Evolving Concepts in the Management of Jugular Paraganglioma: A Comparison of Radiotherapy and Surgery in 88 Cases

ABSTRACT

Surgery for jugular paraganglioma (PGL) tumors often results in the acquisition of neurological deficits where none had been present previously. This has a significant impact on the quality of life. Radiotherapy is a recognized alternative therapy. The aim of this study was to compare the results of radiotherapy and surgery for the management of jugular PGL in terms of function and tumor control to define a treatment algorithm. We conducted a retrospective and comparative analysis of the treatment of 41 patients by conventional radiotherapy and 47 patients by surgery via tertiary referral at an academic medical center. Forty-seven patients with type C and/or D jugular PGLs (mean age, 46 years) underwent surgery after endovascular embolization between 1984 and 1998 using an infratemporal fossa type A approach. The facial nerve was transposed in 18 patients. An adjunctive neurosurgical procedure was required in 14 patients. Mean follow-up was 66 months (range, 17 months to 14 years). Forty-one patients with type C jugular PGLs (mean age, 59.5 years) were treated by external beam or conformational radiotherapy between 1988 and 2003 with a total mean dose of 45 Gy (range, 44 to 50 Gy). Mean follow-up was 50 months (range, 18 months to 13 years). The primary outcome measures were tumor control and cranial nerve status. Surgical resection, total or subtotal, yielded an overall 86% rate of either cure or tumor stabilization. Radiotherapy achieved local control in 96% of patients. For surgery, the main postoperative complications were dysphagia, aspiration, and facial paralysis. Patients treated by radiotherapy developed minor disabilities. We concluded that radiotherapy and surgery achieve similar oncologic outcomes, but the former achieves tumor control with less morbidity. Our data favor radiotherapy as treatment for jugular PGLs, but we acknowledge that the aims of these two treatment modalities are different, namely, eradication of tumor by surgery versus stabilization of tumor with radiotherapy. The search for the better quality of life has to be weighed against the uncertainty of the long-term behavior of the tumor.

