Tumor progression in tympanojugular paragangliomas: the role of radiotherapy and wait and scan

INTRODUCTION

Tympanojugular paragangliomas (TJ PGLs) are rare tumors characterized by bone infiltration and erosion and a close relationship with critical structures, such as cranial nerves and internal carotid artery. For these reasons, their management represents a tough challenge. Since the fifties, radio-therapy (RT) has been proposed as an alternative treatment aimed at avoiding tumor progression. However, the indolent nature of the tumor, characterized by slow growth, is a crucial factor that needs to be considered before offering radiation.

METHODS

This study aims to examine tumor progression in RT patients through a systematic review of the literature and in TJ PGL patients who underwent solely wait and scan at our department.

RESULTS

The rate of tumor progression in the RT group was 8.9%, while in the wait and scan cohort was 12.9%. This data suggests the innate slow growth of PGLs. However, it is not possible to draw certain conclusions because of the wide heterogeneity of the studies.

CONCLUSION

When complete surgical excision of TJ PGLs is not feasible, appropriate counseling and patient selection, including comprehensive tumor classification, should be performed before proposing RT to control tumor progression, since wait and scan may represent a reasonable option in selected cases.

Systemic Inflammatory Syndrome Associated with a Case of Jugular Paraganglioma

Jugular paraganlioma is a benign, slow-growing tumor originating from the paraganglion cells and it is associated with catecholamine secretion. Paragangliomas can secrete Interleukin-6 (IL-6) and present as a systemic inflammatory syndrome; these characteristics have not been previously associated with jugular paragangliomas. A 63-year-old man with a jugular tumor in the skull base was referred to our hospital for an evaluation of pyrexia, back pain, and acute inflammation. His serum IL-6 level was elevated on admission and it decreased after radiotherapy. This is the first known case of a jugular paraganglioma exhibiting systemic inflammatory syndrome.

[Glomus tumor with diplopia]

This paper highlights the case of a 46-year-old female patient who seeks ophthalmic medical advice for her complaint about double vision on right gaze. Patient's medical history reveals several symptoms like headaches, progressive hearing loss on right side and dysphonia for which all investigations proved irrelevant. Thourough clinical examination, lab exams and imaging techniques revealed the cause for this symptoms i.e. glomic tumour with middle ear extention. We find this case to be exceptional as ocular symptoms led to the diagnose of a non-ocular serious, possible life threatening condition, bearing in mind that previously occured non-ocular symptoms couldn't elucidate the cause.

Long-term results of irradiation for paraganglioma

PURPOSE

The management of paragangliomas is controversial. Observation, surgery, external-beam radiotherapy (EBRT), and stereotactic radiosurgery (SRS) may, alone or in combination, be appropriate, depending on the size and extent of the tumor, previous treatment, and patient age, general health, and neurologic condition. Few data exist regarding long-term tumor control and late effects after EBRT or SRS.

METHODS AND MATERIALS

We performed a retrospective review of all patients treated with EBRT or SRS for paraganglioma at our institution between 1967 and 1994. The endpoints of the study were tumor control and late complications.

RESULTS

The 33 patients in this study had a median follow-up of 13 years (range, 4 months to 36 years). The 10-year tumor control rate was 92% (95% confidence interval, 75-98%). At the last follow-up visit, no patient had developed a radiation-induced malignancy.

CONCLUSION

External-beam RT and SRS are safe and effective for enlarging and/or symptomatic paragangliomas. The risk of developing a delayed radiation-induced malignancy after EBRT or SRS is low. This risk must be weighed against the significant immediate and permanent risk of cranial nerve deficits if the tumor is untreated or is surgically resected. This risk must also be weighed against the immediate but low risk of surgical mortality.

Radical radiotherapy alone for glomus jugulare and tympanicum tumours

The management of glomus jugulare and tympanicum tumours is controversial due the long natural history and morbidity associated with intervention. We report the experience of radical radiotherapy (RT) alone for these tumours. Between 1965 and 1987, 49 patients received RT. Median age at presentation was 55 years (range, 23-82). Common presentations were deafness in 27 patients, tinnitus in 25 and cranial nerve palsies in 18. RT was given as a 2D simulator-planned wedge pair in the majority with a median dose of 45 Gy (range, 37.5-50.0) in 15 or 16 fractions over 21 days (range, 20-26). Median follow-up was 7.4 years (range, 2.0-23.4). At 6 months post-RT, complete clinical response was seen in 38 patients, partial response in 4, no response in 1 and no data were available for 6. At both 5 and 10 years, 92% of patients were recurrence-free and cancer-specific survival was 96%. There were no reports of radionecrosis. Although tumour eradication is not the aim, RT can achieve good local control, survival and symptom relief without the significant morbidity that can be associated with radical surgery. Therefore, RT alone has a significant role in the management of these tumours.

