Extra-adrenal paragangliomas of the retroperitoneum: A clinicopathologic study of 12 tumors

Non‑functional paraganglioma: A case report

Paraganglioma (PGL) usually presents as the elevation of blood pressure and metabolic changes in patients, and its common symptoms are persistent or paroxysmal hypertension. However, some patients have no typical clinical symptoms, such as patients with non-functional PGL. Therefore, the present study reviewed the literature and summarized the present rare case to provide more accurate and in-depth help for clinical diagnosis and comprehensive treatment. The case was a 64-year-old female with epigastrium malaise for 1 year and aggravation for 7 days. Contrast-enhanced CT revealed that the soft tissue of the irregular mass was in the front of the kidney on the right abdomen with a clear boundary and the size was ~6.5x5.4x6.6 cm. Large vessels were observed in the interior and edge of the lesion. The present study prepared for retroperitoneal tumour resection according to the diagnosis of PGL. After the operation, the patient recovered smoothly and was discharged from the hospital. As of March 2023, the general condition of the patient is good.

Functional retroperitoneal paraganglioma invading the inferior vena cava in the elderly, a case report and literature review

INTRODUCTION AND IMPORTANCE

Phaeochromocytomas and paragangliomas are rare neuroendocrine neoplasms that grow outside the adrenal gland and arise from the primitive neural crest cells. The retroperitoneal location is extremely rare with an incidence of 2-8 per million.

CASE PRESENTATION

Here we report a case of an 80 years old man presenting with abdominal pain and vomiting associated with hypertensive peaks and weight loss. CT scan showed a retroperitoneal para-aortic tumor invading the inferior vena cava, with significantly elevated urinary catecholamine levels. Histopathological and immunohistochemistry examinations confirmed the diagnosis of paraganglioma. A medical preparation by alpha-blockers was performed. Complete resection of the tumor with the reconstruction of the vena cava was achieved without postoperative complications. After surgery, blood pressure and HbA1c were on the targets and the urinary catecholamine levels were normal.

CLINICAL DISCUSSION

The diagnosis of paragangliomas is suspected by clinical symptoms in the case of functional paragangliomas and the confirmation is biological by the plasmatic or urinary catecholamines. Non-functional paragangliomas often represent a diagnostic challenge. In our case, the large size, the location of the tumor, and the invasion of adjacent structures represented a surgical challenge to perform a complete resection.

CONCLUSION

In the elderly, this pathology is quite uncommon. Retroperitoneal paraganglioma is a rare location of this type of tumor. Endocrinologists, surgeons, and anesthesiologists should work together to ensure an appropriate diagnosis and treatment of paraganglioma. The gold standard treatment is the complete resection after a medical preparation.

Non-Functional Yet Terminal: A Case of Asymptomatic Retroperitoneal Paraganglioma With Distant Metastasis

Retroperitoneal paraganglioma remains an extremely rare type of tumor that arises from either sympathetic or parasympathetic neural crest cells. It could be functional or non-functional. Non-functional paraganglioma may present as a diagnostic challenge since patients are usually asymptomatic and tend to present to the hospital with complications from the invasion of the tumor. Malignancy is usually determined by the degree of metastasis. The gold standard of diagnosis is biopsy and obtaining a sample for histological examination. This author presents a case of asymptomatic, non-functional retroperitoneal paraganglioma with distant metastasis.

Pancreatic paraganglioma with multiple lymph node metastases found by spectral computed tomography: A case report and review of the literature

BACKGROUND

Primary pancreatic paraganglioma is exceedingly rare. Most patients with pancreatic paraganglioma lack a typical clinical presentation, and the tumor is difficult to accurately differentiate from other pancreatic neuroendocrine tumors, making the misdiagnosis rate extremely high. Surgical excision is the primary treatment modality but is considered high risk. Because of its rich vascularity, the tumor easily bleeds during surgery, especially malignant paragangliomas invading large blood vessels. Thus, a thorough preoperative evaluation of the tumor is necessary. Here, we report a primary malignant pancreatic paraganglioma, the second such case in a young patient that was successfully resected surgically.

CASE SUMMARY

A 26-year-old female patient was admitted to the hospital with unexplained abdominal pain. Dual-layer spectral-detector computed tomography (DLCT) revealed a mixed density mass in the pancreatic body and tail. The patient was transferred to our hospital after previous failed surgical resection at other hospitals. The patient and her family strongly desired surgery. After a thorough preoperative evaluation and adequate preparation, a large mass with the greatest dimension of 8.0 cm was successfully resected. The final pathological diagnosis was malignant paraganglioma. The patient was discharged in good condition 2 wk postoperatively.

CONCLUSION

The rare malignant pancreatic paraganglioma reported here was difficult to diagnose preoperatively. Early filling of the draining vein may be a crucial diagnostic imaging feature. DLCT can provide more precise information for surgical resection through dual-energy imaging.

Unusually large paraganglioma complicated with successive catecholamine crises: A case report and review of the literature

Background

Paragangliomas are rare neuroendocrine tumors that could secret catecholamines. Hypertension and heart failure caused by the catecholamine crisis are fatal cardiovascular events. However, silent paragangliomas that lack typical symptoms of catecholamine pose a significant diagnostic challenge.

