[Paraganglioma of Zuckerkandl's organ. Report of two pediatric cases]

INTRODUCTION

Pheochromocytoma is an infrequent neuroendocrine tumor, originated from neural crest cells. 10% of them are extra adrenal, located at sympathetic nodules and are known as paragangliomas. The most common place is the Zuckerkandl organ, 10 to 26% are malign and has a mortality around de 26% of the cases.

CASE REPORT

We present two cases of teenagers with Zuckerkandl's organ paraganglioma, who debut with high blood pressure, diaphoresis and dyspnea. Complete tumor resection was performed in both cases, during which they presented hipertensive crisis and, after vascular pedicle ligation, hypotension.

CONCLUSIONS

Zuckerkandl's organ paraganglioma is a rare pathology in pediatric population, therefore represents an important diagnostic and therapeutic challenge. Surgery differs from other tumors because of catecholamine secretion that produces hemodynamic changes and demands prompt and accurate management from surgeon and anesthetist.

Risk factors related to metastasis of para-aortic lymph nodes in pancreatic ductal adenocarcinoma: A retrospective observational study

This study was designed to explore the risk factors related to metastasis of para-aortic lymph node (PALN).Clinicopathologic data of 241 patients with resectable or borderline resectable pancreatic cancer who underwent pancreaticoduodenectomy with extended lymphadenectomy between January 2008 and December 2015 were collected, potential factors related to metastasis of PALN were analyzed.Positive rate of PALN was 19.5% (47/241). Univariate analysis showed that back pain (P = .028), preoperative CA19-9 level (P < .001), tumor size (P < .001), portal vein (PV)/superior mesenteric vein (SMV) invasion (P < .001), superior mesenteric artery (SMA) invasion (P < .001), and diameter > 1.0 cm were in correlation with PALN involvement, multivariate analysis revealed that preoperative CA19-9 level, PV/SMV invasion, SMA invasion and diameter > 1.0 cm were independent risk factors to metastasis of PALN. Patients with LN8+ had a higher positive rate of PALN than with LN8- (38.1% vs 15.6%, P = .001), similar results could be found when LN12+ (35.8% vs 13.2%, P < .001) and LN14+ (41.2% vs 11.0%, P < .001), multivariate analysis showed that LN8+ and LN14+ were closely in correlation with PALN metastasis.Several factors were related to the status of PALN, preoperative CA19-9 level, PV/SMV invasion, SMA invasion and diameter > 1.0 cm were 4 independent risk factors to PALN metastasis. LN8+ and LN14+ were 2 strong predictors of PALN metastasis. A comprehensive analysis covering all possible risk factors related to metastasis of PALN should be given before design of treatment plan whenever involvement of PALN was suspected.

[Vascular anatomy and abnormalities of retroperitoneal pelvic and paraaortic area in relation to the radical oncogynecological surgery - individual experiences]

OBJECTIVE

The overview of vascular anatomy and abnormalities of retroperitoneal pelvic and paraaortic area in relation to the radical oncogynecological surgery.

DESIGN

Retrospective study.

SETTING

Gynecologic Oncology Center, Department of Obstetrics and Gynecology, Faculty of Medicine, Masaryk University and University Hospital Brno.

MATERIAL AND METHODS

The overview of visualized vascular anatomy of retroperitoneal pelvic, infrarenal suprapelvic and subhepatic area in relation to the radical oncogynecological surgery. Presentation of physiological vascular anatomy. Summary of the most common abnormalities and potential complications in terms of vascular injury. Basic management of these complications from the viewpoint of oncogynecologist.

CONCLUSION

The perfect knowledge of vascular anatomy and its possible abnormalities has represented an absolute necessity for uncomplicated course and sufficient extent of radical surgery.

Utility of alpha-blockade in a hypotensive pheochromocytoma patient with myocardial infarction

OBJECTIVE

The aim of this case study is to emphasize the importance of α-blockade in managing a rare complication of an untreated pheochromocytoma.

CLINICAL PRESENTATION AND INTERVENTION

A 41-year-old man with previous bilateral pheochromocytoma presented with chest pain. He was suffering from cardiac failure and persistent hypotension requiring an inotrope. Cardiac markers, an electrocardiogram and an echocardiogram confirmed acute myocardial infarct with poor ejection fraction and global hypokinesia. An (18)F-fluorodeoxyglucose PET/CT scan showed progressive left suprarenal and organ of Zuckerkandl pheochromocytomas. Blood pressure stabilisation proved challenging but was achieved by titrating an incremental dose of α-blocker against a tapering inotropic dose.

CONCLUSION

This case showed the efficacy of an α-blocker despite persistent hypotension in a patient with pheochromocytoma-induced cardiomyopathy.

