Successful perioperative management of a middle mediastinal paraganglioma

Middle mediastinal paraganglioma enclosing the left anterior descending artery: A case report

RATIONALE

Paragangliomas are extremely rare neuroendocrine tumors arising from ganglia. These tumors are barely found in the middle mediastinum.

PATIENT CONCERNS

A 31-year-old male patient was admitted to our hospital for treatment of an middle mediastinal tumor which was found incidentally on echocardiography during a medical checkup. Contrast-enhanced chest computed tomography (CT) demonstrated a well-defined hypervascularized heterogeneous mass located in the middle mediastinum. The tumor showed strong 18F-fluorodeoxyglucose (FDG) activity on positron emission tomography-computed tomography (PET-CT).

DIAGNOSIS

Before the surgery, we presumed the mass was an angiogenic or neurogenic tumor. As a result, the histological features favored a diagnosis of paraganglioma.

INTERVENTIONS

The tumor was completely removed by anterior thoracotomy, along with the proximal segment of the left anterior descending artery (LAD), and coronary artery bypass grafting (CABG) was performed immediately after the tumor excision.

OUTCOMES

The patient had an uneventful recovery. The patient did well in the postoperative follow-up without any complications and signs of recurrence at 3 months, 1 year, 2 year and 4 year.

LESSONS

This report can increase the confidence in surgeries of mediastinal paragangliomas adhering tightly the adjacent structures.

Pulmonary artery transection for resection of a middle mediastinal paraganglioma

We report the case of a 65‐year‐old male patient who presented with chest pain and was found to have a mediastinal paraganglioma between the left atrium and main pulmonary artery. This is the first reported case of a mediastinal paraganglioma resection utilization transection of the main pulmonary artery.

Diaphragmatic paraganglioma protruding into the right thoracic cavity

Paragangliomas in the diaphragm are extremely rare. We report the case of a 27‐year‐old woman with a nonfunctioning paraganglioma protruding superiorly from the right diaphragm. The patient underwent an anterior thoracotomy, and a supradiaphragmatic tumor (70 mm in diameter), which compressed the inferior vena cava and the right hepatic vein, was completely resected by combined partial resection of the right diaphragm and pericardium. To our knowledge, this is the first report of a paraganglioma situated both on the diaphragm and close to the inferior vena cava and hepatic vein.

Key points

Highly Symptomatic Progressing Cardiac Paraganglioma With Intracardiac Extension Treated With 177Lu-DOTATATE: A Case Report

INTRODUCTION

Primary cardiac paragangliomas are rare tumors. Metastatic disease is even rarer. Surgical management is technically challenging, and sometimes even impossible. Available therapeutic modalities for metastatic disease include external beam radiation therapy as well as systemic treatments, namely ¹³¹I-MIBG and more recently, peptide receptor radionuclide therapy (PRRT) with ¹⁷⁷Lu-DOTATATE. To our knowledge, this is the first case of progressive unresectable cardiac paraganglioma with intracardiac extension treated with dosimetry based personalized PRRT to be reported. This case is of particular interest since it documents for the first time the efficacy, and especially the safety of the ¹⁷⁷Lu-DOTATATE PRRT in this precarious context for which therapeutic options are limited.

CASE PRESENTATION

A 47-year-old man with no medical history consulted for rapidly decreasing exercise tolerance. The investigation demonstrated an unresectable progressing metastatic cardiac paraganglioma with intracardiac extension. The patient was treated with personalized ¹⁷⁷Lu-DOTATATE PRRT and showed complete symptomatic and partial anatomical responses, with a progression-free survival of 13 months.

CONCLUSIONS

PRRT with ¹⁷⁷Lu-DOTATATE should be considered for inoperable cardiac paraganglioma. No major hemodynamic complications were experienced. Therapy resulted in safety and substantially improved quality of life.

Pulmonary and mediastinal paragangliomas: rare endothoracic malignancies with challenging diagnosis and treatment

Background

Pulmonary and mediastinal paragangliomas are rare tumors that may have neuroendocrine activity or be non-functional, incidental, in asymptomatic patients, or causing mass effect symptoms. Although being low-grade tumors, they can display an aggressive behaviour, developing local infiltration and distant metastases. We report our experience with three endothoracic paragangliomas and a Literature review, to point out diagnostic difficulties and problems related to surgical treatment.

Methods

From 2009 to 2017, we treated 3 patients with histological diagnosis of paraganglioma: 2 pulmonary, 1 mediastinal. No one presented catecholamine-secreting syndromes; pulmonary cases were asymptomatic, while the mediastinal one had aspecific cough and dyspnea. Imaging diagnosis was based on chest computerized tomography (CT) and magnetic resonance imaging (MRI) scan. No patient had preoperative histological diagnosis. Intraoperative pathological examination was suggestive for malignancy: in pulmonary cases, wedge resection and lobectomy were performed; the middle mediastinal mass was completely removed after challenging dissection, isolation and section of numerous vascular pedicles.

