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Safdar MN, Faiz Z, Khalid A, Iqbal S, Fatimi SH. Mediastinal paraganglioma of the aortopulmonary subtype - A surgical challenge. Int J Surg Case Rep 2023; 108:108448. [PMID: 37406536 PMCID: PMC10382815 DOI: 10.1016/j.ijscr.2023.108448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE This case report describes the successful surgical management of a 30-year-old male with a non-functional carotid body tumor and a mediastinal paraganglioma occupying the aortopulmonary space. The report highlights the rarity of mediastinal paragangliomas and the challenges in their surgical management. CASE PRESENTATION The patient underwent pre-op angioembolisation of the carotid body tumor, followed by excision and left cervical lymph node dissection. A large mediastinal mass was identified and resected during surgery without needing a cardiopulmonary bypass. The patient recovered well from surgery. Histopathology confirmed the diagnosis of clinically recurrent paraganglioma. CLINICAL DISCUSSION Mediastinal paragangliomas are rare and challenging to manage due to their proximity to major vascular structures. Surgical intervention is the preferred treatment, but the risk of complications is high. In this case, the surgical approach involved resection of the mediastinal mass without cardiopulmonary bypass. This approach reduced the risk of complications associated with bypass procedures. The procedure's success underscores the importance of early diagnosis and prompt surgical intervention. CONCLUSION This case report highlights the successful surgical management of a rare and clinically challenging mediastinal paraganglioma without cardiopulmonary bypass. The report underscores the importance of prompt diagnosis and surgical intervention in mediastinal paragangliomas.
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Affiliation(s)
| | - Zohaa Faiz
- Medical Student, Aga Khan University, Karachi, Pakistan.
| | | | - Sara Iqbal
- Department of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Saulat H Fatimi
- Department of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi, Pakistan
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2
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Zhang B, Liu G, Li J, Wan P, MD. Middle mediastinal paraganglioma enclosing the left anterior descending artery: A case report. Medicine (Baltimore) 2022; 101:e30377. [PMID: 36107546 PMCID: PMC9439848 DOI: 10.1097/md.0000000000030377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Paragangliomas are extremely rare neuroendocrine tumors arising from ganglia. These tumors are barely found in the middle mediastinum. PATIENT CONCERNS A 31-year-old male patient was admitted to our hospital for treatment of an middle mediastinal tumor which was found incidentally on echocardiography during a medical checkup. Contrast-enhanced chest computed tomography (CT) demonstrated a well-defined hypervascularized heterogeneous mass located in the middle mediastinum. The tumor showed strong 18F-fluorodeoxyglucose (FDG) activity on positron emission tomography-computed tomography (PET-CT). DIAGNOSIS Before the surgery, we presumed the mass was an angiogenic or neurogenic tumor. As a result, the histological features favored a diagnosis of paraganglioma. INTERVENTIONS The tumor was completely removed by anterior thoracotomy, along with the proximal segment of the left anterior descending artery (LAD), and coronary artery bypass grafting (CABG) was performed immediately after the tumor excision. OUTCOMES The patient had an uneventful recovery. The patient did well in the postoperative follow-up without any complications and signs of recurrence at 3 months, 1 year, 2 year and 4 year. LESSONS This report can increase the confidence in surgeries of mediastinal paragangliomas adhering tightly the adjacent structures.
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Affiliation(s)
- Bing Zhang
- Department of Radiology, The Chenjiaqiao Hospital of Shapingba District of Chongqing, China
| | - Guofang Liu
- Department of Radiology, Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Jian Li
- Department of Cardiovascular surgery, Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Pinghua Wan
- Department of Radiology, The Chenjiaqiao Hospital of Shapingba District of Chongqing, China
| | - MD
- Department of Radiology, The Chenjiaqiao Hospital of Shapingba District of Chongqing, China
- *Correspondence: Pinghua Wan, No. 17, Chendong Road, Chenjiaqiao Street, Shapingba District, Chongqing, China, 401331 (e-mail: )
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3
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Bouassida I, Zayene B, Zribi H, Abdelkbir A, Ayadi R, Marghli A. Mediastinal paraganglioma as a large dumbell tumor: A case report. Int J Surg Case Rep 2022; 95:107160. [PMID: 35636209 PMCID: PMC9136310 DOI: 10.1016/j.ijscr.2022.107160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/30/2022] [Accepted: 04/30/2022] [Indexed: 11/24/2022] Open
Abstract
Mediastinal paraganglioma presented as a large dumbbell tumor is a rare entity. We report a case of a 47 year old woman who suffered from spinal pain and sporadic lower limb paresis. The imaging studies showed a voluminous mass occupying the posterior mediastinum with right foraminal extension. For excellent results, a combined effort was necessary including thoracic and neurosurgeons teams. Complete resection was successfully performed without laminectomy. The operative course was uneventful.
