Less-aggressive surgical management and long-term outcomes of jugular foramen paragangliomas: a neurosurgical perspective

Abstract

OBJECTIVE The aim of this study was to analyze the neurological functional outcome and recurrent risks in surgically treated jugular foramen paragangliomas (JFPs) and to propose an individualized therapeutic strategy. METHODS Clinical charts and radiological information were reviewed retrospectively in 51 consecutive cases of JFPs. Less-aggressive surgical interventions were adopted with the goal of preserving neurovascular structures. Scheduled follow-up was performed. RESULTS The mean age of the patients in the cases reviewed was 41.6 years, and the group included 27 females (52.9%). The mean preoperative Karnofsky Performance Scale (KPS) score was 78.4. The mean lesion size was 3.8 cm. Forty-three cases (84.3%) were Fisch Type D, including 37 cases (72.5%) of Type Di1 and Di2. Thirty-seven cases (72.5%) were Glasscock-Jackson Type III-IV. Gross-total resection and subtotal resection were achieved in 26 (51.0%) and 22 (43.1%) cases, respectively. Surgical morbidities occurred in 23 patients (45.1%), without surgery-related mortality after the first operation. The mean postoperative KPS scores at discharge, 3 months, 1 year, and most recent evaluation were 71.8, 77.2, 83.2, and 79.6, respectively. The mean follow-up duration was 85.7 months. The tumor recurrence/regrowth (R/R) rate was 11.8%. Compared with preoperative status, swallowing function improved or stabilized in 96.1% and facial function improved or stabilized in 94.1% of patients. A House-Brackmann scale Grade I/II was achieved in 43 patients (84.3%). Overall neurological status improved or stabilized in 90.0% of patients. Pathological mitosis (HR 10.640, p = 0.009) was the most significant risk for tumor R/R. A 1-year increase in age (OR 1.115, p = 0.037) and preoperative KPS score < 80 (OR 11.071, p = 0.018) indicated a risk for recent poor neurological function (KPS < 80). Overall R/R-free survival, symptom progression-free survival, and overall survival at 15 years were 78.9%, 86.8%, and 80.6%, respectively. CONCLUSIONS Surgical outcomes for JFPs were acceptable using a less-aggressive surgical strategy. Most patients could adapt to surgical morbidities and carry out normal life activities. Preserving neurological function was a priority, and maximal decompression with or without radiotherapy was desirable to preserve a patient's quality of life when radical resection was not warranted. Early surgery plus preoperative devascularization was proposed, and radiotherapy was mandatory for lesions with pathological mitosis.

Head and neck paragangliomas: A two‐decade institutional experience and algorithm for management

“…Conversely, radiation was prompted by tumor recurrence/regrowth in three cases (roughly one in five JP patients undergoing sub-total resection) validating rates of recurrence/regrowth seen in other JP cohorts. 33 Increased utilization of this function-preserving approach to JP treatment may therefore necessitate patient counseling regarding likelihood of adjuvant treatment and/or timely adjuvant radiation therapy to preempt tumor recurrence/regrowth. At our institution, unilateral and bilateral CBP, JP, VP, and SCP frequently undergo angiographic embolization 24-72 hours prior to surgery, though our data suggest larger size does not reliably influence surgeon preference for embolization.…”

Endonasal access to lower cranial nerves: From foramina to upper parapharyngeal space

“…23 Branches from the ascending pharyngeal artery to the HC were detected in all 12 sides; thus, deserving attention to avoid inadvertent injury and postoperative dysfunction of the lower cranial nerves. 24 In this cadaveric study, an EEA provided a full direct access to the HC and the jugular foramen, and adequate exposure of the medial, superior, and anterior aspects of the jugular foramen could be realized. This suggests that a schwannoma originating from the lower cranial nerves may be directly accessed through an EEA or that it could be used as a complementary approach 25 ; to avoid the need for a transposition of the facial nerve through a lateral approach in properly selected patients.…”

“…Moreover, the ascending pharyngeal artery (a common feeding artery for tumors in this region) originates from the external carotid artery and travels upward at the anteromedial or posteromedial aspects of the parapharyngeal ICA 23 . Branches from the ascending pharyngeal artery to the HC were detected in all 12 sides; thus, deserving attention to avoid inadvertent injury and postoperative dysfunction of the lower cranial nerves 24 …”

Surgical management of embolized jugular foramen paragangliomas without facial nerve transposition: Experience of a public tertiary hospital in Brazil

“…As these are hypervascularized lesions, preoperative intravascular[ 3 , 17 , 18 , 20 , 34 ] or direct percutaneous[ 17 ] embolization has been used. Intraoperative blood loss ranges from 0 to 8.000 ml,[ 3 , 23 , 24 , 26 , 27 ] for embolized and nonembolized tumors. Intraoperative blood loss was reported from 300 to 8000 ml (mean = 3057.8 ± 1934.6 ml) for all patients and 3922 ml versus 2716 ml for patients undergoing intraoperative ligation of ECA branches and undergoing preoperative embolization respectively (non-significant difference).…”

“…[ 4 , 19 , 20 , 28 , 33 , 38 ] In the last decade, they ranged from 61% to 100% (mean = 80.4 ± 11.7) and 0.6–31.2% (M = 17 ± 11), respectively, and the regrowth rate ranged from 6.3% to 69%. [ 3 , 4 , 8 , 12 , 20 , 21 , 23 , 24 , 26 , 27 , 32 , 37 ] Ten-year recurrence ranged from 13.2% to 28.2%, and the 15-year RFS was 79%. [ 24 , 35 ] Total resection of JFP Fisch C/D using IFTA without transposition of the FN transposition is reported ranging from 63% to 91%.…”