Virilizing adrenal ganglioneuroma in a woman with subclinical Cushing syndrome

Retrospective Analysis of Retroperitoneal-Abdominal-Pelvic Ganglioneuromas: An International Study by the Transatlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG)

OBJECTIVE

The Transatlantic Australasian Retroperitoneal Sarcoma Working Group conducted a retrospective study on the disease course and clinical management of ganglioneuromas.

BACKGROUND

Ganglioneuromas are rare tumors derived from neural crest cells. Data on these tumors remain limited to case reports and single-institution case series.

METHODS

Patients of all ages with pathologically confirmed primary retroperitoneal, intra-abdominal, and pelvic ganglioneuromas between January 1, 2000, and January 1, 2020, were included. We examined demographic, clinicopathologic, and radiologic characteristics, as well as clinical management.

RESULTS

Overall, 328 patients from 29 institutions were included. The median age at diagnosis was 37 years with 59.1% of patients being female. Symptomatic presentation comprised 40.9% of cases, and tumors were often located in the extra-adrenal retroperitoneum (67.1%). At baseline, the median maximum tumor diameter was 7.2 cm. One hundred sixteen (35.4%) patients underwent active surveillance, whereas 212 (64.6%) patients underwent resection with 74.5% of operative cases achieving an R0/R1 resection. Serial tumor evaluations showed that malignant transformation to neuroblastoma was rare (0.9%, N=3). Tumors undergoing surveillance had a median follow-up of 1.9 years, with 92.2% of ganglioneuromas stable in size. With a median follow-up of 3.0 years for resected tumors, 84.4% of patients were disease free after resections, whereas recurrences were observed in 4 (1.9%) patients.

CONCLUSIONS

Most ganglioneuromas have indolent disease courses and rarely transform to neuroblastoma. Thus, active surveillance may be appropriate for benign and asymptomatic tumors particularly when the risks of surgery outweigh the benefits. For symptomatic or growing tumors, resection may be curative.

Current management of benign retroperitoneal tumors

Benign retroperitoneal tumors (BRT) represent a rare group of heterogeneous diseases. The literature lacks high-quality evidence about the optimal management of BRT, and most of the information available takes the form of case reports or case series. The aim of this review is to provide an overview of current management strategies for adult patients with BRT. A literature search using PubMed indexed articles was conducted and BRT were classified into five different biological subgroups: 1) lipomatous tumors, 2) smooth muscle tumors, 3) peripheral nerve sheath tumors, 4) myofibroblastic tumors, and 5) others. Tumors that are primarily pelvic in origin were excluded. Despite the significant heterogeneity of the disease, several generic considerations have emerged and can be applied to the management of BRT. Specifically, the risk of misdiagnosing a BRT with another pathology such as retroperitoneal sarcoma is notable. When encountered, suspected BRT should therefore be referred to a specialized sarcoma center. Multidisciplinary tumor boards, present at these centers, have a pivotal role in managing BRT. The decision of whether to offer surgery, nonsurgical treatment or a "watch-and-wait" approach should be made after multidisciplinary discussion, depending on tumor histology. Moving forward, collaborative research efforts dedicated to BRT remain crucial in gathering evidence and knowledge to further optimize patient care.

Dopamine secreting adrenal tumor-ganglioneuroma rather than pheochromocytoma: case report

Ganglioneuromas are rare, benign, well-differentiated neural crest tumors arising in the paravertebral sympathetic chain, and are classically non-secretory and clinically asymptomatic. As the diagnosis of ganglioneuroma is based on histopathology, the clinical presentation prior to surgical excision often mirrors that of pheochromocytoma or adrenal cortical adenoma. We describe a case of an incidentally found right sided calcified adrenal mass with evidence of marked dopamine excess, suspicious for pheochromocytoma in a 70-year-old female. The patient endorsed a 6-month history of intermittent right flank pain and a 2-year history of weight loss and fatigue. She reported mild symptoms of hypomania but denied other symptoms of dopamine excess including agitation, anxiety, nausea, and vomiting. Exam revealed isolated mild hypertension. The imaging features of this mass were concerning for malignancy including the presence of macrocalcification and irregular borders. After preoperative alpha blockade, the patient underwent open right adrenalectomy and the final pathology was consistent with ganglioneuroma rather than pheochromocytoma. Following resection, the dopamine level normalized, confirming the resected right adrenal ganglioneuroma as the source of dopamine excess. This case represents a rare presentation of dopamine-secreting adrenal ganglioneuroma. This illustrates that although rare, ganglioneuroma should be included on the differential diagnosis for functional adrenal tumors.