FIGO IVB (para-aortic lymph adenopathy) squamous cell carcinoma of uterine cervix associated with a left pelvic kidney: a therapeutic challenge

The standard of care for locally advanced carcinoma of uterine cervix is concurrent chemoradiation therapy followed by intracavitary brachytherapy, when there is para-aortic lymphadenopathy, radiation field needs to be extended to para-aortic region. In the latter case dose limiting organs are spinal cord, kidneys and small intestine. We present a challenging case of FIGO IVB squamous cell carcinoma of cervix and a pelvic kidney. This patient received chemoradiation to pelvis and para-aortic field, brachytherapy was not performed as patient already had undergone attempted hysterectomy. Treatment, outcome and challenges encountered in this case are presented and literature is reviewed.

A large deletion in the succinate dehydrogenase B gene (SDHB) in a Japanese patient with abdominal paraganglioma and concomitant metastasis

Recently, mutations in nuclear genes encoding two mitochondrial complex II subunit proteins, Succinate dehydrogenase D (SDHD) and SDHB, have been found to be associated with the development of familial pheochromocytomas and paragangliomas (hereditary pheochromocytoma/paraganglioma syndrome: HPPS). Growing evidence suggests that the mutation of SDHB is highly associated with abdominal paraganglioma and the following distant metastasis (malignant paraganglioma). In the present study, we used multiplex ligation dependent probe amplification (MLPA) analysis to identify a large heterozygous SDHB gene deletion encompassing sequences corresponding to the promoter region, in addition to exon 1 and exon 2 malignant paraganglioma patient in whom previously characterized SDHB mutations were undetectable. This is the first Japanese case report of malignant paraganglioma, with a large SDHB deletions. Our present findings strongly support the notion that large deletions in the SDHB gene should be considered in patients lacking characterized SDHB mutations.

[Experience of complete Carney's triad showing pulmonary hamartoma associated with gastrointestinal stromal tumor and para-arotic paraganglioma]

A 34-year-old man, who had undergone the gastrectomy for gastrointestinal stromal tumor (GIST) and para-aortic paraganglioma 3 years before, was found to have a left lung tumor on a computed tomography. The tumor was revealed to be a pulmonary hamartoma, and diagnosed as Carney's triad. This is a rare case of complete type Carney's triad of an adult male.

Pelvic and para-aortic lymphadenectomy in patients with endometrioid adenocarcinoma of the endometrium

BACKGROUND

The purpose is to determine the rate of lymph node metastases in women with endometrioid adenocarcinoma of the endometrium (EAE) undergoing systematic lymphadenectomy.

METHODS

Patients (349) underwent a complete pelvic and para-aortic lymphadenectomy from caudal to the median circumflex to the level of the renal vessels.

RESULTS

Grade 1 tumors accounted for 32.7% of the tumors and 31.0% of the positive nodes, grade 2 accounted for 47.3% of the tumors (37.9% of positive nodes), and grade 3 accounted for 20.1% of the tumors and 31.0% of the positive nodes (P>0.05). Positive nodes were found in 15.8% of grade 1 tumors, 13.3% of grade 2 tumors and 25.7% of grade 3 tumors (P>0.05). Isolated para-aortic involvement without pelvic nodal involvement occurred in 29% of patients with positive nodes.

CONCLUSIONS

When complete lymphadenectomies are performed in EAE, positive lymph nodes (including isolated para-aortic lymph nodes) are common in all grades.

Laparoscopic transmesocolic excision of paraganglioma in the organ of Zuckerkandl

Extra-adrenal pheochromocytomas (paragangliomas) are rare. We report the case of a 20-year-old female at 15 weeks gestation, who was detected to have a large paraganglioma (6.5 x 5 cm) in the organ of Zuckerkandl during an antenatal visit. After medical termination of the pregnancy, successful laparoscopic excision of the paraganglioma was performed.

Organs of Zuckerkandl: their surgical significance and a review of a century of literature

BACKGROUND

Organs of Zuckerkandl (O of Z) harbor the potential for deadly paragangliomas. Paragangliomas are one of the surgical causes of hypertension. Major treatises of medicine offer very little information on this topic.

METHODS

PubMed Medline and Google searches were performed to obtain reported cases of paragangliomas of the O of Z. A total of 135 cases of paragangliomas of the O of Z were found. Each case was reviewed and charted. Charts then were analyzed.

RESULTS

Seventy-four percent of patients with this neoplasm have hypertension. Eighty percent of patients undergo an operation with more than 30% having an incorrect preoperative diagnosis. These tumors have a 43% mortality when presenting acutely.

CONCLUSIONS

Individuals aged < or =50 years with hypertension should be considered for screening for pheochromocytoma/paraganglioma with uring and/or serum catecholamines. Twenty-four-hour collections for urinary metanephrines and vanillylmandelic acid are diagnostic of functional tumors. A high degree of suspicion should follow with radiologic and chemical diagnostic studies. Triple-phase helical computed tomographic scans, metaiodobenzyl-guanidine scans, and magnetic resonance imaging with gadolinium-diethylenetriaminepentaacetic acid infusion are the standard for radiologic diagnosis. Treatment is always surgical excision. Phase II trials are in order for neoadjuvant and adjuvant treatment options.

