Intracranial catecholamine secreting paragangliomas

Three intracranial catecholamine-secreting paragangliomas are described. They involved a glomus jugulare, a sphenopalatine ganglion and the clivus and upper cervical spine respectively. The extent of the tumours was shown by CT and MRI. They were all highly vascular with a substantial blood supply from systemic arteries which was subjected to particulate embolisation, followed in two cases by surgery. The importance of studying any tumour which could possibly be a paraganglioma for hormonal and, especially, for catecholamine secretion prior to any invasive procedure, including angiography and embolisation, is emphasised: all such procedures should be covered with catecholamine blocking agents and, in addition, carefully monitored with resuscitation facilities immediately available.

Catecholamine-secreting paragangliomas of the base of the skull. Report of two cases

Two cases of catecholamine-secreting paragangliomas of the base of the skull are described. The patients presented with uncontrollable hypertension and, after investigation, tumors were discovered in the regions of the glomus jugulare and pterygopalatine ganglion, respectively. After cardiovascular stabilization and tumor embolization, the tumors were surgically removed, with subsequent resolution of hypertension. The incidence of these tumors is discussed.

Duodenal gangliocytic paragangliomas: a study of 10 cases with immunocytochemical neuroendocrine markers

Ten cases of duodenal paraganglioma were studied by conventional histologic and immunocytochemical techniques at both light and electron microscopic levels. Histologically, mixtures of epithelial, ganglion, and spindle cells were seen. In all of the cases immunoreactivity for neuron-specific enolase (NSE) and protein gene product (PGP) 9.5 was seen in each component. Pancreatic polypeptide immunoreactivity was detected in eight cases, mainly in epithelial cells. Somatostatin immunoreactivity was present in epithelial and ganglion cells in nine cases. In seven cases immunoreactivity for neurofilaments, a marker for neurons, was seen in ganglion and spindle cells. However, immunoreactivity for chromogranin, a protein found in endocrine storage granules, was found in only two cases, and the staining was confined to well-granulated epithelial cells. The spindle cells were immunostained only for neuronal markers, NSE and neurofilaments, and the glial marker S-100 protein.

Multiple endocrine neoplasia with Cushing's syndrome due to paraganglioma producing corticotropin-releasing factor and adrenocorticotropin

A male patient with corticotropin-releasing factor (CRF) and adrenocorticotropin (ACTH)-producing syndrome is described. Soon after being referred to us the patient developed pneumonia, anaemia, oedema and respiratory distress, and died on the 24th day after admission. Autopsy and histology revealed that he had a rare type of multiple endocrine neoplasia (type 1 + paraganglioma) with a mediastinal paraganglioma, parathyroidal hyperplasia, pancreatic islet cell adenoma, duodenal multiple carcinoid tumours and adrenocortical nodular hyperplasia. It was not possible to examine the pituitary. The paraganglioma contained a large amount of immunoreactive (IR)-CRF (606 ng/g wet weight), IR-ACTH (59.4 ng/g wet weight), IR-human proopiomelanocortin n-terminal (1-76) peptide (hNT, 156.8 ng/g wet weight) and IR-beta-lipotropin (beta-LPH, 146.9 ng/g wet weight). The major IR-ACTH, beta-LPH and IR-hNT were eluted at ACTH-(1-39), beta-LPH and hNT marker positions, respectively. Big ACTH was not detected. IR-CRF eluted at the human CRF marker position on Sephadex G-75 chromatography and high performance liquid chromatography (HPLC). The IR-CRF fraction from the HPLC showed CRF bioactivity which paralleled that of synthetic human CRF in monolayer cultured rat anterior pituitary cells. Our results suggest that not only ACTH but CRF produced by the paraganglioma was responsible for the patient's Cushing's syndrome.

Paraganglioma of urinary bladder in patient with neurofibromatosis

Pheochromocytoma in patients with von Recklinghausen's neurofibromatosis is a well-known association. However, extra-adrenal pheochromocytoma with this association is rare. Herein we report a case of urinary bladder paraganglioma in a patient with neurofibromatosis.