Total resection of a giant retroperitoneal and mediastinal ganglioneuroma-case report and systematic review of the literature

BACKGROUND

Ganglioneuromas (GNs) are extremely rare, slowly growing, benign tumors that can arise from Schwann cells, ganglion cells, and neuronal or fibrous tissues. Due to their origin from the sympathetic neural crest, they show neuroendocrine potential; however, most are reported to be hormonally inactive. Nevertheless, complete surgical removal is recommended for symptom control or for the prevention of potential malignant degeneration.

CASE REPORT

A 30-year-old female was referred to our oncologic center due to a giant retroperitoneal and mediastinal mass detected in computed tomography (CT) scans. The initial symptoms were transient nausea, diarrhea, and crampy abdominal pain. There was a positive family history including 5 first- and second-degree relatives. Presurgical biopsy revealed a benign ganglioneuroma. Total resection (TR) of a 35 × 25 × 25 cm, 2550-g tumor was obtained successfully via laparotomy combined with thoracotomy and partial incision of the diaphragm. Histopathological analysis confirmed the diagnosis. Surgically challenging aspects were the bilateral tumor invasion from the retroperitoneum into the mediastinum through the aortic hiatus with the need of a bilateral 2-cavity procedure, as well as the tumor-related displacement of the abdominal aorta, the mesenteric vessels, and the inferior vena cava. Due to their anatomic course through the tumor mass, the lumbar aortic vessels needed to be partially resected. Postoperative functioning was excellent without any sign of neurologic deficit.

CONCLUSION

Here, we present the largest case of a TR of a GN with retroperitoneal and mediastinal expansion. On review of the literature, this is the largest reported GN resected and was performed safely. Additionally, we present the first systematic literature review for large GN (> 10 cm) as well as for resected tumors growing from the abdominal cavity into the thoracic cavity.

Cause of postprandial vomiting - a giant retroperitoneal ganglioneuroma enclosing large blood vessels: A case report

BACKGROUND

Ganglioneuroma (GN) is a rare neurogenic tumor that accounts for about 0.1%-0.5% of all tumors of the nervous system. It originates from neural crest cells. GN has no specific clinical symptoms or laboratory findings, which leaves it easily overlooked and misdiagnosed as other tumors. Retroperitoneal GN with very large volume and vascular penetration is extremely rare.

CASE SUMMARY

We present the imaging and pathological findings of a giant retroperitoneal GN in a child. A 4-year-old boy had suffered from postprandial vomiting for more than 6 mo with no precipitating factors. Abdominal computerized tomographic examination showed a giant cystic mass in the retroperitoneal area. After injection of contrast agent, the mass showed heterogeneous enhancement. Surgery with local excision of the mass was performed to address the embedded abdominal blood vessels, and the histopathological and immunohistochemical diagnosis of the mass was GN. Postprandial vomiting was relieved, and no complications occurred after the operation.

CONCLUSION

In the diagnosis of giant retroperitoneal hypodense masses in children, GN should be considered if the mass presents delayed enhancement, punctate calcification, and vascular embedding but no invasion. Pathology is the golden standard for the diagnosis of GN, and surgical excision is the optimal treatment for GN.

Imaging Analysis of Ganglioneuroma and Quantitative Analysis of Paraspinal Ganglioneuroma

BACKGROUND This study evaluated the imaging features of ganglioneuroma (GN) and assessed the diagnostic value of the enhancement rate (ER) of CT for GN. MATERIAL AND METHODS We retrospectively reviewed records of 49 patients with histopathologically confirmed GN who underwent preoperative contrast-enhanced CT or MRI between 2010 and 2018. The independent samples t test and chi-square test were used. Receiver operating characteristic (ROC) curves were generated to analyze the diagnostic sensitivity (SE) and specificity (SP). Positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS The CT values were 32.59±3.61 Hounsfield units (HU) for plain scans, 38.87±5.09 HU for the arterial phase, and 54.26±8.14 HU for the venous phase, and the incidence of calcification and cysts was 32.6% and 10.2%, respectively. There was no significant difference in CT results and clinical parameters between mediastinal ganglioneuroma (MGN) and retroperitoneal ganglioneuroma (RGN) (p>0.05). The area under the curves (AUCs) for the arterial enhancement rate (AER), venous enhancement rate (VER), and AER/VER combined index in diagnosing GN were 0.735, 0.980, and 0.990, respectively. The VER of 0.2819 exhibited the SE and SP at 92.9% and 92.9%, respectively, to characterize the GN, whereas the AER of 0.1779 had SE and SP of 52.4% and 90.5%, respectively. The SE and SP for the combined index were 88.1% and 100%, respectively. The GN showed hypointensity on T1WI, hyperintense, or slightly high signal on T2WI with the linear hypointensity, and hyperintense on DWI. CONCLUSIONS A hypodense mass was observed for GN on plain scan and presented delayed enhancement on contrast enhancement. VER or AER/VER combination is more accurate than AER for the diagnosis of paravertebral GN.