Case summary

A 45-year-old woman who presented with more than 1-year history of abdominal discomfort was suspected of having a gastrointestinal stromal tumor by a local hospital since a vast metastatic mass occupied her left abdomen. Thus, she was recommended to our hospital. After completing the gastroscopy, she unexpectedly developed acute heart failure and was transferred to the Intensive Care Unit (ICU) where the initial diagnosis of paraganglioma was considered through path. However, a second catecholamine crisis due to constipation led to acute heart failure again. After anti-heart failure therapy and rigorous preoperative preparation, surgery was arranged to remove the tumor. Postoperative pathology confirmed the paraganglioma, and the patient was discharged from the hospital in good condition.

Conclusion

We reported a rare case of huge retro-peritoneal paraganglioma with successive catecholamine crises and acute heart failure. This was probably the largest retro-peritoneal paraganglioma since the 1980s. Besides, we were the first to use surgical drawing to illustrate its complex anatomical adjacent relationship of retro-peritoneal paraganglioma. Our case emphasizes the inclusion of extra-adrenal paraganglioma in the differential diagnosis of retroperitoneal tumors. In suspected paragangliomas, catecholamine testing is preferable to invasive procedures including gastroscopy and biopsy to avoid triggering a catecholamine crisis. Surgical resection is the primary treatment. We highlight the priority of dealing with the venous reflux branches of the tumor to prevent the release of catecholamines into the blood. In particular, preoperative preparation plays a vital role in managing paraganglioma. Moreover, it is necessary to schedule genetic testing and clinical follow-up due to the metastatic potential of paragangliomas.

Extra-adrenal paraganglioma of a urinary bladder in an adolescent male: A rare case report

Introduction and importance

Paraganglioma of the urinary bladder is unusual and reported rarely. The patient usually presents with the complaint of hematuria and fluctuating blood pressure.

Case presentation

We discuss the case of a 21-year old male, who had been experiencing gross hematuria, was found to have a mass on ultrasonography. Further evaluation with contrast-enhanced computerized tomography (CECT) revealed an irregular soft tissue density of endophytic mass arising from the left posterior wall of the urinary bladder. The histopathological examination of the excised mass was suggestive of a tumor of neural origin, which was further confirmed as paraganglioma by immunohistochemistry.

Clinical discussion

Imaging prior to the surgery must be done for a provisional diagnosis of paraganglioma to avoid fluctuating blood pressure during elective surgery. On histopathological examination tumor cells are arranged in the nest like fashion forming a specific ‘Zellballen’ pattern. Positive staining for synaptophysin and chromogranin in immunohistochemistry confirms the diagnosis.

Conclusion

It is difficult to diagnose paraganglioma of the urinary bladder with the aid of imaging only, particularly if the patient presents without specific symptoms of fluctuating blood pressure. So, a multidisciplinary approach is essential for the diagnosis and proper therapy of this entity. However, prompt surgical resection is the mainstay of treatment.

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Paraganglioma of the urinary bladder is a rare tumor.

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It is suspected if the patient presents with fluctuating blood pressure during micturition and imaging shows a mass.

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Histopathological examination and immunohistochemical studies of the lesion aid in reaching a definitive diagnosis.

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Surgical resection is the mainstay of treatment.

Pancreatic paraganglioma diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report and review of literature

BACKGROUND

Pancreatic paragangliomas (PPGL) are rare benign neuroendocrine neoplasms but malignancy can occur. PPGL are often misdiagnosed as pancreatic neuroendocrine tumor or pancreatic adenocarcinoma.

CASE SUMMARY

We reviewed 47 case reports of PPGL published in PubMed to date. Fifteen patients (15/47) with PPGL underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Only six (6/15) were correctly diagnosed as PPGL. All patients with PPGL underwent surgical resection except three (one patient surgery was aborted because of hypertensive crisis, two patients had metastasis or involvement of major vessels). Our patient remained on close surveillance as she was asymptomatic.

CONCLUSION

Accurate preoperative diagnosis of PPGL can be safely achieved by EUS-FNA with immunohistochemistry. Multidisciplinary team approach should be considered to bring the optimal results in the management of PPGL.

Pancreatic/peripancreatic neurogenic tumor; little known masses not to be missed

BACKGROUND

Retroperitoneal neurogenic tumors are extremely rare pathological entities; therefore, few clinical features and natural courses, especially originating from the pancreatic/peripancreatic regions, have been reported. This study aimed to investigate the clinicopathological features of pancreatic and peripancreatic neurogenic tumors and assess the diagnostic value of computed tomography (CT) and endoscopic ultrasound-guided fine needle biopsy (EUS-FNB).

METHODS

Between 2006 and 2018, patients who were diagnosed with neurogenic tumors were included. In total, 90 histologically confirmed cases of neurogenic tumors located in the pancreatic/peripancreatic regions were selected for analysis.

RESULTS

The mean age was 49.2 ± 13.1 years. There were no differences in sex distribution of the tumors. Schwannomas (44.4%) and paragangliomas (41.1%) were the most common neurogenic tumors. The sensitivity of CT was 62.2% in 90 cases. EUS-FNB was performed in 30 cases and the sensitivity of it was 83.3%. The diagnosis of neurogenic tumors with EUS-FNB or CT was not significantly associated with tumor location and size. Surgical resection was performed in 78 cases. Of the 12 patients who did not undergo surgery, 10 cases were followed-up without any increase in tumor size.

CONCLUSIONS

Through the present study, we verified radiological, pathological, and clinical aspects of the pancreatic/peripancreatic neurogenic tumors which little known before, therefore, this study can serve as the basis for research to present an optimal diagnosis and treatment of neurogenic tumors. In addition, EUS-FNB is useful in the diagnosis of pancreatic/peripancreatic neurogenic tumors with relatively high sensitivity and can help establish therapeutic plans before the surgery.

