A Systematic Review and Meta-Analysis of the Presentation and Surgical Management of Patients With Carotid Body Tumours

Abstract

WHAT THIS PAPER ADDS This is the largest systematic review and meta-analysis detailing the presentation, management, and procedural complications following carotid body tumour (CBT) surgery. Although relatively rare, complications associated with CBT are not inconsiderable, especially in the more challenging Shamblin III CBTs where procedural stroke rates were about 4%, while cranial nerve injury rates approached 20%. The increasing morbidity associated with Shamblin III tumours must be considered during the consent process.Objectives: The aim was to determine the mode of presentation and 30 day procedural risks in 4418 patients with 4743 carotid body tumours (CBTs) undergoing surgical excision. Methods: This is a systematic review and meta-analysis of 104 observational studies. Results: Overall, 4418 patients with 4743 CBTs were identified. The mean age was 47 years, with the majority being female (65%). The commonest presentation was a neck mass (75%), of which 85% were painless. Dysphagia, cranial nerve injury (CNI), and headache were present in 3%, while virtually no one presented with a transient ischaemic attack (0.26%) or stroke (0.09%). The majority (97%) underwent excision, but only 21% underwent pre-operative embolisation. Overall, 27% were Shamblin I CBTs; 44% were Shamblin II; and 29% were Shamblin III. The mean 30 day mortality was 2.29% (95% CI 1.79e2.93). The mean 30 day stroke rate was 3.53% (95% CI 2.91e4.29), while the mean 30 day CNI rate was 25.4% (95% CI 24.5e31.22). The prevalence of persisting CNI at 30 days was 11.15% (95% CI 8.42e14.64). Twelve series (544 patients) correlated 30 day stroke with Shamblin status. Shamblin I CBTs were associated with a 1.89% stroke rate (95% CI 0.92e3.82), increasing to 2.71% (95% CI 1.43e5.07) for Shamblin II CBTs and 3.99% (95% CI 2.34e 6.74) for Shamblin III tumours. Twenty-six series (1075 patients) correlated CNI rates with Shamblin status: 3.76% (95% CI 2.62e5.35) for Shamblin I CBTs, 14.14% (95% CI 11.94e16.68) for Shamblin II, and 17.10% (95% CI 14.82e19.65) for Shamblin III tumours. The prevalence of neck haematoma requiring re-exploration was 5.24% (95% CI 3.45e7.91). The proportion of patients with a neck haematoma requiring re-exploration was not reduced by pre-operative embolisation (5.92%; 95% CI 2.56e13.08) vs. no embolisation (5.82%; 95% CI 2.76e11.88). Pre-operative embolisation did not reduce drainage losses (639 mL vs. 653 mL). Conclusions: This is the largest meta-analysis of outcomes after CBT excision. Procedural risks associated with tumour excision were considerable, especially with Shamblin III tumours where 4% suffered a peri-operative stroke and 17% suffered a CNI.

Simple and complex carotid paragangliomas. Three decades of experience and literature review

“…Our 30‐day results are an improvement on those presented in the most extensive meta‐analysis carried out to date (with 4418 patients and 4743 CPGs) 14 . The percentages of morbidity and mortality are lower in relation to stroke (2.4% vs 3.5%), cranial nerve injury (16.7% vs 25.4%), and mortality (0% vs 2.2%).…”

“…In addition to an American registry, 5 the CPGs published in PubMed do not exceed 5000 cases. 7,14 Therefore, if CPGs are infrequent, the complex forms we discuss below are even more rare (Table 5). Low frequency and high complexity pose a challenge for the surgeon.…”

Differential Diagnosis and Treatment Outcomes of Tumors at the Carotid Bifurcation

“…The other important point is early division of the feeding vessels to the tumor to reduce the amount of tumor bleeding. Paragangliomas usually receive their blood supply from the branches of external carotid artery, most commonly from the ascending pharyngeal branch [ 11 ]. Some authors have asserted the importance of preoperative tumor embolization to reduce intraoperative bleeding and to allow easier dissection during the removal of the hypervascular tumor [ 12 , 13 ].…”

Precision Surgery for Pheochromocytomas and Paragangliomas

“…HNPGLs associated with cranial nerves are often best followed with active surveillance if asymptomatic and may be treated with external beam radiation with local control achieved in 79-100 % of cases [123]. The largest meta-analysis to date of observational and retrospective studies (no randomized controlled trials exist for these rare tumors) for the surgical resection of > 4000 CBTs showed that Shamblin classification [124] [28]. Overall CVA rate was 3.5 %, cranial nerve injury persisting beyond thirty days after resection was 11.5 %, and preoperative embolization did not reduce postoperative cervical hematoma [28].…”

“…The largest meta-analysis to date of observational and retrospective studies (no randomized controlled trials exist for these rare tumors) for the surgical resection of > 4000 CBTs showed that Shamblin classification [124] [28]. Overall CVA rate was 3.5 %, cranial nerve injury persisting beyond thirty days after resection was 11.5 %, and preoperative embolization did not reduce postoperative cervical hematoma [28]. Another study of 20 resected CBTs showed that cranial nerve injury was more likely to occur during resection of high riding CBTs as determined on preoperative imaging (superior tip of C2 dens to superior border of CBT = 1.8 vs. 2.9 cm, p < 0.01) [125].…”