of glomus tumors: a multicenter study. J Neurosurg 2012; 117:246-54. [DOI: 10.3171/2012.4.jns11214] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Glomus tumors are rare skull base neoplasms that frequently involve critical cerebrovascular structures and lower cranial nerves. Complete resection is often difficult and may increase cranial nerve deficits. Stereotactic radiosurgery has gained an increasing role in the management of glomus tumors. The authors of this study examine the outcomes after radiosurgery in a large, multicenter patient population.
Methods
Under the auspices of the North American Gamma Knife Consortium, 8 Gamma Knife surgery centers that treat glomus tumors combined their outcome data retrospectively. One hundred thirty-four patient procedures were included in the study (134 procedures in 132 patients, with each procedure being analyzed separately). Prior resection was performed in 51 patients, and prior fractionated external beam radiotherapy was performed in 6 patients. The patients' median age at the time of radiosurgery was 59 years. Forty percent had pulsatile tinnitus at the time of radiosurgery. The median dose to the tumor margin was 15 Gy. The median duration of follow-up was 50.5 months (range 5–220 months).
Results
Overall tumor control was achieved in 93% of patients at last follow-up; actuarial tumor control was 88% at 5 years postradiosurgery. Absence of trigeminal nerve dysfunction at the time of radiosurgery (p = 0.001) and higher number of isocenters (p = 0.005) were statistically associated with tumor progression–free tumor survival. Patients demonstrating new or progressive cranial nerve deficits were also likely to demonstrate tumor progression (p = 0.002). Pulsatile tinnitus improved in 49% of patients who reported it at presentation. New or progressive cranial nerve deficits were noted in 15% of patients; improvement in preexisting cranial nerve deficits was observed in 11% of patients. No patient died as a result of tumor progression.
Conclusions
Gamma Knife surgery was a well-tolerated management strategy that provided a high rate of long-term glomus tumor control. Symptomatic tinnitus improved in almost one-half of the patients. Overall neurological status and cranial nerve function were preserved or improved in the vast majority of patients after radiosurgery.
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Affiliation(s)
- Jason P. Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Shota Tanaka
- 2Neuro-Oncology Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael J. Link
- 3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bruce E. Pollock
- 3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Douglas Kondziolka
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - David Mathieu
- 5Division of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Christopher Duma
- 6Hoag Neurosciences Institute, Hoag Memorial Hospital, Newport Beach, California
| | - A. Byron Young
- 7Department of Neurosurgery, University of Kentucky Medical Center, Lexington, Kentucky
| | - Anthony M. Kaufmann
- 8Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Heyoung McBride
- 9Arizona Oncology Services Foundation; and
- 10Sections of Radiation Oncology and
| | | | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Huai-che Yang
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - L. Dade Lunsford
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
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Suárez C, Rodrigo JP, Bödeker CC, Llorente JL, Silver CE, Jansen JC, Takes RP, Strojan P, Pellitteri PK, Rinaldo A, Mendenhall WM, Ferlito A. Jugular and vagal paragangliomas: Systematic study of management with surgery and radiotherapy. Head Neck 2012; 35:1195-204. [PMID: 22422597 DOI: 10.1002/hed.22976] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The definitive treatment for head and neck paraganglioma (PG) is surgical excision. Unfortunately, surgery, particularly of vagal paraganglioma (VPG; "glomus vagale") and foramen jugulare ("glomus jugulare") tumors, may be complicated by injuries to the lower cranial nerves, a high price to pay for treatment for a benign tumor. Alternatively these tumors may be followed without treatment, or irradiated. The purpose of this review was to compare the existing evidence concerning the efficacy and safety of surgery, external beam radiotherapy (EBRT), and stereotactic radiosurgery (SRS), for jugular paragangliomas (JPGs) and VPGs. METHODS Relevant articles were reviewed using strict criteria for systematic searches. Forty-one surgical studies met the criteria which included 1310 patients. Twenty articles including 461 patients treated with EBRT, and 14 radiosurgery studies comprising 261 patients were also evaluated. Results were compared between treatment modalities using analysis of variance (ANOVA) tests. RESULTS A total of 1084 patients with JPGs and 226 VPGs were treated with different surgical procedures. Long-term control of the disease was achieved in 78.2% and 93.3% of patients, respectively. A total of 715 patients with JPG were treated with radiotherapy: 461 with EBRT and 254 with SRS. Control of the disease with both methods was obtained in 89.1% and 93.7% of the patients, respectively. The