Abdominal paraaortic paraganglioma: Management of intraoperative hemodynamic emergencies during elective resection procedures (A case presentation)

Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.

Abdominal Ultrasound in the Detection of an Incidental Paraganglioma

Paraganglioma is a tumor that originates from neuroendocrine cells of the sympathetic or parasympathetic systems. Patients may suffer from headaches, palpitations, diaphoresis, and hypertension due to catecholamine excess or symptoms from the mass effect of the tumor. In the absence of typical symptoms of catecholamine excess, the diagnosis of a nonfunctional paraganglioma is often delayed. Herein, we report a case of a 63-year-old female patient with a nonfunctional paraganglioma which is an accidental finding during investigation of a fever. Abdominal ultrasonography incidentally detected this lesion as a complex, solid, cystic mass in the left suprarenal retroperitoneum.

Non-functioning retroperitoneal abdominal schwannoma

There are less than 150 cases of non-functioning retroperitoneal abdominal schwannoma (NRS) reported. Hormonal assay is crucial in confirming the diagnosis of NRS, as manipulation of a functional retroperitoneal paraganglioma will instigate an abrupt liberation of catecholamines, resulting in devastating consequences. We report the case of 42-year-old woman who presented with headache, night sweats and abdominal discomfort. Cross-sectional imaging demonstrated a retroperitoneal mass adherent to the aorta and inferior vena cava but biochemical testing of blood and urine was negative for metanephrines and normetanephrines. She underwent successful tumour resection via laparotomy, as location increased the complexity and risk of laparoscopic resection.

Paraganglioma presenting as a mesenteric cystic mass: A case report

The present study aims to raise awareness about the necessity of a thorough differential diagnosis process when diagnosing paraganglioma as it is an extremely rare entity with a high malignant potential. A 64-year-old female patient was admitted to the hospital with symptoms of bowel obstruction and a palpable abdominal mass. Abdominal and pelvic computed tomography revealed a cystic heterogeneously enhanced mass. The tumor was surgically removed and then microscopically analysed. Microscopically, the mass was composed of nests of small polygonal and round cells with central vesicular nuclei, consistent with the diagnosis of mesenteric paraganglioma which was later confirmed by immunohistochemistry. The critical markers for paragangliomas, namely chromogranin A and S100, should be used as the first step in diagnosis, followed by other valuable immunohistochemical markers. A long-term follow-up is extremely important following the diagnosis of paraganglioma as all these tumors have a malignant potential.

Laparoscopic Resection of Subclinical Functioning Para-aortic Paraganglioma

Introduction:

Extra-adrenal pheochromocytomas (paragangliomas) are neuroendocrine tumors derived from extra-adrenal chromaffin cells. Although laparoscopic resection of adrenal pheochromocytomas is a common procedure, there are few reports of the use of this approach in extra-adrenal para-aortic paragangliomas. Here, we report the case of a patient with a subclinical functioning para-aortic paraganglioma that was successfully resected laparoscopically.

Case presentation:

A 58-year-old man was referred to our department for treatment of a para-aortic tumor after endoscopic submucosal dissection of early-stage colorectal cancer. Positron emission tomography-computed tomography showed abnormal accumulation by the para-aortic tumor. During its laparoscopic resection, the patient's blood pressure unexpectedly rose to over 180 mmHg, which suggested that the tumor was a paraganglioma. The diagnosis was confirmed by immunohistochemical staining, which showed chromogranin-positive cells forming a Zellballen pattern. The operation was successfully completed, and the patient's postoperative course was uneventful.

Conclusion:

Laparoscopic resection may be a suitable procedure for the treatment of retroperitoneal paraganglioma.

Diagnosis and surgical treatment of retroperitoneal paraganglioma: A single-institution experience of 34 cases

The present study aimed at identifying the clinical, radiological and pathological characteristics of retroperitoneal paragangliomas, and determining the association between the tumor features and the prognosis of patients following surgery. A total of 34 patients with retroperitoneal paragangliomas, who underwent resection between November 1999 and December 2015, were included in the present retrospective study. The patients' demographics, clinical symptoms and signs, tumor functional status, surgical procedure, intraoperative results, tumor pathology, radiological results, and postoperative survival time were recorded and analyzed. Of the 34 patients, the most common type of presenting symptom was abdominal mass (46%), followed by hypertension (39%) and abdominal pain (32%). Functional tumors occurred in 20 patients (59%). Computed tomography (CT) and magnetic resonance imaging revealed soft-tissue masses, with marked enhancement in the arterial phase, indicative of retroperitoneal paragangliomas. The preoperative CT diagnostic accuracy rate between 2010 and 2015 was markedly improved, compared with that between 1999 and 2009. The tumors were primarily located close to the renal arteries and veins surrounding the abdominal aorta and inferior vena cava. With the exception of one malignant paraganglioma, the majority of paragangliomas were positive for chromogranin A, S-100 protein, vimentin and heat-shock protein 90, and exhibited decreased expression of Ki-67 antigen and insulin-like growth factor 2. All tumors were completely removed by surgery. Distant metastasis, but not tumor size, functional status and local invasion, was markedly associated with survival. The preoperative diagnostic accuracy rate of retroperitoneal paragangliomas may be improved by focusing on the predilection sites and CT characteristics. In addition, immunohistochemical markers were useful to determine tumor malignancy. Complete surgical resection was appropriate for all patients and postoperative survival time was identified to be associated with tumor metastasis.