Radiation therapy for glomus tumors of the temporal bone

The treatment of glomic tumors has been controversial since its first description. It can be done with surgery, radiotherapy or just expectation.

Aim

The objective of this paper was to evaluate the effectiveness and complications of radiotherapy.

Study design

clinical with transversal cohort.

Material and Method

It was made a retrospective review in the charts of the patients with glomus jugulare tumors treated with radiotherapy. Disease control was determined by (1) no progression of symptoms or cranial nerve dysfunction or (2) no progression of the lesion in radiological follow-up. It was also evaluated the follow-up period and the sequelae of the treatment.

Results

Twelve patients were included, 8 of then women. The follow-up period was from 3 to 35 years, with a media of 11,6 years. The main symptoms were: hearing loss, pulsate tinnitus, dizziness and vertigo. The signs were pulsate retrotympanic mass, facial palsy and cofosis. The tumors were staged using Fisch's classification. The radiotherapy was performed with linear accelerator with dose ranging from 4500-5500 in 4–6 weeks. In the follow-up period were possible to identify sequelaes like dermatitis, meatal stenosis, cofosis and facial palsy.

Discussion

The signs and symptoms were the same found in the medical literature. The type and dosages of the radiotherapy were also the same of others reports. All patients had improvement of the symptoms and only one was not considered as having disease controlled. Complications were, in general, minor complications, with exception of the cofosis and facial palsy.

Conclusion

Radiotherapy is a viable alternative to treatment of these tumors because their good response and low level of complications. It should be considered specially in advanced tumors where a surgical procedure could bring a high level of morbidity.

[Diagnosis and therapy of glomus tympanicum and glomus jugulare tumors]

OBJECTIVE

To report on a series of patients with glomus tympanicum or glomus jugulare tumors, and to focus on its diagnosis, treatment, and outcomes.

METHODS

Ten patients with glomus tympanicum or glomus jugulare tumors at Peking Union College Hospital during a 17-year period were reviewed retrospectively.

RESULTS

There were 7 patients with glomus tympanicum, 3 with glomus jugulare tumors, 1 patient with familial paraganglioma and 1 with functioning glomus jugulare tumors. The most common presenting symptoms were pulsatile tinnitus and hearing loss. Other symptoms included facial nerve paralysis, vertigo, otalgia, dysphagia, hoarseness, throat sore, episodic hypertension with headaches and tachycardia. The most common physical sign was a vascular middle ear mass. The other physical signs included Brown sign, upper neck mass, pharyngeal plump, Collet-Sicard syndrome, Homer's syndrome as well as deficit of cranial nerve V. The radiographic evaluation included computed tomograph (9 cases), angiography (4 cases) and magnetic resonance imaging (1 case). Eight patients initially refered to ENT department, and 2 patients initially consulted neurology or endocrinology specialists. The treatment included preoperative embolization in 2 cases, simple surgery in 4 cases and surgery followed by radiation therapy in 6 cases. No significant complications occurred. Nine of the 10 patients were followed up, but 1 was lost. The mean follow-up time was 12 years (ranged, 2-19 years). No tumor recurrence occured in the 6 cases with total tumor removal. Three cases with subtotal tumor resection had no tumor progression.

CONCLUSIONS

The diagnosis and treatment of glomus tympanicum and glomus jugulare tumors is particularly challenging. Typical clinical manifestations and radiographic evaluation should be considered together to establish the diagnosis. The primary treatment for glomus tympanicum is surgery, if necessary, followed by radiotherapy. Subtotal tumor resection followed by radiation yields satisfying outcome for glomus jugulare tumors.

Glomus jugulare tumors: historical overview of the management of this disease

The treatment of glomus jugulare tumors presents the surgeon with a significant management problem. Because the neoplasm originates in the region of the jugular bulb, it frequently involves the lower cranial nerves, with occasional extension into the posterior fossa. Despite extensive work on the development of surgical and radiation treatment strategies, considerable controversy still exists regarding the optimal management of these lesions. A historical review of the development of management options for glomus jugulare tumors is presented in an effort to offer a foundation for understanding their contemporary treatment.

[Malignant transformation of giant jugular chemodectoma]

Chemodectoma is a very rare neoplasm classified on the border of the benign and malignant tumours. A case of a large paraganglioma was presented. The method of choice in treatment these tumors should consist of surgery and radiation therapy postoperatively.

