Lessons to be learned: a case study approach. Paraganglioma of the urinary bladder

Paraganglioma (pheochromocytoma) of the urinary bladder: A systematic review with a diagnostic, management and treatment algorithm

Introduction:

Paraganglioma of the urinary bladder is a rare but well-documented tumour. Herein, we provide the largest, comprehensive systematic review of the literature and aim to increase familiarity with this rare but significant neoplasm.

Methods:

A systematic review of the literature was conducted on the NCBI PubMed database. The search criteria were not limited to any specific years or languages. There were 418 articles between January 1953 and August 2020, of which 255 case reports were selected.

Results:

Paragangliomas of the urinary bladder most commonly occurred in Caucasians in the fifth decade of life, most commonly presenting with haematuria and variations of ‘micturition attacks’. Eighty percent of tumours were functionally active. The mucosa was normal in 91% of patients. In all, 25% of tumours were treated with transurethral resection alone, 65% had partial cystectomy and 5% had radical cystectomy. Alpha-blockers were administered pre-operatively in 38% of patients and the risk of intra-operative hypertensive crisis was over three times greater in those who did not receive an alpha-blocker. The tumour was confined to the bladder in 75% of cases. Metastasis occurred in 20% of cases, most commonly to iliac nodes. The mean follow-up time was 26.5 months. In cases that documented follow-up, 18.6% had recurrence, most commonly in lymph nodes and bone.

Conclusion:

All patients presenting with micturition attacks or haematuria with a computed tomography showing an enhancing, well-defined submucosal bladder lesion and/or cystoscopy showing a lesion with normal overlying mucosa should be worked up for a possible paraganglioma of the urinary bladder.

Level of evidence:

Not applicable

Clinical significance of functional and anatomical classifications in paraganglioma of the urinary bladder

OBJECTIVES

Paragangliomas of the urinary bladder (PUBs) are challenging catecholamine-producing neuroendocrine tumors. We aimed to facilitate their diagnosis and treatment by functional and anatomical classifications.

MATERIALS AND METHODS

Between April 2007 and September 2017, 31 cases from 2 centers were retrieved, in which the patients were pathologically diagnosed with PUB. Besides classifying them into functional and nonfunctional PUBs, functional PUBs were further subclassified into typical functional PUB (with typical symptoms and elevated catecholamines/metabolites levels) and atypical functional PUB. Anatomically, they were classified into submucosal, intramural, and subserosal PUBs.

RESULTS

Functionally, these cases comprised 17 (54.8%) functional and 14 (45.2%) nonfunctional PUBs. Functional PUBs had significantly larger diameters than nonfunctional PUBs (P < 0.01). Of the 17 functional PUB cases, 8 were further subclassified into typical functional PUB, of which 4 were diagnosed without cystoscopy. Anatomically, these cases comprised 14 (45.2%) submucosal, 13 (41.9%) intramural, and 4 (12.9%) subserosal PUBs. Intramural and subserosal PUBs had significantly larger diameters and were more likely to be functional than submucosal PUBs (P < 0.05). Cystoscopy failed to detect the tumor in all patients with subserosal PUB. Besides all patients with intramural or subserosal PUB, 1 patient with submucosal PUB underwent partial cystectomy. The remaining 13 patients with submucosal PUB underwent transurethral resection of bladder tumor, 5 of whom required extra surgical intervention.

CONCLUSIONS

By functional classification, omitting cystoscopy is feasible in the diagnosis of typical functional PUBs. By anatomical classification, intramural, and subserosal PUBs tend to be large and functional. Moreover, negative cystoscopic findings are not sufficient to exclude subserosal PUBs. Finally, not all submucosal PUBs are amenable to transurethral resection of bladder tumor.

Pheochromocytoma of the urinary bladder: a systematic review of the contemporary literature

Background

Pheochromocytoma (paraganglioma) of the urinary bladder is a rare tumor. Herein we sought to review the contemporary literature on pheochromocytomas of the urinary bladder in order to further illustrate the presentation, treatment options and outcomes of patients diagnosed with these tumors.

Methods

A comprehensive review of the current literature was conducted according to the PRISMA guidelines by accessing the NCBI PubMed database and using the search terms “paraganglioma, pheochromocytoma, bladder.” This search resulted in the identification of 186 articles published between January 1980 and April 2012 of which 80 articles were ultimately included in our analysis.

Results

Pheochromocytomas usually occurred in young adult Caucasians (mean age, 43.3 years; range,11–84 years). According to the literature, the most common symptoms and signs of pheochromocytomas of the urinary bladder were hypertension, headache, and hematuria. Of the 77 cases that commented on catecholamine production, 65 patients had biochemically functional tumors. Approximately 20% of patients were treated by transurethral resection alone, 70% by partial cystectomy and 10% by radical cystectomy. The 75 patients with follow-up information had a mean follow-up of 35 months. At the time of last follow-up, 15 (14.2%) had disease recurrence, 10 (9.4%) had metastasis, and 65 (61.3%) were alive.

Conclusions

Pheochromocytomas of the urinary bladder tend to be functional and occur mostly in young adult Caucasians. Patients with localized tumors have an extremely favorable prognosis and may be managed by less aggressive modalities, whereas patients with metastatic disease have a significant reduction in survival rates despite aggressive treatment.

Emergencies caused by pheochromocytoma, neuroblastoma, or ganglioneuroma

Pheochromocytoma may lead to important emergency situations, ranging from cardiovascular emergencies to acute abdomen and multiorgan failure. It is vital to think about this disease in any emergency situation when conventional therapy fails to achieve control or symptoms occur that do not fit the initial diagnosis. The importance of keeping this diagnosis in minds is underscored by the fact that, in 50% of pheochromocytoma patients, the diagnosis is initially overlooked. Two other tumors of the sympathetic nervous system, neuroblastoma and ganglioneuroma, are less commonly associated with emergency conditions. If they occur, they are often linked to catecholamine excess, paraneoplastic phenomena, or local tumor mass effect.

Paraganglioma of the Bladder: Controversy regarding Treatment

Paragangliomas or extra-adrenal pheochromocytomas account for approximately 15% of all pheochromocytomas. They are usually found in an intradiaphragmatic location. Paragangliomas of the urinary bladder are infrequent and represent 6% of the paragangliomas and 0.06% of all bladder tumors. We describe 2 cases of urinary bladder paragangliomas attended to our center and review the literature with special attention to treatment, since there is some controversy around the management of these tumors. Surgical options include partial or total cystectomy and transurethral resection, but there is no consensus regarding these treatment modalities. The 2 patients presented underwent transurethral resection with a good outcome and no recurrence or residual disease.