Clinical characteristics and surgical treatment of spinal paraganglioma: A case series of 18 patients

BACKGROUND AND OBJECTIVES

Paraganglioma rarely develops in the spine. With few cases reported, little knowledge about this disease was known. The objective of this study is to illustrate the clinical features, imaging manifestations, pathological appearances and long-term outcomes of the consecutive surgeries by literature review.

METHODS

The clinical and follow-up data of 18 patients who were diagnosed of spinal paraganglioma and treated with surgeries in our hospitals from 2003 to 2014 were retrospectively analyzed.

RESULT

A total of fourteen patients radiographed of intra-spinal tumor underwent extra-capsular tumor resection. Of five patients with obvious vertebral bone damage, four cases underwent piecemeal resection, and the left one with sacral tumor underwent en bloc tumor excision. Spinal reconstruction was performed in all cases. Follow-up lasted for 16-96 months (44.1 months on average). There was no local recurrence or distant metastasis in cases without obvious bone invasion. Of those five cases with vertebral bone damage, one case suffered and survived from the repeat relapse of T1 vertebral body tumor. Local recurrence was not observed in one case with T10 vertebral tumor after tumor resection, but the tumor metastasized to T2 attachment during the follow-up and was finally eradicated by re-operation. No tumor recurrence was observed in the left three cases.

CONCLUSION

Paraganglioma, usually benign, rarely occurs. Surgical resection, especially complete surgical resection, is preferred to treat spinal paraganglioma. Chemotherapy, radiotherapy, use of octreotide and other somatostatin are selected as adjuvant therapies, but their effects remain unknown.

Leptomeningeal dissemination of a low-grade lumbar paraganglioma: case report

Leptomeningeal dissemination of paraganglioma is rare, with only 2 prior cases in the literature. The authors present the case of a metastatic low-grade lumbar paraganglioma via leptomeningeal dissemination. This report emphasizes the utility of 3,4-dihydroxy-6-¹⁸F-fluoro-l-phenylalanine (¹⁸F-FDOPA) PET scanning for diagnosis, as well as the combination of radiation therapy and alkylating chemotherapeutic agents for the treatment of this rare phenomenon. The patient was a 61-year-old woman who presented with low-back pain and was found to have an isolated L-3 intrathecal tumor on MRI. Sixteen months after gross-total en bloc resection of the paraganglioma, the patient again became symptomatic with new neurological symptoms. MRI findings revealed enhancing leptomeningeal nodules throughout the spine. ¹⁸F-FDOPA PET/CT scanning was used to confirm the diagnosis of disseminated paraganglioma. Intrathecal thiotepa, radiation therapy, and systemic therapy with capecitabine and temozolomide have been used sequentially over a 2-year period, with each able to stabilize tumor growth for several months. The authors also summarize the 2 other reports of leptomeningeal dissemination of paragangliomas in the literature and compare the course and management of the 3 cases.

Extraadrenal Retroperitoneal Paraganglioma with Osseous Metaplasia

We report a case of extraadrenal retroperitoneal paraganglioma in a 24-year-old female. This case is unusual in that the neoplasm showed extensive calcification, osseous metaplasia, and marrow elements. Although calcification may occur in paragangliomas, to the best of our knowledge, osseous metaplasia with marrow elements have not been previously reported in the English literature. Int J Surg Pathol 4(3):00-00, 1997

Paragangliomas

Eleven Chinese patients with paragangliomas were studied to evaluate the clinicopath ological features in detail. Their age ranged from 19 to 68 years with a mean of 41.7 years. Carotid body paragangliomas were the most common, followed by jugulotym panic paragangliomas. The patients with carotid body tumors were younger than the other patients in the group (eg, those with retroperitoneal paragangliomas). Retroperi toneum tumors were typically larger (the largest one was 8 cm in diameter), while tumors in the middle ears were smaller (0.5 to 1 cm in diameter). All the paraganglio mas were tested by a panel of panneuroendocrine markers (neuron-specific enolase, synaptophysin, and chromogranin), and they all stained strongly with synaptophysin. Thus, synaptophysin was shown to be a useful neuroendocrine marker for paraganglio mas. Int J Surg Pathol 1 (1):111-116, 1993

A resected case of liver metastases from extra-adrenal retroperitoneal paraganglioma with von Recklinghausen's disease 16 years after the initial surgery

The patient was a 46-year-old man who had undergone resection for a bulky retroperitoneal tumor 16 years previously during a follow-up for von Recklinghausen’s disease. Histopathological examination of the resected specimen showed that the tumor was an extra-adrenal paraganglioma. After the surgery, he had survived without any recurrence of the tumor. However, 16 years after the initial surgery, liver tumors were identified, and he was referred to our hospital for further investigation and treatment. Abdominal imaging modalities showed three masses in the left lateral segment of the liver. Fluorodeoxyglucose-positron emission tomography/computed tomography showed an abnormal uptake of fluorodeoxyglucose corresponding to the mass lesions. The patient was diagnosed with a metastatic paraganglioma based on histopathological examination of a liver mass biopsy. The patient underwent left lateral sectionectomy of the liver. Histopathological examination of the resected specimen revealed proliferating cells with basophilic cytoplasm and oval densely stained nuclei arranged in an alveolar pattern, which was similar to the findings of the initial resection specimen. Immunohistochemical staining was positive for synaptophysin and chromogranin A. Based on these findings, the resected tumors were histopathologically diagnosed with liver metastases from the retroperitoneal paraganglioma. We concluded that this is an extremely rare case of liver metastases occurring long after the initial resection of extra-adrenal peritoneal paraganglioma with von Recklinghausen’s disease.

