Primary Pulmonary Paraganglioma: Report of a Functioning Case With Immunohistochemical and Ultrastructural Study

PHOX2B is a Sensitive and Specific Marker for the Histopathological Diagnosis of Pheochromocytoma and Paraganglioma

Pheochromocytomas (PCCs) and paragangliomas (PGLs) are non-epithelial neuroendocrine neoplasms originating from the adrenal medulla and paraganglion of the sympathetic and parasympathetic nervous system, respectively. PCCs and PGLs show histological similarities with other epithelial neuroendocrine neoplasms and olfactory neuroblastomas (ONBs), and the differential diagnosis of PGLs is particularly difficult. Therefore, we compared the sensitivity of PHOX2A, PHOX2B, and tyrosine hydroxylase (TH) in the histopathological diagnosis of PCCs and PGLs immunohistochemically using the tissue microarrays of 297 neoplasms including PCCs, PGLs, neuroblastomas, ganglioneuromas, epithelial neuroendocrine neoplasms, and ONBs. Using cutoff values of 25%, 5%, and 5% of tumor cells expressing PHOX2A, PHOX2B, and TH, respectively, as positive, 40 of 51 PCCs, 32 of 33 parasympathetic/head and neck PGLs (HNPGLs), 17 of 19 sympathetic/thoracoabdominal PGLs (TAPGLs), and 12 of 152 epithelial neuroendocrine neoplasms, including 123 well-differentiated and 29 poorly differentiated neuroendocrine neoplasms, were PHOX2A-positive. All 51 PCCs, 33 HNPGLs, and 19 TAPGLs were PHOX2B-positive, while all 152 epithelial neuroendocrine neoplasms were PHOX2B-negative. Moreover, 50 of 51 PCCs, 13 of 33 HNPGLs, all TAPGLs, and 12 of 152 epithelial neuroendocrine neoplasms were TH-positive. All ONBs were negative for PHOX2A, PHOX2B, and TH. PHOX2B was the most sensitive and specific diagnostic marker for PCCs and PGLs among PHOX2A, PHOX2B, and TH. PHOX2B can facilitate identification of PCCs and PGLs from epithelial neuroendocrine neoplasms and ONBs, especially in the case of HNPGLs, in which TH is often negative.

Primary pulmonary paraganglioma: Two cases

Paraganglioma is a rare tumor originating from extra-adrenal chromaffin cells. Primary pulmonary paraganglioma can also be seen in pediatric patients. Due to its endobronchial localization, morphological features, and neuroendocrine immunohistochemical profile, primary pulmonary paraganglioma can be confused with carcinoid tumor. Primary pulmonary paraganglioma should be considered in the differential diagnosis of endobronchial tumors and necessary precautions should be taken, considering that it may be functioning. In appropriate cases, bronchial sleeve resection provides curative treatment. In this article, we present two cases: First was a functioning primary pulmonary paraganglioma that underwent lobectomy and second was an entirely endobronchial tumor without any extra-bronchial spread that underwent bronchial sleeve resection.

Frequency and extent of cytokeratin expression in paraganglioma: an immunohistochemical study of 60 cases from 5 anatomic sites and review of the literature

The absence of cytokeratin expression in paraganglioma helps to differentiate it from other neuroendocrine neoplasms such as carcinoid tumor. Although rare cytokeratin positive paragangliomas have been reported, there are no large systematic studies of this phenomenon. The aim of this study was to determine the frequency and extent of cytokeratin expression in paragangliomas using a large cohort of cases from multiple anatomic sites. Immunohistochemical staining for keratin AE1/AE3 (mouse monoclonal, MAB3412; Millipore) and CAM 5.2 (mouse monoclonal, 349 205; Becton-Dickinson) was performed on whole-tissue sections from 60 resected paragangliomas from the head and neck (36), thorax (10), abdomen (8), intradural/epidural spine (5) and bone, left iliac (1). Cytokeratin expression was identified in only 2/60 (3.3%) cases. One was a mediastinal paraganglioma with moderate to strong expression of keratin AE1/AE3 and CAM 5.2 in <5% tumor cells. The other was a lumbar intradural paraganglioma positive for CAM 5.2 (moderate to strong, 80% of tumor cells) but negative for keratin AE1/AE3. All other paragangliomas (58/60, 96.7%) were negative for keratin AE1/AE3 and CAM 5.2. This study - the largest series of cytokeratin-stained whole-tissue sections of paragangliomas to date - supports the dictum that most paragangliomas are cytokeratin negative. Rare exceptions may be site-related.