[Ectopic hormone production and gene expression in tumors]

Recent progress in research into ectopic hormone production and hormone gene expression in tumors is reviewed. Biochemical, immunochemical and morphological studies have shown that differentiation between "ectopic" and "eutopic" has become difficult and that the types of peptide hormones, neural peptides and growth factors produced, their molecular heterogeneities and ability of plural hormone production are greatly different in each tumor. Recently, the gene structures of many hormones and amino acid sequences of hormone precursors have been determined by genetic recombination techniques. However, the nature of hormone genes, the mechanism of gene expression and the processing mechanisms of hormone precursors in normal and tumor cells remain to be studied.

Meta-[I-131]iodobenzylguanidine uptake in a nonsecreting paraganglioma

In a patient with a paraganglioma at the carotid bifurcation, intense uptake of meta-[I-131]iodobenzylguanidine (I-131 MIBG) in the tumor was found. There was no clinical or biochemical evidence for catecholamine secretion by the tumor, although analysis of the tissue revealed that catecholamine biosynthesis took place. We conclude that accumulation of I-131 MIBG may occur in a paraganglioma, but does not necessarily indicate endocrine activity of the tumor.

Gangliocytic paraganglioma of the duodenum: an immunocytochemical study

Two cases of duodenal paragangioliomas that were studied using light microscopy and immunocytochemical methods are reported. The tumors showed immunoreactivity to somatostatin, cholecystokinin, calcitonin, gastrin, vasoactive intestinal polypeptide, serotonin, met-enkephalin, leu-enkephalin, and substance P. The similarities of duodenal paragangioliomas to other neoplasms occurring in similar anatomic locations are outlined.

A functioning catecholamine-secreting vagal body tumor. A case report and review of the literature

There are few cases of catecholamine-secreting paragangliomas of the neck reported in the literature, most of these being of the carotid body and glomus-jugulare type. This report cites the second case of a functioning vagal body tumor secreting norepinephrine predominantly and producing labile hypertension and symptoms of pheochromocytoma. A brief update on vagal body tumors and a review of the functioning paragangliomas of the head and neck are also presented.

Use of metyrosine in the anaesthetic management of patients with catecholamine-secreting tumours. A case report

Metyrosine 1.5 g daily for days decreased 24-h urine metanephrine concentration by about 60% in a patient with multiple catecholamine-secreting paragangliomas. Despite the considerable inhibition of catecholamine synthesis, this patient exhibited stress-induced sympathetic overactivity, indicated by increases in arterial pressure and serum catecholamine and urine metanephrine concentrations. It is concluded that metyrosine should be introduced early to the preoperative regimen. In this way, optimal inhibitory effect on catecholamine synthesis can be obtained and maintained for a sufficient time to allow catecholamine stores to become as close to normal as possible. Attainment of the optimal therapeutic effect is not clearly defined, but would seem to be best gauged by a combination of clinical tests of sympathetic responses and of suppression of urinary excretion of metanephrines or VMA.

Paragangliomatosis with numerous catecholamine-producing tumors

Catecholamine-producing tumors may be found wherever paraganglion tissue exists, and they may be associated with a variety of conditions (multiple endocrine neoplasia types 1, 2a and 2b). The patient described in this report had 21 paragangliomas removed between the ages of 13 and 17 years, and she has evidence of additional tumors. This is the greatest number of paragangliomas reported, and the tumors involved numerous sites. In addition, the patient has multiple congenital anomalies that have not been reported previously in association with paraganglioma. Unifying theories of pathogenesis and several features in the management of this patient are discussed.

Immunoreactive somatostatin in catecholamine-producing extra-adrenal paraganglioma

A patient with catecholamine-producing extra-adrenal paraganglioma was found to have a high concentration of immunoreactive somatostatin (IR-SRIF) in the peripheral blood plasma (47.0 pg/ml, normal; 13.3 +/- 5.3 pg/ml, mean +/- SD). After removal of the tumor, the plasma SRIF level fell within normal range (8.7 pg/ml). In the resected tumor, a considerable amount of IR-SRIF (71.0 ng/g wet weight)( was also detected and SRIF-positive tumor cells were demonstrated by the immunoperoxidase technique. Chromatographic analysis of an extract of the tumor showed the presence of two IR-SRIF components of large molecular size besides a component consistent with authentic tetradecapeptide SRIF (SRIF 14), and one of these had the same molecular size as octacosapeptide SRIF (SRIF 28). This seems to be the first report of a catecholamine-producing extra-adrenal paraganglioma that produces IR-SRIF with molecular heterogeneity.