Retroperitoneal non-functioning paraganglioma: A difficult tumour to diagnose and treat

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We report a case of non-functional retroperitoneal paraganglioma.

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Non-functioning retroperitoneal paragangliomas are rare and difficult to diagnose.

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Surgical excision is recommended given potential malignant transformation.

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Lifelong follow up is recommended as recurrence and metastasis are common.

Paragangliomas are rare neoplasms arising from cells of the primitive neural crest. These tumours are often difficult to diagnose and treat. We report a case of a 42 year old female presenting with abdominal pain who had a retroperitoneal tumour situated at the aortic bifurcation. Serum catecholamine levels were normal. Complete resection of the tumour was performed. The histological examination and immunohistochemical analyses concluded the diagnosis of an organ of Zuckerkandl paraganglioma.

Non-functioning Aortocaval Paraganglioma Masquerading as Celiac Lymphnodal Metastasis

An extra-adrenal paraganglioma is a rare tumour derived from chromaffin cells of sympathetic ganglia. This report documents a rare case of a non-functional aortocaval paraganglioma in a 24-year-old woman with persistent abdominal pain. Computed tomography revealed a solid mass, measuring 2.5x3cms, localized between the celiac trunk and superior mesenteric artery in aortocaval location along with right ovarian cystic mass. A clinical diagnosis of malignant ovarian tumour with celiac nodal metastasis was made. Excision and pathological analysis of both revealed an aortocaval extra-adrenal paraganglioma and benign ovarian cyst. On serial follow-up the patient was in a good health, asymptomatic and without evidence of tumour recurrence. This case emphasizes the necessity of including extra-adrenal paraganglioma in the differential diagnosis and management of retroperitoneal tumours, despite its rarity.

Retroperitoneal paraganglioma with metastasis to the abdominal vertebra: a case report

Background

Extra-adrenal paraganglioma of the retroperitoneum with metastasis to the vertebra is very rare. To our knowledge this is the first report of this kind of disease in the literature.

Case presentation

Here, we present an oroginal case of paraganglioma of the retroperitoneum with metastasis to the abdominal vertebra in a 42-year-old female patient who was successfully treated by complete removal of the tumor and its metastasis. The patient was followed up for four years and remained disease-free.

Conclusion

Our case demonstrated the need to consider paraganglioma of the retroperitoneum in the differential diagnosis of retroperitoneal mass, metastatic tumors to the vertebra, and the importance of radical surgery for a successful management of the disease.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1956611954880197

Mesenteric paraganglioma: Report of a case

We report a rare case of paraganglioma that developed in the mesentery of terminal ileum. A 78-year-old woman complained of right-sided abdominal pain. Abdominal computed tomography revealed a solid heterogeneously enhanced mass in the right lower abdomen. The tumor was laparoscopically excised. The mesenteric tumor was well circumscribed, ovoid, and encapsulated and measured 3 cm × 1.5 cm × 1.5 cm. Histological examination showed a cellular neoplasm comprised of nests and groups of tumor cells separated by fibrovascular connective tissue, giving a characteristic nested Zellballen pattern. Immunohistochemically, the tumor cells were positive for chromogranin, synaptophysin, CD56, and vimentin and negative for cytokeratins, SMA, CD34, CD117/c-kit and S100. On the basis of histologic and immunohistochemical features, a diagnosis of mesenteric paraganglioma was made. The operative and postoperative courses were unremarkable, and the patient was discharged on postoperative day 7. She was doing well 1 year after the surgery with no signs of recurrence. Extra-adrenal paragangliomas most commonly develop adjacent to the aorta, particularly the area corresponding to the organ of Zuckerkandl. Mesenteric paraganglioma, as in our case, is extremely rare; only 11 cases have been reported in the literature. We herein discuss the clinical findings of these cases.

Metastatic paraganglioma of the spine: case report and review of the literature

Paragangliomas are relatively rare tumors, accounting for only about 0.3% of all neoplasms. Most paragangliomas are defined as benign in nature, but 10-20% possess metastatic potential. There have been scattered reports of metastatic paraganglioma in the literature, but in rare circumstances, paragangliomas can metastasize to the spinal column causing destruction or compression of the spinal cord, clinically manifesting as pain or neurological deficit. We report a case of metastatic paraganglioma in which a 47-year-old man had spinal metastasis from a primary abdominal paraganglioma and was found to be positive for SDHB mutation, portraying negative implications for prognosis. Long-term follow-up is reported. In addition, we review the literature on the topic of metastatic paraganglioma, management of paragangliomas involving spine, and touch on the importance of the presence of SDHB mutations in these cases.

Soft tissue tumours of the retroperitoneum

Purpose. This review summarizes the more prevalent soft tissue tumours arising in the retroperitoneum and highlights some recent fundamental and diagnostic developments relevant to mesenchymal tumours.