Pulmonary paraganglioma in a 10-year-old: a case report and review of the literature

Paraganglioma is a rare extra-adrenal tumor of the paraganglia often found in association with sympathetic and parasympathetic nerves. The case presented is of a 10-year-old boy with hemoptysis who was found to have an obstructive bronchial mass. He underwent surgical resection and biopsy confirmed primary pulmonary paraganglioma. He was subsequently found to have an associated genetic syndrome. This is the first case report describing a primary pulmonary paraganglioma in a child.

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.

A Peculiar Primary Paraganglioma of the Distal Thumb

A paraganglioma is a highly vascularized neuroendocrine tumor most commonly found within the adrenal gland as a pheochromocytoma. Extra-adrenal paragangliomas are frequently located in the head, neck, thorax, and abdomen. We report the first documented case of a primary paraganglioma found within the appendicular skeleton. Only 2 additional cases of paragangliomas in the extremities have been documented, one in the soft tissue of the forearm and other within the median nerve. Our patient underwent amputation of the distal phalanx, with no sign of recurrence at greater than 1 year of follow-up. Because of the geographic and clinical similarity to a benign enchondroma, radiographic imaging alone may not be sufficient to rule out malignancies inside bones. Thus paraganglioma should remain in the differential and immunohistochemistry is both vital and necessary to confirm the diagnosis. Vigilant and appropriate follow-up is necessary to detect metastases early in these patients.

Alveolar soft part sarcoma of lung: report of a unique case with emphasis on diagnostic utility of molecular genetic analysis for TFE3 gene rearrangement and immunohistochemistry for TFE3 antigen expression

Alveolar soft part sarcoma (ASPS) is a rare, malignant mesenchymal tumor of distinctive clinical, morphologic, ultrastructural, and cytogenetical characteristics. It typically arises in the extremities of adolescents and young adults, but has also been documented in a number of unusual sites, thus causing diagnostic confusions both clinically and morphologically. The molecular signature of ASPS is a specific der(17)t(X;17)(p11.2;q25) translocation, which results in the fusion of TFE3 transcription factor gene at Xp11.2 with ASPL at 17q25. Recent studies have shown that the ASPL-TFE3 fusion transcript can be identified by reverse-transcriptase polymerase chain reaction analysis and TFE3 gene rearragement can be detected using a dual-color, break apart fluorescence in situ hybridization assay in paraffin-embedded tissue, and the resultant fusion protein can be detected immunohistochemically with antibody directed to the carboxy terminal portion of TFE3. Herein, we report a unique case of ASPS presenting as an asymptomatic mass in the lung of a 48 year-old woman without evidence of a primary soft tissue tumor elsewhere at the time of initial diagnosis. To the best of our knowledge, this is the third report of such cases appearing in the English language literature to date. We emphasize the differential diagnoses engendered by ASPS including a series of tumors involving the lung that have nested and alveolar growth patterns, and both clear and eosinophilic cytoplasm, and demonstrate the utility of molecular genetic analysis for TFE3 rearrangement and immunohistochemistry for TFE3 antigen expression for arriving at accurate diagnosis.

Neuroendocrine tumors: beyond the abdomen

Several classification systems for neuroendocrine tumors (NETs) exist, which use variable terminology and criteria for grading and staging. This variability in terminology can cause confusion and difficulty in recognizing which tumors are, in fact, members of this heterogeneous group of malignancies. The largest group of NETs, the gastroenteropancreatic NETs, has been well described and characterized; however, there are less-recognized extra-abdominal NETs that can arise from nearly any organ in the body. In this article, the clinical features and imaging appearances of the extra-abdominal NETs will be reviewed, compared, and contrasted. This diverse group consists of paragangliomas, Merkel cell carcinomas, esthesioneuroblastomas, NETs of the lung, and medullary thyroid carcinomas. Recognition of these tumors as part of the larger group of NETs is important for understanding how best to approach imaging for their diagnosis, staging, and potential treatment. Familiarity with the computed tomographic and magnetic resonance imaging appearances and the role of radionuclide imaging of these heterogeneous groups aids in the correct diagnosis and in treatment planning.

