UC SF Carotid Body Tumor UC SF Mass Left Side of Neck PDFs...A. Malignant carotid body tumor B....

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VASCULAR SURGERY • UC SAN FRANCISCO

Carotid Body TumorHow to Get It Out

Charles Eichler, MD

San Francisco, Ca

April 16, 2015

UCSF


Mass Left Side of Neck• 55yo m with 10 yr hx of mass on left

side of neck—assx except for swelling

• 5 yrs ago, attempted resection

• f/u neck radiation

• Represents 6 months ago -5cm mass

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CT-intensely enhancing mass splaying carotid

bifrucationUCSF


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• Patient opted against resection

• Repeat CT at 6 months revealed mass increased in size with associated node

• Angiogram

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• DX???

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What is the most likely diagnosis?

A. Malignant carotid body tumor

B. Schwannoma

C. SarcomaD. Metastatic disease

E. None of the above

67%

0%

22%

0%

11%

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Paragangliomas Uncommon neuroendocrine tumors arising from extraadrenal paraganglia of the autonomic nervous system

Head/neck-carotid bifrucation---CBT

Most common-1:30,000

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Presentation

• Painless neck mass

• Functionally active tumor is extremely rare

• Cranial neuropathy in very large tumors

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CTA• Defines superior & medial tumor

extent

• Other lesions

• Nodal enlargement

• Preop embolization for Shamblin II & III

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• Tumors are most often benign

• Malignancy seen in 6-10%-usually dx’d by resection and evidence of local invasion

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Surgical management only curative rx

Challenging-cr n injury>15% as well as high risk of vascular comlplication

Predicted by Shamblin class

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Shamblin ClassificationShamblin Size Surronding

or infiltationof carotid vessels

I <4cm No

II >4cm Partially

III >4cmIntimately

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• Vein map & prep thigh for possible replacement

• Decision for carotid resection often based on preop imaging

• Embolization for all Shamblin II & III

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How I do itNasotracheal intubation

Allows for mobilization of the jaw making subluxation of the jaw rare

Work with OHNS for large tumors for resection of styloid process and possible mandibulectomy

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• Vertical incision or transverse

• Develop field bordered by omohyoid, diagartic, IJV, pharynx

• Large tumors require parotid mobilization and diagastric division requiring ID of facial n

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• Identify vagus & hypoglossal nerves early in the dissection

• Superior laryngeal n lies behind the tumor

• Facial, and IX and XI may also be involed with large tumors

• Use of bipolar very helpful

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• Isolate CCA, ICA & ECA

• Free tumor away from these vessels in cranial to caudal direction

• Bifrucation last

• Resection of ICA with very large tumors

• Measure stump pressures & shunt if appropriate

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• Completely free tumor away from the vessels

• Resect mass posteriorly from bottom to top extent and remove

• If needed, vein graft replacement

• Close w or w/o drain

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Recent case • Patient presented to OSH large

neck mass

• CTA c/w CBT

• Attempt resection-aborted due to bleeding and unexplained hypotension

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Angiogram- Left UCSF


Angiogram Right

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Conclusion • Surgery rx of choice-smaller tumors

easier to remove

• Vascular morbidity relatively low

• Cranial nerve injury is greatest risk

UC SF Carotid Body Tumor UC SF Mass Left Side of Neck PDFs...A. Malignant carotid body tumor B....

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