A rare case of paraganglioma of the sella with bone metastases

Gamma Knife Radiosurgery: An Adjuvant Therapy for Primary Sellar Paraganglioma

Sellar paraganglioma (SP) is a rare benign tumor, usually treated by surgery. SPs are lobulated, firm, adherent, and highly vascular, allowing mostly partial resection. We present the case of a 52-year-old man diagnosed with primary SP, treated with a transcranial-transsphenoidal (TC-TS) surgical approach, followed by adjuvant Gamma Knife stereotactic radiosurgery (GKSR). The tumor has an extra-pituitary origin, with a sellar-suprasellar, right cavernous sinus extension that encroached the bilateral optic nerve and anterior cerebral artery. Histopathology confirmed SP with a Zellballen pattern. Despite postoperative tumor growth observed at four and 10 months, a stable residual tumor was noted at a follow-up two years after GKSR. SP is diagnosed mainly in middle age or in adolescent males. The TC-TS approach offers a bidirectional view that allows greater resection by minimizing blind spots, thus reducing complications. Similar to the paragangliomas of other sites, the efficacy of GKSR was observed for primary SP. SP is a rare differential diagnosis of pituitary diseases; however, it should be considered. After surgical resection of primary SP, GKSR is observed as an effective adjuvant therapy.

Case Report: Paraganglioma in the sellar region: longitudinal observation and surgical outcome

Background

Paraganglioma in the sellar region is an extremely rare entity, with a limited number of cases reported in the literature. Due to the paucity of clinical evidence, the diagnosis and treatment of paragangliomas in the sellar region remain challenging. Herein, we reported a case of sellar paraganglioma with parasellar and suprasellar extension. Particularly, the dynamic evolution of this benign tumor within a 7-year longitudinal observation was presented. Additionally, the relevant literature regarding sellar paraganglioma was comprehensively reviewed.

Case description

A 70-year-old woman presented with progressive visual deterioration and headache. Brain magnetic resonance imaging demonstrated a mass in the sellar region with parasellar and suprasellar extension. The patient refused surgical treatment. Seven years later, brain magnetic resonance imaging showed the lesion significantly progressed. Neurological examination revealed bilateral tubular contraction of visual fields. Laboratory examinations showed endocrine hormone levels were normal. Surgical decompression was performed via a subfrontal approach, and subtotal resection was achieved. Histopathological examination confirmed a diagnosis of paraganglioma. Postoperatively, she developed hydrocephalus, and ventriculoperitoneal shunting was performed. Eight months later, cranial CT showed no recurrence of the residual tumor, and the hydrocephalus had been relieved.

Conclusion

Paraganglioma occurring in the sellar region is rare, and the preoperative differential diagnosis is difficult. Owing to the infiltration to the cavernous sinus and internal carotid, complete surgical resection is usually impracticable. There has been no consensus regarding postoperative adjuvant radiochemotherapy for the tumor residue. In-situ recurrence and metastasis have been reported in the literature, and close follow-up is warranted.

Endoscopic Endonasal Surgery for Uncommon Pathologies of the Sellar and Parasellar Regions

Endoscopic skull base surgery has become an integral part of the present neurosurgical armamentarium. The pioneering efforts in which the purely endoscopic transsphenoidal approach was introduced have triggered a growing tide of using the endoscopic endonasal procedures for a large variety of skull base lesions. Because of their anatomical peculiarities, lesions of the sellar and parasellar regions lend themselves very well to the endoscopic endonasal approaches. Apart from the common pathological entities, many other less frequent pathologies are encountered in the sellar and parasellar area. In this chapter, we review the surgical technique of the endoscopic endonasal transsphenoidal approach and its extensions applied to a variety of rare and uncommon pathological entities involving the sella turcica and clivus. An overview of these pathological entities is also presented and exemplified.

Case Report: Malignant Primary Sellar Paraganglioma With Unusual Genetic and Imaging Features

BACKGROUND

Paraganglioma occurs rarely in the sellar/parasellar region. Here, we report a patient with malignant paraganglioma with primary sellar location with unusual genetic and imaging features.

