Paragangliomas of the head and neck region: a clinical study of 69 patients

Glomus vagale tumors

We present a case of a multicentric chemodectoma, with the unusual combination of a glomus vagale and a glomus tympanicum tumor. Multicentricity was suspected before selective carotid arteriography. Our patient, although asymptomatic, had elevated levels of urinary catecholamines preoperatively, which returned to normal postoperatively, suggesting biochemical activity of the tumor. Intraoperative hemostasis was assisted by the use of preoperative selective embolization of the tumor mass and the peripheral location of the injected Ivalon was confirmed histologically. The vagus nerve was anatomically spared and complete function was restored within 10 months. The asymptomatic small glomus tympanicum tumor was treated with embolization alone, as the patient chose to defer treatment at this time, but only time will reveal the effectiveness of this method of management.

Histopathology, cytology and cytochemistry of pheochromocytomas and paragangliomas including chemodectomas

The results of histopathological, histochemical and ultrastructural investigations on pheochromocytomas and paragangliomas have been reported. These results allowed the functional identification of the cell types composing many of such tumours. Moreover, comparison of these data with clinico-pathologic findings outlined the advantages and limits of cytologic studies for understanding the natural history of pheochromocytomas and paragangliomas and improving our diagnostic and prognostic criteria.

Nonfunctioning paraganglioma of the posterior mediastinum. Case report

A case of nonfunctioning paraganglioma of the posterior mediastinum in a 20-year-old white man is presented. The diagnosis of aorticosympathetic paraganglioma (Glenner-Grimley classification) was established by histologic examination after surgical removal of the tumor.

Paraganglioma of the cauda equina region. Clinicopathologic study of 31 cases with special reference to immunocytology and ultrastructure

Thirty-one paragangliomas of the cauda equina region were studied (18 men and 13 women, ages 30-71 years [mean, 51 years]). Symptoms (1 day to 15 years in duration; mean, 48 months) included low back pain (87%), sensory/motor deficits (35%), urinary/fecal incontinence (13%), and paraplegia (6%). All patients studied had some myelographic block. Cerebrospinal fluid protein level ranged from 56 to 7000 mg/dl (mean, 1109 mg/dl). Most tumors were limited to the filum terminale, although one also involved the conus medullaris and two clearly arose from a caudal nerve root. All but one were entirely intradural. The tumor was totally excised in 26 cases; these patients remain disease-free. Of three patients whose tumors were excised subtotally, two received radiotherapy; the one non-radiated patient died of tumor-related complications. No autopsy was performed. One partially encapsulated tumor that had been subjected to biopsy and irradiation presented 1 year later with osseous invasion and retroperitoneal extension; 20 years after subtotal excision, this patient is alive but paraplegic. Morphologically, all tumors resembled paraganglioma at other sites. Cytologic atypia and mitotic activity generally were absent to mild. Fourteen (45%) cases showed ganglionic differentiation. All tumors tested were immunoreactive for neuron-specific enolase and neurofilament protein, and most showed somatostatin or serotonin reactivity. S-100 protein immunoreactivity was noted in sustentacular cells and, to a lesser extent, within chief cells and neurons. The authors conclude that paragangliomas are largely benign and encapsulated and respond to simple resection. When surgically feasible, gross total removal should be the goal of surgery. When subtotal resection is necessary or when local invasion leaves a question as to completeness of tumor removal, irradiation seems mandatory although far from guaranteeing prevention of recurrence. Biopsy alone is undesirable.

Management of a glomus jugulare tumour with internal carotid artery involvement

A previously healthy 40-year-old female presented for surgical resection of a large glomus jugulare tumour with extensive involvement of the carotid siphon and intracranial extension. Conduct of anaesthesia with specific reference to cerebral protection is discussed. A combination of induced hypothermia, barbiturate therapy, normotension, normocarbia and prior clamping of the distal internal carotid artery was chosen. The role of barbiturates as a therapeutic intervention is debated.

