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

Presentation of metastatic carotid body paraganglioma on F-18 FDG PET/CT: a rare disease

Carotid body paraganglioma is a slow growing tumor of head and neck region. It can rarely be malignant in nature which is characterized by distant metastases on anatomical imaging. We share an interesting presentation of a malignant carotid body on F-18 FDG PET/CT in form of liver and skeletal metastases.

The Radiosurgery Society Case-Based Discussion of the Management of Head and Neck or Skull Base Paragangliomas with Stereotactic Radiosurgery and Radiotherapy

Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) have been used for the treatment of head and neck or skull base paraganglioma for a considerable time, demonstrating promising local control rates and a favorable safety profile compared with surgical approaches. Nevertheless, the choice of treatment must be carefully tailored to each patient's preferences, tumor location, and size, as well as anticipated treatment-related morbidity. This case-based review serves as a practical and concise guide for the use of SRS and FSRT in the management of head and neck or skull base paragangliomas, providing information on the diagnosis, treatment, follow-up considerations, and potential pitfalls.

Exploring Head and Neck Paraganglioma: A Case Report

Paragangliomas (PGLs) are tumors that are rarely malignant; the majority of them are benign. Similar to pheochromocytoma, they develop from the autonomic nerve system. This system originates from neural crest cells and can undergo neoplastic transformation. PGLs can arise either inside or outside the adrenal glands. Head and neck PGLs are very scarce. The primary locations where this tumor commonly originates within this region are the carotid body, jugular bulb, and vagal body. Hence, in our case report, we attempt to highlight the uncommon presentation of this disease in a 46-year-old female, who initially presented with hypertension and persistent dysphonia. The patient underwent successful external radiotherapy. This case report aims to raise awareness of the characteristics of these rare malignancies.

Carotid Body Tumor: A Case Report and Review of Literature

Carotid body tumour (CBT) is a rare hypervascular tumor in the head and neck region. It develops from neural crest origin paraganglionic tissue which is an arterial chemoreceptor. It presents as a slow growing mass at the carotid bifurcation. Its optimal evaluation and treatment requires involvement of multiple specialities. Because of the high rate of neurovascular complications, resection of this tumor is challenging for surgeons. Early tumor detection, meticulous evaluation and multidisciplinary approach are vital for successful management of these tumors. A case of CBT in a 50 year-old lady managed at our centre is being reported here along with a review of literature.

Neurological Manifestations of Paragangliomas of the Head and Neck

PURPOSE OF REVIEW

This paper will outline the clinical neurologic presentation and diagnostic evaluation of patients with paragangliomas of the head and neck. Contemporary management options will be outlined for these rare and complex tumors.

RECENT FINDINGS

The majority of recent publications and research on these tumors are dedicated to traditional and robotic image-guided radiosurgery in the treatment of head and neck paragangliomas. Paragangliomas are rare, slow-growing tumors of the head and neck which usually cause silent cranial nerve deficits or compensated mild speech or swallowing symptoms. While radiologic surveillance is often the best treatment option, subtotal resection with case-specific radiosurgery is commonly used in patients with large tumors.

Thoracic Extradural Paraganglioma Localized on 68Ga-DOTANOC PET/CT

ABSTRACT

We present the case of a 33-year-old woman with complaints of headache and palpitations with raised urinary catecholamines. Ultrasound of the abdomen was noncontributory, and the patient was referred for 68Ga-DOTANOC PET/CT, which revealed tracer accumulation in the thecal sac/spinal canal at D5-D7 level, suggestive of a thoracic paraganglioma. MRI of the spine subsequently confirmed the presence of an extradural mass in the spinal canal extending from D4 to D8.

Long-Term Surgical Outcomes of Carotid Body Tumors With Pathological Fibrosis: A Cohort Study

Objective

To compare the surgical outcomes of carotid body tumor (CBT) with or without pathological fibrosis, and evaluate the associated factors of fibrous CBT (FCBT).

Materials and Methods

Paraffin-embedded tissues of 236 patients with unilateral CBTs at our center were retrospectively reviewed from January 2008 to May 2020. Based on the pathologic features, CBTs were divided into FCBT and conventional CBT (CCBT) groups. The clinical data and surgical outcomes of the two groups were compared.

Results

Of 236 patients, 53 had FCBT and 183 had CCBT. FCBTs showed higher vascular invasion (24.53%), marked pleomorphism (22.64%), internal carotid artery reconstruction (37.74%), estimated blood loss (559.62 cm³), and postoperative nerve injury (49.06%), with lower 10-year recurrence- (89.2%) and major adverse event-free survival (87.3%) compared to CCBTs. Nerve injury was correlated with the Shamblin grade; major adverse events and nerve injury were both correlated with pathological fibrosis.

Conclusion

Compared with CCBT, FCBT is prone to increased recurrence, metastasis, major adverse events, and nerve injury risk. Early surgical resection, routine excision of surrounding abnormal lymph nodes, and closer clinical surveillance in FCBT patients are recommended.

