UC UC SF SF Carotid Body Tumor Mass Left Side of Neck How to - - PowerPoint PPT Presentation

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UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

Carotid Body Tumor

How to Get It Out Charles Eichler, MD San Francisco, Ca April 16, 2015

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VASCULAR SURGERY • UC SAN FRANCISCO

Mass Left Side of Neck

• 55yo m with 10 yr hx of mass on left

side of neck—assx except for swelling

• 5 yrs ago, attempted resection
• f/u neck radiation
• Represents 6 months ago -5cm

mass

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CT-intensely enhancing mass splaying carotid bifrucation UC SF

VASCULAR SURGERY • UC SAN FRANCISCO

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• Patient opted against resection
• Repeat CT at 6 months revealed

mass increased in size with associated node

• Angiogram

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• DX???

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What is the most likely diagnosis?

• A. Malignant carotid body tumor
• B. Schwannoma
• C. Sarcoma
• D. Metastatic disease
• E. None of the above

67% 0% 22% 0% 11%

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Paragangliomas

Uncommon neuroendocrine tumors arising from extraadrenal paraganglia

• f the autonomic nervous system

Head/neck-carotid bifrucation---CBT Most common-1:30,000

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Presentation

• Painless neck mass
• Functionally active tumor is

extremely rare

• Cranial neuropathy in very large

tumors

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CTA

• Defines superior & medial tumor

extent

• Other lesions
• Nodal enlargement
• Preop embolization for Shamblin II

& III

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• Tumors are most often benign
• Malignancy seen in 6-10%-usually

dx’d by resection and evidence of local invasion

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Surgical management only curative rx Challenging-cr n injury>15% as well as high risk of vascular comlplication Predicted by Shamblin class

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Shamblin Classification

Shamblin Size Surronding

• r infiltation
• f carotid vessels

I <4cm No II >4cm Partially III >4cm Intimately

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• Vein map & prep thigh for possible

replacement

• Decision for carotid resection often

based on preop imaging

• Embolization for all Shamblin II & III

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How I do it

Nasotracheal intubation Allows for mobilization of the jaw making subluxation of the jaw rare Work with OHNS for large tumors for resection of styloid process and possible mandibulectomy

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• Vertical incision or transverse
• Develop field bordered by
• mohyoid, diagartic, IJV, pharynx
• Large tumors require parotid

mobilization and diagastric division requiring ID of facial n

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• Identify vagus & hypoglossal nerves

early in the dissection

• Superior laryngeal n lies behind the

tumor

• Facial, and IX and XI may also be

involed with large tumors

• Use of bipolar very helpful

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• Isolate CCA, ICA & ECA
• Free tumor away from these

vessels in cranial to caudal direction

• Bifrucation last
• Resection of ICA with very large

tumors

• Measure stump pressures & shunt

if appropriate

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• Completely free tumor away from

the vessels

• Resect mass posteriorly from

bottom to top extent and remove

• If needed, vein graft replacement
• Close w or w/o drain

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Recent case

• Patient presented to OSH large

neck mass

• CTA c/w CBT
• Attempt resection-aborted due to

bleeding and unexplained hypotension

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Angiogram- Left UC SF

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Angiogram Right

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Conclusion

• Surgery rx of choice-smaller tumors

easier to remove

• Vascular morbidity relatively low
• Cranial nerve injury is greatest risk