Extra-adrenal pheochromocytoma: an unusual cause of deep vein thrombosis

We report a case of extra-adrenal pheochromocytoma within the organ of Zuckerkandl that presented initially with a left iliofemoral deep venous thrombosis (DVT). At the time of presentation, the DVT was thought to be idiopathic as no underlying cause was detected. Subsequently, because of a series of medical events, the patient was further investigated. This led to a diagnosis of extra-adrenal pheochromocytoma. We discuss the management of patients presenting with DVT, the nature of pheochromocytoma within the organ of Zuckerkandl, and problems relating to its diagnosis.

Retroperitoneal para-aortic paraganglioma

Paragangliomas or chemodectomas are neoplasms that arise from neural crest cells and histologically resemble their adrenal counterpart, the pheochromocytoma. Seventy-one percent of the extra-adrenal paragangliomas are located in the superior or inferior paraaortic area. This tumor usually presents as an abdominal mass producing back pain. Tumor localization has improved remarkably through the use of computed tomography and I131 metaiodobenzyl-guanidine scintigraphy, particularly when tumors are hormonally active. Surgical excision remains the mainstay of treatment, although vascularity can at times make excision difficult.

Pheochromocytoma of the organ of Zuckerkandl. Unusually small lesion detected with magnetic resonance imaging

A case report of a 40-year-old female with an unusually small pheochromocytoma of the organ of Zuckerkandl is discussed. The tumor is diagnosed by magnetic resonance imaging MRI examination, which was requested to evaluate her as a potential renal donor. There is a family history of Carney s triad gastric leiomyosarcoma, extra-adrenal pheochromocytoma and pulmonary chondroma. The MRI technique and findings are discussed.

Preaortic paraganglioma mimicking a hypervascular tumor of the pancreas

Paragangliomas are rare tumors that arise from neuroepithelial cells. They are most frequently located in the para-aortic region and they may be confused with other retroperitoneal tumors, especially pancreatic tumors. We present a case of a secreting preaortic paraganglioma in a young patient which was mimicking a hypervascular tumor of the pancreas, and that was completely resected 5 years after the failure of a first attempt to remove the tumor.

The interleukin-1 beta-converting enzyme inhibitor pralnacasan reduces dextran sulfate sodium-induced murine colitis and T helper 1 T-cell activation

The proinflammatory cytokines interleukin (IL)-1beta and IL-18 are supposed to play a crucial role in the pathogenesis of human inflammatory bowel disease. To exert biological activity, the precursors of both IL-1beta and IL-18 need to be cleaved by the interleukin-1beta-converting enzyme (ICE). IL-18 induces the synthesis of IFN-gamma in T cells and NK cells. In the present study, we investigated the effect of the specific ICE inhibitor pralnacasan in dextran sulfate sodium-induced murine colitis. Colitis was induced in BALB/c mice by 3.5% dextran sulfate sodium dissolved in drinking water for 10 days. Pralnacasan was administered either intraperitoneally or orally every day. To assess in vivo efficacy, a clinical disease activity score was evaluated daily. Colon length, expression of IL-18 in colonic tissue, expression of interferon-gamma (IFN-gamma) in paraaortal lymphocytes, and systemic production of IFN-gamma in splenocytes were analyzed post mortem. Intraperitoneally administered pralnacasan significantly reduced the clinical score compared with the dextran sulfate sodium control group from day 6 to day 10. Oral administration of pralnacasan also significantly reduced the clinical score at days 8 and 9. Administration of pralnacasan i.p. reduced the expression of intracolonic IL-18 significantly. Furthermore, pralnacasan reduced the number of IFN-gamma-positive lymphocytes in paraaortal lymph nodes. IFN-gamma synthesis in stimulated splenocytes was significantly suppressed in all pralnacasan-treated groups. No side effects of pralnacasan were observed. In conclusion, pralnacasan is effective in the prevention of dextran sulfate sodium-induced colitis. This effect is probably mediated by suppression of the proinflammatory cytokines IL-18, IL-1beta, and IFN-gamma.

Does systematic lymphadenectomy have a benefit on survival of suboptimally debulked patients with stage III ovarian carcinoma? A DEGOG* Study

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate whether systematic lymphadenectomy is necessary in suboptimally cytoreduced patients with stage III ovarian carcinoma.

METHODS

Prognostic significance and the effect on survival of systematic pelvic and para-aortic lymphadenectomy were investigated retrospectively in 61 suboptimally debulked patients with stage III ovarian carcinoma. All patients received platinum-based chemotherapy after surgery; 51 patients had been followed for > or =1 year, or until death. Survival curves were calculated according to the Kaplan-Meier method and were evaluated by log-rank test.

