Stereotactic Radiosurgery in Patients With Glomus Jugulare Tumor
Stereotactic Radiosurgery in Patients With Glomus Jugulare Tumor
Object: Microsurgical removal of glomus jugulare tumors is frequently associated with injury of the lower cranial nerves. To decrease the morbidity associated with tumor management in these patients, gamma knife surgery (GKS) was performed as an alternative to resection.
Methods: Between 1990 and 2003, 42 patients underwent GKS as the primary management (19 patients) or for recurrent glomus jugulare tumors (23 patients). Facial weakness and deafness were more common in patients with recurrent tumors than in those in whom primary GKS was performed (48% compared with 11%, p = 0.02). The mean tumor volume was 13.2 cm; the mean tumor margin dose was 14.9 Gy. The mean follow-up period for the 39 patients in whom evaluation was possible was 44 months (range 6149 months). After GKS, 12 tumors (31%) decreased in size, 26 (67%) were unchanged, and one (2%) grew. The patient whose tumor grew underwent repeated GKS. Progression-free survival after GKS was 100% at 3 and 7 years, and 75% at 10 years. Six patients (15%) experienced new deficits (hearing loss alone in three, facial numbness and hearing loss in one, vocal cord paralysis and hearing loss in one, and temporary imbalance and/or vertigo in one). In 26 patients in whom hearing could be tested before GKS, hearing preservation was achieved in 86 and 81% at 1 and 4 years posttreatment, respectively. No patient suffered a new lower cranial nerve deficit after one GKS session; the patient in whom repeated GKS was performed experienced a new vocal cord paralysis 1 year after his second procedure.
Conclusions: Gamma knife surgery provided tumor control with a low risk of new cranial nerve injury in early follow-up review. This procedure can be safely used as a primary management tool in patients with glomus jugulare tumors that do not have significant cervical extension, or in patients with recurrent tumors in this location.
Glomus jugulare tumors arise from the paraganglia of the chemoreceptor system and occur in intra- and extracranial locations. Local invasion of adjacent structures or the effect of the tumor mass causes symptoms. Neurovascular structures within the hypoglossal canal, jugular foramen, and temporal bone can be affected. Treatment has included resection, embolization, external-beam radiation therapy, or a combination of these modalities.
Surgery has been performed most frequently in young patients or in those with complete loss of cranial nerve function. Complete surgical removal is not always possible; gross-total resection has been accomplished in 40 to 80% of cases in reported series. External-beam radiation therapy has been used in elderly patients and for symptomatic tumors that were considered unresectable, were in completely removed, or had recurred after resection. Control of glomus jugulare tumors after external-beam radiation therapy has ranged from 85 to 100%, with complication rates of 0 to 10%. Complications associated with external-beam radiation therapy have included necrosis of the temporal bone or brain, mastoiditis, and other local tissue injury.
As an alternative to resection or external-beam radiation therapy, radiosurgery has been used to manage disease in patients with glomus jugulare tumors in the hope of achieving high tumor control rates and symptom response similar to those seen with external-beam radiation therapy. In this paper we describe our experience with GKS in glomus jugulare tumors over the past 15 years.
Object: Microsurgical removal of glomus jugulare tumors is frequently associated with injury of the lower cranial nerves. To decrease the morbidity associated with tumor management in these patients, gamma knife surgery (GKS) was performed as an alternative to resection.
Methods: Between 1990 and 2003, 42 patients underwent GKS as the primary management (19 patients) or for recurrent glomus jugulare tumors (23 patients). Facial weakness and deafness were more common in patients with recurrent tumors than in those in whom primary GKS was performed (48% compared with 11%, p = 0.02). The mean tumor volume was 13.2 cm; the mean tumor margin dose was 14.9 Gy. The mean follow-up period for the 39 patients in whom evaluation was possible was 44 months (range 6149 months). After GKS, 12 tumors (31%) decreased in size, 26 (67%) were unchanged, and one (2%) grew. The patient whose tumor grew underwent repeated GKS. Progression-free survival after GKS was 100% at 3 and 7 years, and 75% at 10 years. Six patients (15%) experienced new deficits (hearing loss alone in three, facial numbness and hearing loss in one, vocal cord paralysis and hearing loss in one, and temporary imbalance and/or vertigo in one). In 26 patients in whom hearing could be tested before GKS, hearing preservation was achieved in 86 and 81% at 1 and 4 years posttreatment, respectively. No patient suffered a new lower cranial nerve deficit after one GKS session; the patient in whom repeated GKS was performed experienced a new vocal cord paralysis 1 year after his second procedure.
Conclusions: Gamma knife surgery provided tumor control with a low risk of new cranial nerve injury in early follow-up review. This procedure can be safely used as a primary management tool in patients with glomus jugulare tumors that do not have significant cervical extension, or in patients with recurrent tumors in this location.
Glomus jugulare tumors arise from the paraganglia of the chemoreceptor system and occur in intra- and extracranial locations. Local invasion of adjacent structures or the effect of the tumor mass causes symptoms. Neurovascular structures within the hypoglossal canal, jugular foramen, and temporal bone can be affected. Treatment has included resection, embolization, external-beam radiation therapy, or a combination of these modalities.
Surgery has been performed most frequently in young patients or in those with complete loss of cranial nerve function. Complete surgical removal is not always possible; gross-total resection has been accomplished in 40 to 80% of cases in reported series. External-beam radiation therapy has been used in elderly patients and for symptomatic tumors that were considered unresectable, were in completely removed, or had recurred after resection. Control of glomus jugulare tumors after external-beam radiation therapy has ranged from 85 to 100%, with complication rates of 0 to 10%. Complications associated with external-beam radiation therapy have included necrosis of the temporal bone or brain, mastoiditis, and other local tissue injury.
As an alternative to resection or external-beam radiation therapy, radiosurgery has been used to manage disease in patients with glomus jugulare tumors in the hope of achieving high tumor control rates and symptom response similar to those seen with external-beam radiation therapy. In this paper we describe our experience with GKS in glomus jugulare tumors over the past 15 years.
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