KEYWORDS

Jugular paraganglioma - surgery - radiotherapy

REFERENCES

• 1 Fisch U, Mattox D. Infratemporal fossa approach type A. In: Microsurgery of the Skull Base. Stuttgart; Thieme 1988: 135-281
• 2 Al-Mefty O, Teixeira A. Complex tumors of the glomus jugulare: criteria, treatment, and outcome.  J Neurosurg. 2002;  97 1356-1366
• 3 Pensak M L, Jackler R K. Removal of jugular foramen tumors: the fallopian bridge technique.  Otolaryngol Head Neck Surg. 1997;  117 586-591
• 4 George B, Lot G, Tran Ba Huy P. The juxtacondylar approach to the jugular foramen (without bone drilling).  Surg Neurol. 1995;  44 279-284
• 5 Gjuric M, Wigand M E, Wolf S R et al.. Cranial nerve and hearing function after combined approach surgery for glomus jugulare tumors.  Ann Otol Rhinol Laryngol. 1996;  105 949-954
• 6 Patel S J, Sekhar L N, Cass S P et al.. Combined approaches for resection of extensive glomus jugulare tumors.  J Neurosurg. 1994;  80 1026-1038
• 7 Krych A J, Foote R L, Brown P D et al.. Long-term results of irradiation for paraganglioma.  Int J Radiat Oncol Biol Phys. 2006;  65 1063-1066
• 8 Li G, Chang S, Adler J R et al.. Irradiation of glomus jugulare tumors: a historical perspective.  Neurosurg Focus. 2007;  23 E13
• 9 Cosetti M, Linstrom C, Alexiades G et al.. Glomus tumors in patients of advanced age: a conservative approach.  Laryngoscope. 2008;  118 270-274
• 10 Tran Ba Huy P, Chao P Z, Benmansour F, George B. Long-term oncological results in 47 cases of jugular paraganglioma surgery with special emphasis on the facial nerve issue.  J Laryngol Otol. 2001;  115 981-987
• 11 Gottfried O N, Liu J K, Couldwell W T. Comparison of radiosurgery and conventional surgery for the treatment of glomus jugulare tumors.  Neurosurg Focus. 2004;  17 E4
• 12 Gstoettner W, Matula C, Hamzavi J, Kornfehl J, Czerny C. Long-term results of different treatment modalities in 37 patients with glomus jugulare tumors.  Eur Arch Otorhinolaryngol. 1999;  256 351-355
• 13 Saringer W, Kitz K, Czerny C et al.. Paragangliomas of the temporal bone: results of different treatment modalities in 53 patients.  Acta Neurochir (Wien). 2002;  144 1255-1264
• 14 Poe D S, Jackson G, Glasscock M E, Johnson G D. Long-term results after lateral cranial base surgery.  Laryngoscope. 1991;  101 372-378
• 15 Gzaiel D, Deffrennes D, Tran Ba Huy P. Les complications iatrogènes de la chirurgie des paragangliomes du foramen jugulaire.  Ann Otolaryngol Chir Cervicofac. 1993;  110 429-436
• 16 Lawson W, Eden A R, Biller H F et al.. Complications in the management of large glomus jugulare tumors.  Laryngoscope. 1987;  97 152-157
• 17 Briner H R, Linder T E, Pauw B, Fisch U. Long-term results of surgery for temporal bone paragangliomas.  Laryngoscope. 1999;  109 577-583
• 18 Selesnick S H, Abraham M T, Carew J F. Rerouting of the intratemporal facial nerve: an analysis of the literature.  Am J Otol. 1996;  17 793-805
• 19 Boedeker C C, Ridder G J, Schipper J. Paragangliomas of the head and neck: diagnosis and treatment.  Fam Cancer. 2005;  4 55-59
• 20 Foote R L, Pollock B E, Gorman D A et al.. Glomus jugular tumor: tumor control and complications after stereotactic radiosurgery.  Head Neck. 2002;  24 332-338
• 21 Lalwani A K, Jackler R K, Gutin S M et al.. Lethal fibrosarcoma complicating radiation therapy for benign glomus jugulare tumor.  Am J Otol. 1993;  14 398-402
• 22 Schild S E, Foote R L, Buskirk S J et al.. Results of radiotherapy for chemodectomas.  Mayo Clin Proc. 1992;  67 537-540
• 23 Gerosa M, Visca A, Rizzo P et al.. Glomus jugulare tumors: the option of gamma knife radiosurgery.  Neurosurgery. 2006;  59 561-569
• 24 Varma A, Nathoo N, Neyman G et al.. Gamma knife radiosurgery for glomus jugulare tumors: volumetric analysis in 17 patients.  Neurosurgery. 2006;  59 1030-1036
• 25 Jordan J A, Roland P S, McManus C et al.. Stereotactic radiosurgery for glomus jugular tumors.  Laryngoscope. 2000;  110 35-38
• 26 Maarouf M, Voges J, Landwehr P et al.. Stereotactic linear accelerator-based radiosurgery for the treatment of patients with glomus jugulare tumors.  Cancer. 2003;  97 1093-1098
• 27 Lim M, Gibbs I C, Adler J R, Chang S D. Efficacy and safety of stereotactic radiosurgery for glomus jugulare tumor.  Neurosurg Focus. 2004;  17 E11
• 28 Pollock B E. Stereotactic radiosurgery in patients with glomus jugulare tumors.  Neurosurg Focus. 2004;  17 E10
• 29 Zabel A, Milker-Zabel S, Huber P et al.. Fractionated stereotactic conformal radiotherapy in the management of large chemodectomas of the skull base.  Int J Radiat Oncol Biol Phys. 2004;  58 1445-1450
• 30 Watkins L D, Mendoza N, Cheesman A D, Symon L. Glomus jugular tumours: a review of 61 cases.  Acta Neurochir (Wien). 1994;  130 66-70
• 31 Elshaikh M A, Mahmoud-Ahmed A S, Kinney S E et al.. Recurrent head-and-neck chemodectomas: a comparison of surgical and radiotherapeutic results.  Int J Radiat Oncol Biol Phys. 2002;  52 953-956
• 32 Jansen J C, van den Berg R, Kuiper A et al.. Estimation of growth rate in patients with head and neck paraganglioma influences the treatment proposal.  Cancer. 2000;  88 2811-2816
• 33 Oosterwijk J C, Jansen J C, van Schothorst E M et al.. First experiences with genetic counselling based on predictive DNA diagnosis in hereditary glomus tumors (paraganglioma).  J Med Genet. 1996;  33 379-383
• 34 Neumann H P, Pawlu C, Peczkowska M et al.. Distinct clinical features of paraganglioma syndromes associated with SDHB and SDHD gene mutations.  JAMA. 2004;  292 943-951
• 35 Duet M, Sauvaget E, Petelle B et al.. Clinical impact of somatostatin receptor scintigraphy in the management of paraganglioma of the head and neck.  J Nucl Med. 2003;  44 1767-1774
• 36 Van der Mey A G, Frijns J H, Cornelisse C J et al.. Does intervention improve the natural course of glomus tumors? A series of 108 patients seen in a 32-year period.  Ann Otol Rhinol Laryngol. 1992;  101 635-642
• 37 Willen S N, Einstein D B, Maciunas R J, Megerian C A. Treatment of glomus jugular tumors in patients with advanced age: planned limited surgical resection followed by staged gamma knife radiosurgery: a preliminary report.  Otol Neurotol. 2005;  26 1229-1234