Discussion. The retroperitoneum is an underestimated site for benign and malignant neoplastic disease, and represents the second most common site of origin of primary malignant soft tissue tumours (sarcomas) after the deep tissues of the lower extremity. In contrast to the predominance of benign soft tissue lesions over malignant sarcomas elsewhere, retroperitoneal mesenchymal lesions are far more likely to be malignant. The differential diagnosis is primarily with the more common lymphoproliferative and parenchymatous epithelial lesions arising in this area, and with metastatic disease from known or unknown primary sites elsewhere.The most prevalent mesenchymal tumours at this site are of a lipomatous, myogenic or neural nature.Their generally late clinical presentation and poorly accessible location provides numerous clinical challenges; optimal radiological imaging and a properly performed biopsy are essential cogs in the management route. Histopathological diagnosis may be complicated, but has been aided by developments in the fields of immunohistochemistry and tumour (cyto)genetics. Despite significant advances in oncological management protocols, the prognosis remains generally less favourable than for similar tumours at more accessible sites.

Chronic epigastric pain in a middle-aged man

OBJECTIVE

The objective of this article is to describe and show a number of imaging findings that are classical for an intussusception in an adult and discuss the clinical manifestations and associated findings. We also discuss the differential diagnosis of intussusception in an adult and the most likely causes.

CONCLUSION

A malignant cause of intussusception is more likely when an intussusception involves the large bowel, in which case primary adenocarcinoma of the colon is the most prevalent. Therefore, surgical resection followed by careful pathologic analysis is typically indicated in nonresolving cases. Nevertheless, when intussusception is transiently diagnosed in an asymptomatic adult, follow-up is favored over surgery.

Paragastric paraganglioma: a case report with unusual alveolar pattern and myxoid component

Paragangliomas are neural crest-derived neuroendocrine tumors. Nearly 5 to 10% occur in extraadrenal sites, from the upper cervical region to the pelvis, related to the autonomic nervous system. Very few cases of gastric or paragastric paragangliomas have been reported. We report a paraganglioma attached to the stomach of an 85-year-old man. The tumor was 15 cm in diameter and was surgically resected via a subtotal gastrectomy. Fine-needle aspiration smears showed round epithelioid cells forming acini and spindle cells attached to capillaries. Occasional cells showed excentric nuclei and pale vesicular cytoplasm. Microscopically, the tumor was characterized by an alveolar and solid pattern of growth with some unusual features, such as myxoid stroma and pseudoalveoli that contained myxoid material. Spindle cells stained with vimentin and S-100 protein, whereas epithelioid cells showed diffuse cytoplasmic staining with chromogranin A. Electron microscopy of the tumor tissue revealed the presence of neurosecretory granules. To the best of our knowledge, this pattern of growth has yet to be described in the literature and may result in a misdiagnosis if sufficient immunohistochemical markers are not employed. We briefly discuss the cytomorphological features and differential diagnosis of this tumor, which was discovered in a rare location.

Paraganglia mimicking metastatic seminomatous tumor

Two cases are presented in which microscopic groups of retroperitoneal paraganglionic cells simulated metastatic seminomatous tumor. Both patients had histories of mixed testicular germ cell tumor with abdominal metastases and had been treated with chemotherapy. Persistent retroperitoneal disease was favored on follow-up imaging studies. Subsequent retroperitoneal lymph node dissection disclosed multifocal epithelioid cell groups with clear/vacuolated cytoplasm in the fibroconnective and adipose tissue, ranging from 1.0 to 3.0 mm in size. These cell groups were initially interpreted as recurrent metastatic seminoma, but were later reinterpreted as paraganglionic cells, which were confirmed by immunohistochemical analysis. The pathologic features for distinguishing paraganglionic cells from metastatic seminoma are discussed. Awareness of the presence of paraganglia and their distinction from metastatic disease is of practical importance in avoiding an overdiagnosis of malignancy and assuring proper patient management.

Successful outcome after resection of liver metastasis arising from an extraadrenal retroperitoneal paraganglioma that appeared 9 years after surgical excision of the primary lesion

A 54-year-old man underwent surgery for excision of a retroperitoneal tumor that measured 12 cm in diameter, and histopathological examination revealed the tumor was an extraadrenal retroperitoneal paraganglioma. He presented 9 years later with epigastric discomfort. Abdominal ultrasound showed a solitary liver tumor. The diagnosis, based on radiological workup, was metastatic paraganglioma. The tumor was surgically resected and the histological findings resembled those of the primary tumor. The patient has been followed up for 3 years and remains recurrence-free. Surgical resection is an effective treatment approach for primary and secondary paragangliomas, but the resectability of liver metastatic lesions is usually low, although complete resection with a wide surgical margin was possible in this patient. This case suggests that a good prognosis after the resection of hepatic metastasis depends not only on the curative resection of the metastatic lesion but also on the tumor characteristics, such as slow growth or low aggressiveness.

Renal hilar pheochromocytoma: a case report

Paraganglioma is a rare tumor arising from undifferentiated cells of the primitive neural crest. These tumors are most commonly found in the adrenal gland, other localisations are also possible. A 58-year-old woman who presented with history of left lumbar pain, headache, hypertension, palpitation and sweating was found to have a secreting left renal hilar pheochromocytoma. Radical excision of the tumor was therefore undertaken and her hypertension was controlled. From the case report and literature review, the authors suggest a diagnostic and therapeutic strategy for the management of ectopic localization of pheochromocytoma.