treatment outcomes of a JPG treated with surgery or radiotherapy were compared. Tumor control failure, major complication rates, and the number of cranial nerve palsies after treatment were significantly higher in surgical than in radiotherapy series. The results of SRS and EBRT in JPGs were compared and no significant differences were observed in tumor control. Because only 1 article reported on the treatment of 10 VPGs with radiotherapy, no comparisons with surgery could be made. Nevertheless, the vagus nerve was functionally preserved in only 11 of 254 surgically treated patients (4.3%). CONCLUSION There is evidence that EBRT and SRS offer a similar chance of tumor control with lower risks of morbidity compared with surgery in patients with JPGs. Although the evidence is based on retrospective studies, these results suggest that surgery should be considered only for selected cases, but the decision should be individual for every patient.
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Affiliation(s)
- Carlos Suárez
- Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain.
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14
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Paragangliomas temporales. Experiencia de 12 años. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2011; 62:375-80. [DOI: 10.1016/j.otorri.2011.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 05/04/2011] [Accepted: 05/19/2011] [Indexed: 11/19/2022]
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15
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Lee CC, Pan DHC, Wu JC, Chung WY, Wu HM, Yang HC, Liu KD, Guo WY, Shih YH. Gamma Knife Radiosurgery for Glomus Jugulare and Tympanicum. Stereotact Funct Neurosurg 2011; 89:291-8. [DOI: 10.1159/000328890] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Accepted: 04/26/2011] [Indexed: 12/25/2022]
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16
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Fayad JN, Schwartz MS, Brackmann DE. Treatment of recurrent and residual glomus jugulare tumors. Skull Base 2011; 19:92-8. [PMID: 19568346 DOI: 10.1055/s-0028-1103130] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Residual and recurrent glomus jugulare tumors are rare but challenging. Treatment options include microsurgical resection, stereotactic radiotherapy, a combination of modalities, and "observation." Choice of treatment must be made on a case-by-case basis, considering patient age, health status, location and size of tumor, status of the lower cranial nerves, and, of course, patient desire. Surgery is preferred when total resection of the tumor with preservation of function is deemed achievable. When function of the lower cranial nerves has been compromised, total surgical resection may also be possible, provided that the patient's health allows it. Cases where function is still preserved despite presence of a large tumor are more challenging, and a combination modality may be most effective. The goal of treatment is to provide tumor control with low morbidity. Current surgical techniques and the availability of stereotactic radiotherapy make this possible in the majority of cases.
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Affiliation(s)
- Jose N Fayad
- House Clinic and House Ear Institute, Los Angeles, California
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Guss ZD, Batra S, Limb CJ, Li G, Sughrue ME, Redmond K, Rigamonti D, Parsa AT, Chang S, Kleinberg L, Lim M. Radiosurgery of glomus jugulare tumors: a meta-analysis. Int J Radiat Oncol Biol Phys 2011; 81:e497-502. [PMID: 21703782 DOI: 10.1016/j.ijrobp.2011.05.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 04/22/2011] [Accepted: 05/10/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE During the past two decades, radiosurgery has arisen as a promising approach to the management of glomus jugulare. In the present study, we report on a systematic review and meta-analysis of the available published data on the radiosurgical management of glomus jugulare tumors. METHODS AND MATERIALS To identify eligible studies, systematic searches of all glomus jugulare tumors treated with radiosurgery were conducted in major scientific publication databases. The data search yielded 19 studies, which were included in the meta-analysis. The data from 335 glomus jugulare patients were extracted. The fixed effects pooled proportions were calculated from the data when Cochrane's statistic was statistically insignificant and the inconsistency among studies was <25%. Bias was assessed using the Egger funnel plot test. RESULTS Across all studies, 97% of patients achieved tumor control, and 95% of patients achieved clinical control. Eight studies reported a mean or median follow-up time of >36 months. In these studies, 95% of patients achieved clinical control and 96% achieved tumor control. The gamma knife, linear accelerator, and CyberKnife technologies all exhibited high rates of tumor and clinical control. CONCLUSIONS The present study reports the results of a meta-analysis for the radiosurgical management of glomus jugulare. Because of its high effectiveness, we suggest considering radiosurgery for the primary management of glomus jugulare tumors.
