Jugular paraganglioma – postoperative radiosurgery for residual tumor
SKULL BASE REGION
Jugular foramen
HISTOPATHOLOGY
Paraganglioma
PRIOR SURGICAL RESECTION
Yes
PERTINENT LABORATORY FINDINGS
Elevated serum dopamine and norepinephrine
Case description
A 30-year-old patient was initially evaluated for palpitations, progressive unilateral hearing loss, and pulsatile tinnitus, and was found to have a catecholamine-secreting jugular paraganglioma ( Figure 10.49.1 ). Given the severely elevated catecholamines, the decision was made to proceed with surgical resection after pharmacological optimization of autonomic dysfunction. After preoperative embolization, the patient underwent a transmastoid transjugular approach to surgical resection with overclosure of the ear canal, resulting in an aggressive subtotal resection with preservation of the medial wall of the jugular bulb and normal postoperative cranial nerve function ( Figure 10.49.2 ). Catecholamine levels returned to normal within 3 weeks. The patient elected to undergo adjuvant stereotactic radiosurgery (SRS) treatment 5 months postoperatively for treatment of the residual tumor ( Figure 10.49.3 ).
Radiosurgery Machine
Gamma Knife
Radiosurgery Dose (Gy)
16 at the 50% isodose line
Number of Fractions
1
Figure 10.49.1.
Initial MRI 1 month prior to surgery: Axial T1-weighted image with gadolinium showing a brightly enhancing tumor involving the left jugular foramen and bulb with abutment of the carotid artery.
Figure 10.49.2.
A. Postoperative MRI 1 month prior to stereotactic radiosurgery (SRS): Axial T1-weighted image with gadolinium, fat saturated, showing that the medial wall of the jugular bulb continues to enhance along the foramen and carotid artery. B. Postoperative MRI 1 month prior to SRS: Coronal T1-weighted image with gadolinium, fat saturated.
Figure 10.49.3.
Imaging of the treatment plan. Yellow line, 16 Gy; green line, 8 Gy; pink line, cochlea outline.
Critical Structure
Dose Tolerance
Brainstem
15 Gy maximum point dose
Internal carotid artery in canal
Unknown dose tolerance
Cochlea
4 Gy maximum point dose (extrapolated from vestibular schwannoma literature)
Lower cranial nerves in foramen
Unknown dose tolerance
Only gold members can continue reading. Log In or Register to continue
Esthesioneuroblastoma – delayed postoperative radiosurgery for recurrence at long-term
Null cell – delayed postoperative radiosurgery for growing perioptic residual
Suprasellar non-small cell lung carcinoma metastasis – upfront radiosurgery
Chondrosarcoma – definitive radiosurgery after subtotal resections
Large vestibular schwannoma – delayed postoperative radiosurgery for growing residual
Trigeminal neuralgia due to petroclival meningioma – upfront radiosurgery