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Affiliation(s)
- Imene Bouassida
- Department of Thoracic and Cardiovascular Surgery, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Bochra Zayene
- Department of Thoracic and Cardiovascular Surgery, Abderrahman Mami Hospital, Ariana, Tunisia.
| | - Hazem Zribi
- Department of Thoracic and Cardiovascular Surgery, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Amina Abdelkbir
- Department of Thoracic and Cardiovascular Surgery, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Rahma Ayadi
- Department of Anatomopathology, Abderrahman Mami Hospital, Ariana, Tunisia
| | - Adel Marghli
- Department of Thoracic and Cardiovascular Surgery, Abderrahman Mami Hospital, Ariana, Tunisia
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4
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Zhou AL, Halub ME, Lotfalla M, Shou BL, Kilic A. Pulmonary artery transection for resection of a middle mediastinal paraganglioma. Clin Case Rep 2022; 10:e05600. [PMID: 35425604 PMCID: PMC8991763 DOI: 10.1002/ccr3.5600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/17/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022] Open
Abstract
We report the case of a 65‐year‐old male patient who presented with chest pain and was found to have a mediastinal paraganglioma between the left atrium and main pulmonary artery. This is the first reported case of a mediastinal paraganglioma resection utilization transection of the main pulmonary artery.
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Affiliation(s)
- Alice L. Zhou
- Division of Cardiac Surgery Department of Surgery Johns Hopkins Hospital Baltimore Maryland USA
| | - Meghan E. Halub
- Division of Cardiac Surgery Department of Surgery Johns Hopkins Hospital Baltimore Maryland USA
| | - Mira Lotfalla
- Division of Surgical Pathology Department of Pathology Johns Hopkins Hospital Baltimore Maryland USA
| | - Benjamin L. Shou
- Division of Cardiac Surgery Department of Surgery Johns Hopkins Hospital Baltimore Maryland USA
| | - Ahmet Kilic
- Division of Cardiac Surgery Department of Surgery Johns Hopkins Hospital Baltimore Maryland USA
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5
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Jia Y, Yan Y, Lu M, Kirkpatrick IDC. Paraganglioma with highly malignant potential involving the rib - Case report and review of the literature. Radiol Case Rep 2021; 16:1845-1850. [PMID: 34093930 PMCID: PMC8165291 DOI: 10.1016/j.radcr.2021.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
Paragangliomas are rare neuroendocrine tumors arising from paraganglion cells in sympathetic or parasympathetic chains, which may develop in the abdomen, chest, skull base, and neck. As paragangliomas have a wide range of imaging features, the diagnosis often requires tissue sampling. We present a unique case of a paraganglioma which originally presented as a rib tumor. A 64-year-old male with right flank pain for 2 months’ was referred for a noncontrast renal colic CT. He was found to have a 3.7 × 3.5 cm soft tissue mass invading the left posterior 9th rib and paraspinal muscle. This was fluorodeoxyglucose F 18, (18F-FDG) avid, with no other distant metabolic activity. He underwent ultrasound-guided core biopsy which revealed a diagnosis of paraganglioma. A right thoracotomy with chest wall resection of 8, 9, and 10 ribs were subsequently performed. The tumor was removed along with a small portion of adherent lung. The tumor was positive for CD56, synaptophysin and chromogranin. S-100 highlighted occasional sustentacular cells, consistent with a pathologic diagnosis of a paraganglioma. The patient remains symptom free for 6 months’ after the operation. Our case highlights that, when paragangliomas occur within the chest wall, they may present as a rib tumor and can mimic metastasis, myeloma or other primary neoplastic etiologies originating from ribs. Both imaging and pathologic diagnosis can be challenging.
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Affiliation(s)
- Yong Jia
- Department of Pathology, Max Rady College of Medicine Rady Faculty of Health Sciences, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9, Canada
| | - Yi Yan
- Department of Radiology, Max Rady College of Medicine Rady Faculty of Health Sciences, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9, Canada
| | - Miao Lu
- Department of Pathology, Max Rady College of Medicine Rady Faculty of Health Sciences, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9, Canada
| | - Iain D C Kirkpatrick
- Department of Diagnostic Radiology, University of Manitoba, Room O2055, St Boniface General Hospital, 409 Tache Avenue, Winnipeg, MB R2H 2A6, Canada
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Ozawa Y, Hiroshima M, Maki H, Hara M, Shibamoto Y. Imaging findings of lesions in the middle and posterior mediastinum. Jpn J Radiol 2021; 39:15-31. [PMID: 32740793 DOI: 10.1007/s11604-020-01025-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
Lesions in the middle and posterior mediastinum are relatively rare, but there are some useful radiological clues that can be used to diagnose them precisely. It is useful to determine the affected mediastinal compartment and the locations of the main thoracic nerves on medical images for diagnosing such mediastinal lesions. Neurogenic tumors can occur in the middle mediastinum, although they generally arise as posterior mediastinal tumors. Based on the above considerations, we review various characteristic imaging findings of middle and posterior mediastinal lesions, and their differential diagnoses.