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Affiliation(s)
- Zachary D Guss
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
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Ivan ME, Sughrue ME, Clark AJ, Kane AJ, Aranda D, Barani IJ, Parsa AT. A meta-analysis of tumor control rates and treatment-related morbidity for patients with glomus jugulare tumors. J Neurosurg 2011; 114:1299-305. [DOI: 10.3171/2010.9.jns10699] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Because of the rarity of glomus jugulare tumors, a variety of treatment paradigms are currently used. There is no consensus regarding the optimal management to control tumor burden while minimizing treatment-related morbidity. In this study, the authors assessed data collected from 869 patients with glomus jugulare tumors from the published literature to identify treatment variables that impacted clinical outcomes and tumor control rates.
Methods
A comprehensive search of the English-language literature identified 109 studies that collectively described outcomes for patients with glomus jugulare tumors. Univariate comparisons of demographic information between treatment cohorts were performed to detect differences in the sex distribution, age, and Fisch class of tumors among various treatment modalities. Meta-analyses were performed on calculated rates of recurrence and cranial neuropathy after subtotal resection (STR), gross-total resection (GTR), STR with adjuvant postoperative radiosurgery (STR+SRS), and stereotactic radiosurgery alone (SRS).
Results
The authors identified 869 patients who met their inclusion criteria. In these studies, the length of follow-up ranged from 6 to 256 months. Patients treated with STR were observed for 72 ± 7.9 months and had a tumor control rate of 69% (95% CI 57%–82%). Those who underwent GTR had a follow-up of 88 ± 5.0 months and a tumor control rate of 86% (95% CI 81%–91%). Those treated with STR+SRS were observed for 96 ± 4.4 months and had a tumor control rate of 71% (95% CI 53%–83%). Patients undergoing SRS alone had a follow-up of 71 ± 4.9 months and a tumor control rate of 95% (95% CI 92%–99%). The authors' analysis found that patients undergoing SRS had the lowest rates of recurrence of these 4 cohorts, and therefore, these patients experienced the most favorable rates of tumor control (p < 0.01). Patients who underwent GTR sustained worse rates of cranial nerve (CN) deficits with regard to CNs IX–XI than those who underwent SRS alone; however, the rates of CN XII deficits were comparable.
Conclusions
The authors' analysis is limited by the quality and accuracy of these studies and may reflect source study biases, as it is impossible to control for the quality of the data reported in the literature. Finally, due to the diverse range of data presentation, the authors found that they were limited in their ability to study and control for certain variables. Some of these limitations should be minimized with their use of meta-analysis methods, which statistically evaluate and adjust for between-study heterogeneity. These results provide the impetus to initiate a prospective study, appropriately controlling for variables that can confound the retrospective analyses that largely comprise the existing literature.
