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Huang WP, Gao G, Chen Z, Qiu YK, Gao JB, Kang L. Multimodality Imaging Evaluation of Primary Right Atrial Paraganglioma: A Case Report and Literature Review. Front Med (Lausanne) 2022; 9:942558. [PMID: 35847796 PMCID: PMC9280297 DOI: 10.3389/fmed.2022.942558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundCardiac paraganglioma (CPGL) accounts for 1–3% of cardiac tumors and is usually benign. In total, 35–50% of CPGL lesions secrete catecholamines, causing hypertension, excessive sweating, palpitations, headache, and other symptoms. Preoperative imaging evaluation is important to determine the location of the cardiac mass, its blood supply vessels, and the relationship with surrounding structures. Multimodal imaging techniques combine with morphological and functional information to provide powerful methods for preoperative diagnosis and lesion localization. Furthermore, they can assist to reduce the incidence of intraoperative and postoperative complications and improve patient prognosis.Case ReportA 67-year-old woman suffered from paroxysmal palpitations with a heart rate of 110 beats per minute 1 month ago. Urine catecholamine and methoxyepinephrine levels were significantly increased. The patient had a 5-year history of hypertension with a maximum blood pressure of 160/100 mmHg. Computed tomography (CT) examination found a soft tissue mass in the right atrium with heterogeneous and significant enhancement, whose blood supply was from the left ileal branch artery. The patient then underwent cardiac magnetic resonance (CMR). The lesion showed inhomogeneous iso signals on the T1-weighted image (T1WI), slightly high signals on the T2 fat-suppression image, inhomogeneous high signals on the diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) images. The mass exhibited heterogeneous and significant enhancement on the first perfusion and delayed scans after intravenous contrast injection. However, abnormal signals were surprisingly found in the patient’s right lung, and the possibility of metastatic lesions could not be excluded. The patient underwent F-18 fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) to rule out metastatic lesions. A fluorodeoxyglucose (FDG)-avid soft tissue mass was shown in the right atrium, with the maximum standardized uptake value (SUVmax) at about 15.2, as well as a pathological intake of brown fat throughout the body. Combined with clinical symptoms, CPGL was considered without significant sign of metastasis in 18F-FDG PET/CT. Finally, the patient underwent surgical resection and the post-operative pathology confirmed a CPGL.ConclusionThe combination of 18F-FDG PET/CT with the CMR containing different image acquisition sequences provides a powerful aid for preoperative non-invasive diagnosis, localization, and staging of CPGL, which helps to reduce intraoperative and postoperative complications and improve patient prognosis.
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Affiliation(s)
- Wen-peng Huang
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, China
| | - Ge Gao
- Department of Radiology, Peking University First Hospital, Beijing, China
| | - Zhao Chen
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, China
| | - Yong-kang Qiu
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, China
| | - Jian-bo Gao
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Kang
- Department of Nuclear Medicine, Peking University First Hospital, Beijing, China
- *Correspondence: Lei Kang,
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Marthy AG, Smith N, Samy S, Britton L, Fabian T, Scott W. Robotic approach to a subcarinal functional paraganglioma. Respir Med Case Rep 2020; 30:101092. [PMID: 32528840 PMCID: PMC7283145 DOI: 10.1016/j.rmcr.2020.101092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 11/19/2022] Open
Abstract
Intro Functional mediastinal paragangliomas arise from extra-adrenal tissues and are rare. These cases create challenges related to diagnosis, peri-operative management, and surgical management. We present a case that demonstrates a planned robot-assisted thoracoscopic resection of a mediastinal paraganglioma that ultimately required a trans-sternal resection of the tumor off the left atrium. Case report Our patient is a 42-year-old male with a prolonged history of refractory hypertension, palpitations, headaches, and diaphoresis, which led to the discovery of a subcarinal functional mediastinal paraganglioma. The patient was brought to the operating room for a right robotic-assisted thoracoscopic subcarinal dissection with attempted resection of the mass. Subsequently, the patient's paraganglioma was successfully resected off the left atrium using a trans-sternal approach, cardiopulmonary bypass, and cardioplegic arrest. He was successfully transitioned to minimal anti-hypertensive medication post-operatively. Discussion Pheochromocytomas are neural-crest derived tumors that typically arise from the adrenal medulla. Rarely, paragangliomas arise in the thoracic cavity, at an approximate incidence of 2%. Our sequential approach offered the potential for a minimally invasive resection, and though initially unsuccessful, safely elucidated the feasibility of resection using cardiopulmonary bypass after confirming no invasion of the airway, esophagus, or other mediastinal structures.
