In Response to Letter to the Editor Entitled, “The Role of Radiation in Tympanojugular Paragangliomas Needs to be Re-evaluated”

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In Reply: We would like to thank the authors for this letter to the editor regarding our study. The eminent authors of this letter have helped to establish the surgical standards within the skull base surgery field regarding the management of these tumors and we greatly value their comments. The authors raised the concern regarding the use of the term “glomus.” In spite of regional differences with use of these labels and the presence of two other recently published reports using this terminology (1,2), we agree that there is value in consistency with terminology. Histopathologically, these tumors are accurately described as paragangliomas. Additionally, the authors raised concern regarding the pretreatment growth characteristics. This is a limitation of our study and is an important consideration in skull base radiotherapy. A recent study demonstrated an 86% growth control in tumors that had demonstrated pretreatment growth (1); however, this area needs further research.
Secondly, the authors raised concern regarding the average length of the follow-up in this study, which was 27.6 months. We agree that this is a limitation of this study and we acknowledged this in the discussion section. The management of these tumors has primarily been surgical in the past and only recently has there been interest in single modality management thus long-term follow-up is limited. There are other similar recent reports with longer follow-up, 39.1 months (1) and 51.5 months (2), with similar tumor growth control rates.
Thirdly, the authors have suggested that surgical management be used as the primary treatment of these tumors. We agree that surgical management continues to be an excellent option. However, medical comorbidities may complicate surgical candidacy and radiation therapy can be considered as an alternative. Our manuscript does not diminish the role of surgical management but presents outcomes related to single modality radiotherapy. There is evidence of improved quality of life in patients with these tumors treated with radiotherapy alone compared with multimodality treatment (3).
Finally, the authors rightly raise concern regarding the possibility of radiation-induced malignant transformation. This must be taken into consideration and is considered a standard of care discussion point with patients considering radiotherapy. It is established that these tumors have higher spontaneous malignant degeneration rate compared with other benign skull base tumors (4). The unfortunate case presented by these authors illustrates this concern. Ongoing research is needed to fully inform our patients regarding evidenced-based treatment options that will improve outcomes and quality of life.

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