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Carotid body tumor
CASE
REPORTS
Carotid W.M.
COCKE, JR.,
From tbe Department Orleans, Louisiana.
of Surgery,
M.D.
Body
AND PAUL T. DECAMP, M.D., New Orleans,
HERE
CASE REPORT A fifty-nine year old engineer from the CanaI Zone was admitted to Ochsner Foundation Hos-
American
Journal
o/ Surgery,Volume
IO& September
rg64
Louisiana
pital on September 16, 1952, because of a large mass in the left side of the neck. The growth was so prominent that urchins would stare and jeer at the patient, causing him considerabIe distress. Twenty-three years before admission, the patient noticed a smaI1, freely movable, pea-sized mass in the Ieft cervica1 region, which had remained asymptomatic unti1 three months before admission but had sIowIy increased in size. A surgeon in the CanaI Zone expIored the patient’s neck three years before admission but made no attempt to excise the tumor. The patient complained of hoarseness and shght sore throat for three months before admission. Examination revealed a firm, irreguIar mass measuring 12 by 12 by 8 cm. which extended from beneath the Ieft ear to 2 cm. above the clavicle. (Fig. I .) A slight, nonexpansile puIsation and bruit were noted. Compression of the Ieft carotid artery caused no untoward symptoms. A Ieft carotid arteriogram revealed compIete occIusion of the common carotid artery in the substance of the tumor. (Fig. 2.) In view of the unsightly appearance and resulting emotiona distress, pIus the possibility of the tumor being malignant, surgica1 remova was considered indicated. With the existing compIete occIusion of the common carotid artery, there was no fear of further compromising the cerebra1 circuIation and, hence, this was not considered a surgica1 contraindication. On September g, 1962, operation was carried out through a Iong obIique incision over the mass. Considerable vascuIarity caused by numerous arteria1 and venous coIIateraIs was noted. To remove the tumor, it was necessary to sacrifice the superior poIe of the thyroid gIand, the recurrent IaryngeaI nerve, vagus nerve, Iingual nerve, interna jugular vein and IinguaI artery. Portions of the common carotid artery, external carotid artery and internal carotid artery up to its entrance into the skuI1 were excised. It was necessary to remove the submaxiIIary salivary gIand and a
Ocbsner Clinic, New
are few reports of successfu1 remova of enormous carotid body tumors. In 1952 Brown and Fryer [I] reported what they thought was the Iargest recorded case; the tumor weighed 140 gm. However, in Igzo Reid [z] reported a case of a carotid body tumor weighing Igo gm. In 1952 a patient was seen in the Ochsner Clinic because of a Iarge growth in his neck, which proved to be a carotid body tumor weighing 330 gm. We have been unabIe to find any reports in the Iiterature of successful remova of carotid body tumors weighing as much as this, and it is for this reason that we wish to record this case.
T
Tumor
406
Carotid
Body Tumor
portion of Ihc parotid gland. Dissection was carried up to the mucous membrane of the oropharynx, alld continued as high as the jugular foramcn. Two liters of blood were given during this procedure. The resected tumor measured 7.5 cm. in diameter and weighed 330 gm. It was surrounded by the tumor appeared a capsufe. On cut section, beefy red with streaks of white fibrous tissue. Microscopically, it w-as a benign carotid body tumor. The patient was discharged six days after (Fig. 3.) Hoarseness and dysphagia operation. were aggravated by the operation and were still present at examination two years postoperativeIy. The patient enjoyed good general health during this time. The patient died eLsewhere two and a haIf years after operation of profound right hemipIegia complicated by severe bronchopneumonia. Postmortem examination reveaIed generaLed arterioscIerosis and extensive encephalomalacia invoIving the parietal, temporal and occipital Iobes of the Ieft cerebra1 hemisphere. There was no evidence of recurrence or metastasis of the carotid body tumor. Metastatic adenocarcinoma was found in the right tenth rib. The primary lesion was thought to be in the prostatr gland.
Frc. J,. Postoperative operat ivc defect .