Malignant retroperitoneal paragangliomas

The authors reviewed the clinical features of 13 cases of malignant retroperitoneal paragangliomas reported in the English literature and report the 14th case. The reported case represents the first such tumor occurring in the familial form of the disease. Good response to combination chemotherapy in the reported case emphasizes the need to study the role of chemotherapy in the management of this neoplasm.

Carotid body tumors: a subject review and suggested surgical approach

Carotid body tumors are a rare but potentially difficult surgical entity. Their pathology, physiology, and natural history are reviewed along with surgical results reported in the literature. A surgical approach for removal of these tumors is presented which differs significantly from the recommended techniques in that emphasis is placed on intraoperative monitoring of cerebral blood flow, the the selective use of shunts, a tumor-adventitial plane of dissection, preservation of the carotid artery complex, and mobilization of the parotid gland. Thirteen cases using these techniques are reviewed. The mortality rate and the incidence of cerebrovascular sequelae were both 0%. The major morbidity consisted of injury to the lower cranial nerves in five patients (39%) with tumors larger than 5 cm in length.

High-altitude paragangliomas diagnostic and therapeutic considerations

Forty-one cervical paragangliomas that occurred in 40 patients born and living in Mexico City, Mexico, were studied. Tumors were most common in women (38/40); were unilateral (39/40), without a side preference; were of the nonhereditary type; and were not malignant. Tumor imaging with radionucleaide angiographic scanning was noninvasive, innocuous, and reliable for screening, whereas selective carotid angiography allowed for definitive diagnosis and clinical stratification of patients. Surgical resection was performed in 29 patients; in 23 cases, en bloc resection was accomplished without a vascular compromise, whereas in 4 patients, a portion of the external carotid artery had to be ligated and resected. Two other patients required a vascular graft to restore blood flow to the internal carotid. Seven patients had postoperative transient cranial nerve palsies, and one had an incomplete hemiplegia. Permanent nerve damage occurred in seven patients. It was concluded that high-altitude paragangliomas are hyperplastic growths that result from adaptation to hypoxia. They are rarely true neoplasm and, in general, are not associated with functional loss. In view of this and of the high morbidity rate associated with surgical removal, it was recommended that these patients be referred to research centers where efforts toward the elucidation of the etiology and pathophysiology of these tumors can be carried out. Surgery should be reserved for symptomatic cases or cases in which the diagnosis remains in doubt. The decision to operate must weigh the following factors: The tumor's benign nature, its slow growth rate, the technical difficulties associated with its resection, the high postoperative morbidity rate, and the general condition of the patient.

Total internal carotid artery occlusion by a benign carotid body tumor: a rare occurrence

A rare case of a carotid body tumor that completely occluded the internal carotid artery is presented. To our knowledge this is only the second such case documented by angiography. In the present computed tomography era, the role of vascular imaging in these tumors is discussed and the varied clinical presentations of these neoplasms are reviewed. The confusion between the locally malignant behavior of some of these lesions and the accepted definition of a malignant carotid body tumor is discussed.

Laryngeal neuroendocrine tumour with features of a paraganglioma, intracytoplasmic lumina and acinar formation

A supraglottic laryngeal neuroendocrine tumour in a 71-year-old female is presented. In addition to the typical features of extra-adrenal paragangliomas it showed unusual, numerous intracytoplasmic lumina and occasional true acini with accumulation of alcian blue and PAS positive secretory product in them which led originally to an erroneous diagnosis of metastatic adenocarcinoma. Ultrastructurally, the tumour was composed of light and dark chief cells containing varying numbers of dense-core secretory granules. Intracytoplasmic lumina and true acini contained microvilli with glycocalyceal material and varying amounts of membranous and amorphous material, possibly secreted via small, smooth-surfaced cytoplasmic vesicles but typical mucin granules were not seen. These features have not been previously described in laryngeal paragangliomas but are seen in endocrine tumours of other sites and have been used as an argument in favour of an endodermal rather than ectodermal origin for endocrine cells in those sites. Laryngeal paragangliomas are often malignant and the presence of spasmodic pain appears to be the most reliable indication of possible malignancy, histological criteria being as yet poorly defined.

