CASE REPORT
The im por t a n ce of pr e ope r a t ive e m boliza t ion for t h e t r e a t m e n t of t h e
ca r ot id body t u m or : ca se r e por t a n d r e vie w of t h e lit e r a t u r e
Lucia na M a r ins Ca va lca nt iI; Cr ist ia no Ba r bosa Cr uzI; Ale x a ndr e José de Sou za Gue de sI I; Gust a vo Andr a deI I I; Ca r los Gust a vo Cout inho Aba t hI I I; Ra que l Aline Fe r na nde sI I
IResident , Vascular Surgery, Hospit al da Rest auração, Recife, PE, Brazil.
I IMSc. in Vascular Surgery. Precept or, Residence in Vascular Surgery, Hospit al da Rest auração, Recife, PE, Brazil.
I I IPrecept or, Residence, Angiorad, Recife, PE, Brazil.
Correspondence
J Vasc Bras. 2008; 7( 2) : 163- 166.
ABSTRACT
Carot id body t um ors are rare neoplasm s originat ing from t he sm all chem o- and barorecept ors locat ed in t he advent it ia of t he com m on carot id art ery bifurcat ion. They are a disease of great int erest for vascular surgeons, given t hat t hey grow adhered t o t he advent it ia of vessels
com prising t his bifurcat ion. For t hat , t heir surgery requires not only anat om ical knowledge of t he region, but also perfect fam iliarizat ion w it h vascular repair t echniques. Carot id body t um ors are a part icular problem as t o t heir m anagem ent , due t o rich vascularizat ion and int im acy w it h im port ant st ruct ures of t he cervical region, such as nerves and large vessels. We report on a m ale pat ient wit h carot id body t um or adhered t o t he right carot id art ery, diagnosed by punct ure biopsy and t reat ed at t wo different t im e periods: first by endovascular t reat m ent , w it h percut aneous em bolizat ion of t he t um or; and lat er by surgical resect ion, which represent s t he com bined t reat m ent suggest ed in t he current lit erat ure.
Ke yw or ds: Carot id body t um or, paragangliom a, chem odect om a.
RESUM O
Os t um ores do corpo carot ídeo são neoplasias raras, que se originam dos pequenos órgãos quim io e barorrecept ores localizados na advent ícia da bifurcação da art éria carót ida com um . Const it uem-se um a doença de grande int eresuem-se para o cirurgião vascular, na m edida em que crescem aderidos à advent ícia dos vasos que com põem essa bifurcação. Por isso, sua cirurgia requer não só o
conhecim ent o anat ôm ico da região, m as t am bém perfeit o reconhecim ent o das t écnicas de
direit a, diagnost icado por punção biópsia e t rat ado em dois t em pos, sendo o prim eiro por t rat am ent o endovascular, realizando em bolização percut ânea do t um or, e, no segundo, a
ressecção cirúrgica do m esm o, o que evidencia o t rat am ent o com binado, segundo at ual lit erat ura.
Pa la vr a s- cha ve : Tum or do corpo carot ídeo, paragangliom a, quim iodect om a.
I n t r odu ct ion
Carot id body t um or is also known as chem odect om a or paragangliom a. I t is derived from neural crest cells, and has t he sam e hist ological charact erist ics of a norm al t issue. I t is locat ed in t he post erolat eral region of t he carot id bifurcat ion.1
The carot id body has bot h a barorecept or and chem orecept or funct ion. A sim ilar t issue is found in t he j ugular bulb, m iddle ear, ganglion nodosum of t he vagal nerve, advent it ia of t he ascending aort a, abdom inal aort a, and pulm onary surface.1
The m ain com plaint is usually presence of consist ent , uncom pressible and painless cervical m ass below t he m andible angle. Som e classical signs can be observed on physical exam inat ion, such as t he finding of a firm t um or on palpat ion, locat ed bet ween t he int ernal and ext ernal carot id art eries ( Kocher's sign I ) ; unfixed t um or in t he horizont al and fixed in t he vert ical ( Font aine's sign) ; and t um or locat ed in t he t onsilar region ( Kocher's sign I I ) .1
The m ost com m on different ial diagnosis is wit h increased lym phat ic nodules, brachial cyst , m ixed t um ors, and carot id art ery aneurysm .2 Such range of different ial diagnoses m akes t his a rich
clinical case.