RESULTS

Most patients had stage IIIC disease (60.7%), poorly differentiated tumor (45.9%), and serous histological type (59%). Systematic pelvic and para-aortic lymphadenectomy was performed in 29 patients (47.5%). Lymph node metastases were found in 17 (58.6%) patients; the median number of metastatic nodes was 7 (5-10). Lymph node metastasis was significantly higher in patients with residual disease of >2 cm (P < 0.05). Both univariate and multivariate analyses showed that systematic pelvic and para-aortic lymphadenectomy was not a significant prognostic factor (P > 0.05). In lymph node-dissected patients, survival was significantly longer in patients with minimal residual tumor than in those with residual tumor size >2 cm (P = 0.005).

CONCLUSIONS

Lymphadenectomy seems not to have an evident prognostic value and a benefit on survival in suboptimally debulked patients with stage III ovarian carcinoma.

Lymphatic spread among women with primary peritoneal carcinoma

BACKGROUND AND OBJECTIVES

Our knowledge regarding the pathologic lymphatic spread pattern of primary peritoneal carcinoma (PPC) is limited. The aim of this study was to compare the incidence and the pathologic patterns of pelvic and para-aortic lymph node metastases among women with PPC and those with papillary serous ovarian carcinoma (PSOC).

METHODS

We conducted a prospective study over the last 4 years among women with FIGO stage III and IV PPC and PSOC who had optimal primary cytoreductive surgery (<1 cm residual). The same surgeon performed pelvic and para-aortic lymphadenectomy on all the patients using a similar technique. The same pathologist reviewed all lymph nodes and recorded nodal involvement with cancer, diameter of the largest nodal tumor, capsular integrity, and pattern of immune response (lymphocyte predominant, germinal cell predominant, unstimulated, or lymphocyte depletion). Both groups were compared in their characteristics, FIGO stage, tumor grade, number of lymph nodes, proportion of lymph nodes with metastases, and the pathologic characteristics of the positive lymph nodes.

RESULTS

Eleven women had PPC and 27 had PSOC. Patients with PPC were older than those with PSOC (mean age: 63.2 years +/- 11.0 vs. 57.4 +/- 13.4, P = 0.181). There was no difference in FIGO stage or tumor grade between both groups. There was no difference among the mean numbers of pelvic and para-aortic lymph nodes between women with PPC and those with PSOC (10.8 +/- 7.3 vs. 11.0 +/- 6.7 and 3.0 +/- 3.3 vs. 3.4 +/- 2.1, P = 0.768 and 0.706, respectively). The incidences of pelvic, para-aortic, and pelvic and/or para-aortic lymph node metastases were similar among women with PPC and those with PSOC (72.7% vs. 66.6%, P = 0.701, 72.7% vs. 48.1%, P = 0.172, and 72.7% vs. 77.8%, P = 0.736, respectively). Similarly, pelvic and para-aortic nodal tumor size, capsular integrity, and immune response were similar in both groups. The incidence of significant complications related to lymphadenectomy was low among women with PPC and those with PSOC (9.1% vs. 7.4%, respectively).

CONCLUSIONS

PPC and PSOC exhibit similar pathologic lymphatic spread patterns. Pelvic and para-aortic lymphadenectomy should be considered among women with PPC in whom the tumor could be optimally cytoreduced.

Laparoscopic lower para-aortic staging lymphadenectomy in stage IB2, II, and III cervical cancer

The presence of metastases in the para-aortic lymph nodes has important implications in the management of cervical carcinoma in many centers. In this study we investigated the role of laparoscopic lower para-aortic lymphadenectomy in patients with cervical carcinoma. In 42 consecutive patients with stage IB2-IIIB cervical carcinoma without suspicious para-aortic lymph nodes on CT scanning, a laparoscopic lower para-aortic lymphadenectomy was performed between January 1998 and April 2001. The transperitoneal route was used in the first 21 patients, and in the remaining 21 patients the procedure was started with the left retroperitoneal approach. The number of patients with stage IB2, II, and III was 7, 30, and 5, respectively. The median age was 51 years (range 30-81). The median weight and length were 62 kg (range 45-83) and 162 cm (range 150-175), respectively. In four patients-two operated via the transperitoneal route and the other two operated via the retroperitoneal route-the procedure was abandoned, in three patients because of adhesions following prior surgery and in one because of a camera failure. Conversion from the retropertitoneal to the transperitoneal approach was necessary because of a peritoneal tear in five of the 21 cases (all of them in the first 10 cases). Median estimated blood loss during the operation was 78 ml (range 10-300). The median hemoglobin (Hb) decrease was 1.3 g/dL (range 0-3.7). The median duration of the procedure was 64 min (range 20-115). Lymphadenectomy was stopped when one of the nodes was positive on frozen section. The number of para-aortic lymph nodes removed ranged from one to 15 (median 6). In seven (18%) of the 38 patients with successful lymphadenectomy, para-aortic metastases were observed (stage IB2, 1/6; stage II, 5/28 and stage III, 1/4). The only major complication was the development of a retroperitoneal hematoma on the first postoperative day in one patient (Hb fall of 3.7 g/dL). Patients with para-aortic lymph node metastases were treated with extended field para-aortic radiotherapy. None of these developed bowel obstruction. The median follow-up was 15 months (range 1-40 months). Actuarial 1-year crude survival was 88% and 33%, respectively, for patients with negative and positive para-aortic nodes. Laparoscopic para-aortic staging in cervical carcinoma is feasible with low morbidity. Eighteen percent of the patients, without suspicion of para-aortic metastases on CT, proved to have metastases in the lower para-aortic region.