Pararectal paraganglioma

Paragangliomas are neoplasms that arise from neural crest cells and histologically resemble their adrenal counterpart, the phaeochromocytoma. The majority of extra-adrenal tumours develop within the abdomen and are associated with the coeliac, superior and inferior mesenteric ganglia, which run parallel to the aorta. The organ of Zuckerkandl origin is most common. Pararectal paragangliomas are extremely rare. This case report presents ultrasound, magnetic resonance and histological features of such a case.

Ectopic pheochromocytoma: does the rule of tens apply?

INTRODUCTION

The rule of "tens" is often stated to reflect the distribution and histology of pheochromocytomas, with 10% being bilateral, 10%; ectopic in origin, and 10%; malignant. The objective of this study was to review the ectopic pheochromocytomas in a tertiary endocrine center and to establish whether the rule of tens holds true.

METHODS

Retrospective data were collected on all adrenalectomies and ectopic pheochromocytoma resections performed between 1993 and 2005 at our institution.

RESULTS

In total, 77 patients had pheochromocytomas: 75%; (58/77) adrenal and 25%; (19/77) ectopic. Of the adrenal pheochromocytomas, 10%; (6/58) were bilateral. The anatomic locations of the ectopic pheochromocytomas were as follows: 26%; (5/19) adjacent to the adrenals, 53%; (10/19) in the organ of Zuckerkandl, 11%; (2/19) in the bladder, 5%; (1/19) in the mediastinum, and 5%;(1/19) in the neck.

CONCLUSIONS

Our series demonstrates an incidence of 10%; for bilateral pheochromocytoma, which is similar to that in the published reports. However, 25%; of the pheochromocytomas were ectopic. Zuckerkandl pheochromocytomas were the most common among the ectopic lesions. Rarely, these tumors present outside the abdominal cavity.

An incidentally discovered small and asymptomatic para-aortic paraganglioma

Preoperative diagnosis of asymptomatic paraganglioma is difficult due to the lack of specific symptoms. In this report, we present a rare case of a small and asymptomatic para-aortic paraganglioma. A 34-year-old woman who complained of back pain was admitted for further examination. No abnormal findings were observed on physical or laboratory examinations. An abdominal CT scan and an abdominal MRI incidentally noted a mass about 3 cm in diameter adjacent to the right edge of the inferior vena cava. The following aortic angiography showed the tumor with a feeding artery diverting directly from the aorta. The tumor was completely resected by laparotomy. The resected tumor, 3 x 3 x 3 cm in size, was soft, dark-reddish and encapsulated. Immunohistochemical examinations showed that it was positive for neuron-specific enolase, chromogranin A and adrenocorticotropin. Under these findings, the diagnosis of para-aortic paraganglioma was determined. Seven years after the operation, she remains asymptomatic and free of disease.

Paraganglioma of the greater omentum: Case report and review of the literature

Background

Extra-adrenal, intra-abdominal paraganglioma constitutes a rare neoplasm and, moreover, its location in the greater omentum is extremely infrequent.

Case presentation

A 46-year-old woman with an unremarkable medical history presented with an asymptomatic greater omentum mass that was discovered incidentally during ultrasonographic evaluation due to menstrual disturbances. Clinical examination revealed a mobile, non-tender, well-circumscribed mass in the right upper and lower abdominal quadrant. Blood tests were normal. Contrast-enhanced abdominal computed tomography (CT) scan confirmed a huge (15 × 15 cm), well-demarcated, solid and cystic, heterogeneously enhanced mass between the right liver lobe and right kidney. Exploratory laparotomy revealed a large mass in the greater omentum. The tumor was completely excised along with the greater omentum. Histopathology offered the diagnosis of benign greater omentum paraganglioma. After an uneventful postoperative course, the patient was discharged on the 4^th postoperative day. She remains free of disease for 2 years as appears on repeated CT scans as well as magnetic resonance imaging (MRI) and scintigraphy performed with radiotracer-labeled metaiodobenzyl-guanidine (MIBG) scans.

Conclusion

This is the second reported case of greater omentum paraganglioma. Clinical and imaging data of patients with extra-adrenal, intra-abdominal paragangliomas are variable while many of them may be asymptomatic even when the lesion is quite large. Thorough histopathologic evaluation is imperative for diagnosis and radical excision is the treatment of choice. Since there are no definite microscopic criteria for the distinction between benign and malignant tumors, prolonged follow-up is necessary.

[Difficult diagnosis of a pancreatic paraganglioma]

INTRODUCTION

The paraganglioma is a rare tumour that can sometimes develop near to the pancreatic gland and can occasionally mimic an intra pancreatic mass. Invasive investigations with puncture or primary surgical resection must be avoided because of the risk of vital complications.

EXEGESIS

We report on the case of a 41 years old woman presenting with a mass apparently affecting the pancreatic gland. She also presented with malaises. Paraganglioma was suspected because of the malaises and the blood pressure crises. The diagnosis was permitted by the findings of high urinary metanephrine levels. So the tumour was resected without previous fine needle aspiration and with specific anaesthetic measures. No complication was observed.

CONCLUSION

When a patient presents with a pancreatic mass, physician must carefully take into account the possibility of a paraganglioma particularly when malaises are present.