Adrenal Ganglioneuroma: Features and Outcomes of 42 Cases in a Chinese Population

BACKGROUND

Adrenal ganglioneuromas (AGNs) are extremely rare benign neoplasms. This study is to share our experience regarding diagnostic and operative management of these tumors.

METHODS

Clinical details as well as follow-up data were retrospectively analyzed in 42 primary AGN patients who received operative resection at a tertiary referral hospital in China between May 2005 and July 2016.

RESULTS

The mean age of the patients at diagnosis was 35.3 years (range 13-59 years). Among the patients, 28 were asymptomatic. The mean preoperative size was 5.3 ± 2.2 cm (range 2.1-14.0 cm), and 17 cases were larger than 5 cm. All patients underwent operative resection as open adrenalectomy in 20 patients and laparoscopy in 22 patients. The mean tumor size on pathologic examination was 6.0 ± 2.6 cm (range 2.2-17.0 cm). Laparoscopic operation showed its advantages over open surgery on the postoperative duration (5.0 vs. 7.3 days, p < 0.001) and estimated blood loss (69.5 vs. 157.5 ml, p = 0.047). No patient had recurrence or metastasis during a median follow-up of 70.5 months (range 3.7-164.3 months).

CONCLUSIONS

We describe the largest AGN series reported to date. The preoperative diagnosis of AGN remains difficult despite of the progression of imaging examination. After complete resection, the prognosis of AGN patients is excellent. Laparoscopic approach has its advantages in the resection of AGNs.

Alterations in hair follicle dynamics in women

Endocrine changes supervening after parturition and menopause participate in the control of sebum production and hair growth modulation. The ensuing conditions include some peculiar aspects of hair loss (effluvium), alopecia, and facial hirsutism. The hair cycling is of major clinical relevance because most hair growth disorders result from disturbances in this chronobiological feature. Of note, any correlation between a biologic abnormality and hair cycling disturbance does not prove a relationship of causality. The proportion of postmenopausal women is rising in the overall population. Therefore, the prevalence of these hair follicle disturbances is globally on the rise. Current therapies aim at correcting the underlying hormonal imbalances, and at improving the overall cosmetic appearance. However, in absence of pathogenic diagnosis and causality criteria, chances are low that a treatment given by the whims of fate will adequately control hair effluvium. The risk and frequency of therapeutic inertia are further increased. When the hair loss is not controlled and/or compensated by growth of new hairs, several clinical aspects of alopecia inexorably develop. Currently, there is little evidence supporting any specific treatment for these endocrine hair disorders in post-partum and postmenopausal women. Current hair treatment strategies are symptomatic and nonspecific so current researchers aim at developing new, targeted methods.

Ganglioneuroma of the adrenal gland and retroperitoneum: A case report

Context:

Ganglioneuromas are benign tumors of the sympathetic nervous system that rarely arise in the adrenal gland. Majority of cases are detected incidentally since they are usually asymptomatic. Up to the current era of laparoscopic adrenal mass excision, this unusual entity has not been adequately reported in the surgical literature.

Case Report:

A 51 year old male with history of hypertension was found to have abdominal bruit during a regular physical examination. A 4 cm right adrenal mass with upper pole calcification and a 6 cm retro-pancreatic mass were subsequently found on a computed tomography scan. Endoscopic ultrasound-guided needle biopsy was indeterminate. Preoperative endocrine evaluation showed mildly elevated vanillyl mandelic acid with normal 24-hour cathecolamine, metanephrine and cortisol levels. Histopathologic examination after an uneventful laparoscopic excision was consistent with ganglioneuroma.

Conclusions:

Ganglioneuroma occurs rarely in adrenal gland and preoperative diagnosis is difficult since symptoms are usually nonspecific. Due to widespread utilization of abdominal imaging, however, it should be included in differential diagnosis of adrenal or retroperitoneal mass. Histopathologic examination is currently the mainstay of diagnosis.

Large adrenal ganglioneuroma

We herein report the case of a 41-year-old male patient with an incidentally identified large adrenal ganglioneuroma (GN). His endocrine examinations were normal except for one episode of elevated urinary dopamine and noradrenaline levels. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a large solid tumor with calcifications and a slightly lobular edge in the right adrenal gland. We performed open tumor excision and diagnosed it as adrenal ganglioneuroma. Adrenal GN is a rare benign tumor, and its hormonal activity and imaging characteristics are occasionally very similar to those of other adrenal tumors. Therefore, it needs careful evaluation by endocrine examinations and multiple imaging procedures to rule out other types of tumors.

Experience with adrenal schwannoma in a Chinese population of six patients

OBJECTIVES

Benign adrenal schwannoma is an extremely uncommon cause of incidentaloma. This article describes our experience with the diagnosis and treatment of adrenal schwannoma in a Chinese population of 6 patients. To our knowledge, this is the largest series of this uncommon adrenal tumor treated in a single center.

