Paraganglioma of cauda equina: report of seven cases

Primary Paraganglioma of the Spine: A Systematic Review of Clinical Features and Surgical Management in Cauda Equina vs Non-Cauda Equina Lesions

BACKGROUND

Primary spine paragangliomas are rare tumors. Surgical resection plays a role, but aggressive lesions are challenging. We reviewed the literature on primary spine paragangliomas.

METHODS

PubMed, Scopus, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies on primary spine paragangliomas. Clinical-radiological features, treatments, and outcomes were analyzed and compared between cauda-equina vs non-cauda-equina tumors.

RESULTS

We included 143 studies comprising 334 patients. Median age was 46 years (range, 6-85). The most frequent symptoms were lower-back (64.1%) and radicular (53.9%) pain, and sympathetic in 18 patients (5.4%). Cauda-equina paragangliomas (84.1%) had frequently lumbar (49.1%) or lumbosacral (29%) locations. Non-cauda-equina tumors were mostly in the thoracic (11.4%), thoracolumbar (5.1%), and cervical (3.6%) spine. Median tumor diameter was 2.5cm (range, 0.5-13.0). Surgical resection (98.5%) was preferred over biopsy (1.5%). Decompressive laminectomy (53%) and spine fusion (6.9%) were also performed. Adjuvant radiotherapy was delivered in 39 patients (11.7%) with aggressive tumors. Post-treatment symptomatic improvement was described in 86.2% cases. Median follow-up was 19.5 months (range, 0.1-468.0), and 23 patients (3.9%) had tumor recurrences. No significant differences were found between cauda-equina vs non-cauda-equina tumors.

CONCLUSION

Surgical resection is effective and safe in treating primary spine paragangliomas; however, adjuvant treatments may be needed for aggressive lesions.

Paraganglioma of the cauda equina: a tertiary centre experience and scoping review of the current literature

Cauda equina paragangliomas are rare benign extra-adrenal neuroendocrine tumours arising from the neural crest cells associated with autonomic ganglia. These tumours are often mistaken preoperatively for ependymomas or schwannomas. Patients present with axial or radicular pain with or without neurological deficits. Recurrence, secretory features and length of follow-up are controversial. We conducted a retrospective cohort study of paraganglioma through searching a prospectively maintained histopathology database. Patient demographics, presentation, surgery, complications, recurrence, follow-up and outcome between 2004 and 2016 were studied. The primary aim was to collate and describe the current evidence base for recurrence and secretory features of the tumour. The secondary objective was to report outcome and follow-up strategy. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Ten patients were diagnosed (M:F 7:3) with a mean age of 53.6 ± 5.1 (range 34–71 years). MRI scans revealed intradural lumbar enhancing lesions. All patients had complete microsurgical excisions without adjuvant therapy with no recurrence with a mean follow-up of 5.1 ± 1.4 years. Tumours were attached to the filum terminale. Electron microscopic images demonstrated abundant neurosecretory granules with no evidence of catecholamine production. A total of 620 articles were screened and 65 papers (including ours) combining 121 patients (mean age 48.8 and M:F 71:50) were included. The mean follow-up was 3.48 ± 0.46 (range 0.15–23 years). Back pain was the most common symptom (94%). Cure following surgery was achieved in 93% of the patients whilst 7% had recurrence. Total resection likely results in cure without the need for adjuvant therapy or prolonged follow-up. However, in certain situations, the length of follow-up should be determined by the treating surgeon.

Spinal paraganglioma as unusual finding in von Hippel-Lindau disease

A 20-year-old patient with a history of von Hippel-Lindau disease reported on thoracic back pain radiating to the left shoulder for 10 weeks. Magnetic resonance imaging revealed a progressive contrast-enhancing tumor (14 × 21 × 28 mm) compressing the spinal cord and extending into the left neural foramen at T5/6. After embolization of supplying vessels, the tumor was completely resected via hemilaminectomy of T5. The postoperative course was uneventful without surgery related morbidity. The pathological examination disclosed a paraganglioma WHO grade I. We discuss the differential diagnoses and pitfalls of this unexpected finding in this patient with von Hippel-Lindau disease.

[Paraganglioma of the cauda equina region: Report of 9 cases]

INTRODUCTION

The paraganglioma of the cauda equina is a rare tumor, the diagnosis is morphological and the immunohistochemistry provides a definite diagnosis. The objective of our study is to specify the clinical signs, radiological and associated pathological criteria and to compare our data with those of the literature.