Malignant chemodectoma (paraganglioma) of the larynx. A case report with electron microscopy and biochemical assay

This reports presents a case of malignant chemodectoma in the epiglottic region of a 47-year-old man. His initial complaint was laryngeal discomfort and he expired from generalized metastases of the tumor about one year after operation. The tumor was detected by laryngoscopy and laryngogram. The yellow parenchymatous tumor, 2.8 x 2.5 x 1.5 cm in size, was resected together with two enlarged regional lymph nodes. The mass was subjected to a histopathological study and biochemical assay. Microscopically, the tumor was located in the submucosa of the epiglottis and showed an alveolar growth pattern of comparatively uniform tumor cells. Neurosecretory granules were clearly demonstrated by Grimelius' method and by electron microscopy. The biochemical assay revealed that the tumor contained small amounts of serotonin, epinephrine, norepinephrine, and dopamine. The distribution of paraganglia as the source of these tumors, the clinicopathological review of the previous reports and significance of neurosecretory granules are discussed.

Paraganglioma of the cauda equina. Report of a rare tumor

The rare occurrence of a paraganglioma of the cauda equina is described. The correct diagnosis was made only retrospectively after examination of a recurrence nine years after initial surgery. Paragangliomas have not been mentioned in large tabulations of spinal cord tumors, perhaps reflecting the fact that it is only within the last decade that such tumors have been recognized in this unusual location. A literature review has revealed six cases of paraganglioma of the cauda equina reported since 1970. An awareness of the possibility of a paraganglioma intimately associated with the spinal cord as well as the histopathologic appearance are the bases of a correct diagnosis. These tumors are histopathologically similar to paragangliomas in conventional locations, exhibit ultrastructural granules and may, as in the current case, also demonstrate argyrophilic granules.

Surgical management of tumors of the middle ear and mastoid

The author has presented the two most common tumors of the ear, cancer of the ear and glomus tumors. Most experience has been with extensive carcinomas involving the temporal bone and indeed the author has treated 132 cases with cancer of the ear, of which 105 cases were resectable. The total experience yielded a cure rate of 28 per cent. The best management program should entail an en bloc resection of the temporal bone followed by post-operative radiation therapy. Glomus tumors are generally benign and when confined to the middle ear present no surgical problem. However, when extension occurs into the jugular bulb region and into the jugular vein, the surgery becomes more formidable and the extent of the tumor should be established before surgery. Wide surgical exposure should avoid entering into the tumor prematurely and thereby compromising a total resection. Advanced extension of the tumor intracranially mandates a combined neurosurgical and otolaryngological approach. Radiotherapy, while not destroying the glomus tumor, will shrink down the size of the tumor by causing thrombosis in its blood vessels and subsequent fibrosis of the tumor itself. The management of each tumor should be individualized according to its size, location, and the general status and age of the patient.

Cyanotic congenital heart disease with malignant paraganglioma

A malignant paraganglioma of the subclavian (supra-aortic) area and organ of Zuckerkandl with metastases to the liver and pancreas was discovered at autopsy in a 22-year-old man with known transposition of the great arteries. Light microscopy showed the typical "Zellballen" pattern and Grimelius stain showed intracytoplasmic argyrophilic granules, which appeared ultrastructurally as electron dense granules. Review of the literature disclosed 59 previously reported cases of hypoxia associated with endocrine tumors. The case presented is believed to be the first example of a subclavian paraganglioma associated with hypoxemia. One previous case of a paraganglioma arising in the organ of Zuckerkandl that occurred in a hypoxic state has been reported. The possibility of cyanotic congenital heart disease with chronic long-standing hypoxia, predisposing to the development of paraganglioma with malignant transformation is presented.

Paraganglioma of the sphenoid sinus appearing as labile hypertension

Paragangliomas, also known as glomus tumors, are unusual, generally benign tumors most commonly found in association with major vessels and cranial nerves. Only a small number of these tumors have been described arising in the paranasal sinuses, and none of these has been physiologically active. The following case report describes a metabolically active paraganglioma arising in the sphenoid sinus.