Results

Postoperative course was uneventful in all cases. No patient received adjuvant treatments. At a median follow-up of 47 months (range, 6-102 months), two patients are alive, without local or distant recurrence; one patient died 6 months after surgery, due to disease progression.

Conclusions

Endothoracic paragangliomas, rare and often asymptomatic tumors, are of difficult diagnosis and should be considered malignant tumors, due to the potential aggressive behaviour of cases with high mitotic index and the frequent possibility of recurrence and metastases. Surgical resection is the treatment of choice and careful intraoperative manipulation is recommended, due to the high vascularity of these tumors, to prevent complications. After complete excision, long-term prognosis is generally good. However, even after surgical removal, a close, periodical and life-long follow-up is mandatory.

Robotic resection of a middle mediastinal mass

Aorto-pulmonary paraganglioma is an exceptionally rare condition, and its diagnosis and treatment are a challenge for the general thoracic surgeon. We describe the case of a 35 years old man who was incidentally diagnosed with a visceral mediastinal mass, deeply encased in the aorto-pulmonary window. To our knowledge this is the first case of its kind to be successfully treated with the adoption of a minimally invasive technique. We conclude that the dissection was made easier by the robotic instrumentation and by the camera system, and a minimally invasive approach would have been more difficult by traditional thoracoscopy.

Mediastinal Paraganglioma

Paragangliomas of the mediastinum are rare, with only approximately 150 cases reported in the literature. Surgical excision is the treatment of choice; however, these tumors often lie near critical vascular structures. Here we present the case of a patient with a mediastinal paraganglioma discovered during a diagnostic procedure.

Asymptomatic but functional paraganglioma of the posterior mediastinum

A 72-year-old woman was referred to our hospital because of a posterior mediastinal tumor. On the basis of detailed imaging tests, including (123)I-metaiodobenzylguanidine single photon emission computed tomography-computed tomography, and elevated values of catecholamines in the plasma and urine, the tumor was diagnosed as a functional mediastinal paraganglioma even in the absence of symptoms. After preoperative blood pressure control, surgical resection was performed. During the operation, the systemic blood pressure increased transiently as a result of surgical manipulation of the tumor. Soon after the tumor was removed, the patient conversely experienced hypotension. The postoperative course was uneventful, and pathologic diagnosis revealed a paraganglioma.

Superior mediastinal paraganglioma associated with von Hippel-Lindau syndrome: report of a case

Extra-adrenal pheochromocytomas are termed paragangliomas. Paragangliomas in the mediastinum, especially the superior mediastinum, are extremely rare. It is known that paragangliomas or pheochromocytomas occur in combination with von Hippel-Lindau syndrome. We present the case of a non-functional superior mediastinal paraganglioma in a patient with von Hippel-Lindau syndrome, without a familial history suggestive of the condition. This case highlights that we should be aware of possible sporadic von Hippel-Lindau syndrome in patients with a mediastinal paraganglioma.

Resection of an intrapericardial paraganglioma under cardiopulmonary bypass

We describe the case of a 52-year-old woman with a non-functional middle mediastinal paraganglioma. Radiologic diagnosis of paraganglioma was confirmed by multidetector computed tomography and (18)F-fluorodeoxyglucose positron-emission tomography, without biopsy. Surgical resection was performed via a median sternotomy, and cardiopulmonary bypass was required for complete resection of the tumor because of invasion to the intrapericardial pulmonary artery. Preoperative pathological diagnosis of mediastinal paraganglioma by biopsy is dangerous due to bleeding, and should be avoided.

Successful resection of a huge paraganglioma utilizing cardiopulmonary bypass

A 54-year-old woman was diagnosed with a large paraganglioma in the left paraaortic area, extending into the aortopulmonary window and up to a right-sided superior vena cava. The tumor was treated with repeated embolizations that failed to reduce its size. Complete surgical excision was achieved utilizing cardiopulmonary bypass. The patient made a full recovery.

Glomus caroticum tumors: A case report of an operated giant carotid body tumor with a review of our experience in 47 patients

Glomus caroticum tumors, usually used as an alternative term for carotid body tumor, are of neuroectodermal origin and a part of the extra adrenal neuroendocrine system pathologies. These abnormalities are the most frequently detected paraganglioma in the localization of the head and neck. In our report, we present a giant tumor mass on the left side which was operated on successfully with a review of our experience retrospectively. Between the dates of June 1995 and October 2009, 47 patients, all of which had a glomus caroticum tumor, underwent to surgery. Tumor presented a wide variety of size and clinical presentations.