Carotid Body Tumors: Review of 56 cases

Amr Gad,MD

Prof. of Vascular Surgery

Cairo University

Carotid Body Tumors

Arise from paraganglionic cells derived

from the neural crest

>50% of neck paragangliomas (PGLs)

Incidence less than 1 in 30 000

Disastrous History…1743 Von

Haller first described the carotid body

1880 Reigner attempted excision, but the patient died.

1886 Maydl attempted excision but the patient developed a stroke.

1889 Albert first successful CBT excision

1891 Marchand first description of the histologicappearance

1903 Scudder first successful resection in USA

1903 Kohn first introduced the term paraganglioma(PGL)

Till 1950s mortality and morbidity remained very high

Patients

54 Patients

( 25 y )

2 Bilateral

56 CBTs

56 CBTs

39 (69.64%)

In males

17 (30.36%)

In females

Age 42 y

range( 32 : 47)

Patients

54 Patients

(25 y )

2

Bilateral

56 CBTs

GROUP A

35(62.5%)

CORRECT DIAGNOSIS

56 CBTs

GROUP B

21(37.5%)

MISS DIAGNOSIS

(Prior trial of excision)

Radiologic Imaging

Shamblin’s Classification (1971)

I=27 (48.21%) II=22 (39.29%) III=7 (12.5%)

Suggested Modification by Luna-Ortiz et al Eur Arch Otorhinolaryngol (2006) 263: 171–175

Dissection Technique (Periadventitial Plane)

Vascular Reconstruction was Inevitable in 10 cases(17.85%)

54 Patients

2 bilateral

56 CBTs

56 CBTs

46 Resection10

Resection +VR

Vein interposition graft 7

End to end anastomosis 1

lateral sutures 2

Vascular Reconstruction was Inevitable in 17.85% of our cases

This emphasizes the need for vascular experience among

the operating team.

A multicenter review of CBTs reported that 80% of cases

were operated on by vascular surgeons.

Sajid et al, Eur J Vasc Endovasc Surg 34, 127-130 (2007)

It was obvious that vascular reconstruction is

significantly higher among patients with prior removal

attempts (9/21 vs. 1/35, p<0.05), reflecting the

difficulties that may be encountered when operating on a

CBT that was not correctly identified from the beginning.

n=10

Vascular Reconstruction was Inevitable in 17.85% of our cases

Vascular Reconstruction was Inevitable in 17.85% of our cases

Complication Number (%)Cerebrovascular stroke (transient hemiparesis) 2 (3.57%)

TIA 2 ( 3.57%)

Hypoglossal nerve injury 6 (10.71%)

Superior laryngeal nerve injury 1 (1.78%)

Hematoma 1 (1.78%)

Total 12 (21.43%)

Postoperative Complications

Permanent 3.57%

Study name & year Number of

operated CBTs

CNI %* Vascular

reconstruction %

CVA%

Total Permanent

Studies between 1980-2000

Rosen et al (1981)15 29 28 NA NA NA

Lees et al (1981)16 41 NA 18 NA NA

Dickinson et al (1986)17 37 19 NA NA 4

Gaylis et al (1987)18 52 7 NA 13 2

Hallett et al (1988)13 139 30-46† NA 33 3-23†

Williams et al (1992)19 33 13 3 NA 27‡

Netterville et al (1995)20 46 13 NA 26 0

Muhm et al (1997)21 28 32 NA 36 NA

Rodriguez-Cuevas et al (1998)22 80 20 NA NA 4

Westerband et al (1998)23 31 13 NA 25 6

Wang et al (2000)24 36 41 24 NA 0

Studies between 2000-2010

Makeieff et al (2008)10 57 42 14 28 14‡

Sajid et al (2007)8 95 19 1 NA 1

Qin et al (2009)25 33 53 NA 30 NA

Plukker et al (2001)26 45 11 7 13 10

Papaspyro et al (2009)27 40 NA§ NA§ 25 0

van der Bogt et al (2008)12 111 21-42† 7-26† 2-4† 0

Patetsios et al (2002)28 34 46 17 28 0

Luna-Ortiz et al (2005)1 69 49 38 6 4

Dardik et al (2002)29 27 33 NA 41 4

Ma et al (2009)2 55 27 6 11 4

Kakkos et al (2009)14 41 32 10 18 7

Koskas et al (2009)30 39 NA§ 15 22 3

Ünlü et al (2009)31 28 3 NA 29 0

Paris et al (2006)32 29 NA§ NA§ 14 0

Preoperative Embolization Attractive Option Prior to Surgery to Reduce Bleeding and Tumor Bulk.

Against:

o Associated with an inflammatory response that makes precise

periadventitial dissection more difficult .

Netterville et al Laryngoscope 1995;105(2):115-26

o A risk of intracranial embolization

Makeieff et al, Annals of Surgical Oncology 2008 ;15(8):2180-2186

o It did not affect the probability of need for vascular repair

Smith et al Ann Vasc Surg 2006;20:435-9

o Can be quite tedious and hazardous.

Currently, recommended only for:

o Tumors that are large (5cm in size)

o Shamblin’s class III

o Extend significantly cranially

Kakkos et al, J Vasc Surg 2009;49:1365-73

Preoperative Embolization

Covered Stent Placement of ECA Scanlon et al, J Vasc Surg 2008;48:1322-4

Radiotherapy

Radiosensitive but “total resolution” of the tumors is rare.

Local control means stability (or regression)

Possible indications:

Minimal residual tumors

Tumor destaging.

Non-resectable tumors

Rodrı´guez-Cuevas et al, Head Neck,(1998) 20: 374–378

Luna-Ortiz et al, Oral Oncology (2005) 41, 56–61

Our patients’ showed characteristics similar to LatinAmerican series as:

● Lower incidence of malignancy (4%vs.>10%)

● Lower incidence of bilaterality (9%vs.>10%)

● Lower incidence of familial cases (0%)

This could reflect a potential genetic pattern which needsto be further investigated.

Conclusion CBTs should be resected by surgeons with

experience in carotid reconstruction.

Correct preoperative diagnosis and planning

for treatment are essential to avoid

complicated surgical procedures.

CNI continue to appear in all studies in spite

of the advances in the management and

techniques, but they present minor morbidity.

Cairo University School of Medicine

Thank You