Long-term results of different treatment modalities in 37 patients with glomus jugulare tumors

The results of different forms of treatment of 37 patients with previously untreated glomus jugulare tumors were compared retrospectively. According to the Fisch classification system, 6 patients presented with class B tumors, 19 class C and 12 patients with class D. Twenty-eight patients underwent surgery and 9 patients had primary radiation therapy (to 50 Gy). In 20 of the surgical cases (71%), radical tumor removal could be achieved and required no further treatment over a follow-up period of 8.6 years (range 2-15 years). Incomplete tumor resection with postoperative radiation therapy resulted in progressive tumor growth in three cases. One patient in this group experienced subarachnoid bleeding that had to be managed by salvage surgery. After primary radiation therapy, glomus jugulare tumors were still evident on magnetic resonance imaging scans, but showed no signs of disease progression. As a result of our experience, we found that a one-stage radical tumor resection performed in collaboration by otologic surgeons and neurosurgeons was the best treatment for patients with large glomus jugulare tumors.

p53 and p16INK4A mutations during the progression of glomus tumor

Glomus tumors are significantly rare tumors of carotid body. The great majority of these tumors are benign in character. Here we present two brothers with hereditary glomus jugulare tumor who had consanguineous parents. Radiotherapy was applied approximately 8 and 10 years ago for treatment in both cases. Eight years later, one of these cases came to our notice due to relapse. The mutation pattern of p53, p57KIP2, p16INK4A and p15NK4B genes which have roles in the cell cycle, was analyzed in tumor samples obtained from the two affected cases in the initial phase and from one of these cases at relapse. The DNA sample obtained from the case in initial diagnosis phase revealed no p53, p57KIP2, p16INK4A or p15INK4B mutation. He is still in remission phase. Despite the lack of p53, p57KIP2, p16INK4A and p15INK4B mutation at initial diagnosis the tumor DNA of the other case in relapse revealed p53 codon 243 (ATG-->ATC; met-->ile) and p16 codon 97 (GAC-->AAC; asp-->asn) missense point mutations. No loss of heterozygosity in p53 and p16INK4A was observed by microsatellite analysis of tumoral tissues in these cases. P53 and p16INK4A mutations observed in relapse phase were in conserved regions of both genes. No previous reports have been published with these mutations in glomus tumor during progression. The mutation observed in this case may due to radiotherapy. In spite of this possibility, the missense point mutations in conserved region of p53 and p16INK4A genes may indicate the role of p53 and p16INK4A in tumor progression of glomus tumors.

[Jugulotympanic paraganglioma: therapy concepts under development]

BACKGROUND

The operative treatment and radiation therapy of jugulotympanic paragangliomas (JTP) are still a matter of controversial discussion. In spite of various improvements during the last 50 years, selecting the appropriate treatment modality (surgery, radiation, or observation) is still a challenge.

PATIENTS

During a 16-year period, 44 patients with 45 JTP (10 at level A/B and 35 at level C/D according to Fisch) were seen at the ENT-department in Fulda. Forty-one cases were treated surgically.

RESULTS

Complete resection was possible for level A/B in 100% of the patients (n = 10). Residual tumor was demonstrated for level C in 23% of the patients (5/22) and for level D in 40% (4/10) with a median follow-up time of 69 months. In two cases residual tumor was treated by radiation. Six patients with residual paraganglioma tissue were maintained under observation without any evidence of tumor progression (median follow-up time 39 months). We report one death after the attempt to resect a large residual paraganglioma that had already caused brain stem compression. A sufficient duraplasty could not be achieved following radiation therapy.

CONCLUSIONS

Complete tumor resection of jugulotympanic paragangliomas of levels A and B is often possible without injury to the cranial nerves. Extensive tumors present difficulties in complete tumor resection and increase the risk of cranial nerve injuries. Advanced paragangliomas therefore require an individualized therapeutic regime including surgery, radiation therapy, and observation of tumor growth.

[Function preserving surgery of glomus jugulare tumors. An achievable goal?]

In this retrospective study, oncologic and functional results of 24 patients treated for glomus jugulare tumor stages C and D are reported. The surgical approach used was a combined transmastoid-transcervical approach, which was modified according to individual tumor growth. As needed, this was combined with a transtemporal or retrosigmoid approach. Complete tumor removal resulted in a cure rate of 100%. Surgically induced cranial nerve palsies developed in 38% of the patients. In 54% of cases it was possible to retain middle ear function. Seven patients had incomplete tumor removal requiring postoperative irradiation, with tumor progression occurring in 2 patients. Radical tumor removal was modified by efforts to reduce mutilating resections. These results show that individually tailored and combined multidirectional surgical approaches can allow total tumor removal to be performed with lower morbidity.