PATIENTS AND METHOD

This is a retrospective study of nine cases of paragangliomas of the cauda equina diagnosed in our department from 2003 to 2018. The median age of the patients was 50 years-old with a male predominance (sex ratio: 3,5/1). All patients had preoperative magnetic resonance imaging (MRI) and surgery to remove the tumor. The diagnosis was performed after HES (Hematoxylin Eosin Saffron) and immunohistochemical sections examination.

RESULTS

Radiculalgia was the chief symptom of these tumors. MRI showed an oval lesion uniformly enhanced by Gadolinium in the eight patients whose records were available. Histologically, the tumors had a lobular and trabecular pattern with neuroendocrine-like cells and a rich vascularization. By immunohistochemistry, the cells expressed chromogranin, synaptophysin and CD56.

DISCUSSION AND CONCLUSION

Paragangliomas of the cauda equina are rare, benign tumors. Except for cases of secreting tumors, the preoperative diagnosis is difficult. MRI is useful and may reveal radiological features suggestive of these tumors. However, it is rare for the diagnosis to be made before surgery. The diagnosis is established by histological examination and immunohistochemical techniques must be used to confirm the diagnosis. The paragangliomas of the cauda equina are well encapsulated tumors whose complete excision is curative. When the excision is incomplete, treatment with radiotherapy is recommended. Long-term clinical and radiological monitoring is recommended because of the slow evolution of the tumor and the potential for recurrence.

Acute Paraplegia Revealing a Hemorrhagic Cauda Equina Paragangliomas

Cauda equina paragangliomas are rare neuroendocrine benign and slow-growing tumors. Acute paraplegia, occurring because of sudden intratumoral hemorrhage, represents an extremely rare clinical picture of this disease. We report the case of a 64-year-old male presenting with a 5-day acute lower back pain, sciatica, and leg weakness. Spinal imaging showed an intradural mass of the cauda equina region and an emergent surgical treatment was achieved. The lesion was removed “en bloc,” and subarachnoid blood was noticed during surgery. The postoperative course was uneventful, with complete regression of pain and progressive motor recovery. The histological study revealed typical microscopic and immunohistochemical features of paragangliomas.

Paraganglioma of the cauda equina region

BACKGROUND CONTEXT

Cauda equina paragangliomas (CEPs) are rare neuroendocrine tumors. The difficulty in differential diagnosis with other tumors of this region may be misleading for surgical planning and prognostic expectations.

PURPOSE

To report on a rare case of CEP and review the most current information regarding the diagnosis, treatment options, and outcomes.

STUDY DESIGN

Case report and literature review.

PATIENT SAMPLE

One patient affected by CEP.

METHODS

We report on a 33-year-old woman with a 2-month history of worsening low back pain, aggravated by sitting, bending, and coughing. Neurological examination revealed normal power and muscular tone, no sensory or sphincter abnormality, and normal reflex. Magnetic resonance imaging of the lumbar spine demonstrated an intradural extramedullary lesion at L3, with homogeneous contrast enhancement and hypointense punctate foci. The patient underwent an L3 laminectomy and tumor removal. Relevant articles covering CEPs from 1970 to the present were reviewed.

RESULTS

The histopathological examinations described paraganglioma features. The postoperative course was uneventful, and all the symptoms resolved, with no tumor recurrence after 3 years' follow-up.

CONCLUSIONS

Cauda equina paragangliomas are rare, benign, and slow-growing tumors. Except for its secreting tumor characteristics, preoperative CEP diagnosis is very difficult. Magnetic resonance imaging is important and may suggest specific radiological features for these tumors; however, these are only relative, and it is rare that diagnosis is made before surgery. Diagnosis is established by histological examination and electron microscopy, and immunohistochemical techniques must be used to achieve a correct diagnosis. Cauda equina paragangliomas are well-encapsulated tumors that may be cured by surgery alone, whereas radiotherapy is reserved for incompletely resected tumors. Overall, prolonged postoperative observation is mandatory because of the slow tumor evolution and the possibility of tumor relapse even up to 30 years after surgery.

Clinical features and surgical outcomes of primary cauda equina tumours

BACKGROUND

To identify clinical features, radiological findings and surgical outcomes of primary cauda equina tumours.

METHODS

A consecutive series of 64 operations in 60 patients with primary cauda equina tumours from April 1999 to May 2009 at one institution comprised the study. The cases were divided into tumours of neural sheath origin (TNS, n = 48) and tumours of non-neural sheath origin (TNNS, n = 22). We analysed pain intensity, neurological abnormalities, MRI findings, surgical extent and functional outcome.