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Affiliation(s)
- Andrew G. Marthy
- Department of Surgery – General Surgery Resident, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA
- Corresponding author.
| | - Nathan Smith
- Department of Surgery - Fellow, Division of Thoracic Surgery, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Sanjay Samy
- Department of Surgery, Division of Adult Cardiac Surgery, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Lewis Britton
- Department of Surgery, Division of Adult Cardiac Surgery, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Thomas Fabian
- Department of Surgery, Division of Thoracic Surgery, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Walter Scott
- Department of Surgery, Division of Thoracic Surgery, Albany Medical College, 47 New Scotland Ave, Albany, NY, 12208, USA
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Rotolo N, Imperatori A, Bacuzzi A, Conti V, Castiglioni M, Dominioni L. Management of hypertension in intrapericardial paraganglioma. Int J Hypertens 2014; 2014:812598. [PMID: 24688789 PMCID: PMC3943413 DOI: 10.1155/2014/812598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 01/07/2014] [Indexed: 12/24/2022] Open
Abstract
Functioning paraganglioma is extra-adrenal catecholamine-secreting tumours that may cause secondary hypertension. Primary intrapericardial paragangliomas are very rare and are located adjacent to the great vessels or heart, typically near the left atrium. These tumours are an exceptionally uncommon finding during the investigation of refractory hypertension. However, in recent years, intrapericardial paragangliomas have been diagnosed incidentally with increased frequency, due to the extensive use of radiologic chest imaging. The mainstay of treatment of functioning intrapericardial paraganglioma is surgical removal, which usually achieves blood pressure normalization. Due to the locations of these tumours, the surgical approach is through a median sternotomy or posterolateral thoracotomy, and manipulation-induced catecholamine release may cause paroxysmal hypertension. Typically in these patients, blood pressure fluctuates dramatically intra- and post-operatively, increasing the risk of cardiovascular complications. We review here the current modalities of perioperative fluid and hypotensive drug administration in the setting of surgery for functioning intrapericardial paraganglioma and discuss the recently proposed paradigm shift that omits preoperative preparation.
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Affiliation(s)
- Nicola Rotolo
- Center for Thoracic Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy
| | - Andrea Imperatori
- Center for Thoracic Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy
| | - Alessandro Bacuzzi
- Department of Anaesthesiology, Ospedale di Circolo, Via Guicciardini 9, 21100 Varese, Italy
| | - Valentina Conti
- Center for Thoracic Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy
| | - Massimo Castiglioni
- Center for Thoracic Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy
| | - Lorenzo Dominioni
- Center for Thoracic Surgery, Department of Surgical and Morphological Sciences, University of Insubria, Via Guicciardini 9, 21100 Varese, Italy
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Cardiac paraganglioma: Clinical presentation, diagnostic approach and factors affecting short and long-term outcomes. Int J Cardiol 2013; 166:315-20. [DOI: 10.1016/j.ijcard.2012.04.158] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 04/23/2012] [Accepted: 04/28/2012] [Indexed: 11/18/2022]
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Marshall L, Shah P, Yeung S, Mundy J. Synchronous presentation of cardiac and abdominal paragangliomas. Ann Thorac Surg 2012; 93:e115-7. [PMID: 22541232 DOI: 10.1016/j.athoracsur.2011.11.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 11/07/2011] [Accepted: 11/28/2011] [Indexed: 12/24/2022]
Abstract
A 28-year-old male presenting with a hypertensive crisis was found to have synchronous right atrial and retrocaval masses. Serum normetadrenaline was elevated in keeping with functional paragangliomas. After preoperative optimization both masses were successfully excised, including a saphenous vein graft to the right coronary artery. Serum catecholamines returned to the normal range postoperatively and all antihypertensive therapy was ceased.