Multidisciplinary practice guidelines for the diagnosis, genetic counseling and treatment of pheochromocytomas and paragangliomas

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors that arise from chromaffin cells of the adrenal medulla and the sympathetic/parasympathetic neural ganglia, respectively. The heterogeneity in its etiology makes PPGL diagnosis and treatment very complex. The aim of this article was to provide practical clinical guidelines for the diagnosis and treatment of PPGLs from a multidisciplinary perspective, with the involvement of the Spanish Societies of Endocrinology and Nutrition (SEEN), Medical Oncology (SEOM), Medical Radiology (SERAM), Nuclear Medicine and Molecular Imaging (SEMNIM), Otorhinolaryngology (SEORL), Pathology (SEAP), Radiation Oncology (SEOR), Surgery (AEC) and the Spanish National Cancer Research Center (CNIO). We will review the following topics: epidemiology; anatomy, pathology and molecular pathways; clinical presentation; hereditary predisposition syndromes and genetic counseling and testing; diagnostic procedures, including biochemical testing and imaging studies; treatment including catecholamine blockade, surgery, radiotherapy and radiometabolic therapy, systemic therapy, local ablative therapy and supportive care. Finally, we will provide follow-up recommendations.

Metastatic non-functional paraganglioma to the lung

Introduction

Paragangliomas are rare endocrine tumors that arise from the extra-adrenal autonomic paraganglia and sympathetic paragangliomas usually secret catecholamines and are located in the sympathetic paravertebral ganglia of thorax, abdomen, and pelvis. In contrast, most parasympathetic paragangliomas are nonfunctional and located along the glossopharyngeal and vagal nerves in the neck and at the base of the skull. Such neoplasms, although rare, are clinically important because they may recur after surgical resection and 10% of them give rise to metastases causing death with the lymphatic nodes, bones, liver, and lungs being the most common locations.

Case presentation

We present a case of a 26-year-old male patient that was diagnosed with paraganglioma of the right-frontal lobe infiltrating the falx and frontal bone which was diagnosed after suffering from a headache and abnormal vision. On initial work-up he was found to have right pulmonary nodules that increased in size after follow up and other nodules appeared in the contralateral lung. He underwent subtotal resection of the brain tumor and complete resection of the bilateral pulmonary nodules.

Conclusion

To our knowledge, paraganglioma is considered to be a rare entity in the central nervous system with very few cases being reported in the supratentorial region and no cases were reported of metastatic such paraganglioma to the lung.

Intraoperative Gamma Probe Detection of Head and Neck Paragangliomas with 111In-Pentetreotide: A Pilot Study

Aims and background

The aim of this study was to assess whether intraoperative radiolocalization of head and neck paragangliomas with 111In-pentetreotide may increase surgical effectiveness, reducing the risk of recurrence.

Methods

Our study included eight patients with untreated, recently diagnosed paragangliomas (four unilateral and four bilateral tumors of the carotid body). After iv injection of −150 MBq 111In-pentetreotide, preoperative somatostatin receptor scintigraphy (SRS) was performed. SPECT of the neck was performed at four hours and planar Images of the head and neck were also obtained at four and 24 hours post injection. Scintigraphy was always compared with the results of conventional imaging methods (MRI, angiography and sonography). Intraoperative detection was performed on 11 lesions 24 hours after radiopharmaceutical administration using a handheld gamma probe.

Results

Preoperative SRS showed high radiotracer uptake in all patients. All the intraoperatively detected lesions were radically resected and histologically confirmed to be involved by tumor. No false positive results were recorded. Gamma probe detection revealed a small intracranial extension not detected by other imaging methods in a patient with a paraganglioma of the right carotid, and partial involvement of the carotid artery in another patient. During follow-up (median 3.5 years; range, 4 months-7 years) all patients remained disease free according to all parameters.

Conclusions

To our knowledge, this is the first experience of radioguided surgery in paraganglioma. Although our study included a relatively small number of patients, we suggest that intraoperative gamma probe detection may be a powerful tool to improve surgical effectiveness.

Thyroid Paraganglioma: Our Experience and Systematic Review of the Literature on a Rare Tumor

INTRODUCTION

Primary paraganglioma (PG) of the thyroid gland is an extremely rare neuroendocrine tumor with potential for misdiagnosis. We describe 2 cases of thyroid PG, suggest a possible diagnostic and therapeutic management strategy, and present a systematic review of the literature.

CASE REPORTS

Two 67-year-old women presented similarly with asymptomatic but rapidly growing thyroid nodules in which malignancy was suspected after fine needle aspiration biopsy, "THY 4" according to the 2014 SIAPEC classification, both undergoing total thyroidectomy. Unexpectedly, immunohistochemistry showed neuroendocrine cellular architecture that was negative for common markers of well-differentiated follicular neoplasms, thyroglobulin, thyroid transcription factor 1, cytokeratins and medullary thyroid cancer, calcitonin, carcinoembryonic antigen, whereas neuron-specific enolase, synaptophysin, chromogranin A, and S-100 protein were highly expressed, confirming the diagnosis of primary thyroid PG. The patients were both discharged on postoperative day 2, without any other therapy and are currently well without evidence of local recurrence of metastatic disease, after 4 years and 3 months of follow-up, respectively.

DISCUSSION

These are the only 2 cases of thyroid PG experienced in our center which specializes in thyroid surgery. Thyroid PG is a rare neuroendocrine neoplasm first described by Van Miert in 1964 with just over 50 cases reported in the literature. Our experience is concordant with the literature that the diagnosis of the primary PG of the thyroid is challenging, due to its low prevalence and the cytologic and histopathologic similarities with other more frequently diagnosed benign and malignant thyroid tumors. Immunohistochemistry is required for definitive diagnosis but gross tumor characteristics are also helpful for diagnosis. Surgical resection is the recommended standard treatment.