Malignant paraganglioma of the retroperitoneum with lung metastases: a 13-year survivor after radical surgery

We present a 23-year-old patient with extra-adrenal retroperitoneal paraganglioma with lung metastases who was successfully treated by complete removal of the tumour. Lung metastases were the first manifestation of the disease, and an abdominal computed tomography scan showed a large mass in the retroperitoneum with marked contrast enhancement. Angiography demonstrated a hypervascular mass with many feeding arteries, but vascular invasion was not apparent. The retroperitoneal tumour was resected completely followed by resection of lung metastases after 1 month of observation. The patient was disease free for 13 years after this radical surgery. The survival rate in patients with retroperitoneal paraganglioma with lung metastasis is low, and this case represents the longest surviving period reported in the literature. These tumours are usually large and located in the para-aortic region, and hence resection is sometimes challenging. We believe that a complete and meticulous surgical procedure is a prerequisite for long survival from this rare disease.

Small extra-adrenal pheochromocytoma causing severe hypertension in an elderly patient

We report the case of a 67-year-old woman with severe hypertension caused by an extra-adrenal pheochromocytoma. The tumor was detected by 131I metaiodobenzylguanidine scintigraphy and it was found to be small (2 cm ø) by enhanced CT. After the extirpation of the tumor, the blood pressure of the patient immediately normalized. It should be taken into account that a small extra-adrenal pheochromocytoma can be one of the causes of secondary hypertension in elderly patients. Since small extra-adrenal pheochromocytomas are difficult to detect, it is also important to perform suitable examinations to establish the diagnosis. Furthermore, we emphasize the importance of an accurate diagnosis in elderly patients with pheochromocytoma, for they often have less symptomatology and more severe cardiovascular complications due to refractory hypertension than younger patients.

Extraadrenal paragangliomas of the body: imaging features

OBJECTIVE

This article illustrates the anatomic distribution of the healthy paraganglion system and the imaging and pathologic features of various extraadrenal paragangliomas occurring in the head and neck, chest, and abdomen.

CONCLUSION

Although paragangliomas can occur in a variety of anatomic locations, the majority are seen in relatively predictable regions of the body. Extraadrenal paragangliomas have nearly identical imaging features, including a homogeneous or heterogeneous hyperenhancing soft-tissue mass at CT, multiple areas of signal void interspersed with hyperintense foci (salt-and-pepper appearance) within tumor mass at MRI, and an intense tumor blush with enlarged feeding arteries at angiography.

Histopathology and immunohistochemistry of adrenal medullary tumors and paragangliomas

Paragangliomas arise from sympathetic or parasympathetic paraganglia and should now be defined by their site and type. The term pheochromocytoma is reserved for intra-adrenal tumors. This short review discusses the gross and microscopic features, the immunohistochemical profile, the problem of recognizing malignant potential, and the rare instances where a differential diagnosis has to be considered.

Case report: intra-renal paraganglioma masquerading as a renal cyst

A case is reported in which a 46-year-old normotensive male patient presented with large right-sided painless abdominal mass. On sonography there was a large cyst in the lower pole of right kidney. Intravenous urography showed distortion of pelvicollecting system and medial shift of upper right ureter. Exploration revealed a cystic mass (18 x 15 cm) located in lower pole of right kidney. It contained brownish fluid and because of suspicion of malignancy radical nephrectomy was carried out. Histological examination showed the cystic mass to be adrenal tissue infiltrated by neoplastic cells. Characteristic organoid nests of malignant cells ("Zellaballen" were present. Cells stained positively for chromogranin, neurone specific enolase (NSE), neurofilament, and synaptophysin. Sustentacular cells showed positive reaction to S-100 protein. No further treatment was offered. Patient remains well at 30 months follow-up. On medline search there is record of three cases of intra-renal paraganglioma in English literature and the present case appears to be the fourth one.

Paragangliomas de la cauda equina: a propósito de dos casos

Extraadrenal paragangliomas involving the spinal cord are not common and usually take the compression of the cauda equine. Two cases of paraganglioma of the cauda equina with a different presentation are reported, and the clinical and histopathology findings of this tumor, as well as diagnosis, treatment and prognosis are review. We stress the importance of the high tumor vascularization form of intradural that can make impossible achieve a complete resection. Laminotomy and intraoperatory echography are very useful in the approach to intradural tumors, such as paraganglioma.

Flow cytometric DNA analysis for determination of malignant potential in adrenal pheochromocytoma or paraganglioma: an Indian experience

BACKGROUND

We analyzed the histological features and DNA flow cytometric results in 34 patients with pheochromocytoma and paragangliomas and attempted correlation with the biological behavior for determination of the malignant potential of these tumors.

METHODS

DNA analysis was done on a FACSort flow cytometer using paraffin-embedded tissues. Histopathological analysis was performed using parameters, i.e., cell size (large, medium, and small), cell size variation, mitotic rate, nuclear pleomorphism, golden yellow to brown pigment in the tumor, necrosis, and venous invasion.

RESULTS

Six tumors had high (>5/10HPF) mitotic rate while venous invasion was seen in three tumors. Fifty percent (18/34) of patients had aneuploid tumors, and 68% (23/34) of patients had high (>10%) S-phase fraction tumors. Aneuploidy correlated with >5/10HPF mitotic rate (P <.05) and diploidy with golden yellow to brown pigment (P <.01). The patients with aneuploid tumor had a worse prognosis than patients with diploid tumors (P =.004). No such difference was observed with low and high S-phase fractions (P =.748), presence and absence of venous invasion (P =.927), and mitotic rate (P =.159). Nuclear pleomorphism and necrosis were not significant factors in prognosis.

CONCLUSIONS

Flow cytometric DNA analysis of paragangliomas and pheochromocytomas correlated with biological behavior in the patients with regard to metastasis and overall survival in the patients.