Comment: This carotid body tumor had become so Iarge that it had compIeteIy occIuded the common carotid artery and caused paresis of crania1 nerves incorporated into the tumor.
no demonstrabIe function.
photograph
illustratirlg
lrGrlirn:tl
rc‘unsightIy tumor was successfuIl~moved, but the necessary sacrifice of involved nerves somewhat aggravated the neurogenic symptoms. AIthough the patient had tolerated gradual and complete occlusion of the carotid arteries by the tumor, and had withstood operative division of possibIe coIIatera1 channeIs, he died two and a haIf years Iater of arterial insuffrciency of the ipsiIatera1 cerebra1 hemisphere. Progressive arterioscIerosis undoubtedly precipitated the stroke. CervicaI sympathectomy at the time of remova of the tumor might have provided some protection.
The
COMMENTS
Carotid body tumors deveIop from the carotid body and consist of Iarge poIyhedra1 ceIIs with fine granuIar cytopIasm and Iarge hyperchromatic nucIei. NeopIastic ceIIs are simiIar to norma carotid body ceIIs, onIy Iarger. The usuai reported weight of these tumors ranges from 25 to 60 gm. with an average diameter of 3.5 cm. These tumors have chemoreceptive
or hormona1
A diagnosis of carotid body tumor should be suspected if a patient has a sIowIy enIarging 407
Cocke
and
DeCamp rary or permanent interruption of bIood Aow through the interna carotid artery [4,8,9]. This probIem did not arise in our patient, as the artery had been compIeteIy occIuded by the tumor.
mass at the bifurcation of the carotid artery. The mass may be painfu1. Because of direct involvement of adjacent nerves, the patient may compIain of dysphagia, dysphonia, headache or earache. Facial or accessory nerve weakness and occasionaIIy paraIysis of the tongue or Horner’s syndrome may deveIop. RareIy, a hypersensitive patient may demonstrate symptoms of the carotid sinus syndrome. There may be a systoIic bruit associated with compression of the carotid vesseIs. The mass can be moved in the horizonta1 but not in the vertica1 direction. BranchiaI cIeft cyst, neurofibroma, metastatic carcinoma from thyroid, Iymphadenopathy and aneurysm must be considered in the differentia1 diagnosis. Carotid arteriograms are heIpfu1 in demonstrating compression of the carotid artery by the tumor [3]. A tumor of the carotid body may appear at any time in Iife but most commonIy occurs at middIe age. It is encountered in both sexes and may be biIatera1, but is usuaIIy uniIatera1. It grows sIowIy and is usuaIIy benign, but can recur IocaIIy [4,y]. If maIignant, it may metastasize IocaIIy to regiona nodes and occasionaIIy to the vertebrae, mediastinum, ribs or Iungs [6,7]. One danger encountered in extirpation of these tumors is reIated to tempo-
REFERENCES I. BROWN, J.
B. and FRYER, M. P. Carotid body tumors; report of remova of tumor thought to be Iargest recorded. Surgery, 32: 997, 1952. 2. REID. M. R. Adenomata of carotid bodv. Bull. Johns Hopkins Hosp., 31: 177, 1920. 3. MONRO, R. S. The natura1 history of carotid body tumors and their diagnosis and treatment. Brit. I
J. Surg., 37: 445, 1950. A.. AREAN. V. M. Recurrent carotid bodv tumor. Arch. Patb:, 60: 530, 1955. 5. LAHEY, F. H. and WARREN, K. W. A Iong term appraisal of carotid body tumors with remarks on their remova1. Surg. Gynec. &+ Obst., 92: 481, 1951. 6. HODGE, G. B., HAGGERTY, W. C. and HODGE, J. Carotid body tumors-chemoreceptomas. J. Soutb Carolina M. A., 57: 106, 1961.. 7. WARREN, K. W. Tumors of carotid body. S. Clin. Nortb America, 33: 677, 1953. 8. LAHEY, F. H. and WARREN, K. W. Tumors of carotid body. Surg. Gynec. &’ Obst., 85: 281, 1947. 9. MARTORELL, F. Tumor of carotid body. Angiology, 7: 228, 1956. IO. KAHLE, H. R. The differentiated diagnosis of tumors of the neck. In: Ochsner, A. and DeBakey, M. E. Christopher’s Minor Surgery, 8th ed., p. 144. Philadelphia, 1959. W. B. Saunders.