Paraganglioma Presenting as a Nasal Septal Mass: Case Report and Literature Review

Objectives

To describe a rare case of a paraganglioma arising from the nasal septum and review the diagnosis and management of paragangliomas in the nasal cavity and paranasal sinuses.

Methods

We present a case of a 70-year-old female presenting with persistent nasal congestion and obstruction. Nasal endoscopy revealed a posterior septal mass approaching the sphenoid sinuses and partially obstructing the nasopharynx. A biopsy of the mass was taken, and histologic analysis confirmed a diagnosis of paraganglioma.

Results

The patient underwent an endoscopic resection of the tumor. There has been no evidence of disease recurrence after 3 months of follow‐up.

Conclusions

Paragangliomas arising from the nasal septum are exceedingly rare, but should be considered in the differential diagnosis in patients presenting with nasal septal masses. These tumors are typically benign, although few cases of malignant sinonasal paragangliomas have been reported. Treatment requires surgical excision with close follow-up as several cases of tumor recurrence have been reported.

Nasal Cavity Paraganglioma: Literature Review and Discussion of a Rare Case

Paragangliomas can be found from the skull base to the sacrum. Sinonasal paragangliomas are infrequent. A 16-year-old female reported spontaneous discrete bilateral epistaxis once a month beginning when she was 3 years of age. Computed tomography showed an expansive hypervascular mass occupying the right nasal cavity and nasopharynx. Sinonasal paragangliomas usually occur in middle-aged women. Radiologic investigation is essential for the diagnosis of sinonasal paragangliomas and evaluating extension of the lesion. Endoscopic and conventional approaches are effective, and preoperative embolization is paramount for reducing bleeding risk. Histopathological features cannot differentiate benign from malignant paragangliomas, and since metastasis may eventually occur, follow-up must be carried out for a long period of time.

Active surveillance management of head and neck paragangliomas: case series and review of the literature

Background:

Head and neck paragangliomas are rare. They are usually slow-growing, benign, non-catecholamine secreting tumours, traditionally treated with surgical excision. Complications of surgical excision include lower cranial nerve palsies, stroke and death.

Method:

A retrospective case note analysis was conducted of patients with head and neck paragangliomas treated with a watch-and-scan policy from March 2003 to September 2015, and the relevant literature was reviewed.

Results:

Fifteen head and neck paragangliomas were identified. None of the patients developed a new lower cranial nerve palsy or progression of their presenting hearing loss during the follow-up period. Five patients displayed an increase in maximum linear dimension of 4 mm over an average of 57.4 months. A review of the literature showed that a watch-and-surveillance scan policy is evolving as a treatment option for head and neck paragangliomas without malignant risk factors.

Conclusion:

Readily available surveillance scanning in head and neck paragangliomas enables the monitoring of head and neck paragangliomas, which may allow for avoidance of major surgery.

External-beam radiation therapy for malignant paraganglioma of the head and neck

BACKGROUND

Malignant paragangliomas of the head and neck are very rare tumors of the neuroendocrine cells associated with the peripheral nervous system. There are limited data available to help guide treatment of these tumors and the role of radiation therapy (RT) is not well-defined. This article briefly reviews the pathology, clinical presentation, and treatment modalities of these tumors and reviews our institutional experience in treating this malignancy.

PATIENTS AND METHODS

From November 1993 through May 2005, 5 patients with 5 malignant paragangliomas of the jugular bulb and carotid body were treated with RT at the University of Florida to a median dose of 70 Gy at 1.8 Gy per fraction. Mean and median follow-up times are 12.8 years and 14.4 years, respectively.

RESULTS

We were able to achieve significant disease-free intervals of >10 years for 3 of 5 patients and >5 years for 4 of 5 patients. Of the 2 patients who failed treatment, 1 recurred 7.3 years after the RT salvage treatment following combination surgery and RT at another institution, and 1 experienced distant metastasis 2.8 years after treatment without obvious recurrence of local disease.

CONCLUSION

Malignant paragangliomas are a very rare entity whose main treatment modality has yet to be well established. Overall, data concerning outcomes are sparse, but particularly data on the role of RT in the treatment of these difficult tumors. We recommend doses to 70 Gy at 2 Gy per once-daily fraction as an adjuvant treatment with surgery to both remove the source of disease and provide microscopic control. Patients with incompletely resectable tumors are treated with RT alone.

Granular cell tumor of the stellate ganglion presenting with Horner's syndrome

We report a granular cell tumor (GCT) that occurred within the stellate ganglion of a 26-year-old woman who initially presented with a unilateral Horner's syndrome and progressive right upper extremity pain. We also review the literature related to the differential diagnoses of such a cervicothoracic tumor, with particular emphasis on the embryologic origin of these possibilities. GCT are rare tumors of Schwann cell origin which are more often found in subcutaneous locations than in relation to neural elements. In this woman, a mass identified on preoperative imaging was positioned anterolateral to the T1 vertebral body and displaced the vertebral artery anteriorly. During surgery, the lesion was observed within the sympathetic chain in the area of the stellate ganglion. The sympathetic chain was transected above and below the mass in order to achieve an adequate resection. The pathology demonstrated polygonal cells with diffuse eosinophilic granular cytoplasm positive for CD68 (a marker of lysosomes) and S-100 (a marker of neural crest derivatives) which established the diagnosis of GCT. This is the first patient, to our knowledge, with a granular cell tumor arising from the stellate ganglion.