METHODS

From May 1999 to May 2009, 6 patients with incidentally discovered adrenal schwannoma were operated on at a tertiary referral hospital in Eastern China. Clinical details, radiographic features, laboratory examinations, pathological findings, and follow-up data of these patients were analyzed.

RESULTS

Of the 6 patients, 4 were females (F) and 2 were males (M), with a mean age of 40.5 yr (range: 30-47, M:F=2:1). The 6 patients were managed with open unilateral adrenalectomy; 5 patients had schwannomas on the left side, and 1 on right side. Abnormal urine catecholamine was detected in 1 patient. The mean pathological size of these tumors was 4.3 ± 1.1 cm. The diagnosis of schwannoma was based on classic histological findings, and supported by immunohistochemistry of S-100, vimentin, and ABC positivity. In the follow- up of 47.5 ± 32.3 months, no recurrence and metastasis were observed.

CONCLUSIONS

Although there may be some clues for radiological diagnosis of adrenal schwannoma, preoperative misdiagnosis is not infrequent. Those tumors may occasionally have endocrine function. Histological examination is the key of diagnosis, and surgical resection is the treatment of choice once malignancy cannot be excluded by preoperative analyses.

Clinical and biochemical features of seven adult adrenal ganglioneuromas

BACKGROUND

Adrenal ganglioneuroma (GN) is seldom considered in the differential diagnosis of adrenal lesions, and its clinical presentation is not well known.

OBJECTIVE

Our aim was to describe the clinical, biochemical, and radiological features of adrenal GNs in adults.

METHODS

Seven adults underwent endocrine investigation for adrenal lesions that were confirmed to be adrenal GNs.

RESULTS

Mean age of the seven patients was 49 yr (range, 23 to 71 yr). Average tumor diameter was 5.0 cm (range, 1.5 to 10.4 cm). In five patients, the adrenal lesions were found incidentally. A 49-yr-old female carried a germline mutation in MSH2 gene. A 57-yr-old female presented with mild virilization and increased testosterone levels. Bilateral adrenal venous sampling revealed testosterone production from her right adrenal lesion. All tumors showed nonenhanced attenuation between 25 and 40 Hounsfield units on computed tomography scan. Magnetic resonance imaging revealed low- to iso-signal intensity on T1-weighted imaging and high-signal intensity on T2-weighted imaging. [(18)F]-2-Fluoro-deoxy-d-glucose-positron emission tomography scan (n = 5) disclosed a mean standard uptake value of 2.4. Three tumors were composite pheochromocytoma-GN. Microsatellite instability study and immunohistochemical analysis of MSH2 protein in a patient carrying a MSH2 mutation showed normal MSH2 protein expression and low microsatellite instability, indicating that the adrenal GN was not related to the patient's MSH2 germline defect.

CONCLUSIONS

We describe one of the largest series of adult adrenal GNs. Adrenal GNs may secrete testosterone or be part of a composite tumor with pheochromocytoma. The association of adrenal GN with MSH2 mutation seems to be a coincidental finding.

Adrenal ganglioneuromas: incidentalomas with misleading clinical and imaging features

BACKGROUND

Ganglioneuromas are benign neoplasms of the neural crest, occurring rarely in the adrenal glands. This study presents our experience regarding diagnostic and therapeutic management of these neoplasms and a review of the relevant literature.

METHODS

Among 150 patients with of incidentalomas, we had 7 primary ganglioneuromas. Their clinical, imaging, and operative data were collected retrospectively, and the literature was reviewed using MEDLINE. There were 4 females and 3 males, with mean age of 50 years (range, 39-64). All neoplasms were discovered incidentally with ultrasonography and were evaluated subsequently with computed tomography (CT). One patient was studied further with (131)I-MIBG due to asymptomatic increased in urine vanillylmandelic acid, and 1 patient with history of breast cancer underwent additional FDG-PET/CT.

RESULTS

All but 2 patients were asymptomatic. Two patients complained of epigastric pain and hypertension, respectively. The preoperative mean size on CT was 6.8 cm, whereas the postoperative true mean histologic size was 7.7 cm. Both patients who were evaluated with radionuclide studies had false positive results, suggestive of pheochromocytoma and adrenal metastasis, respectively. Three patients underwent open adrenalectomy due to preoperative suspicion of carcinoma, and the remaining 4 underwent laparoscopic anterior adrenalectomy. Histologically, all 7 neoplasms were completely differentiated, mature ganglioneuromas. We had no mortality or significant morbidity. No recurrence occurred during a mean follow-up of 6 years (range, 1-18).

CONCLUSION

Adrenal ganglioneuromas are rare incidentalomas that can mimic primary or secondary adrenal malignancies as well as pheochromocytomas. Despite their usually large size, resection via laparoscopic approach is safe and effective.