Challenges of Surgical Resection of Carotid Body Tumors - Multiple Feeding Arteries and Preoperative Embolization

Abstract

Background: Carotid body tumor is a hypervascular tumor with multiple feeding arteries and unique orientation at the carotid bifurcation. Although resection is a radical therapy for this tumor, complete resection is challenging. Materials and Methods: Articles reporting carotid body tumor treatment and surgical resection were reviewed including case-control series and review articles. Results: Selected reports were reviewed and discussed focusing on choice of treatment, surgical difficulties and preoperative embolization of feeding arteries. Conclusion: Multiple feeding arteries and adhesion of the tumor to the carotid arterial wall are causes of difficulties in carotid body tumor resection. The effectiveness of preoperative embolization remains controversial due to the varied situations in performing surgical resection among the institutions. However, perfect embolization and resection immediately after embolization reduce blood loss and operative time of surgery for carotid body tumor.Carotid body tumor (CBT) is a rare disease that originates from the paraganglion cells (paraganglioma) of the carotid body at the carotid bifurcation. The World Health Organization classification designated this tumor as malignant because it has a malignant potency and there is no requirement to distinguish benign from malignant features in the pathological findings of specimens (1).It is well-known that malignant tumors cannot always be identified by their morphological features in histopathological examinations; clinical findings such as metastatic activity can distinguish malignant tumors from their benign counterparts. Only clinical findings, such as lung, liver, or bone metastasis, indicate that a tumor is malignant. The slow-growing feature of CBT represents an almost benign character and embryonic origin plus germline mutation of this tumor. Its potential for metastatic activity highlights the need for surgical resection. Surgical resection of CBT by head and neck surgeons must be considered once a patient is referred to a hospital. However, in contrast to the slow-growing feature of this tumor, characteristic features, such as a rich vascular network of its capsule supplied by many feeding arteries, complicate resection (2).In recent years, it has been revealed by molecular biological studies that various types of gene alterations exist in the succinate dehydrogenase (SDH) gene family such as point mutations (3-5). Most patients with CBT were shown to have variants with germline mutations, such as SDHB and SDHD. Conversely, the idea of "hereditary paragangliomapheochromocytoma syndrome" has been frequently used to explain patients with familial paraganglioma, and it extends to patients with CBT who have a family history of the disease and gene alterations (6-8). Therefore, analyses of gene alterations are needed for patients with CBT. In addition, systemic diagnosis is needed to identify other types of paraganglioma, such as pheochromocytoma, since patients with SDH variants tend to have multiple paragangliomas (9).The Sha...

Study on the Influencing Factors of Short‐Term Recovery of Neurological Symptoms after Carotid Body Tumor Resection

“…Most CBTs have multiple blood supply arteries derived from ECA branches [22]. Intraoperative bleeding due to the multiple blood supply arteries is a difficult problem for surgery.…”

Multidisciplinary care improves outcomes for patients with carotid body paragangliomas—The UCLA experience

“…Surgical treatment, however, can be challenging particularly in larger tumors and higher Shamblin classes. Higher grade tumors can have multiple feeding arteries and adhere to the carotid artery wall, contributing to a greater risk of blood loss and cranial nerve deficits 4 . Reported neurovascular complications following CBT resection include injuries to the vagus, hypoglossal, cervical sympathetic, and superior laryngeal nerves leading to issues with swallowing and voicing 5 .…”

Commentary: Resection of a Left Carotid Body Tumor With Preoperative Embolization: 2-Dimensional Operative Video

“…Although there is no prospective randomized study comparing the results of outcome between surgical resection and radiotherapy to know which treatment modality is superior, there is a general consensus that surgery is adopted for smaller tumors, whereas radiotherapy is used for larger tumors or postoperative residuals. 3 The difficulty of surgical resection of carotid body tumors is related to its high vascularity and the presence of multiple arterial feeders as well as the presence of adhesions between the tumor and the arterial wall of the carotid vessels. For this reason, embolization might be considered before surgical resection to reduce vascularity and increase safety of the procedure.…”

“…1 Nevertheless, selective embolization, when performed with some elaboration by skilled personnel, can reduce blood loss during surgical resection significantly and decrease operative time of the procedure. 3 The classification of Shamblin et al 4 which was proposed in 1971 has been widely used to predict technical difficulty in resection and the need of vessel wall replacement during surgery. This classification is based on the relationship between the lesion and vascular structures and involvement of the carotid vessels.…”

“…Although there is no prospective randomized study comparing the results of outcome between surgical resection and radiotherapy to know which treatment modality is superior, there is a general consensus that surgery is adopted for smaller tumors, whereas radiotherapy is used for larger tumors or postoperative residuals. 3…”