Cushing's syndrome due to ectopic ACTH production by a nasal paraganglioma

A patient is described with Cushingoid features and a tumor of the paranasal sinuses. Laboratory studies revealed hyperglycemia, hypokalemia, alkalosis, hypercortisolemia, and elevated serum ACTH levels. The cortisol level increased briskly in response to parenteral ACTH, but was only partially suppressed by dexamethasone. Microscopically, the tumor was found to be a paraganglioma containing many neurosecretory granules.. Treatment with methyrapone, o,p'DDD, and irradiation of the tumor resulted in a lasting remission. It is concluded that this unique patient suffered from Cushing's syndrome due to ectopic ACTH production by a paraganglioma of the paranasal sinuses.

Tracheal paraganglioma: a case report with review of the literature

Only three cases of tracheal paraganglioma have been reported in the literature. This paper describes an additional case, which showed pharmacological and ultrastructural evidence of hormone secretion. It is suggested that this tumor is derived from true paraganglia located in the trachea and not from misplaced or aberrant paraganglionic tissue. Hemoptysis was the only presenting symptom in two of the four reported cases and significant bleeding occurred during biopsy in the other two cases. The long-term prognosis appears good if complete resection is possible.

Tracheal paraganglioma: a case report with review of the literature

Only three cases of tracheal paraganglioma have been reported in the literature. This paper describes an additional case, which showed pharmacological and ultrastructural evidence of hormone secretion. It is suggested that this tumor is derived from true paraganglia located in the trachea and not from misplaced or aberrant paraganglionic tissue. Hemoptysis was the only presenting symptom in two of the four reported cases and significant bleeding occurred during biopsy in the other two cases. The long-term prognosis appears good if complete resection is possible.

The triad of gastric epithelioid leiomyosarcoma, functioning extra-adrenal paraganglioma, and pulmonary chondroma

The triad of gastric epithelioid leiomyosarcoma, functioning extra-adrenal paraganglioma, and pulmonary chondroma was found in two young female Mayo Clinic patients, and two of these tumors occurred in another two. Review of the world literature disclosed nine patients who probably had two or more of the three neoplasms. We are also aware of two other patients with two of the three tumors. The association of gastric epitheloid leiomyosarcoma, functioning extra-adrenal paraganglioma, and pulmonary chondroma may well constitute a syndrome because of 1) the improbability of the coincidental occurrence of this triad of tumors, 2) the multicentricity of the tumors in the organs or system affected, and 3) the development of the tumors at a young age. Because two of the components of the triad are potentially lethal, it is important that patients less than 35 years of age who have any one of the three tumors be examined periodically to search for the others.

[Biosynthesis of C19- and C21-steroids in tissue slices of paraganglioma and pheochromocytoma (author's transl)]

The biogenesis of C19- and C21-steroids has been studied in tissue slices of a paraganglioma, of a pheochromocytoma and of human adrenal cortex using radioactive steroids. Slices of paraganglioma as well as of pheochromocytoma metabolise 17-hydroxyprogesterone to cortisone, cortisol, 11-deoxycortisol and testosterone. The rate of formation of these steroids, however, by the two tumours is 8--15 times less than that in normal adrenal cortex tissue. After incubation of dehydroepiandrosterone with tissue slices of paraganglioma and pheochromocytoma, 7alpha-hydroxydehydroepiandrosterone, 11beta-hydroxy-4-androstene-3,17-dione and 4-androstene-3,17-dione were found as metabolites; testosterone was converted by both tissues to 4-androstene-3,17-dione. 17-Hydroxypregnenolone was converted to a small extent (1.7%) to dehydroepiandrosterone by slices of paranganglioma. These results show that enzymes of steroid biosynthesis (hydroxylases, oxidoreductases, delta4(-5)-isomerases, C17(-20)-desmolases) are present in both paraganglioma and pheochromocytoma.