CASE PRESENTATION

A 31-year-old male presented with mild hypertension, headache, nausea, and vomiting. A sellar/parasellar tumor mass was revealed by magnetic resonance imaging (MRI), while an endocrine work-up found partial hypopituitarism, suggesting that it was a non-functioning pituitary tumor. Antihypertensive therapy and hormone replacement were initiated. Tumor reduction was achieved with transsphenoidal neurosurgery. However, histological diagnosis was not possible due to extensive tissue necrosis. After 4 years of stable disease, the residual tumor showed re-growth requiring gamma knife radiosurgery. Four years after the radiosurgery, MRI showed a significant tumor progression leading to a second neurosurgery. This time, pathological and immunohistochemical findings revealed paraganglioma. Plasma levels of metanephrine and normetanephrine were normal. A gene sequencing panel performed on DNA extracted from blood excluded germline mutations in 17 susceptibility genes. The patient developed new tumor masses in the neck, and the third surgery was performed. Immunohistochemistry demonstrated lack of ATRX (alpha thalassemia/mental retardation syndrome X-linked) protein in tumor cells, indicating an ATRX gene mutation. Molecular genetic analysis performed on tumor DNA revealed a combination of ATRX and TP53 gene abnormalities; this was not previously reported in paraganglioma. MRI and 68Ga-DOTANOC PET/CT revealed the full extent of the disease. Therapy with somatostatin LAR and 177Lu-DOTATATE Peptide Receptor Radionuclide Therapy (PRRT) was initiated.

CONCLUSION

Although rare, paraganglioma should be considered in the differential diagnosis of sellar/parasellar tumor lesions, even in the absence of typical imaging features. ATRX gene mutation in paraganglioma is an early predictor of malignant behavior and a potential novel therapeutic marker when pharmacological therapy targeting mutated ATRX becomes available.

Sellar-Suprasellar Paraganglioma: Report of 2 Cases and Review of Literature

BACKGROUND

Intracranial paragangliomas are infrequent and those occurring in the sellar-suprasellar region are rare, with only 31 cases described in literature.

CASE DESCRIPTION

We describe 2 cases of sellar-suprasellar paragangliomas in the light of a literature review. The first patient was a 13-year-old boy who presented with an intensely enhancing lesion in the sellar-suprasellar region with multiple flow voids within. Resection of the lesion was limited to a biopsy in view of its hypervascular nature. A second attempt at resection following partial embolization of the lesion was also unsuccessful. The tumor showed progressive reduction in size following radiotherapy. The second case was a 20-year-old man who presented with a similar tumor in the same location. He also had a probable metastatic deposit in the foramen of Magendie. An attempted surgical resection of the suprasellar lesion was abandoned after a biopsy. The patient improved symptomatically after radiotherapy.

CONCLUSIONS

We report 2 cases of paraganglioma occurring in a rare location. Presence of flow voids within tumors in the sellar-suprasellar location should alert the surgeon to this entity. The hypervascular nature of these tumors may limit the extent of resection. In cases of inadequate tumor decompression, or if there is evidence of growth of residual tumor, radiotherapy can help to stabilize the disease.

Two Extraordinary Sellar Neuronal Tumors: Literature Review and Comparison of Clinicopathologic Features

Objectives

The list of tumors involving the pituitary gland has been expanded to include a variety of neuronal and paraneuronal tumors in the 2017 World Health Organization tumor classification of endocrine organs. All the entities included in this category are distinctly rare, with limited case reports in the literature.

Methods

We illustrate two extraordinary sellar tumors with neuronal differentiation: a sellar paraganglioma and a sellar neurocytoma, with thorough literature review and comparison of the clinicopathologic features of these entities.

Results

Both entities are exceptionally rare and tend to be misdiagnosed as pituitary adenoma preoperatively. Both entities demonstrate frequent clinical recurrence compared with pituitary adenoma, as well as the rare occurrence of metastatic disease.

Conclusions

In evaluating a sellar tumor with an uncommon morphology and neuroendocrine differentiation, an increased awareness of the unusual entities that may involve the sellar region and a judicious panel of immunohistochemical studies should improve the diagnosis.

The Diagnosis and Clinical Significance of Paragangliomas in Unusual Locations

Paragangliomas are neuroendocrine neoplasms, derived from paraganglia of the sympathetic and parasympathetic nervous systems. They are most commonly identified in the head and neck, being most frequent in the carotid body, followed by jugulotympanic paraganglia, vagal nerve and ganglion nodosum, as well as laryngeal paraganglia. Abdominal sites include the well-known urinary bladder tumors that originate in the Organ of Zuckerkandl. However, other unusual sites of origin include peri-adrenal, para-aortic, inter-aortocaval, and paracaval retroperitoneal sites, as well as tumors in organs where they may not be expected in the differential diagnosis of neuroendocrine neoplasms, such as thyroid, parathyroid, pituitary, gut, pancreas, liver, mesentery, lung, heart and mediastinum. The distinction of these lesions from epithelial neuroendocrine neoplasms is critical for several reasons. Firstly, the determination of clinical and biochemical features is different from that used for epithelial neuroendocrine tumors. Secondly, the genetic implications are different, since paragangliomas/pheochromocytomas have the highest rate of germline susceptibility at almost 40%. Finally, the characterization of metastatic disease is unique in these highly syndromic lesions. In this review, we summarize updated concepts by outlining the spectrum of anatomic locations of paragangliomas, the importance of morphology in establishing the correct diagnosis, the clinical implications for management, and the impact of genetics on the distinction between multifocal primary tumors compared with malignant disease.