Neuroendocrine tumours--challenges in the diagnosis and classification of pulmonary neuroendocrine tumours

Pulmonary neuroendocrine (NE) proliferations are a diverse group of disorders which share distinct cytological, architectural and biosynthetic features. Tumours composed of NE cells are dispersed among different tumour categories in the WHO classification of tumours and as such do not conform to a singular group with regards to treatment and prognosis. This is reflected by the highly variable behaviour of NE proliferations, ranging from asymptomatic, for instance in diffuse idiopathic pulmonary NE cell hyperplasia and tumourlets, to highly malignant cancers such as small cell lung cancer and large cell NE carcinoma. In this review NE proliferations are described as distinct entities ranging from low grade lesions to high grade cancers. The differential diagnoses are considered with each of the entries. Finally, mention is made of tumours which may show some NE features.

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.

Primary paraganglioma of the lung: a case report and literature review

Only 22 cases of primary pulmonary paraganglioma have been reported previously. This report presents a case of paraganglioma that arose in the lung of a 38-year-old woman who presented with chest pain and paroxysmal cough with little sputum. Positron emission tomography-computed tomography scan demonstrated two homogeneous masses in the left lower lobe accompanied by multiple mediastinal lymph node metastases. After resection, gross pathological examination confirmed two solid masses, which had a yellow-grey complexion and decreased blood supply and that invaded the mediastinum. Immunohistochemical analysis confirmed the presence of several biological tumour markers. This is the first known report to describe the computed tomography imaging characteristics of a paraganglioma, thereby improving understanding of its morphological features and helping in the differential diagnosis of lung tumours.

Surgical management of endoscopically unresectable duodenal gangliocytic paraganglioma in a patient with partial upper gastrointestinal obstruction

Context:

Gangliocytic paragangliomas are unusual and often misunderstood tumors that occur almost exclusively in the second portion of the duodenum, although they have been described in other sites such as the urinary bladder, spermatic cord, prostate, urethra, uterus and scalp. We describe our experience with the surgical management of an endoscopically unresectable gangliocytic paraganglioma located in the third part of the duodenum causing a partial upper gastrointestinal obstruction.

Case Report:

A fifty-two-year-old male presented to the Geisinger clinic with a four-year history of postprandial projectile vomiting associated with epigastric discomfort. Computed tomography scan revealed an oval-shaped filling defect in the third part of the duodenum. Endoscopic ultrasonography showed a 22 × 16 × 35 mm submucosal mass that was not amenable to an endoscopic resection. Exploratory laparotomy revealed an absence of extraduodenal involvement. A long-stalked tumor was successfully excised and extruded through a longitudinal duodenotomy. The pathology report showed a gangliocytic paraganglioma with negative lymph nodes.

Conclusions:

In patients presenting with prolonged recurrent attacks of vomiting, diagnostic workup to exclude anatomic causes is mandatory. Gangliocytic paraganglioma must be considered in the differential diagnosis of an intraduodenal tumor.

Paragangliomas and paraganglioma syndromes

Paragangliomas are rare tumors of neural crest origin. They are benign in the majority of cases and are characterized by a strong vascularisation.

In the head and neck region they most commonly occur as carotid body tumors. Jugulotympanic and especially vagal paragangliomas are seen less frequently. Complete surgical resection represents the only curative treatment option even though resection of locally advanced tumors regularly results in lesions of the lower cranial nerves and major vessels.