Cranial nerve and hearing function after combined-approach surgery for glomus jugulare tumors

In this retrospective study, oncologic and functional results of 46 patients treated for glomus jugulare tumor are reported. The standard surgical approach was the combined transmastoid-transcervical approach, modified according to the individual tumor growth, and eventually combined with a transtemporal or a suboccipital approach. Complete tumor removal resulted in a cure rate of 90%. New-onset cranial nerve palsies developed in less than 22% of patients. In 54% of cases it was possible to retain middle ear function. From a total of 12 patients with incomplete tumor removal and postoperative irradiation, progressive tumor growth was noted in 4 patients, and was controlled by salvage irradiation or surgery. Radical tumor removal by ablative surgery can be modified by efforts to reduce multilating resections. In their place, individually tailored and combined multidirectional surgical approaches may allow total tumor removal with lower morbidity.

Hearing conservation in surgery for glomus jugulare tumors

The most common ground on which surgery for glomus jugulare (GJ) tumors is criticized is the perceived risk of functional incapacity that attends possible cranial nerve (CN) loss. It is aggregate lower CN loss that is most often highlighted as particularly disabling to the quality of postsurgical survival. The documented success of both conservation surgery and operative rehabilitation of phonopharyngeal surgical deficits has, however, neutralized much of this criticism. The issue of hearing conservation (HC) in neurotologic skull base surgery, on the other hand, has not been well documented toward this end. The presence of a GJ neoplasm need not reflexly nor technically forfeit preexisting hearing. HC is, admittedly, a subordinate priority to total tumor removal, successful distal control of the internal carotid artery, and even facial nerve integrity. Yet, in appropriately selected patients, existing operative technology permits hearing preservation, a noteworthy addition to the high-grade functional outcome we have come to reasonably expect of conservation surgery. Hearing salvage further serves to define the concept of neurotologic skull base surgery. Hearing preservation in 122 GJ tumor patients is reviewed. Intuitively, as for acoustic tumor, HC appears tumor size related. Selection criteria for conservation surgery and its operative technique are detailed. Outcome is appropriately scored. The radiation therapy literature on this subject will be assiduously scrutinized for comparison.

Glomus jugulare tumor metastatic to the sacrum after high-dose radiation therapy: case report

A 47-year-old woman with left ear pain and hearing loss was diagnosed with a glomus jugulare tumor for which she received radiation therapy as the primary treatment. Over a period of 20 years, she developed temporal bone necrosis, brain stem calcifications, local tumor recurrence, and eventually metastases to her lungs and sacrum. This case underscores the often indolent nature of glomus jugulare tumors, the late sequelae of radiation therapy for benign intracranial tumors, and the potential of these tumors to metastasize. This patient's history suggests that aggressive surgical resection should be considered early for such tumors, particularly because radiation treatment does not ablate the tumor. This is only the second reported case of a glomus jugulare tumor metastatic to the sacrum.

Jugulotympanic paragangliomas

Eleven patients with glomus jugulotympanicum tumours were seen in our department between January 1983 and December 1993. Nine patients received a full course of radiotherapy with doses ranging from 35 to 54 Gy. Four patients were available for assessment after 48 months. All were alive and asymptomatic at the time of writing. In 4 other patients, pain had improved although cranial nerve function had not at the last follow-up (1-9 months). One patient died 1 month after treatment. Radiotherapy can provide long-term local control and survival in the treatment of glomus jugulotympanicum tumours. The details of clinical presentation, follow-up and the methods of investigation are presented together with a review of the literature.

Long-term results of treatment for glomus jugulare and glomus vagale tumors with radiotherapy

Since 1954, 39 cases of glomus jugulare or vagale tumor have been treated by the authors with radiotherapy. The initial results with orthovoltage (280 kV) therapy were unpredictable, but 30 patients with 32 tumors treated with megavoltage radiotherapy (Cobalt-60 [60Co] or linear accelerator) have shown either no evidence of recurrence or complications, with one exception, or died of causes unrelated to their glomus tumor. Megavoltage radiotherapy is recommended for primary treatment of all glomus tumors that present with evidence of bone invasion or nerve involvement.