Sleep-mediated heart rate variability after bilateral carotid body tumor resection

STUDY OBJECTIVES

The carotid bodies are thought to play an important role in sleep-dependent autonomic changes. Patients who underwent resection of bilateral carotid body tumors have chronically attenuated baroreflex sensitivity. These subjects provide a unique opportunity to investigate the role of the baroreflex during sleep.

DESIGN

One-night ambulatory polysomnography (PSG) recording.

SETTING

Participants' homes.

PARTICIPANTS

Nine patients with bilateral carotid body tumor resection (bCBR) (four women, mean age 50.4 ± 7.2 years) and nine controls matched for age, gender, and body mass index.

INTERVENTIONS

N/A.

MEASUREMENTS

Sleep parameters were obtained from PSG. Heart rate (HR) and its variability were calculated using 30-s epochs.

RESULTS

In bCBR patients, HR was slightly but not significantly increased during wake and all sleep stages. The effect of sleep on HR was similar for patients and controls. Low frequency (LF) power of the heart rate variability spectrum was significantly lower in bCBR patients in active wakefulness, sleep stage 1 and REM sleep. No differences were found between patients and controls for high frequency (HF) power and the LF/HF ratio.

CONCLUSIONS

Bilateral carotid body tumor resection (bCBR) is associated with decreased low frequency power during sleep, suggesting impaired baroreflex function. Despite this, sleep-related heart rate changes were similar between bCBR patients and controls. These findings suggest that the effects of sleep on heart rate are predominantly generated through central, non-baroreflex mediated pathways.

Primary paraganglioma of the spine: A clinicopathological study of eight cases

Context:

Spinal paragangliomas are rare neuroendocrine tumors of the extra-adrenal paraganglionic system.

Aims:

This study describes the clinicopathological features of eight cases of spinal paraganglioma and highlights the significance of important morphological features and immunohistochemistry in the diagnosis of paraganglioma at this unusual site.

Material and Methods:

All the cases of primary spinal paragangliomas diagnosed during the last six years (2008-2013) in the Department of Pathology at our hospital were reviewed.

Results:

There were six males and two females. The mean age at diagnosis was 50.4 years. All patients presented with low back pain. All tumors were located in the cauda equina or conus medullaris region. Magnetic Resonance Imaging and intraoperative appearance were that of a vascular, well-circumscribed intradural, extramedullary tumor suggestive of either schwannoma or ependymoma. All the patients underwent gross total resection of the tumor. Histopathology in five of the cases showed ‘ependymoma-like histology’ while only three cases had a predominant classic ‘zellballen’ pattern. Two cases had prominent ‘gangliocytic differentiation’. In the five cases with ‘ependymoma-like histology’, the diagnosis was confirmed on Immunohistochemistry (IHC).

Conclusions:

Even though relatively rare, paraganglioma should be considered in the differential diagnosis of spinal tumors and due to their clinical, radiological and histopathological similarity to schwannoma and ependymoma, the diagnosis should be based on close examination of the clinical, radiological and pathological findings.

Coexistence of a carotid body tumor and thyroglossal duct carcinoma with cervical lymph node metastasis

Thyroglossal duct carcinoma is uncommon, occurring in approximately 1% of all thyroglossal duct remnants. This rare neoplasm is characterized by relatively nonaggressive behavior with infrequent lymph nodal spread. Another rare neoplasm of the head and neck region is a carotid body tumor. A 78-year-old woman with a 3-year history of midline and bilateral neck masses was referred to us. Fine needle aspiration biopsies and a computed tomography scan suggested the diagnosis of thyroglossal duct carcinoma with cervical lymph node metastasis. Interestingly, the left-side neck mass was found to be splaying the carotid bifurcation, on computed tomography imaging. Carotid arteriography demonstrated a highly vascular mass in the bifurcation of the carotid artery that was compressing the internal and external carotid arteries. To our knowledge, this is the first reported instance of a thyroglossal duct carcinoma with neck metastasis accompanied by a carotid body tumor. In addition, the carotid body tumor in this case mimicked neck metastasis from the thyroglossal duct carcinoma.

No difference in phenotype of the main Dutch SDHD founder mutations

OBJECTIVE

SDHD mutations predispose carriers to hereditary paraganglioma syndrome. The objective of this study was to assess the genotype-phenotype correlation of a large Dutch cohort of SDHD mutation carriers and evaluate potential differences in clinical phenotypes due to specific SDHD gene mutations.

DESIGN

Retrospective, descriptive single-centre study.

PATIENTS

All consecutive SDHD mutation carriers followed at the Department of Endocrinology of the Leiden University Medical Center were included.

MEASUREMENTS

Subjects were investigated according to structured protocols used for standard care, including repetitive biochemical and radiological screening for paragangliomas.