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Affiliation(s)
- Lachlan Marshall
- Department of Cardiothoracic Surgery, Princess Alexandra Hospital, Woolloongabba, Brisbane, Australia.
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Li L, Zhu W, Fang L, Zeng Z, Miao Q, Zhang C, Fang Q. Transthoracic echocardiographic features of cardiac pheochromocytoma: a single-institution experience. Echocardiography 2011; 29:153-7. [PMID: 22066682 DOI: 10.1111/j.1540-8175.2011.01556.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Cardiac pheochromocytoma is extremely rare. Previous papers usually are reports of a single case. Transthoracic echocardiography (TTE) offers a useful option, but the features of cardiac pheochromocytoma on TTE have not been favorably reported. In this study, the findings of cardiac pheochromocytoma on TTE in nine cases were presented. METHODS TTE images (especially two-dimensional ultrasound) of nine patients with cardiac pheochromocytomas were analyzed retrospectively and compared with the findings from surgery. RESULTS Among the nine patients with cardiac pheochromocytomas identified in Peking Union Medical College Hospital (PUMCH) clinical and echocardiographic database, TTE identified one cardiac tumor in seven cases (77.8%), two cardiac tumors in one case (11.1%), and a false-negative result in another (11.1%). Cardiac pheochromocytomas were usually located on the base of the heart, near the origin of great arteries. The tumors were usually round or ovoid, ranging from 1.4 cm to 7.7 cm in diameter, with homogeneous and moderate echoes and low activity. They could press or invade surrounding cardiac structures and influence hemodynamics. In this study the majority of cardiac pheochromocytoma seemed marginated and appeared to be encapsulated on TTE. Apical four-chamber view and parasternal short-axis view of the aortic valve were most effective in identifying cardiac pheochromocytomas. The findings on TTE were similar to those from surgical procedures. CONCLUSION Cardiac pheochromocytomas presented characteristic TTE appearances in aspect of location, size, texture, and shape of tumors. Understanding of these characteristics on TTE can help correctly recognize this extremely rare disease.
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Affiliation(s)
- Ling Li
- Department of Cardiology, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Vaughan P, Pabla L, Hobin D, Barron DJ, Parikh D. Cardiac paraganglioma and gastrointestinal stromal tumor: a pediatric case of Carney-Stratakis syndrome. Ann Thorac Surg 2011; 92:1877-8. [PMID: 22051283 DOI: 10.1016/j.athoracsur.2011.03.123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 02/16/2011] [Accepted: 03/21/2011] [Indexed: 11/28/2022]
Abstract
The eponymous Carney triad reported the association of gastric leiomyosarcoma, also known as a gastrointestinal stromal tumor, extra-adrenal paraganglioma and pulmonary chondromata. Subsequently, Carney and Stratakis distinguished the inherited gastrointestinal stromal tumor with paraganglioma syndrome from the classical Carney Triad as an autosomal dominant condition in adult patients. This combination of gastrointestinal stromal tumor and cardiac paragangliomata in a child is almost unique.
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Affiliation(s)
- Paul Vaughan
- Department of Cardiothoracic Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom.
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Mediastinal Paragangliomas: The Mayo Clinic Experience. Ann Thorac Surg 2008; 86:946-51. [PMID: 18721588 DOI: 10.1016/j.athoracsur.2008.04.105] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 04/26/2008] [Accepted: 04/29/2008] [Indexed: 11/23/2022]
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Goldsby RE, Fitzgerald PA. Meta[131I]iodobenzylguanidine therapy for patients with metastatic and unresectable pheochromocytoma and paraganglioma. Nucl Med Biol 2008. [DOI: 10.1016/j.nucmedbio.2008.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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