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Prajsnar A, Balak N, Walter GF, Stan AC, Deinsberger W, Tapul L, Bayindir C. Recurrent paraganglioma of Meckel's cave: Case report and a review of anatomic origin of paragangliomas. Surg Neurol Int 2011; 2:45. [PMID: 21660268 PMCID: PMC3108444 DOI: 10.4103/2152-7806.79763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 03/22/2011] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Paragangliomas are rare, usually benign tumors of neural crest origin. They account for only 0.6% of all head and neck tumors. In the craniocervical area, they are more common in the carotid body and tympanico-jugular regions. To the authors' knowledge, a case of paraganglioma in Meckel's cave has not yet been reported in the medical literature. The pathogenesis and natural history of paragangliomas are still not well understood. We present a case of recurrent paraganglioma in Meckel's cave. CASE DESCRIPTION A 53-year-old woman was diagnosed with trigeminal neuralgia, dysesthesia and hypoesthesia on the left side of the face, hearing disturbance and a history of chronic, persistent temporal headaches. Magnetic resonance imaging (MRI) showed a lesion located in Meckel's cave on the left side, extending to the posterior cranial fossa and compressing the left cerebral peduncle. The lesion was first thought to be a recurrence of an atypical meningioma, as the pathologist described it in the tissue specimen resected 3 years earlier, and a decision for re-operation was made. A lateral suboccipital approach to the lesion was used under neuronavigational guidance. The tumor was removed, and histological examination proved the lesion to be a paraganglioma. Five months later, the follow-up MRI showed local regrowth, which required subsequent surgical intervention. CONCLUSIONS A paraganglioma in Meckel's cave is an uncommon tumor in this location. Although ectopic paragangliomas have been described in the literature, a paraganglioma atypically located in Meckel's cave makes a topographic correlation difficult, mainly because paraganglionic cells are usually not found in Meckel's cave. Another peculiarity of the case is the local recurrence of the tumor in a relatively short time despite an attempted, almost gross total resection.
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Affiliation(s)
- Anna Prajsnar
- Department of Neurosurgery, Klinikum Kassel, Kassel, Germany
| | - Naci Balak
- Goztepe Education and Research Hospital, Istanbul, Turkey
| | | | | | | | - Leyla Tapul
- Department of Histology, Istanbul Faculty of Medicine, University of Istanbul, Turkey
| | - Cicek Bayindir
- Department of Neuropathology, Istanbul Faculty of Medicine, University of Istanbul, Turkey
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Linac-based stereotactic body radiation therapy for treatment of glomus jugulare tumors. Radiother Oncol 2010; 97:395-8. [PMID: 20950881 DOI: 10.1016/j.radonc.2010.09.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 08/23/2010] [Accepted: 09/07/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND Glomus jugulare tumors are rare, typically benign, tumors that arise from the neural crest cells that are associated with the autonomic ganglia in and around the jugular bulb. Treatment options for glomus jugulare tumors include embolization followed by resection, fractionated external beam radiation therapy (EBRT), stereotactic radiosurgery (SRS), and/or stereotactic body radiation therapy (SBRT). MATERIALS AND METHODS 18 patients were treated with linear-accelerator based stereotactic body radiation therapy (SBRT) between May 2002 and November 2008. Fifteen patients (83%) had single glomus jugulare tumors and 3 patients had bilateral glomus jugulare tumors (although each of these patients had a single tumor targeted). The median tumor volume was 5.83 cm(3) (range, 0.32-35.47 cm(3)). Ten tumors (56%) were previously untreated, and 8 (44%) tumors were persistent after previous surgical resection. One patient had undergone previous EBRT and 2 patients were previously treated with Gamma Knife radiosurgery to the intracranial portion of their tumor, with planned SBRT to the extracranial portion 2-4 months later at our institution. The median prescribed dose was 20 Gy in 3 fractions (range: 16-25 Gy in 1-5 fx) to the 80% isodose line. The median prescription coverage of the tumor was 93.6% (range: 83-98.72%). RESULTS Median follow-up for the entire cohort was 22 months. All the patients were alive at the time of the last follow-up with imaging available for review. The tumor was stable in 17 patients and decreased in size in one patient--yielding a local control rate of 100%. No patients experienced any new or worsening treatment-related neurologic deficits. CONCLUSIONS SBRT is a safe and efficacious treatment modality for glomus jugulare tumors.