Ca se r e por t
A 44- year- old m ale pat ient , Caucasian, born and resident in Vit ória de Sant o Ant ão, Brazil, driver had com plaint of painless t um or in t he right cervical regions for 2 years. He was referred t o t he vascular surgery out pat ient clinic wit h a hist opat hologic result of punct ure biopsy com pat ible w it h carot id body paragangliom a.
On physical exam inat ion, he was in good general and nut rit ional st at us, aware, ruddy, febrile, wit h no palpable adenom egalies and no alt erat ions in cardiovascular, respirat ory, digest ive and nervous exam s. On cervical palpat ion t o t he right , a rounded m ass of approxim at ely 3 x 3 cm , pulsat ile, unfixed in t he lat erolat eral direct ion and fixed in t he longit udinal direct ion, painless, wit h no flogist ic or fluct uat ion signs was det ect ed.
The pat ient already had an art eriography com pat ible wit h t he diagnosis of carot id body t um or. Aft er a clinical m eet ing at t he Vascular Surgery Service of Hospit al da Rest auração, choice was t o perform preoperat ive percut aneous em bolizat ion of t he t um or t o reduce it s size and
revascularizat ion, facilit at ing it s resect ion and reducing int raoperat ive bleeding.
embolized using polyvinyl alcohol particles (PVA). Such particles favor embolization in the blood supply to hypervascular tumors and arteriovenous malformations. The PVA measured 150 μ and were compatible with vessel caliber. Middle and lower thirds were fed by multiple thin branches originating from the occipital artery and from the external carotid artery. Because it is impossible to perform a microcatheterization of each branch, temporary occlusion of the occipital artery and external carotid artery was performed using Gelfoam,• which is a hemostatic gelatin sponge, followed by embolization of the external carotid artery origin with particles. Final angiographic control showed complete devascularization of the middle and upper third, with discrete capture of contrast in the lower third (Figure 1).
Thirty-six hours after embolization, the patient was submitted to tumor excision in a procedure that lasted approximately 2 hours, in which the incision is performed along the medial sheath of the sternocleidomastoid muscle for access to the common carotid artery and bifurcation. The
The surgical specim en was sent t o t he pat hologic anat om y of t he hospit al, whose report was given as paragangliom a (Figure 3).
The pat ient had no m ot or or sensory deficit in t he post operat ive period. He was discharged on t he sixt h day wit h no com plaint s.
Thirt y days lat er, t he pat ient ret urned t o t he vascular surgery out pat ient clinic wit h com plaint of m ild num bness around t he surgical wound. He is current ly under out pat ient follow- up by t he Vascular Surgery Service of t he hospit al.
D iscu ssion
The first descript ion of t he carot id body was perform ed by Von Haller in 1743. I n 1880, Reigner perform ed t he first surgery for t um ors in t his region, resect ing t he t um or along wit h int ernal and ext ernal carot id art eries ( t he pat ient died) . Maydl successfully rem oved a glom us t um or from t he carot id body, but t he pat ient was aphasic and hem iplegic. Schudder was t he first t o rem ove one of t hese t um ors and preserve t he ext ernal and int ernal carot id art eries.2
it s incidence is 1: 1,170,000. They are benign t um ors, which are developed in t he vessel advent it ia, in t he com m on carot id art ery bifurcat ion, in post erom edial locat ion. They are richly vascularized and receive innervat ion of t he nint h cranial nerve. The lesion is bilat eral in about 5% of cases, and m ay reach 32% if it has fam ily origin ( dom inant aut osom al) .2
At t ent ion should be given t o different ial diagnoses of m asses in t he neck region. Singh et al. described a case of pulsat ile m ass in t he neck in which clinical exam inat ion and t om ography suggest ed diagnosis of carot id body t um or. During t he surgical procedure, t he carot id art ery was resect ed and reconst ruct ed. Hist opat hologic analysis recognized it as a vagal paragangliom a.3
Ult rasonography is a useful diagnost ic m odalit y in different ial diagnosis of cervical t um ors, and can be associat ed wit h t he color m ode t o det erm ine it s associat ion wit h t he carot id bifurcat ion.