Long-term effects of radiation therapy for a catecholamine-producing glomus jugulare tumor. Case report

A 42-year-old woman presented with otorrhea 22 years after extracranial resection of a norepinephrine-secreting glomus jugulare tumor with intravascular embolization and radiation therapy to the intracranial portion of the tumor. Tumor growth was arrested and was associated with a decrease in blood and urine norepinephrine levels. Extensive evaluation of the otorrhea, including computerized tomography-cisternography, gadolinium-enhanced magnetic resonance imaging, and arteriography showed marked diffuse necrosis of the temporal bone and skull base with limited tumor vascularity. Cerebrospinal fluid (CSF) collected from the right ear showed norepinephrine levels of 2975 pg/ml; plasma norepinephrine levels were normal. The precise site of CSF leakage could not be delineated. Exploration of the posterior fossa revealed a large dural defect at the anteromedial aspect of the petrous bone through which CSF flowed over the surface of the residual extradural glomus tumor. The defect was successfully sealed with a fascial patch. Postoperatively, CSF norepinephrine levels were normal and no further leakage was observed.

Glomus jugulare tumours: a review of 61 cases

A retrospective study of 61 patients with glomus jugulare tumours treated at the National Hospital for Neurology and Neurosurgery, and at the Royal National Throat, Nose and Ear Hospital, London. The average age at presentation was 41.7 years. The patients were mainly treated by a posterolateral combined otoneurosurgical approach. 42/61 of the patients had total or subtotal excision of their tumours, 7/61 had partial removal and the remaining 11/61 had no operation. Only one case required a 2-staged procedure. There were two deaths in the postoperative period, one from intracerebral haemorrhage and the other from the left hemisphere infarction. Postoperative radiotherapy was given to 5/7 of the patients who had partial removal. 3/40 of the patients with total removal had postoperative radiotherapy, and a further 3/40 had received radiotherapy pre-operatively. Of the 11 patients who did not undergo surgery, 7/11 were treated with radiotherapy and 4/11 had embolisation only.

Irradiated paragangliomas of the head and neck: CT and MR appearance

PURPOSE

To present the spectrum of CT and MR findings of glomus tumors of the head and neck successfully treated with radiation therapy.

METHODS

The patient charts and all CT and MR studies of 24 patients (25 tumors) who had been successfully treated with radiation therapy were retrospectively reviewed. Eighteen patients had pre- and posttreatment imaging studies. Tumor size, internal morphology, enhancement pattern, visualization of flow voids, and bone erosion were evaluated before and after radiation therapy. Statistical evaluation of the presence of flows voids and tumor size was performed using the Fischer Exact Test.

RESULTS

All patients had residual tumor after radiation therapy. Sixty-one percent of tumors demonstrated a reduction in size. Only one tumor with pretreatment bone destruction demonstrated healing of the bone. MR findings after radiation therapy included variable alteration in T2 signal, decreased heterogeneous enhancement, and a reduction in flow voids. There was a significant difference in the presence of flow voids based on tumor size.

CONCLUSIONS

Successfully irradiated paragangliomas demonstrate residual masses, the presence of which does not by itself indicate treatment failure. Stabilization or reduction in size, decreased enhancement, diminished flow voids, and reduced T2 signal after radiation therapy are a result of therapy and are indicative of local control. Persistent bone demineralization and erosion without progression is commonly seen in successfully controlled tumors. Paragangliomas are relatively homogeneous in internal morphology except for areas of flow void. Flow voids are not a reliable criterion for diagnosis in lesions less than 2.5 cm.

[Malignant paragangliomas--the results of radiotherapy in 6 patients]

Between February 1984 and May 1989, six patients (four male, two female) with malignant paragangliomas of the carotid body (n = 4) and glomus jugulare (n = 2) were irradiated in the Department of Radiation Oncology at Essen University. All patients had macroscopic (residual) tumor at the start of treatment. Five out of six paragangliomas had to be considered malignant, since histological lymph node involvement or distant metastasis was confirmed. In the sixth case extra- and intracranial tumor growth was observed. Total doses between 40 and 55 Gy using cobalt 60, 10 or 15 MeV photons were administered. Radiation therapy was canceled at 30.6 Gy in one patient because of multiple distant metastasis. Three out of four patients, who received curative treatments, were locally controlled (25 to 91 months). A local recurrence in one patient was detected 18 months after irradiation; this patient died of distant metastasis 23 months after treatment. In one out of two palliatively irradiated patients, local control could be achieved until the patient died of distant metastasis twelve months after treatment. Grade III- or grade IV-treatment toxicity was not observed. Radiation therapy of malignant paragangliomas with doses between 45 and 54 Gy in five to six weeks is an effective treatment with low toxicity and should be preferred to surgery in glomus jugulare and advanced carotid body tumors.