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Hafez RFA, Morgan MS, Fahmy OM. The safety and efficacy of gamma knife surgery in management of glomus jugulare tumor. World J Surg Oncol 2010; 8:76. [PMID: 20819207 PMCID: PMC2942884 DOI: 10.1186/1477-7819-8-76] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Accepted: 09/06/2010] [Indexed: 12/05/2022] Open
Abstract
Background Glomus jugulare is a slowly growing, locally destructive tumor located in the skull base with difficult surgical access. The operative approach is, complicated by the fact that lesions may be both intra and extradural with engulfment of critical neurovascular structures. The tumor is frequently highly vascular, thus tumor resection entails a great deal of morbidity and not infrequent mortality. At timeslarge residual tumors are left behind. To decrease the morbidity associated with surgical resection of glomus jugulare, gamma knife surgery (GKS) was performed as an alternative in 13 patients to evaluate its safety and efficacy. Methods A retrospective review of 13 residual or unresectable glomus jagulare treated with GKS between 2004 and 2008.. Of these, 11 patients underwent GKS as the primary management and one case each was treated for postoperative residual disease and postembolization. The radiosurgical dose to the tumor margin ranged between 12-15 Gy. Results Post- gamma knife surgery and during the follow-up period twelve patients demonstrated neurological stability while clinical improvement was achieved in 5 patients. One case developed transient partial 7th nerve palsy that responded to medical treatment. In all patients radiographic MRI follow-up was obtained, the tumor size decreased in two cases and remained stable (local tumor control) in eleven patients. Conclusions Gamma knife surgery provids tumor control with a lowering of risk of developing a new cranial nerve injury in early follow-up period. This procedure can be safely used as a primary management tool in patients with glomus jugulare tumors, or in patients with recurrent tumors in this location. If long-term results with GKS are equally effective it will emerge as a good alternative to surgical resection.
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Affiliation(s)
- Raef F A Hafez
- Neurosurgery and Gamma knife department, International Medical Center, Cairo, Egypt.
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Hernández Lavado R, Rodríguez Ortega P, Guzmán Carmona C, Rasero Hernández I, Díaz Pérez de Madrid J. [Catecholamine - producing paraganglioma of the eardrum]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2010; 57:35-36. [PMID: 20172485 DOI: 10.1016/s1575-0922(10)70007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Guss ZD, Batra S, Li G, Chang SD, Parsa AT, Rigamonti D, Kleinberg L, Lim M. Radiosurgery for glomus jugulare: history and recent progress. Neurosurg Focus 2009; 27:E5. [DOI: 10.3171/2009.9.focus09195] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this article the authors review the literature for recent studies of radiosurgical treatment for glomus jugulare. These studies demonstrate that radiosurgery results in similar glomus jugulare tumor control and a superior morbidity profile compared with surgical treatment. In addition, patients treated with radiosurgery usually remain stable clinically or improve. Given the indolent nature of these tumors, however, more follow-up is required to ensure that the immediate benefits are lasting. These preliminary reports demonstrate that the use of radiosurgery as a primary treatment for glomus jugulare should be extended to encompass more of the patients who are currently assigned to microsurgical treatment.