Com put ed t om ography and nuclear m agnet ic resonance confirm ed it s ext ension and relat ions w it h adj acent st ruct ures, and art eriography allows for a record of art erial anat om y and also t o perform preoperat ive em bolizat ion of t he t um or.4
Previous art erial em bolizat ion of large carot id body t um ors ( > 2 cm ) is a useful m easure. Such fact has been proposed by m any aut hors as a facilit at or of t um or surgical rem oval due t o reduced blood loss, result ing in reduced inadvert ent lesions of neighboring st ruct ures, such as carot id art ery and regional nerves.5
This procedure should be perform ed up t o 2 weeks before t he surgery, because t here is a possibilit y of t um or revascularizat ion.5
Ot her aut hors quest ion previous em bolizat ion, claim ing t hat it causes a locoregional inflam m at ory response, which leads t o difficult y during periadvent it ial surgical resect ion of t um ors.6 , 7
I n a st udy of 19 cases of carot id t um or on surgical t echniques, in which 11 pat ient s were subm it t ed t o em bolizat ion, recom m endat ion was t hat such procedure should be used by experienced
professionals and in t um ors up t o 3 cm long.8
Use of radiot herapy in t he t reat m ent of carot id body t um or st ill needs t o be invest igat ed. Hu & Perky published a series of cases in 967 pat ient s from 1962 and 2001 and described t hat t he radiat ion t herapy provides equal healing opport unit y t han t he surgery, considering, however, diseases in advanced st ages, wit h neural and brain lesion.9
Surgery is t he t reat m ent of choice for all lesions, regardless of lesion size, since it w ill cont inue t o grow if not resect ed, increasing t he difficult y level of t he surgery. Tum or rem oval can be current ly perform ed wit h st roke and m ort alit y rat e lower t han 1% and is usually t he definit ive t herapy for m ost cases.4
Re fe r e n ce s
1. França LHG, Bredt CG, Vedolin A, Back LA, St ahlke Jr. HJ. Trat am ent o cirúrgico do t um or de corpo: experiência de 30 anos do Hospit al das Clínicas da UFPR. J Vasc Bras. 2003; 2: 171- 6.
2. Sousa AA, Fagundes- Pereyra WJ, Sant os LD, Marques JAP, Carvalho GTC. Tum ores do corpo carot ídeo: revisão de oit o casos e abordagem cirúrgica. Arq Neuro- Psiquiat r. 2000; 58( 2A) ; 315- 23.
Vasc Surg. 2007;46:144.
4. Haimovici H. Cirurgia vascular. 4 ed. S‚o Paulo: Dilivros; 1999.
5. Maffei FHA Lastƒria S, Yoshida WB, Rollo HA, editores. Doen„as vasculares perif…ricas. 3 ed. Rio de Janeiro: MEDSI; 2002.
6. Netterville JL, Reilly KM, Robertson D, Reiber ME, Armstrong WB, Childs P. Carotid body tumor: a review of 30 patients with 46 tumors. Laryngoscope. 1995;105:115-26.
7. Maxwell JG, Jones SW, Wilson E, et al. Carotid body tumor excisions: adverse outcomes of adding carotid endarterectomy. J Am Coll Surg. 2004;198:36-41.
8. LaMuraglia GM, Fabian RL, Brewster DC, et al. The current surgical management of carotid body paragangliomas. J Vasc Surg. 1992;15:1038-44.
9. Knight TT Jr., Gonzalez JA, Rary JM, Rush DS. Current concepts for the surgical management of carotid body tumor. Am J Surg. 2006;191:104-10.
Cor r e sponde nce :
Luciana Marins Cavalcanti
Rua Guedes Pereira, 77/202, Parnamirim CEP 15060-150 – Recife, PE, Brazil Email: [email protected]
No conflicts of interest declared concerning the publication of this case report.