RESULTS

Two hundred and one SDHD mutation carriers with a mean age at presentation of 42·6 ± 14·4 years and a mean follow-up of 5·8 ± 5·4 years were evaluated. Eighty-one percent carried the SDHD c.274G>T (p.Asp92Tyr) mutation and 13% the SDHD c.416T>C (p.Leu139Pro) mutation. No differences in clinical phenotype between these two specific SDHD mutations were found. Ninety-one percent developed one or multiple paragangliomas in the head and neck region (HNPGLs), of which the carotid body tumour was the most prevalent (85%). Eighteen carriers developed pheochromocytomas, fifteen sympathetic paragangliomas and nine carriers (4%) suffered from malignant paraganglioma. By end of follow-up, sixteen SDHD mutation carriers (8%) displayed no biochemical or radiological evidence of manifest disease.

CONCLUSIONS

The two main Dutch SDHD founder mutations do not differ in clinical expression. SDHD mutations are associated with the development of multiple HNPGLs and predominantly benign disease.

Stereotactic radiosurgery for the treatment of Glomus Jugulare Tumors

BACKGROUND

The glomus jugulare tumor is a slowly growing benign neoplasm originating from neural crest. There is a high morbidity associated with surgical resection of glomus jugulare. Radiosurgery play a relevant role as a therapeutic option in these tumors and its use has grown in popularity. The authors describe a retrospective series of 15 patients and reviewed the literature about the glomus jugulare tumors.

METHODS

We reviewed retrospectively the data of 15 patients treated with stereotactic linear accelerator stereotactic radiosurgery (LINAC) radiosurgery between 2006 and 2011.

RESULTS

The average tumor volume was 18.5 cm(3). The radiation dose to the tumor margin ranged between 12 and 20 Gy. The neurological status improved in three patients and remained unchanged in 12 patients. One patient developed a transient 7(th) nerve palsy that improved after clinical treatment. All tumors remained stable in size on follow-up with resonance magnetic images.

CONCLUSIONS

The radiosurgery is a safe and effective therapy for patients with glomus jugulare tumor. Despite the short follow-up period and the limited number of patients analyzed, we can infer that radiosurgery produce a tumor growth control with low morbidity, and may be used as a good option to surgical resection in selected cases.

The management of head-and-neck paragangliomas

Paragangliomas (PGLs) are tumours originating from neural crest-derived cells situated in the region of the autonomic nervous system ganglia. Head-and-neck PGLs (HNPGLs) originate from the sympathetic and parasympathetic paraganglia, most frequently from the carotid bodies and jugular, tympanic and vagal paraganglia, and are usually non-catecholamine secreting. Familial PGLs are considered to be rare, but recently genetic syndromes including multiple PGLs and/or phaeochromocytomas have been more thoroughly characterised. Nowadays, genetic screening for the genes frequently implicated in both familial and sporadic cases is routinely being recommended. HNPGLs are mostly benign, generally slow-growing tumours. Continuous growth leads to the involvement of adjacent neurovascular structures with increased morbidity rates and treatment-related complications. Optimal management mostly depends on tumour location, local involvement of neurovascular structures, estimated malignancy risk, patient age and general health. Surgery is the only treatment option offering the chance of cure but with significant morbidity rates, so a more conservative approach is usually considered, especially in the more difficult cases. Radiotherapy (fractionated or stereotactic radiosurgery) leads to tumour growth arrest and symptomatic improvement in the short term in many cases, but the long-term consequences are unclear. Early detection is essential in order to increase the chance of cure with a lower morbidity rate. The constant improvement in diagnostic imaging, surgical and radiation techniques has led to a safer management of these tumours, but there are still many therapeutic challenges, and no treatment algorithm has been agreed upon until now. The management of HNPGLs requires a multidisciplinary effort addressing the genetic, surgical, radiotherapeutic, oncological, neurological and endocrinological implications. Further progress in the understanding of their pathogenesis will lead to more effective screening and earlier diagnosis, both critical to successful treatment.

Malignant and benign sinonasal paragangliomas

OBJECTIVES/HYPOTHESIS

To report on the clinical course and management of sinonasal paragangliomas (PGLs).

STUDY DESIGN AND METHODS

Retrospective chart review of six patients with PGLs of the nasal cavity and paranasal sinuses.

RESULTS

Three patients had tumors with malignant clinical behavior with cerebral metastases or infiltration of brain and local recurrence, despite surgery and/or radiotherapy, while three patients demonstrated a benign course.

CONCLUSION

Sinonasal paragangliomas are frequently malignant. If malignant, they are very aggressive, with rapid local spread as well as high metastatic potential despite surgical resection; and they have a poor prognosis. Malignancy cannot be diagnosed on histology, but only on the basis of clinical behavior. Intracranial metastasis is commonly expected. Long-term follow-up, with particular emphasis put on the intracranial structures, is mandatory as recurrences or metastasis may occur even after a long time interval.