Ki-ras codon 12 point and P53 mutations: a molecular examination of the main tumor, liver, portal vein, peripheral arterial blood and para-aortic lymph node in pancreatic cancer

OBJECTIVE

Frequent P53 mutations and Ki-ras codon 12 point mutations have been reported in pancreatic cancer. Pancreatic cancer often recurs in the liver and/or lymph nodes shortly after a surgical resection. The purpose of this study is to elucidate the occurrence of microcirculating cancer cells and micrometastasis in pancreatic cancer.

METHODS

P53 mutations and Ki-ras codon 12 point mutations were examined in the main tumor, liver, portal vein, and peripheral arterial blood, and para-aortic lymph nodes of patients with pancreatic cancer using molecular examinations.

RESULTS

P53 mutations in the main tumor were present in nine (29%) of 31 patients with pancreatic cancer, whereas a Ki-ras codon 12 point mutation was evident in 18 (62%) of 29 examined patients. The peripheral arterial and portal vein blood and liver were positive for gene abnormalities in one (5%) of 21, in none (0%) of 19, and in one (1%) of 20, respectively. A P53 mutation in the main tumor was evident in none (0%) of seven stage I or II carcinomas and in nine (38%) of 24 stage III or IV cases, whereas a Ki-ras codon 12 point mutation was present in four (67%) of six stage I or II cases and in 14 (61%) of 23 stage III or IV cases. In addition, 15 (71%) of 21 patients with gene abnormalities (Ki-ras codon 12 point and/or p53 mutation) in the main tumor showed lymph node metastasis at surgery, whereas five (42%) of 12 without gene abnormalities did not demonstrate lymph node metastasis. Two (29%) of six patients with gene abnormalities in the main tumor and without metastatic disease at surgery developed liver metastasis within 6 months after surgery, whereas all five (100%) without the gene abnormalities and metastatic disease at surgery did not develop the metastasis, with the sensitivity being 100%, specificity 44%, the predictive value of the positive test 36%, and the predictive value of the negative test 100%. Two patients who had gene abnormalities in the para-aortic lymph node were free from histopathological metastasis and these two patients developed para-aortic lymph node metastasis within 6 months after surgery.

CONCLUSIONS

A molecular examination of Ki-ras codon 12 and p53 mutations therefore enables us to predict, to some degree, the occurrence of liver and lymph node metastasis in pancreatic carcinoma.

Malignant hypertension and paraganglioma in a 14-year-old girl

A 14-year-old girl presented with malignant hypertension. Physical examination and abdominal computerized tomography revealed a paraaortic mass. Urinary catecholamines, serum renin, and aldesterone levels were high. The mass was totally excised and a paraganglioma of the organ of Zuckerkandl was confirmed. The hypertension resolved after surgery.

Left-sided laparoscopic para-aortic lymphadenectomy: anatomy of the ventral tributaries of the infrarenal vena cava

OBJECTIVE

We evaluated the anatomy of the infrarenal portion of the human inferior vena cava and their ventral tributaries by video laparoscopy.

STUDY DESIGN

A total of 112 patients underwent laparoscopic para-aortic lymphadenectomy for gynecologic malignancies. All procedures were videotaped. The number and anatomic distribution of the infrarenal tributaries of the anterior part of the inferior vena cava was evaluated retrospectively from videotapes. The inferior vena cava was divided into 3 levels: the area of the bifurcation of the vena cava (level 1), the area between the bifurcation and the inferior mesenteric artery (level 2), and the area between the inferior mesenteric artery and the right ovarian vein (level 3).

RESULTS

Tributaries were found in level 1 in 65 (58%) patients, in level 2 in 22 (19.6%) patients, and in level 3 in 1 (0.9%) patient; in 24 (21.5%) patients no tributaries were found. A total of 237 tributaries was counted: 82.3% (195 of 237) were located at level 1, 17.3% (41 of 237) at level 2, and 0.4% (1 of 237) at level 3. Patients with tributaries had a mean of 3 tributaries in level 1, a mean of 1.7 tributaries in level 2, and 1 patient had 1 tributary in level 3.