408
REPORTS
Carotid W.M.
COCKE, JR.,
From tbe Department Orleans, Louisiana.
of Surgery,
M.D.
Body
AND PAUL T. DECAMP, M.D., New Orleans,
HERE
CASE REPORT A fifty-nine year old engineer from the CanaI Zone was admitted to Ochsner Foundation Hos-
American
Journal
o/ Surgery,Volume
IO& September
rg64
Louisiana
pital on September 16, 1952, because of a large mass in the left side of the neck. The growth was so prominent that urchins would stare and jeer at the patient, causing him considerabIe distress. Twenty-three years before admission, the patient noticed a smaI1, freely movable, pea-sized mass in the Ieft cervica1 region, which had remained asymptomatic unti1 three months before admission but had sIowIy increased in size. A surgeon in the CanaI Zone expIored the patient’s neck three years before admission but made no attempt to excise the tumor. The patient complained of hoarseness and shght sore throat for three months before admission. Examination revealed a firm, irreguIar mass measuring 12 by 12 by 8 cm. which extended from beneath the Ieft ear to 2 cm. above the clavicle. (Fig. I .) A slight, nonexpansile puIsation and bruit were noted. Compression of the Ieft carotid artery caused no untoward symptoms. A Ieft carotid arteriogram revealed compIete occIusion of the common carotid artery in the substance of the tumor. (Fig. 2.) In view of the unsightly appearance and resulting emotiona distress, pIus the possibility of the tumor being malignant, surgica1 remova was considered indicated. With the existing compIete occIusion of the common carotid artery, there was no fear of further compromising the cerebra1 circuIation and, hence, this was not considered a surgica1 contraindication. On September g, 1962, operation was carried out through a Iong obIique incision over the mass. Considerable vascuIarity caused by numerous arteria1 and venous coIIateraIs was noted. To remove the tumor, it was necessary to sacrifice the superior poIe of the thyroid gIand, the recurrent IaryngeaI nerve, vagus nerve, Iingual nerve, interna jugular vein and IinguaI artery. Portions of the common carotid artery, external carotid artery and internal carotid artery up to its entrance into the skuI1 were excised. It was necessary to remove the submaxiIIary salivary gIand and a
Ocbsner Clinic, New
are few reports of successfu1 remova of enormous carotid body tumors. In 1952 Brown and Fryer [I] reported what they thought was the Iargest recorded case; the tumor weighed 140 gm. However, in Igzo Reid [z] reported a case of a carotid body tumor weighing Igo gm. In 1952 a patient was seen in the Ochsner Clinic because of a Iarge growth in his neck, which proved to be a carotid body tumor weighing 330 gm. We have been unabIe to find any reports in the Iiterature of successful remova of carotid body tumors weighing as much as this, and it is for this reason that we wish to record this case.
T
Tumor
406
Carotid
Body Tumor
portion of Ihc parotid gland. Dissection was carried up to the mucous membrane of the oropharynx, alld continued as high as the jugular foramcn. Two liters of blood were given during this procedure. The resected tumor measured 7.5 cm. in diameter and weighed 330 gm. It was surrounded by the tumor appeared a capsufe. On cut section, beefy red with streaks of white fibrous tissue. Microscopically, it w-as a benign carotid body tumor. The patient was discharged six days after (Fig. 3.) Hoarseness and dysphagia operation. were aggravated by the operation and were still present at examination two years postoperativeIy. The patient enjoyed good general health during this time. The patient died eLsewhere two and a haIf years after operation of profound right hemipIegia complicated by severe bronchopneumonia. Postmortem examination reveaIed generaLed arterioscIerosis and extensive encephalomalacia invoIving the parietal, temporal and occipital Iobes of the Ieft cerebra1 hemisphere. There was no evidence of recurrence or metastasis of the carotid body tumor. Metastatic adenocarcinoma was found in the right tenth rib. The primary lesion was thought to be in the prostatr gland.
Frc. J,. Postoperative operat ivc defect .