Clinical characteristics and surgical treatment of spinal paraganglioma: A case series of 18 patients

BACKGROUND AND OBJECTIVES

Paraganglioma rarely develops in the spine. With few cases reported, little knowledge about this disease was known. The objective of this study is to illustrate the clinical features, imaging manifestations, pathological appearances and long-term outcomes of the consecutive surgeries by literature review.

METHODS

The clinical and follow-up data of 18 patients who were diagnosed of spinal paraganglioma and treated with surgeries in our hospitals from 2003 to 2014 were retrospectively analyzed.

RESULT

A total of fourteen patients radiographed of intra-spinal tumor underwent extra-capsular tumor resection. Of five patients with obvious vertebral bone damage, four cases underwent piecemeal resection, and the left one with sacral tumor underwent en bloc tumor excision. Spinal reconstruction was performed in all cases. Follow-up lasted for 16-96 months (44.1 months on average). There was no local recurrence or distant metastasis in cases without obvious bone invasion. Of those five cases with vertebral bone damage, one case suffered and survived from the repeat relapse of T1 vertebral body tumor. Local recurrence was not observed in one case with T10 vertebral tumor after tumor resection, but the tumor metastasized to T2 attachment during the follow-up and was finally eradicated by re-operation. No tumor recurrence was observed in the left three cases.

CONCLUSION

Paraganglioma, usually benign, rarely occurs. Surgical resection, especially complete surgical resection, is preferred to treat spinal paraganglioma. Chemotherapy, radiotherapy, use of octreotide and other somatostatin are selected as adjuvant therapies, but their effects remain unknown.

Clival paragangliomas: a report of two cases involving the midline skull base and review of the literature

Head and neck paragangliomas are rare neuroendocrine tumors that arise from paraganglion cells of the parasympathetic nervous system. Paragangliomas arising from the midline skull base have only rarely been reported. Surgery is the mainstay of treatment and adjuvant radiation is often recommended. These tumors can rarely secrete metanephrines and normetanephrines which can complicate operative management. Here we present two cases of clival paragangliomas with unique clinical presentations and review the previous literature on skull base paragangliomas.

33 year-old woman with a large sellar tumor

The authors describe a case of paraganglioma of the sellar region in a young female patient with loss of vision and headache. She presented with amaurosis, depression, anxiety and amenorrhea. Clinical and radiological impression was that it was a meningioma or pituitary adenoma. She received bromocriptine with no reduction of the lesion. She developed panhypopituitarism, but with normal levels of prolactin. It was resected and histological examination revealed nests of large cells with moderate nuclear pleomorphism, vesicular nuclei with occasional nucleoli. There were rare mitotic figures, but no necrosis. Immunohistochemistry was positive for synaptophysin, chromogranin A, and neuron-specific enolase with a few sustentacular cells positive for S100. The Ki67 proliferation was 1-2%. All pituitary hormonal antibodies were negative as well as GFAP, AE1/AE3, p53 and EMA. Paragangliomas affecting the sellar region are extremely rare and might be due to the presence of remnants of paraganglionic tissue or abnormal migration. The patient's post-operative diabetes insipidus remains under medical control.

Sellar paraganglioma: a unique route to a rare destination case report and literature review

OBJECTIVE

Paragangliomas of the sella are rare; 14 cases have been reported in the literature. We describe here the unique case of a sellar paraganglioma that extended into the orbit through the superior orbital fissure. We have also reviewed all reported cases of sellar paragangliomas to better define best management strategies.

CLINICAL PRESENTATION

A 63-year-old male presented with left eye proptosis and conjunctival vessel dilatation.

INTERVENTION

Resection of the intraorbital component of the tumor was accomplished using a transcranial-transorbital approach.

CONCLUSION

This is the first report of a sellar/parasellar paraganglioma extending into the orbit through the superior orbital fissure. While an appropriate treatment paradigm has not been established, a review of all previously reported cases suggests that radiotherapy is an important consideration.