CONCLUSIONS

The ventral tributaries of the inferior vena cava show a specific distribution pattern. The knowledge of these anatomic landmarks can be important for laparoscopic surgeons to avoid accidental injury.

Cytokeratin expression in adrenal phaeochromocytomas and extra-adrenal paragangliomas

AIM

To examine whether adrenal phaeochromocytomas and extra-adrenal paragangliomas are immunoreactive for commercially available and routinely used cytokeratin antibodies.

METHODS

18 extra-adrenal paragangliomas and seven adrenal phaeochromocytomas were stained with CAM 5.2, AE1/3, and 34 beta E12 following microwave antigen retrieval of formalin fixed tissue.

RESULTS

A single case from the cauda equina was positive for both CAM 5.2 and AE1/3. In addition, two other cases--an intravagal and an orbital paraganglioma--also showed strong immunopositivity with CAM 5.2 and AE1/3. All phaeochromocytomas were negative with all epithelial markers.

CONCLUSIONS

Cauda equina paragangliomas are known to stain with cytokeratins; however, occasional paragangliomas from other sites may also be immunoreactive with cytokeratins. If the results of immunohistochemistry are not interpreted in the clinical and morphological context, the failure to recognise that extra-adrenal paragangliomas may on occasion react with anticytokeratin antibodies may lead to their being confused with metastatic carcinomas.

Systematic pelvic and paraaortic lymphadenectomy for advanced ovarian cancer: prognostic significance of node metastases

A retrospective study of 488 patients with untreated advanced ovarian cancer is presented. Systematic pelvic and paraaortic lymphadenectomy was performed in 248 cases (50.8%). Selective sampling and node biopsy was performed in 33 (6.7%) and 47 (9.6%) patients, respectively. Node metastases were found in 194 of 328 patients (59.1%). The incidence of metastatic nodes significantly increased with more advanced stages, with serous histology, and with a greater amount of residual tumor. Node status appeared to be related to pathology findings at second-look. A complete pathologic response was documented in 26 of 31 (83.8%) patients with negative nodes and in 38 of 59 (64.6%) with positive nodes at first surgery. Patients with negative nodes survived significantly longer (5-year survival, 46%; median, 60 months) than those who had node metastases (5-year survival, 25%; median, 36 months). Using multivariate analysis, lymph node status, together with the stage of disease and residual tumor, still had a significant impact on 5-year survival. Moreover, among patients with optimal cytoreduction, 5-year survival was 46% (median, 56 months) and 30% (median, 41 months) for patients who did and did not undergo lymphadenectomy, respectively (P = 0.05). Likewise, when suboptimal cytoreduction was considered, a median 5-year survival of 24 months was obtained in patients who underwent lymphadenectomy compared with 14 months in patients who did not (P < 0.005).

Successful treatment of neuroendocrine small cell carcinoma of the cervix metastatic to regional lymph nodes

Neuroendocrine small cell carcinoma of the cervix is an aggressive tumor that is associated with a poor prognosis. No reports have described a patient with metastatic spread who has had long-term survival. A patient with neuroendocrine small cell carcinoma of the cervix metastatic to regional lymph nodes who is free of disease 92 months after multimodality treatment with radiation, surgery, and chemotherapy is described in this paper.

Pelvic and para-aortic lymphadenectomy for surgical staging of high-risk endometrioid adenocarcinoma of the endometrium

The objective of this study was to analyze the results of pelvic and para-aortic lymphadenectomy in high-risk patients with endometrioid adenocarcinoma of the endometrium and no clinical or gross surgical evidence of extrauterine metastases. From August 1987 to October 1992, 50 patients with high-risk endometrioid adenocarcinoma of the endometrium had pelvic and para-aortic lymphadenectomy performed. The median number of lymph nodes removed was 18. No preoperative radiotherapy was administered. Pelvic lymph node metastases (20.0%) and para-aortic lymph node metastases (16.0%) were the most common sites of extrauterine metastases diagnosed. Eight patients (80.0%) with pelvic lymph node metastases also had para-aortic metastases. All 8 patients with para-aortic lymph node metastases had pelvic lymph node metastases. Pelvic lymphadenopathy was diagnosed on surgical exploration in 30% of patients with pelvic lymph node metastases, and para-aortic lymphadenopathy was present in 50% with para-aortic metastases. Six of 46 patients (13.0%) without pelvic or para-aortic lymphadenopathy had microscopic lymph node metastases. Palpation of the pelvic and para-aortic lymph node areas alone is inadequate in identifying patients with lymph node metastases. The addition of routine pelvic and para-aortic lymphadenectomy to TAH/BSO will identify subclinical lymph node metastases in a significant number of patients who may benefit from individualized postoperative therapy.