RESULTS

The TNS group showed more leg pain (76 % vs. 44 %, p = 0.019) with higher intensity (6.1 ± 1.5 vs. 4.6 ± 1.9, p = 0.04). Motor weakness and bladder dysfunction were more common in the TNNS group (p = 0.028 and p = 0.00 in each). Flow voids of MRI were more frequently observed in TNNS (50 % vs. 4 %, p = 0.01). The TNS group achieved total removal in all operations compared with total removal in 77 % in the TNNS group (p = 0.001). The TNNS group showed higher recurrence rates (18 % vs. 0 %, p = 0.009). The TNS group showed higher improvement of JOA scores postoperatively (p = 0.049). Surgical complications were observed less frequently in the TNS group (19 % vs. 78 %, p = 0.000).

CONCLUSIONS

TNS differs from TNNS by causing more frequent leg pain, higher pain intensity and more frequent flow voids. TNS has better surgical outcomes than TNNS in terms of higher rates of total removal, fewer surgical complications, better functional outcomes and less recurrence.

Paraganglioma of the cauda equina region: A report of three cases

Background:

Cauda equina paragangliomas (CEP) are rare tumors. Low back pain and sciatica are the main presenting symptoms. Magnetic resonance imaging (MRI) is the study of choice and treatment consists of total excision when feasible. Definitive diagnosis can only be made after immunohistochemical investigation. CEP is classified as grade I WHO and after total removal the prognosis is excellent. Nonetheless, after subtotal removal, tumor recurrence can occur.

Case Description:

We present 3 cases of CEP, preoperatively diagnosed as an intradural mass on MRI and suspected to be ependymoma. All 3 patients presented with low back pain and variable sciatic pain. Total resection of the tumor was performed after which all patients fully recovered. There is no recurrence after 13, 11, and 5 years, respectively.

Conclusion:

CEP is a rare tumor. We diagnosed 3 paragangliomas out of a series of 105 intradural extramedullary tumors in adults (1994–2005). No recurrence was seen after total resection. In retrospect, both the intraoperative appearance and the MR image were not completely typical for schwannoma or ependymoma, but final diagnosis can only be made histologically.

Long-term follow-up after en bloc resection and reconstruction of a solitary paraganglioma metastasis in the first lumbar vertebral body: a case report

Introduction

Paragangliomas are rare tumors that originate from the autonomic nervous system-associated paraganglia. They metastasize infrequently. Malignancy can only be demonstrated by the presence of chromaffin tissue at sites where it usually is not present, such as bone, lung or liver, or local recurrence after total resection of a primary mass. Paragangliomas within the central nervous system are usually intradural near the conus medullaris. The metastatic spread of a retroperitoneal paraganglioma to a vertebral body is extremely rare, and there are only a few cases reported in the literature.

Case presentation

We report the case of a 16-year-old Caucasian girl who had undergone resection of a retroperitoneal paraganglioma that measured 15 × 11.5 × 9.5 cm. After further staging, a solitary metastatic paraganglioma was detected in the first lumbar vertebral body. After initial chemotherapy, marginal en bloc resection and reconstruction were performed followed by radiotherapy. Histologic examination of the specimen revealed that the tumor cells did not show any response to preoperative chemotherapy, which is in line with a few other reports in the literature. Ten years after operative treatment, the patient is free of complaints, very satisfied with the result and without signs of local recurrence or distant metastases.

Conclusion

We recommend en bloc spondylectomy and local radiotherapy in the treatment of solitary spinal metastatic paragangliomas.

Composite ganglioneuroma-paraganglioma of the filum terminale

Extraadrenal paragangliomas are most commonly found in the carotid body and are also found with lower frequency in the CNS. These lesions are derived from the sympathoadrenal lineage of neural crest cells. Here, the authors report a rare case of a composite paraganglioma with ganglioneuromatous components found at the filum terminale in a patient who presented with a brief history of low-back pain and paresthesias in the inguinal region. Immunohistochemical analysis of the resected lesion revealed admixed elements of neuroendocrine and neuroblastoma lineages, indicating the presence of divergent differentiation of sympathoadrenal progenitor cells. This case represents a unique opportunity to understand the cell fate of sympathoadrenal progenitor cells. Here, the authors propose that paragangliomas at the filum terminale can revert to a neural crest cell precursor fate, giving rise to divergent neoplastic populations.