Glomus jugulare tumors. Long-term control by radiation therapy

The records of 49 patients with glomus jugulare tumor seen at the University of Virginia from 1932 to 1985 were retrospectively reviewed with the objective of assessing long-term results of treatment. Follow-up ranged from 5 to 31 years, with a minimum of 10 years in 36 patients (73%). According to McCabe's classification, 17 patients (35%) were Group I, 11 patients (22%) were Group II, and 21 patients (43%) were Group III. Analysis by therapeutic technique revealed that 20 patients received surgery alone (41%), 15 patients received radiation therapy alone (31%), and 14 patients received combined therapy (28%). Only 7 patients (14%) have had clinical or radiologic evidence of disease progression. Three of these patients were treated by surgery alone and three by a combination of surgery and radiation, but the dose was less than 4000 cGy. Only one patient treated by radiation therapy alone or with surgery and radiation to a dose in excess of 4000 cGy demonstrated disease progression. Salvage radiation therapy was given to three of the seven patients when progressive disease was detected. Radiation therapy is an effective treatment for glomus jugulare tumor with minimal late progression of disease in adequately treated patients and no significant long-term complications.

Chemodectoma of the head and neck: results of treatment in 84 patients

Eighty-four patients with chemodectoma of the head and neck presented to the Royal Marsden Hospital between 1949 and 1985. For tumors arising at the skull base (glomus jugulare and glomus tympanicum) 46 were treated with radiotherapy alone resulting in an actuarial local control rate of 73% at 25 years; 13 were treated with surgery plus radiotherapy with no recurrences during a median follow-up of 9 years; 4 had surgery alone but all recurred by 7 years. For tumors of the soft tissues of the neck (carotid body and glomus vagale) 13 were treated with surgery alone with an actuarial control rate of 54% at 15 years; 4 were treated with radiotherapy which resulted in local control at 1, 2, 8 and 11 years; and one patient who received both surgery and radiotherapy remained controlled at 1 year. Although comparison between radiotherapy and surgery in terms of tumor control is not simple, the case is argued for more frequent use of radiotherapy at all sites. This case is strengthened by minimal morbidity from radiotherapy in doses which appear effective: in the range of 45-50 Gy in 25 daily fractions over 5 weeks.

Radiation therapy for paragangliomas of the temporal bone

Treatment of paragangliomas of the temporal bone (glomus jugulare and glomus tympanicum tumors) is controversial, with both surgery and radiation therapy having their advocates. This paper discusses the experience at the University of Arizona Health Sciences Center in treating 10 cases of this uncommon tumor between 1971 and 1988. Seven of 10 cases were initially treated using irradiation and achieved complete tumor control for a mean of 67 months (range = 23-107 months). Two patients, one treated surgically and the other by embolization, had recurrences and were salvaged by radiation, and neither has recurred. The final patient is disease-free 9 months after embolization and surgery. There have been no serious sequelae of treatment. We conclude that moderate-dose irradiation can safely control most temporal bone paragangliomas.

[Radiotherapy of glomus jugulare and tympanicum tumors]

Glomus jugulare tumors are difficult to manage therapeutically due to their localisation. Operation may be successful in small tumors but can be hazardous in larger lesions mainly because of bleeding and palsy of cranial nerves. In these cases there should be used radiation therapy under the condition that it is planned by use of computed tomography. Moreover reproducibility of radiation treatment set-up is vital. In this way tumor regression may be achieved. Four own illustrative cases are demonstrated. According to the stage of disease a modified treatment strategy is presented which integrates surgical procedures, angiographic embolization and radiotherapy.

[Current aspects of radiotherapy of glomus jugulare tumors]

Small glomus jugulare tumors can be operated on successfully. The intraoperative risk of bleeding may be reduced by preoperative irradiation or angiographic embolisation. Patients with advanced tumors (bone destruction, paralysis or cranial nerves and/or invasion of brain) are at high risk if they are operated on. In these cases radiotherapy is an effective alternative with a fairly low complication rate. Prerequisites for successful irradiation are assessment of treatment volume and treatment planning by CT, sophisticated stereotactic irradiation techniques, application of high energy photons and reliable immobilisation measures. Furthermore it is possible to deliver higher doses, leading to regression of the tumor and its symptoms. The technique is illustrated by two characteristic cases. Although irradiation alone can achieve tumor remission the long term prognosis remains doubtful.

[Glomus jugulare tumor. Apropos of 2 cases]

We present two clinical cases of jugular glomus in which different kinds of treatment have been adopted. In literature we can find a review of the utility and morbidity of the different methods of exploration as well as the results obtained by the different authors according to the kind of treatment. Nevertheless we don't come to definite conclusions due to the fact that the classifications and curing criteria very in the different series.