Regression and local control rates after radiotherapy for jugulotympanic paragangliomas: systematic review and meta-analysis

The primary treatment goal of radiotherapy for paragangliomas of the head and neck region (HNPGLs) is local control of the tumor, i.e. stabilization of tumor volume. Interestingly, regression of tumor volume has also been reported. Up to the present, no meta-analysis has been performed giving an overview of regression rates after radiotherapy in HNPGLs. The main objective was to perform a systematic review and meta-analysis to assess regression of tumor volume in HNPGL-patients after radiotherapy. A second outcome was local tumor control. Design of the study is systematic review and meta-analysis. PubMed, EMBASE, Web of Science, COCHRANE and Academic Search Premier and references of key articles were searched in March 2012 to identify potentially relevant studies. Considering the indolent course of HNPGLs, only studies with ≥ 12 months follow-up were eligible. Main outcomes were the pooled proportions of regression and local control after radiotherapy as initial, combined (i.e. directly post-operatively or post-embolization) or salvage treatment (i.e. after initial treatment has failed) for HNPGLs. A meta-analysis was performed with an exact likelihood approach using a logistic regression with a random effect at the study level. Pooled proportions with 95% confidence intervals (CI) were reported. Fifteen studies were included, concerning a total of 283 jugulotympanic HNPGLs in 276 patients. Pooled regression proportions for initial, combined and salvage treatment were respectively 21%, 33% and 52% in radiosurgery studies and 4%, 0% and 64% in external beam radiotherapy studies. Pooled local control proportions for radiotherapy as initial, combined and salvage treatment ranged from 79% to 100%. Radiotherapy for jugulotympanic paragangliomas results in excellent local tumor control and therefore is a valuable treatment for these types of tumors. The effects of radiotherapy on regression of tumor volume remain ambiguous, although the data suggest that regression can be achieved at least in some patients. More research is needed to identify predictors for treatment success.

Paraganglioma of the skull base presenting as nasal polyps

The authors report a case of paraganglioma of the skull base presenting as nasal polyps. A 29-year-old patient presented with epistaxis and was found to have nasal polyps. The patient underwent a nasal polypectomy. After pathology showed an unusual appearance, the mass was subsequently excised endoscopically using radiofrequency coblation, and it was found to be originating from the skull base. The diagnosis was made using a combination of clinical findings, radiology, and histopathology examination. It is important to consider paraganglioma in the differential diagnosis of unusual tumors of the nose and skull base.

Gamma Knife surgery for the management of glomus tumors: a multicenter study

Object

Glomus tumors are rare skull base neoplasms that frequently involve critical cerebrovascular structures and lower cranial nerves. Complete resection is often difficult and may increase cranial nerve deficits. Stereotactic radiosurgery has gained an increasing role in the management of glomus tumors. The authors of this study examine the outcomes after radiosurgery in a large, multicenter patient population.

Methods

Under the auspices of the North American Gamma Knife Consortium, 8 Gamma Knife surgery centers that treat glomus tumors combined their outcome data retrospectively. One hundred thirty-four patient procedures were included in the study (134 procedures in 132 patients, with each procedure being analyzed separately). Prior resection was performed in 51 patients, and prior fractionated external beam radiotherapy was performed in 6 patients. The patients' median age at the time of radiosurgery was 59 years. Forty percent had pulsatile tinnitus at the time of radiosurgery. The median dose to the tumor margin was 15 Gy. The median duration of follow-up was 50.5 months (range 5–220 months).

Results

Overall tumor control was achieved in 93% of patients at last follow-up; actuarial tumor control was 88% at 5 years postradiosurgery. Absence of trigeminal nerve dysfunction at the time of radiosurgery (p = 0.001) and higher number of isocenters (p = 0.005) were statistically associated with tumor progression–free tumor survival. Patients demonstrating new or progressive cranial nerve deficits were also likely to demonstrate tumor progression (p = 0.002). Pulsatile tinnitus improved in 49% of patients who reported it at presentation. New or progressive cranial nerve deficits were noted in 15% of patients; improvement in preexisting cranial nerve deficits was observed in 11% of patients. No patient died as a result of tumor progression.

Conclusions

Gamma Knife surgery was a well-tolerated management strategy that provided a high rate of long-term glomus tumor control. Symptomatic tinnitus improved in almost one-half of the patients. Overall neurological status and cranial nerve function were preserved or improved in the vast majority of patients after radiosurgery.

The importance of flowmetry in carotid body tumor surgery: a case report

Carotid body tumors arise from the embryonic neural crest. These tumors are mostly benign, and they rarely show character. Bifurcation of the carotid body cells originates from a common carotid paraganglion; a tumoral mass lateral to the carotid bifurcation is usually found in the neck. A pathologic feature of these tumors is that they have a tendency to wrap because they are not treated with the external and internal carotid arteries. In our clinic, we operated on a patient who had been diagnosed with carotid body tumor. After removal of the internal carotid artery, the mass flow due to a decrease in the light of literature used to evaluate the importance of flowmetry carotid surgery.

HER-2 positive primary solid neuroendocrine carcinoma of the breast: a case report and review of the literature

Primary pure neuroendocrine carcinoma of the breast is an extremely rare tumor. We report a case of primary solid neuroendocrine carcinoma in a 77-year-old postmenopausal woman who was admitted to the hospital with masses on her right breast and axillary region. Radical mastectomy with axillary lymph node resection was performed. Immunohistochemical stainings of the tumor cells with synaptophysin, GCDFP-15, estrogen, progesterone, and c-erbB-2 were positive. Five of 16 lymph nodes were metastatic. She did not receive adjuvant chemotherapy. After 15 months of follow-up she is free of the disease. Literature review revealed that this is the second case of HER-2 positive primary neuroendocrine tumor of the breast.