Comment: This carotid body tumor had become so Iarge that it had compIeteIy occIuded the common carotid artery and caused paresis of crania1 nerves incorporated into the tumor.
no demonstrabIe function.
photograph
illustratirlg
lrGrlirn:tl
rc‘unsightIy tumor was successfuIl~moved, but the necessary sacrifice of involved nerves somewhat aggravated the neurogenic symptoms. AIthough the patient had tolerated gradual and complete occlusion of the carotid arteries by the tumor, and had withstood operative division of possibIe coIIatera1 channeIs, he died two and a haIf years Iater of arterial insuffrciency of the ipsiIatera1 cerebra1 hemisphere. Progressive arterioscIerosis undoubtedly precipitated the stroke. CervicaI sympathectomy at the time of remova of the tumor might have provided some protection.
The
COMMENTS
Carotid body tumors deveIop from the carotid body and consist of Iarge poIyhedra1 ceIIs with fine granuIar cytopIasm and Iarge hyperchromatic nucIei. NeopIastic ceIIs are simiIar to norma carotid body ceIIs, onIy Iarger. The usuai reported weight of these tumors ranges from 25 to 60 gm. with an average diameter of 3.5 cm. These tumors have chemoreceptive
or hormona1
A diagnosis of carotid body tumor should be suspected if a patient has a sIowIy enIarging 407
Cocke
and
DeCamp rary or permanent interruption of bIood Aow through the interna carotid artery [4,8,9]. This probIem did not arise in our patient, as the artery had been compIeteIy occIuded by the tumor.
mass at the bifurcation of the carotid artery. The mass may be painfu1. Because of direct involvement of adjacent nerves, the patient may compIain of dysphagia, dysphonia, headache or earache. Facial or accessory nerve weakness and occasionaIIy paraIysis of the tongue or Horner’s syndrome may deveIop. RareIy, a hypersensitive patient may demonstrate symptoms of the carotid sinus syndrome. There may be a systoIic bruit associated with compression of the carotid vesseIs. The mass can be moved in the horizonta1 but not in the vertica1 direction. BranchiaI cIeft cyst, neurofibroma, metastatic carcinoma from thyroid, Iymphadenopathy and aneurysm must be considered in the differentia1 diagnosis. Carotid arteriograms are heIpfu1 in demonstrating compression of the carotid artery by the tumor [3]. A tumor of the carotid body may appear at any time in Iife but most commonIy occurs at middIe age. It is encountered in both sexes and may be biIatera1, but is usuaIIy uniIatera1. It grows sIowIy and is usuaIIy benign, but can recur IocaIIy [4,y]. If maIignant, it may metastasize IocaIIy to regiona nodes and occasionaIIy to the vertebrae, mediastinum, ribs or Iungs [6,7]. One danger encountered in extirpation of these tumors is reIated to tempo-
REFERENCES I. BROWN, J.
B. and FRYER, M. P. Carotid body tumors; report of remova of tumor thought to be Iargest recorded. Surgery, 32: 997, 1952. 2. REID. M. R. Adenomata of carotid bodv. Bull. Johns Hopkins Hosp., 31: 177, 1920. 3. MONRO, R. S. The natura1 history of carotid body tumors and their diagnosis and treatment. Brit. I
J. Surg., 37: 445, 1950. A.. AREAN. V. M. Recurrent carotid bodv tumor. Arch. Patb:, 60: 530, 1955. 5. LAHEY, F. H. and WARREN, K. W. A Iong term appraisal of carotid body tumors with remarks on their remova1. Surg. Gynec. &+ Obst., 92: 481, 1951. 6. HODGE, G. B., HAGGERTY, W. C. and HODGE, J. Carotid body tumors-chemoreceptomas. J. Soutb Carolina M. A., 57: 106, 1961.. 7. WARREN, K. W. Tumors of carotid body. S. Clin. Nortb America, 33: 677, 1953. 8. LAHEY, F. H. and WARREN, K. W. Tumors of carotid body. Surg. Gynec. &’ Obst., 85: 281, 1947. 9. MARTORELL, F. Tumor of carotid body. Angiology, 7: 228, 1956. IO. KAHLE, H. R. The differentiated diagnosis of tumors of the neck. In: Ochsner, A. and DeBakey, M. E. Christopher’s Minor Surgery, 8th ed., p. 144. Philadelphia, 1959. W. B. Saunders.
408