The histopathological and clinical features of irradiated and nonirradiated temporal paragangliomas

This study was undertaken to determine the effects of radiation on temporal paragangliomas. The histological features were assessed in a blind fashion from 20 surgical specimens obtained from 20 patients, half of whom received radiotherapy. All patients had progressive temporal paragangliomas and were selected on a random basis for this study. The derived data clearly identify the unpredictable response of these tumors to radiation and supports our contention that surgery is the preferred form of treatment for temporal paragangliomas even after radiation therapy. Analysis of clinical histories reveals that previous radiation therapy is associated with a greater operative blood loss and a longer mean postoperative hospital stay due to delayed healing. Despite this, there was no mortality or serious morbidity from surgery.

[Results of radiation and combination therapy of glomus tumors]

Over the period of 1965-1985 radiation and combined therapy for glomus tumors of different sites was provided to 80 patients aged 34 to 79. Radiation therapy alone was given to 51 patients, of them 18 patients had recurrences of malignant tumors. Radiation therapy following surgery was given to 29 patients. Gamma-beam therapy was given from fields, size from 5 X 5 to 8 X 10 cm, using in some cases lattice and wedge-shaped filters, at a single dose of 2-3 Gy up to a total dose of 60-70 Gy. Of 33 patients with primary malignant tumors 30 lived over 5 yrs., of 18 patients with postoperative recurrences 15 lived for 5 yrs. Of 29 patients who had been on combined therapy, 2 died in 3-5 yrs. of causes unrelated to the main disease.

The role of radiation therapy in the management of catecholamine-secreting glomus tumors

The major source of controversy that surrounds the use of radiation for glomus tumors is the finding of persistent chief cells years after completion of the treatment. Questions have been raised as to the viability of the irradiated chief cell and its capacity to proliferate. The radiotherapists consider a stable glomus tumor a radiation "cure," whereas skull base surgeons are fearful that these lesions will continue to slowly grow and cause problems 20 to 30 years later. We have recently managed a patient who was not a candidate for surgery, with a catecholamine-secreting glomus jugulare tumor. After 4750 rad of radiation therapy, no changes in tumor size or in catecholamine secretion have been observed (at 20 months of followup). The implications of the case are discussed.

Radiotherapy in glomus tumours (paragangliomas). A 25 year-review

57 patients have been reviewed. 39 had radiotherapy (28 glomus jugulare, 7 glomus tympanicum and 4 glomus caroticum/vagale tumours). Two patients have died of their tumour and one patient had increasing nerve involvement during two months after irradiation. It is concluded that the results bear comparison with those of surgery and that extensive surgery in tumours with extratympanal growth is not warranted.

Glomus jugulare tumours seen in Oxford 1960-1984

A review of 14 cases of glomus jugulare tumour is presented. Patients with a long delay in diagnosis and those with cranial nerve palsies were found to have a poor prognosis. A dose response effect for local control was not observed with the radiation doses used. Three times weekly fractionation was well tolerated by adjacent normal tissues.

Radiation therapy in the treatment of chemodectomas

Twenty-six patients with chemodectomas were treated with radiation therapy from 1961 to 1983 and followed for at least 4 years. In 16 glomus tympanicum lesions treated primarily with radiation, long-term control was achieved in all (follow-up 4-24 years, mean 10.5). Fifteen of 16 had no clinical evidence of disease at time of death or last follow-up, and one patient had recurrent but stable disease at 10 years and died of an unrelated illness 19 years after treatment. Eight of the glomus tympanicum lesions were referred for radiation therapy with persistent disease after multiple surgical procedures. Two had extensive skull and intracranial involvement at the time of radiation. Six patients with glomus jugulare lesions were treated with radiation. Four achieved long-term control, and two died of their disease. In addition, two glomus vagal and one carotid body tumor were treated with palliative intent. One glomus tympanicum lesion was treated with preoperative radiation and resection. Chemodectoma was the cause of death in 4 of 25 patients--3 from intracranial extension and 1 from lung and mediastinal metastases. All four patients were referred for radiation with metastases or extensive bone involvement at the skull base. Radiation appears to be effective in achieving long-term clinical control of chemodectomas. Adequately treated volume should be determined with arteriography and/or contrast-enhanced computer tomography, allowing for geometric margins. Doses in the range of 4,500 to 5,000 cGy delivered in about 5 weeks are recommended.

Role of radiation therapy in glomus tumor

Since 1964, we have reported twenty-five cases of glomus tumors. Given the evolution of modern surgical technique, we have divided our cases into two groups. The first group includes patients seen from 1964 to 1975: sixteen cases, of whom eleven underwent successful radiotherapy, with a follow-up after ten years. Since 1975 we have adhered to the following therapeutic principles: We have given radiotherapy (5000 rads in twenty-eight days) to patients older than 65 with glomus tumors that had invaded posterior and medial cranial fossa and carotid canal (type C-D, according to Fisch). We have operated on patients with glomus tumors type A-B. Patients treated since 1975 (N = 9) are in the second group.