Neck paraganglioma with a pituitary adenoma. Case report

✓ A 66-year-old man presented for evaluation of a mass of the sella turcica. Previously, he had undergone resection of a neck paraganglioma, which subsequently metastasized to the lungs. A tumor was removed transsphenoidally that proved to be a pituitary adenoma. This combination failed to fit the classical multiple endocrine neoplasia syndromes.

Functioning paraganglioma in the posterior mediastinum

An unusual case of a functioning paraganglioma originating from the posterior mediastinum is reported. The main indications in the 21-year-old patient were hypertension and an abnormal roentgenogram of the chest. Blood and urine catecholamine assay confirmed the diagnosis of norepinephrine-secreting tumor, which was covered by the parietal pleura and attached to the sympathetic trunk. In the literature we could find reports of 25 patients with paraganglioma arising from the sympathetic trunk in the posterior mediastinum, 8 of whom had some symptoms and only 3 of whom were assayed for catecholamines. We diagnosed the present tumor as functioning aorticosympathetic paraganglioma according to the new classification and terminology suggested by Glenner and Grimley [1].

Nonfunctional paraganglioma of the larynx: clinical and pathological considerations

Paraganglioma of the larynx is a rare neoplasm. A review of the 16 previously reported cases in English medical literature is presented along with the details of an additional case. The tumor was analyzed by light and electron microscopy. The anatomy and embryology of the laryngeal paraganglia and controversies in nomenclature are discussed. Hoarseness, pain, dysphagia, and neck mass are the cardinal symptoms of this neoplasm; other clinical characteristics are reviewed. Partial laryngectomy and excision via lateral pharyngotomy and extralaryngeal approaches are the most commonly employed methods of treatment. More aggressive therapy including radical neck dissection, total laryngectomy, and radiation therapy have been used for malignancies.

Malignant carotid body tumors: report of two cases and review of the literature

Paragangliomas may arise in any area of the body where nonchromaffin paraganglia are situated. These include the glomus jugulare, the carotid body, and the retroperitoneum. Malignant behavior of these paragangliomas has been a controversial subject with most authors, who consider them to be benign tumors. Some authors have diagnosed locally recurrent and infiltrative tumors as malignant, whereas most require the demonstration of metastatic potential as the only criterion for malignancy. Two cases of metastasizing carotid body tumors are reported with a review of the literature on this unusual neoplasm.

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.

Malignant carotid body paraganglioma: light and electron microscopic study of the tumor and its metastases

A right carotid body paraganglioma (CBP) was removed from a 30-year-old female after finding metastases to cervical lymph nodes. The tumor and its metastases were studied by light and electron microscopy to determine the neoplastic cell type. Light microscopy confirmed the presence of chief cells but was inadequate alone to exclude sustentacular cells. By electron microscopy, only chief cells were found in both the primary and secondary tumors. This is the first report of an ultrastructural study of a metastasis from a malignant CBP. From our observation, we suggest that CBP be defined as a proliferation of chief and sustentacular cells. Electron microscopy is essential to determine the cell types present and thereby help classify the lesion as a tumor or hyperplasia of the carotid body.

Laryngeal paragangliomas: evaluation and treatment

Paragangliomas are uncommon laryngeal tumors. A comprehensive review of the world literature disclosed the use of a variety of terms to designate the same disease as a result of the historical uncertainty of its origin. Important features of these neoplasms not previously reported include the high mortality rate in patients presenting with laryngeal pain and the need for longer follow-up periods to judge biological aggressiveness. An additional patient is presented to illustrate the diagnostic and therapeutic challenges inherent in the management of laryngeal paragangliomas. Radiotherapy has not been found to be beneficial, and surgery remains the treatment of choice for patients with laryngeal paragangliomas.

Panel discussion: glomus jugulare tumors of the temporal bone. Radiation of glomus tumors of the temporal bone

In a study done at the Geisinger Medical Center in 1976, the results of treatment of 30 cases of glomus tumors involving the ear were reviewed. All 8 cases of glomus tympanicum were controlled with surgery and all of the cases of glomus jugulare treated with high voltage radiotherapy were controlled for from 2 to 12 years. Currently, the length of control extends to 15 years and there have been no late recurrences. Three additional cases showing unusual features of glomus jugulare are presented.

