UC UC SF SF Carotid Body Tumor Mass Left Side of Neck How to Get It Out • 55yo m with 10 yr hx of mass on left side of neck—assx except for swelling Charles Eichler, MD • 5 yrs ago, attempted resection • f/u neck radiation San Francisco, Ca • Represents 6 months ago -5cm mass April 16, 2015 VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO CT-intensely enhancing UC UC SF SF mass splaying carotid bifrucation VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 1
UC UC SF SF • Patient opted against resection • Repeat CT at 6 months revealed mass increased in size with associated node • Angiogram VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 2
UC UC SF SF • DX??? VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF What is the most likely Paragangliomas diagnosis? A. Malignant carotid body tumor Uncommon neuroendocrine tumors arising from extraadrenal paraganglia B. Schwannoma 67% of the autonomic nervous system C. Sarcoma D. Metastatic disease 22% Head/neck-carotid bifrucation---CBT E. None of the above 11% Most common-1:30,000 0% 0% VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 3
UC UC SF SF Presentation CTA • Painless neck mass • Defines superior & medial tumor extent • Functionally active tumor is extremely rare • Other lesions • Cranial neuropathy in very large • Nodal enlargement tumors • Preop embolization for Shamblin II & III VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 4
UC UC SF SF • Tumors are most often benign Surgical management only curative rx • Malignancy seen in 6-10%-usually Challenging-cr n injury>15% as well dx’d by resection and evidence of as high risk of vascular comlplication local invasion Predicted by Shamblin class VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Shamblin Classification • Vein map & prep thigh for possible Shamblin Size Surronding or infiltation replacement of carotid vessels • Decision for carotid resection often I <4cm No based on preop imaging • Embolization for all Shamblin II & III II >4cm Partially III >4cm Intimately VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 5
UC UC SF SF How I do it Nasotracheal intubation • Vertical incision or transverse • Develop field bordered by omohyoid, diagartic, IJV, pharynx Allows for mobilization of the jaw making subluxation of the jaw rare • Large tumors require parotid mobilization and diagastric division requiring ID of facial n Work with OHNS for large tumors for resection of styloid process and possible mandibulectomy VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF • Identify vagus & hypoglossal nerves • Isolate CCA, ICA & ECA early in the dissection • Free tumor away from these • Superior laryngeal n lies behind the vessels in cranial to caudal tumor direction • Facial, and IX and XI may also be • Bifrucation last involed with large tumors • Resection of ICA with very large • Use of bipolar very helpful tumors • Measure stump pressures & shunt if appropriate VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 6
UC UC SF SF Recent case • Completely free tumor away from • Patient presented to OSH large the vessels neck mass • Resect mass posteriorly from • CTA c/w CBT bottom to top extent and remove • Attempt resection-aborted due to • If needed, vein graft replacement bleeding and unexplained hypotension • Close w or w/o drain VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Angiogram- Left Angiogram Right VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 7
UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 8
UC UC SF SF Conclusion • Surgery rx of choice-smaller tumors easier to remove • Vascular morbidity relatively low • Cranial nerve injury is greatest risk VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 9
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