The management of glomus jugulare tumours

The treatment details of 58 patients treated for glomus jugulare tumours in Newcastle upon Tyne are examined in the light of other studies reported in the literature. For the group of 55 patients treated by radiotherapy, the 20 year survival is 94% (determined actuarially). The 20 year disease-free survival (determined actuarially) is 77%. This is comparable with other series reported. As no glomus tympanicum tumour has recurred following surgery and there has been no morbidity due to these tumours they have not been included in the series. It is recommended that patients who are fit and have tumours confined to the tympanum should have primary surgical treatment. All other patients should be treated by accurately planned radiotherapy, using a dose of 50Gy in 5 weeks to the tumour volume. The morbidity of this treatment policy will be low.

[Radiologic surveillance of irradiated glomal tumors]

A favorable clinical result was obtained in 10 patients with jugular glomal tumors treated by external radiotherapy (approximately 50 Gy), alone or combined with surgical treatment, and preceded in some cases by embolization. Radiologic review examinations showed complete stability of lesions without bone reconstruction phenomena, in spite of a decrease in tympanic mass and regression of functional symptoms.

Skull base surgery for glomus jugulare tumors

Thirty-six patients with glomus jugulare tumors have been managed over a 13-year period using various combinations of skull base surgery and irradiation therapy. The data resulting from this study are presented; the techniques of diagnosis and treatment are reviewed. We conclude that irradiation therapy alone is a satisfactory form of treatment for elderly and poor-risk patients; preoperative x-ray therapy followed by skull base surgery is an effective treatment for younger patients.

Glomus jugulare tumors revisited: a ten-year statistical follow-up of 231 cases

Glomus jugulare tumors are rather common in the middle ear and temporal bone. They are usually easy to diagnose and surgically remove. However, there are a comparatively large number of these growths which not only cause extensive local destruction, but can spread distally and even have endocrine manifestations. This group is difficult to diagnose and manage despite recent advances in diagnostic procedures and the advent of skull base surgery. There is a void in the literature of a large series of cases being followed for a long period of time. This paper presents a comprehensive detailed statistical ten-year follow-up of 231 glomus jugulare tumors. The results suggest that our present diagnostic procedures often are inadequate in finding small tumors, and our treatment and follow-up are lacking because these tumors tend to recur often at a late date and in a different form. A comprehensive method of approach of diagnosis and treatment is described to manage all cases of glomus jugulare.

Radiotherapy for unusual tumors of the head and neck

The role of radiotherapy is discussed relative to the management of juvenile nasopharyngeal angiofibroma, glomus tumors of the middle ear region, ameloblastoma, extramedullary plasmacytoma of the head and neck, and soft tissue and bone sarcoma. Moderate doses of carefully applied irradiation are effective and can be safely utilized for these conditions.

Radiation therapy in the management of chemodectomas in Nigeria

Chemodectomas constitute a very rare group of tumours. They have been described at various sites in the body and their management, particularly the glomus jugulare tumours is of interest, as surgery in some cases may be hazardous and possibly fatal as a result of severe haemorrhage associated with these tumours. Radiotherapy has been advocated as the treatment of choice particularly for the glomus jugulare tumour. Our experience in the management of this rare group of tumours seen at the only Radiotherapy Unit in Nigeria between 1975 and 1979 is analysed. Radiation therapy techniques, doses given and complications noticed are analysed. There was complete control of the disease in four out of four (100%) of the cases at 1 year and three out of four (75%) at 3 years. Results from other reports in the literature are reviewed.

The treatment of glomus tumors in the temporal bone by megavoltage radiation

Forty-five patients with glomus tumors in the temporal bone region were treated by radiation therapy. Only three patients had recurrence or progression of tumor during the follow-up period of 3 to 23 years (median, 10 years). No patient died from uncontrolled glomus tumor. The majority of patients noted symptomatic relief after radiation, but objective neurologic deficits usually remained unchanged or showed only partial improvement. The most commonly used radiation dose was 3500 cGy tumor dose delivered in 15 fractions in 3 weeks by a homolateral wedge technique from megavoltage radiation apparatus. This dose is less than that usually recommended for glomus tumors. From these results and from review of the literature, it is suggested that a moderate radiation dose of 3500 cGy in 3 weeks is effective treatment for glomus tumors, even if complete tumor involution does not occur.