Paragangliomas of the head and neck region. A pathologic study of tumors from 71 patients

The histopathology of 72 paragangliomas originating in the head and neck region of 71 patients is presented. There were 45 carotid body, 13 vagal body, eight jugulotympanic, and three nasal paragangliomas. In addition, two arose in the larynx and one in the area of the aortic arch. Tumors occurred in four unrelated families. The two most important histologic features leading to a diagnosis of paraganglioma were zellballen and the presence of cytoplasmic argyrophil granules in all cases in which staining with the Grimelius technique was carried out. Ultrastructural study of three carotid body and two vagal body paragangliomas revealed both light and dark chief cells. Tumor cells contained membrane bound, electron dense neurosecretory types of granules, which usually ranged in diameter from 120 to 200 nm. Follow-up information was available for 67 patients (94 per cent). Two of the three nasal paragangliomas, 50 per cent of the jugulotympanic paragangliomas, 17 per cent of the vagal body paragangliomas, and 10 per cent of those of the carotid body recurred locally following attempted surgical resection. All patients treated with radiation had persistent tumor. Four (9 per cent) of the carotid body paragangliomas were malignant, all four patients dying with widespread metastases. One vagal body paragangliomas metastasized to regional lymph nodes (the patient was alive and well at five years), and another caused death by direct intracranial extension. In contrast to the benign tumors, malignant paragangliomas tended to show foci of necrosis and vascular invasion. Mitotic figures, which usually were not identified in the benign cases, were seen in all malignant tumors.

Aortico-pulmonary paraganglioma: report of a case with ultrastructural study and review of the literature

The light microscopic and ultrastructural features of an aortico-pulmonary paraganglioma (A-PP) are presented. The tumor was characterized by organoid clustering of neoplastic chief cells to form Zellballen. Argyrophilic granules were demonstrated within chief cell cytoplasm using a modified Grimelus technique. Ultrastructurally, three distinct cell types were present within the tumor: endothelial cells, pericytes and neoplastic chief cells. Membrane-bound neurosecretory granules were present and measured 100 to 2000 nm in diameter. "Light" and "dark" chief cells were less distinct than previously reported in other head and neck paragangliomas. Analysis of the 36 documented A-PP reported in the English literature reveals that the tumor has been either incompletely excised or has been considered unresectable in one-third of the cases. The reported surgical mortality is 9%, or approximately equal to the incidence of malignant behavior. The treatment of choice is surgical resection but when this is not possible, radiation may be a useful adjunct in therapy.

Chemodectoma of the larynx. A clinico-pathological study

The present case report is concerned with a clinico-pathological study, including ultrastructural investigation, of a rare and uncommon laryngeal tumour, a chemodectoma, in a 62 year old patient. There have been 23 cases of laryngeal chemodectomas reported in the literature, and only three of them, including our own report, were investigated by electron microscopy. The tumours arise from the superior and inferior larynegeal nonchromaffin paraganglia or possibly from Kultschitzky-cells of the normal bronchial mucosa. Ultrastructurally they have all the characteristics of apudomas whose parent cells (APUD-cells), usually show endocrine function and probably have their origin in the neural crest. The tumours show an aggressive type of behaviour, despite usually benign histological features when compared to chemodectomas at other sites in the head and neck region. Surgery is thus the therapy of choice.

Mediastinal paragangliomas (aortic body tumor): a report of four cases and a review of the literature

Four cases of paraganglioma originating in the supra-aortic or aortico-pulmonary bodies are described. A review of the reported examples of aortic body tumors and a study of these four cases indicate that there is a high incidence of aggressive tumor growth in the mediastinum, with resultant important morbidity or death in 16 of 35 cases. The morphologic features of aortic body tumors are identical to those of paragangliomas of other locations, and the occurrence of invasive growth and/or metastasis cannot be predicted on histologic grounds.