Safety of Nonoperative Management of Carotid Body Tumors

Abstract

Objectives: Carotid body tumors (CBTs) are rare neuroendocrine paragangliomas that are typically asymptomatic and benign with a low rate of biochemical functionality. Historically, early surgical excision was recommended to prevent development of CBT-related complications. Yet, CBT resection can result in significant injury to cranial nerves and the carotid artery. Recent work has shown successful primary observation without resection of noncarotid body, cranial paragangliomas (glomus jugulare, tempanyomastoid, vagal body) with slow growth and a low rate of neuropathies. We hypothesize that primary observation of CBTs is safe and can be considered for the majority of CBTs.Methods: This was a retrospective cohort study of patients at a multihospital health care system with radiologic identification or surgical resection of CBT (2000CBT ( -2019. Tumor size (greatest diameter), associated symptoms, and interventions were recorded at initial evaluation and throughout follow-up. Categorical variables were presented as frequency (percent) and continuous as mean 6 standard deviation or median (interquartile range [IQR]) for normally or skewed distributions, respectively.Results: A total of 108 patients (mean age, 59.4 6 19 years; 67% female; 87% white) underwent initial evaluation for 123 CBTs (mean diameter, 2.4 6 1.2 cm; 43% right; 14% bilateral) with otolaryngologists (48%), vascular surgeons (30%), or other providers (22%). Fifty-six CBTs were initially resected, 63 observed, and 4 irradiated (Fig) . The overall median followup was 4.7 years (IQR, 2.6-9.1 years). Initially observed CBTs were, on average, stable in size (mean, 0.1 6 0.5 cm/year), none became biochemically active, and 2 patients became symptomatic. One patient experienced pain from hemorrhagic conversion treated successfully with radiation and 1 sternal pain from metastatic disease successfully treated with CBT resection and sternal radiation therapy. In total, 62 CBTs were resected, 55 never intervened upon, and 5 irradiated (Table ). Of the 62 surgically resected CBTs, 9 CBTs (16%) underwent preoperative embolization, 6 CBTs (10%) had malignant pathology in 6 patients, of which 4 (67%) had known somatic mutations (polymerase epsilon [n ¼ 1], succinate dehydrogenase-D gene [n ¼ 3]). Of the 59 patients who underwent surgical resection, 42% of patients had postoperative complications, notably including stroke (n ¼ 2), vocal cord paralysis (n ¼ 4), dysphagia (n ¼ 4), and facial asymmetry (n ¼ 7). Four resected CBTs locally recurred, only 2 of which had malignant pathology.Conclusions: Patients with newly diagnosed CBTs require biochemical functionality and known somatic mutation assessment. In the absence of these findings, CBTs can be primarily observed with annual imaging and symptom monitoring as a safe alternative to immediate resection, which demonstrates a high rate of vascular and cranial nerve-related complications and an ongoing risk of recurrence.

Clinical outcomes and challenges of surgical extirpation for carotid body tumor: A single- center case series

“…Although it has been reported that active surveillance is a non-inferior option for CBT management [12,13], many other studies have suggested that surgical resection is the preferred treatment [1,9,14]. When performing surgical treatment for CBT, surgeons must consider vascular reconstruction and monitor for cranial neuropathy as described in this study.…”

Clinical outcomes and challenges of surgical extirpation for carotid body paraganglioma in South Korea: a single-center retrospective study

“…Although active surveillance is reportedly a superior option for CBP management [ 11 , 12 ], complete surgical resection is believed as a primary treatment of choice when it is available [ 1 , 6 , 13 ]. When considering surgical removal of CBP, we worry about two things; intraoperative bleeding and CNP.…”