Intraoperative radiographs to confirm the adequacy of lymph node resection in patients with suspicious lymphangiograms

Between June 1991 and October 1992, we used presurgery lymphangiograms and intraoperative radiographs to identify and remove suspicious nodes in the pelvic and para-aortic chains of 19 patients with bulky pelvic cancers. Surgery comprised extraperitoneal exploration using a midline vertical or paramedian "J" incision. After grossly enlarged nodes were removed, an intraoperative anterior-posterior (AP) abdominal radiograph was obtained. The exposure field approximated the 24-hr delay AP LAG radiograph. Both films were compared in the operating room to confirm removal of abnormal nodes. Initial resection removed all suspicious nodes in 16 of 19 cases. Additional dissection resulted in successful node excision in the other 3 patients. Most of these "missed" nodes were behind or between vessels. The median number of nodes sampled was 15 (range 2-47). Bilateral sampling was performed in 15 cases. Metastatic tumor was present in 14 patients (74%) who had from 1 to 8 positive nodes. Of the 5 negative specimens, all contained lipogranulomata; two had extensive fatty replacement, 2 contained Müllerian inclusions, and 1 had reactive follicular hyperplasia which could be accountable for the radiographic abnormalities. Extracapsular extension was noted in 12 of 14 metastatic samplings. Radiotherapeutic treatment planning was then tailored to lymph node status and the location of positive nodes. Combined use of preoperative LAG and intraoperative films is useful in ensuring that complete resection of abnormal nodes has been accomplished. Whether removal of gross lymph node metastases enhances survival requires further study.

Treatment of metastatic para-aortic paraganglioma by surgery, radiotherapy and I-131 mIBG

A patient with a malignant, functioning, aortico-sympathetic paraganglioma and a solitary bone metastasis causing paraplegia was treated by spinal decompression, irradiation of the metastasis, surgical excision of the primary tumour and systemic I-131 meta-iodobenzyl-guanidine (mIBG). Sixteen months after treatment there was no clinical, radiological or biochemical evidence of residual disease and neurological function was restored. The case supports the use of combined treatment incorporating mIBG in patients with metastatic neuroendocrine tumours which demonstrate mIBG uptake.

[Lymphocyte beta 2-adrenergic receptors in pheochromocytoma]

To assess the effect of chronic exposure to high circulating catecholamine concentrations on the beta 2-adrenergic receptors, the density and affinity of lymphocyte beta 2-adrenergic receptors were measured in 5 patients with pheochromocytoma (2 males and 3 females, with a mean age of 39 +/- 12 years). In 4 patients the studies were repeated 15 days after tumor removal. Before surgery, all patients had high plasma catecholamine concentration. The density of beta 2-adrenergic receptors was reduced, although their affinity was within the reference range. There was an inverse correlation between plasma epinephrine concentration and beta 2-adrenergic receptor density (r = -0.959, p = 0.01). After surgical resection, plasma catecholamine concentrations and receptor density became normal. The dissociation constant decreased in the four patients. In conclusion, in the presence of chronically high levels of circulating catecholamines the density of lymphocyte beta 2-adrenergic receptors is reduced. However, it becomes normal when plasma catecholamine concentration returns to the reference values, the dynamic character of this regulation being thus shown. The measurement of these receptors in the lymphocyte could be useful for the diagnosis and follow up of patients with pheochromocytoma.

Emergency resection of phaeochromocytoma presenting with hyperamylasaemia and pulmonary oedema after abdominal trauma

Phaeochromocytoma may present as an acute emergency with a perplexing variety of symptoms. We report a case in which a tumour of the organ of Zuckerkandl was removed after its unexpected discovery during laparotomy for abdominal trauma. A patient is described in whom a history of abdominal trauma coupled with collapse, pulmonary oedema, raised serum amylase and a positive peritoneal tap for blood, led to laparotomy at which an extramedullary phaeochromocytoma was found unexpectedly. The tumour was successfully resected, but immediate hypotension was life threatening. The inadvisability of resecting a phaeochromocytoma discovered at operation is discussed.

Pheochromocytoma in the organ of Zukerkandl: I-131 MIBG scintigraphic localization

Scintigraphic localization of an extra-adrenal pheochromocytoma in a 27 year-old female with clinical and biochemical evidence of the disease is presented. While both ultrasonography and computed tomography were negative, I-131 MIBG scintigraphy successfully localized the extra-adrenal lesion in the organ of Zukerkandl.