Role of ultrasound and color Doppler imaging in the detection of carotid paragangliomas

INTRODUCTION

Carotid body paragangliomas (PGLs) are highly vascularized lesions that arise from the paraganglia located at the carotid bifurcation.

PURPOSE

To evaluate the usefulness of gray-scale ultrasound (US) and color Doppler ultrasound (CDUS) in the detection and follow-up of carotid PGLs of the neck.

MATERIALS AND METHODS

The authors retrospectively reviewed US and CDUS examinations of the neck performed in 40 patients with PGL syndrome type 1 and single or bilateral neck PGLs confirmed by CT or MRI; the patients had a total of 60 PGLs of the neck. US and CDUS outcome was compared to the outcome of second-line imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT). The following findings were considered: presence/absence of focal lesions at US imaging and difference in maximum diameter of the lesion measured at US and MRI/CT. Results were compared using the Student's t-test.

RESULTS

Of the 60 PGLs of the neck only 5 (8.3%) were not visualized at US or CDUS examination. The difference in maximum diameter of these lesions measured at CT/MRI and US/CDUS ranged between -5 mm and +16 mm (mean difference 2.2 ± 6.0). This difference was statistically significant (p = 0.008).

CONCLUSIONS

US and CDUS are useful methods for identifying carotid PGLs also measuring less than 10 mm in diameter. However, diagnostic accuracy of US and CDUS is reduced in the measurement of the exact dimensions of the lesions.

Jugular and vagal paragangliomas: Systematic study of management with surgery and radiotherapy

BACKGROUND

The definitive treatment for head and neck paraganglioma (PG) is surgical excision. Unfortunately, surgery, particularly of vagal paraganglioma (VPG; "glomus vagale") and foramen jugulare ("glomus jugulare") tumors, may be complicated by injuries to the lower cranial nerves, a high price to pay for treatment for a benign tumor. Alternatively these tumors may be followed without treatment, or irradiated. The purpose of this review was to compare the existing evidence concerning the efficacy and safety of surgery, external beam radiotherapy (EBRT), and stereotactic radiosurgery (SRS), for jugular paragangliomas (JPGs) and VPGs.

METHODS

Relevant articles were reviewed using strict criteria for systematic searches. Forty-one surgical studies met the criteria which included 1310 patients. Twenty articles including 461 patients treated with EBRT, and 14 radiosurgery studies comprising 261 patients were also evaluated. Results were compared between treatment modalities using analysis of variance (ANOVA) tests.

RESULTS

A total of 1084 patients with JPGs and 226 VPGs were treated with different surgical procedures. Long-term control of the disease was achieved in 78.2% and 93.3% of patients, respectively. A total of 715 patients with JPG were treated with radiotherapy: 461 with EBRT and 254 with SRS. Control of the disease with both methods was obtained in 89.1% and 93.7% of the patients, respectively. The treatment outcomes of a JPG treated with surgery or radiotherapy were compared. Tumor control failure, major complication rates, and the number of cranial nerve palsies after treatment were significantly higher in surgical than in radiotherapy series. The results of SRS and EBRT in JPGs were compared and no significant differences were observed in tumor control. Because only 1 article reported on the treatment of 10 VPGs with radiotherapy, no comparisons with surgery could be made. Nevertheless, the vagus nerve was functionally preserved in only 11 of 254 surgically treated patients (4.3%).

CONCLUSION

There is evidence that EBRT and SRS offer a similar chance of tumor control with lower risks of morbidity compared with surgery in patients with JPGs. Although the evidence is based on retrospective studies, these results suggest that surgery should be considered only for selected cases, but the decision should be individual for every patient.

Thyroid paragangliomas are locally aggressive

BACKGROUND

Thyroid paraganglioma (TP) is a very rare neoplasm that can be misdiagnosed. We evaluated the clinical and pathologic characteristics of three patients with TP.

PATIENT FINDINGS

The records of all patients from 1981 to 2008 who had thyroidectomy with a final histologic diagnosis of TP were retrieved, and histology was reviewed by a single pathologist. Head and neck paragangliomas arising outside of the thyroid were excluded. TP accounted for 3 of all 6782 (0.04%) patients undergoing thyroidectomy during three decades. One patient has been previously reported and will not be discussed. In the remaining two patients and a surgical pathology consult case that we also describe herein, the mean age at diagnosis was 56 years (40-67) and two patients were men. Presenting features were indicative of advanced local invasion, including stridor, tracheal invasion, compression of the great vessels, and hemoptysis. The diagnosis of TP was not suspected preoperatively; in two patients, fine-needle aspiration (FNA) cytology was inadequate for diagnosis because of excessive blood. Intraoperative frozen section analysis suggested medullary thyroid cancer in two patients and oncocytic (Hurthle) cell carcinoma in one patient. Local invasion was common, requiring concurrent tracheal resection in two of three patients, and present histologically in all three patients. In all three cases, immunohistochemical analysis was negative for cytokeratin AE1/3, calcitonin, and thyroglobulin but positive for S100, highlighting sustentacular cells. After resection of a large TP with tracheal and vascular invasion, a 67-year-old woman experienced a 7-year disease-free interval.

CONCLUSIONS

Primary TP is indeed rare. It does occur in men, frequently presents with compressive symptoms, and is typically locally aggressive, but does not appear to cause symptoms suggestive of catecholamine excess. Despite invasion of adjacent structures, aggressive resection can achieve a long disease-free interval.