Appoximately 30% of all head and neck paragangliomas (HNPs) are hereditary and associated with different tumor syndromes. The paraganglioma syndromes 1, 3 and 4 (PGL 1, 3 and 4) make up the majority of those familial cases. PGL 1 is associated with mutations of the succinate dehydrogenase subunit D (SDHD) gene, PGL 3 is caused by SDHC and PGL 4 by SDHB gene mutations. Multiple HNPs and the occurance of HNPs together with pheochromocytomas are seen in SDHD as well as SDHB mutation carriers. In patients with SDHB mutations the risk for the development of malignant paraganglial tumors is significantly higher compared to SDHC and SDHD patients as well as patients with sporadic tumors. SDHC mutation carriers almost exclusively present with benign HNP that are unifocal in the majority of cases. The role of transmission is autosomal dominant for all three symptoms. Interestingly, there is a “parent-of-origin-dependent-inheritance” in subjects with SDHD gene mutations. This means that the disease phenotype may only become present if the mutation is inherited through the paternal line. We recommend screening for mutations of the genes SDHB, SDHC and SDHD in patients with HNPs. Certain clinical parameters can help to set up the order in which the three genes should be tested.

Primary intraosseous paraganglioma of the sacrum

Primary intraosseous sacral paraganglioma is a rare case of location for spinal paragangliomas, which generally manifest as intradural extramedullary tumors of the cauda equina region. The diagnosis can be elusive considering the rarity of sacral paragangliomas. The clinical importance of recognizing this relatively benign tumor cannot be overemphasized as the outcome, extent of surgery and management differs significantly from other common bony sacral tumors which are generally malignant. We report a rare case of sacral paraganglioma that was diagnosed only after histopathological examination, along with a relevant review of the literature.

Primary sclerosing neuroendocrine carcinomas of the lung: A clinicopathologic and immunohistochemical study of 10 cases

We describe 10 cases of primary well-differentiated neuroendocrine carcinomas (carcinoid tumor) of the lung with extensive sclerotic changes. The patients were 6 women and 4 men from 20 to 69 years of age. Clinically, patients had symptoms of bronchial obstruction such as cough, dyspnea, and chest pain. Surgical resection of the tumors was accomplished in all the cases. Histologically, all tumors corresponded to the well-differentiated type; however, in 4 cases, lymph node metastases were present. Immunohistochemically, all tumors showed positive staining for neuroendocrine markers, including chromogranin, synaptophysin, CD56, and broad-spectrum keratin. Follow-up information showed that 8 patients were alive after a period ranging from 1 to 5 years. The cases presented highlight an important feature of neuroendocrine carcinomas of the lung not previously addressed, one that may pose a problem not only in the diagnosis but also in the grading of these neoplasms.

Intraosseous sacral paraganglioma with extradural extension: case report

BACKGROUND

Paragangliomas are tumors that arise from the paraganglion system, which is a component of the neuroendocrine system. Approximately 10% are located in the extra-adrenal paraganglion system. Paragangliomas of the spine, however, are rare. They usually present as an intradural tumor in the cauda equina. There are only three reports of primary intraosseous paragangliomas of the sacrum.

CASE DESCRIPTION

A 69-year-old man presented with low back pain and urinary incontinence. Imaging revealed a large intraosseous mass at S2, S3 and S4. Surgical resection was accomplished through a posterior midline incision exposing the spine from L5 to the coccyx. The tumor was located in the extradural space. It was friable, grayish and bleeding. Total tumor removal was performed, with normal bone margins. Follow-up at 2 years showed complete resolution of the preoperative symptoms and no evidence of local recurrence.

CONCLUSION

Although rare, the possibility of paraganglioma should be included in the differential diagnosis of sacral tumors. The majority of the spinal paragangliomas are benign, slowly growing tumors with low proliferative activity. Despite these characteristics, local recurrence has been reported in cases of both macroscopically total and subtotal resection. Postoperative radiation therapy for patients with incomplete excision may not prevent recurrence, so gross tumor removal should be the goal of surgery.

Primary cutaneous paraganglioma of the scalp

Paragangliomas are neuroendocrine tumors that arise in relation to the sympathetic or parasympathetic ganglia of the autonomic nervous system. Rarely, they are reported in unusual locations such as the urinary bladder, prostate, and uterus. Herein, we report a case of primary cutaneous paraganglioma of the scalp in a child. The tumor was studied histologically, immunohistochemically, and ultrastructurally. This case might represent an aberrant migration of neural crest cells in their descent toward the branchial arches. In addition, it highlights the complex interaction of the neural crest and branchial arches/clefts during embryogenesis.