Malignant pheochromocytoma: diagnosis and treatment in fifteen cases

This study reviews the diagnosis and treatment of 15 patients with malignant pheochromocytoma (MP) between 1958 and 1986 in Shanghai Rui-jin Hospital. The main clinical features consisted of sustained elevation of arterial blood pressure, obviously increased catecholamine secretion and a sustained positive phentolamine test. Out of 15 patients only seven survived, two of whom suffered from paraplegia due to metastatic cordal compression. Compared with some earlier results, the prognosis was unsatisfactory. There were several factors which may have been responsible: (1) late diagnosis; (2) incomplete operation, and (3) no regular post-operative assessment of urinary biochemical changes. Because MP is a tumour with a low degree of malignancy, noting the above three factors and using 131I-MIBG to obtain accurate diagnosis and effective treatment enables a better prognosis of this disease.

Malignant paraganglioma of the organ of Zuckerkandl. Initially diagnosed as renal cell carcinoma by biopsy of a right humeral fracture lesion

Malignant paraganglioma of the organ of Zuckerkandl (malignant POZ) in a 38-year-old woman is reported. Ten months before her death, the patient suffered from right shoulder pain. By biopsy of a pathological right humeral fracture, a histological diagnosis of metastatic renal cell carcinoma was initially made. However, autopsy revealed a left retroperitoneal tumor, which was diagnosed as malignant POZ. Upon immunohistochemical examination, tumor cells showed definite positivity for neuronspecific enolase (NSE) and chromogranins, and neurosecretory granules were found electron microscopically. The skeletal system is the most common site for distant metastases of malignant POZ. We were unable to find any previous reports of malignant POZ which were first manifested as humeral metastases, as in the present case. As paraganglioma might be histologically confused with a large variety of neoplasms (e.g. renal cell carcinoma), differential diagnosis of this condition is discussed.

[Pheochromocytoma of the organ of Zuckerkandl]

The authors report the case of a pheochromocytoma of the organ of Zuckerkandl in a 46 year old man. The clinical presentation was severe paroxysmal hypertension; the tumour was located by arteriography, CT scanning, and by scintigraphy with iodine labelled benzylguanidine. The blood pressure returned to normal after surgery. The embryological, anatomical and physiological features of the organ of Zuckerkandl are reviewed: the authors discuss briefly the modern methods of diagnosis and localisation of the tumour.

Pheochromocytoma of the organ of Zuckerkandl presenting as shock

A patient with unusual manifestations of pheochromocytoma, together with a relatively rare localization of the tumor in the organ of Zuckerkandl, is presented. There was a sharp fall in blood pressure to shock levels and transient severe cardiomyopathy, as evidenced by ECG changes, all of which disappeared postoperatively. We suggest several explanations for these unusual manifestations.

Lymphangiography, ultrasonography, and computed tomography in Hodgkin's disease and non-Hodgkin's lymphoma

Findings from histologic analysis, lymphangiography, ultrasonography, and computed tomography were reviewed for 54 cases of Hodgkin's disease and 18 cases of non-Hodgkin's lymphoma. All patients were classified as clinical stage 1 or 2 disease at the time of the imaging studies. The ultrasound and computed tomography studies identified only 30 to 40% of the truly positive patients. This low sensitivity contrasts with lymphangiography, which identified 95% of the truly positive Hodgkin's disease patients and 70% of the patients with abdominal spread of non-Hodgkin's lymphoma. Many errors in interpretation were attributable to location and distribution of disease in these patients and the differing patterns of spread in Hodgkin's disease and non-Hodgkin's lymphoma. The evidence indicates that when findings are positive on computed tomography or ultrasound, no other study is necessary. In stage 1 or 2 lymphoma, non-Hodgkin's patients with negative noninvasive findings and all Hodgkin's patients, regardless of their noninvasive findings, should undergo lymphangiography.

Ectopic decidual cell reaction in para-aortic and pelvic lymph nodes in the presence of cervical squamous cell carcinoma during pregnancy

Bilateral para-aortic lymphadenectomy is routine prior to radical surgery in cancer of the cervix. A pregnant patient with invasive cancer of the cervix and ectopic decidual cell reaction in para-aortic and pelvic nodes is presented. A decidual cell reaction in frozen sections of para-aortic lymph nodes could be confused with metastatic disease. Pathogenesis of ectopic decidual cell reaction is discussed.

Current management of paragangliomas

Since 1948, 33 paragangliomas in 32 patients were seen and studied at Charity Hospital. Tumors of the head and neck comprised the bulk of recorded instances, with only five paragangliomas being noted below the diaphragm. The most frequent symptoms correlated closely with tumor location and were related to local mass effect. Angiography remains an important diagnostic study for tumors of the head and neck with computed tomography scanning becoming increasingly important in large paragangliomas of the jugular region. Paragangliomas of the retroperitoneal space can be successfully located by a computed tomography scan, although a new radionuclide scan may prove to be more specific in the future. Tumors of the urinary bladder and retroperitoneal space are commonly endocrine functional and have a greater metastatic potential than do paragangliomas in other locations. Over-all, total excision is possible with complete recovery in most instances. Prolonged follow-up study is recommended, however, as local recurrences and distant metastases may present years after the initial diagnosis.