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Affiliation(s)
| | | | - Gordon Li
- 2Department of Neurosurgery, Stanford University Medical Center, Stanford; and
| | - Steven D. Chang
- 2Department of Neurosurgery, Stanford University Medical Center, Stanford; and
| | - Andrew T. Parsa
- 3Department of Neurological Surgery, University of California, San Francisco, California
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Paragangliomas of head and neck: a treatment option with CyberKnife radiosurgery. Neurol Sci 2009; 30:479-85. [PMID: 19774334 DOI: 10.1007/s10072-009-0138-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 08/26/2009] [Indexed: 10/20/2022]
Abstract
Paragangliomas are highly vascular and predominantly benign neoplasms that have traditionally been treated by surgery, embolization and/or external beam radiotherapy (EBRT). The aim of this study is to evaluate the short-term local tumor control and safety of CyberKnife radiosurgery for these lesions. Nine patients, eight with jugular glomus paragangliomas and one with a carotid body paraganglioma, were treated. The target contouring was performed on merged CT and MR images. Eight patients were treated with doses ranging from 11 to 13 Gy (mean 12.5 Gy) in a single fraction and one with 24 Gy in three fractions prescribed to 72-83% isodose line. The mean follow-up was 20 months. One patient died from unrelated causes. There were no local recurrences. All eight patients also demonstrated neurological stability or improvement. Neither cranial nerve palsies have arisen, nor has deterioration beyond baseline been observed. In conclusion, CyberKnife radiosurgery appears to be both safe and effective in the treatment of skull base paragangliomas. Determining whether long-term complications will arise will require further investigation.
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Bilateral glomus tumor treated with PET-CT based conformal radiotherapy: a case report. CASES JOURNAL 2009; 2:8402. [PMID: 19918426 PMCID: PMC2769436 DOI: 10.4076/1757-1626-2-8402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 08/31/2009] [Indexed: 11/12/2022]
Abstract
Introduction Glomus tumors are benign, slow growing tumors originating from paraganglionic tissue, mostly located at the carotid bifurcation, jugular foramen, cervical portion vagus nerve, and middle ear cavity. Radiotherapy is treatment of choice for patients with intracranial extension, and patients with bilateral and multiple tumors, or patients who are inoperable. Case presentation We present a 53-year-old female patient with a glomus tumor treated with positron emission tomography computed tomography planning and 3D conformal radiotherapy, and the patient has remained free of disease progression 2 years after. Conclusion It is suggested that radiotherapy is a good treatment modality in patients with glomus tumor, and metabolic imaging and treatment planning with positron emission tomography computed tomography is superior to other imaging modalities.
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Miller JP, Semaan MT, Maciunas RJ, Einstein DB, Megerian CA. Radiosurgery for Glomus Jugulare Tumors. Otolaryngol Clin North Am 2009; 42:689-706. [DOI: 10.1016/j.otc.2009.04.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ramos Macías Á, Borkoski Barreiros S, Pérez Plasencia D, Lisner Contreras I, Armesto Fernández A, Cenjor Espanol C, Masgoret E. Tumores glómicos del hueso temporal. Estudio de 17 casos. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2007. [DOI: 10.1016/s0001-6519(07)74945-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Knisely JPS, Linskey ME. Less Common Indications for Stereotactic Radiosurgery or Fractionated Radiotherapy for Patients with Benign Brain Tumors. Neurosurg Clin N Am 2006; 17:149-67, vii. [PMID: 16793507 DOI: 10.1016/j.nec.2006.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Microsurgical resection remains the mainstay of treatment for truly benign brain tumors that can be safely resected because of the potential for permanent cure with most histologic findings, including most of the histologic findings discussed in this article. Physicians must keep in mind the indolent nature of many of the benign brain tumors and realize that many patients are likely to live out normal life spans if tumor control is achieved. Therefore, it is not sufficient simply to consider local tumor control rates and short-term toxicity risks when choosing between surgery, stereotactic radiosurgery, and fractionated radiotherapy. Patients need to be apprised of all therapeutic options and to make their decisions with all information required to evaluate the risks and benefits. For benign brain tumors, these decisions may have consequences that last for decades.
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Affiliation(s)
- Jonathan P S Knisely
- Department of Therapeutic Radiology, Yale University School of Medicine, Hunter Radiation Therapy Center, PO Box 208040, New Haven, CT 06520-8040, USA.
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Kassam A, Gardner P, Snyderman C, Carrau R, Zimmer L, Hirsch B, Mintz A. Endoscopic, Expanded Endonasal Approach to the Jugular Foramen. ACTA ACUST UNITED AC 2005. [DOI: 10.1053/j.otns.2005.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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