Studies for estimating the biologic behavior and prognosis of paragangliomas in the head and neck

Despite a large number of histopathologic and immunohistochemical studies, the biologic behavior and prognosis of paragangliomas (glomus tumors) of the head and neck still remain uncertain. In the present study 36 specimens from 32 patients who underwent surgery for a paraganglioma were examined. The examinations included routine histology, quantitative DNA analysis based on image cytometry, immunohistochemical detection of the proliferating cell nuclear antigen (PCNA) along with visualization of nucleolar organizer regions (AgNOR). According to LeCompte, the paragangliomas were histologically divided into three subcategories: 16 patients had a paragangliomatous tumor. 14 patients had an adenomatous tumor, and 6 patients had an angiomatous tumor. Quantitative DNA analysis revealed three categories of tumors with characteristical DNA pattern; DNA type I tumors were pure diploid, DNA type II tumors had stemlines at 2c and 4c and were therefore recognized as diploid-tetraploid. Aneuploid cells were not apparent in these two groups. DNA type III tumors had stemline ploidies exceeding 2c and 4c. Aneuploid cells were present in all of these tumors. The biologic behavior of these lesions therefore must be recognized as suspicious. DNA type III tumors and adenomatous tumors showed the highest values for the PCNA scores, indicating a higher proliferation rate and a more rapid growth pattern in these lesions. Twenty patients could be followed over a period of up to 110 months. Five of these patients developed a recurrent tumor. All of them had DNA type III tumors. The DNA indices showed significantly higher values in the recurrent tumor group. The 2c deviation index (DI) and the entropy value had the highest prognostic significance. No correlation to clinical follow-up was found for the AgNOR score. Based on these results, prognostic indices for paragangliomas were developed: patients with a tumor having a 2c DI exceeding 2.0, entropy value of more than 4.0. 5c exceeding rate more than 8.0, and a PCNA score more than 20.0% can be recognized as being at high-risk for developing recurrent disease.

Catecholamine-secreting paragangliomas at the skull base

Paragangliomas (glomus tumors) comprise 15% of all neoplasms at the skull base. Despite extensive growth, these tumors usually do not secrete active biogenic substances into the circulation in sufficient quantities to produce symptoms. When they do secrete large amounts of catecholamines, they will cause symptoms that mimic a pheochromocytoma. The still confusing nomenclature of paragangliomas is reviewed, and the clinical work-up, surgical treatment, and follow-up of five patients with catecholamine-secreting paragangliomas of temporal bone (3), infratemporal fossa (1), and nasopharynx (1) are presented and discussed.

Solitary Paraganglioma of the Hypoglossal Nerve: Case Report

BACKGROUND AND IMPORTANCE:

We report the case history of solitary hypoglossal paraganglioma in a 64-year-old woman. The surgical difficulties encountered in the removal of this challenging tumor are discussed and as a literature review provided.

CLINICAL PRESENTATION:

A 64-year-old woman presented with a short history of dysphonia, occasional dysphagia, tinnitus, altered taste, and unilateral left-sided tongue wasting. On examination, there was left lower motor hypoglossal paralysis. Imaging showed a discrete enhancing lobulated mass, measuring 2 × 2 cm, in the region of the hypoglossal nerve extending into the hypoglossal canal suggestive of hypoglossal paraganglioma. A left dorsolateral suboccipital craniotomy was performed with the patient in the sitting position. The hypoglossal nerve appeared to be enlarged, and the jugular foramen was normal. Complete surgical debulking of the tumor was not attempted because of its vascular nature. The nerve was decompressed, and neuropathology confirmed a low-grade paraganglioma arising from the hypoglossal nerve. The patient was scheduled to receive stereotactic radiation for further management.

CONCLUSION:

When a case of solitary hypoglossal paraganglioma is encountered in clinical practice, the aim of management should be mainly focused on achieving a diagnosis and preserving the hypoglossal nerve function. If there is evidence of vascularity in the lesion noted on magnetic resonance imaging, a preoperative angiogram should be obtained with a view for embolization. We decompressed the hypoglossal canal and achieved good improvement in the patient's symptoms. We recommend stereotactic radiosurgery for remnant and small hypoglossal tumors and regular follow-up with magnetic resonance imaging scans.

A case of carotid body paraganglioma and haemangioblastoma of the spinal cord in a patient with the N131K missense mutation in the VHL gene

The article describes paraganglioma case in woman with von Hippel–Lindau disease. She was found to be a carrier of a rare germline mutation in the VHL gene (393C>A; N131K). The patient developed large, untypical for von Hippel–Lindau disease, carotid body paraganglioma at the common carotid artery bifurcation. The carotid body paraganglioma coexisted with the haemangioblastoma situated intramedullary in region C5/C6. The haemangioblastoma reached the right-sided dorsal part of the spinal cord in section C5/C6. It produced radicular symptoms within C5/C6, followed by the later paresis of the right limbs. The haemangioblastoma was resected completely. Twelve months after the operation, the spinal symptoms receded and the carotid body paraganglioma still was asymptomatic. The current case of carotid body paraganglioma in patient with the 393C>A (N131K) missense mutation in the VHL gene, supports association of this specific mutation and VHL disease type 2, and suggests its correlation with susceptibility to paragangliomas.