HSC Section 8_April 2017

Jugular Paragangliomas

these patients experienced new postoperative cranial nerve deficits. Similar to what was seen in patients undergoing primary surgery, cranial nerve IX (77%) was the most commonly injured nerve. 5 Subtotal resection Subtotal resection of JP has become a mainstay of tumor management in the authors’ practice. This technique has previously been described as applicable to select pa- tients. Jackson and colleagues 33 published their experience using subtotal resection for attempted hearing preservation and noted that success in this regard was inversely related to tumor size. Over time, the authors’ utilization of planned, subtotal resection has increased, particularly in younger patients with advanced tumors (Glasscock- Jackson grade 3–4) and functional lower CN. Reviewing the authors’ experience from 1999 to 2013, 12 patients were identified from this demographic who underwent a planned subtotal resection. Although varying degrees of resection were identified on postoperative radiographic evaluation, no patient developed a per- manent, postoperative cranial neuropathy, and no patient with a residual disease burden of less than 20% of the original tumor size experienced postoperative tumor growth at a mean of approximately 45 months of follow-up. 34 Although these results have helped to validate the authors’ continued use of this strategy, the small size of the patient population and the relatively short time of follow-up prohibit a definitive conclusion that this technique is preferred in all cases. However, the authors believe that the general concept of cranial nerve- and carotid artery-sparing surgery is valid and should be considered in future clinical and research efforts. Observation As previously mentioned, the role of tumor observation remains unclear at this time. The authors recently reviewed their experience with tumor observation, focusing on patients with primary GJT and greater than 2 years of documented follow-up. Fifteen patients (80% female, mean age 64.2 years) with 16 tumors were evaluated. Patients were selected for tumor observation due to advanced age (73%) and patient prefer- ence (73%). Approximately 40% of tumors demonstrated growth at an average of 0.9 mm per year. However, no significant change in cranial nerve function was seen for most patients through nearly 7 years of follow-up. No deaths were attributable to tumor progression. 35 This experience has led the authors to consider observation with a wait-and-scan policy for patients who do not have brainstem compression or concern for malignancy. Radiation Over the last 10 years, 18 patients were treated with linear accelerator-based stereo- tactic radiotherapy for glomus jugulare at the authors’ institution. Over 64% (64.3%) of patients underwent fractionated therapy, and the median follow-up was 28.8 months (range 18.6–56.1 months). Consistent with previous reports, fewer than 10% of pa- tients had experienced disease progression at their last recorded MRI. Although the authors’ experience is limited by a smaller patient sample size and relatively short follow-up, stereotactic radiotherapy currently remains an important part of the treat- ment algorithm.

SUMMARY

JPs continue to represent a management challenge. Surgical resection is complicated by the vascular nature of the tumor and its location relative to the lower CN, the facial nerve, and the carotid artery. Radiation has gained momentum as a viable strategy for

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