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Affiliation(s)
- Yoshiyuki Ozawa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Marehiko Hiroshima
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hiroyuki Maki
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan
| | - Masaki Hara
- Department of Radiology, Nagoya City West Medical Center, Nagoya, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya, 467-8601, Japan
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7
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Miura K, Kobayashi N, Satomi H. Surgical resection of a middle mediastinal paraganglioma that caused diabetes. Surg Case Rep 2020; 6:241. [PMID: 32997281 PMCID: PMC7527386 DOI: 10.1186/s40792-020-00983-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/18/2020] [Indexed: 11/28/2022] Open
Abstract
Background Paragangliomas are rare neuroendocrine tumors originating from chromaffin cells of extra-adrenal origin. Ninety percent of adrenergic tumors originate in the adrenal medulla and are known as pheochromocytomas; the remaining 10% are extra-adrenal and are called paragangliomas. Mediastinum paragangliomas is rare and commonly originate from the posterior mediastinum, while those originating from the middle posterior are quite rare. Some paragangliomas secrete catecholamines, leading to symptoms such as hypertension, tachycardia, and diabetes. Case presentation A 76-year-old woman visited our hospital for the treatment and further evaluation of diabetes. Her hemoglobin A1c levels had risen to 11.0%. To investigate the cause of her diabetes, a contrast-enhanced chest computed tomography scan was performed, revealing a ring-enhancing tumor (30 × 30 mm) in the middle mediastinum. The surgical resection was performed via video-assisted thoracic surgery. Surgery was performed using a vessel-sealing device; however, bleeding was persistent from the surrounding tissue. Total bleeding was 400 g. Blood pressure fluctuations and arrhythmia did not occur during the operation. The patient’s uncontrolled diabetes was cured after the surgery, and the tumor was diagnosed as a functional paraganglioma. Conclusions We encountered a rare case of functional paraganglioma located in the middle mediastinum. Functional paragangliomas should be considered as a potential cause of uncontrolled diabetes, and a whole-body CT scan should be performed to investigate this possible cause.
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Affiliation(s)
- Kentaro Miura
- Department of Thoracic Surgery, Japanese Red Cross Society Nagano Hospital, 5-22-1 Wakasato, Nagano, 380-8582, Japan.
| | - Nobutaka Kobayashi
- Department of Thoracic Surgery, Japanese Red Cross Society Nagano Hospital, 5-22-1 Wakasato, Nagano, 380-8582, Japan
| | - Hidetoshi Satomi
- Department of Pathology, Japanese Red Cross Society Nagano Hospital, Nagano, Japan
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8
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Rahi MS, Gunasekaran K, Amoah K, Rudolph D. Paraganglioma of the middle mediastinum. Respir Med Case Rep 2020; 31:101211. [PMID: 32953448 PMCID: PMC7486602 DOI: 10.1016/j.rmcr.2020.101211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/20/2020] [Accepted: 08/26/2020] [Indexed: 11/12/2022] Open
Abstract
A 60-year-old female was evaluated for significant weight loss, nausea, vomiting, and dysphagia. A computed tomography (CT) of the chest showed a 3 cm mass in the middle mediastinum. CT scan of the abdomen and pelvis revealed no abnormality. Positron emission tomography (PET) of the whole body revealed tracer uptake in the pre-carinal nodal mass. There were no other suspicious foci of tracer uptake. Mediastinoscopy and biopsy revealed a well-differentiated low-grade neuroendocrine tumor. She underwent sternotomy, and after careful mobilization of the great vessels, the middle mediastinal mass was successfully resected. Final pathology revealed a paraganglioma with no morphological signs to suggest malignancy. The right lower paratracheal lymph node did not show any tumor cells. She did well postoperatively.
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Affiliation(s)
- Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Kwesi Amoah
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Daniel Rudolph
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
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9
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Shah MUA, Al-Saadi N, Leatherby R, Xylas D, Shah S. Aortopulmonary paraganglioma masquerading as an anterior mediastinal mass: A fine line between confusion and chaos! J Card Surg 2020; 35:2044-2046. [PMID: 32652640 DOI: 10.1111/jocs.14751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Mediastinal paragangliomas are exceedingly rare neuroendocrine tumors of chromaffin cell origin. They are rarely endocrinologically functional, but complications often arise due to mass effect within the mediastinal cavity. We present a case of a 67-year-old gentleman referred to our unit for excision of a large mediastinal mass, thought to be thymic in origin, but without confirmatory preoperative histological diagnosis. Intra-operatively it became clear that the tumor was intra-pericardial, originating from aortic tissue, mandating pericardectomy, and ascending aortic replacement on cardiopulmonary bypass for its complete excision. Histopathological evaluation later confirmed the mass to be an aorticopulmonary paraganglioma.
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Affiliation(s)
- Muhammad Usman Ali Shah
- Department of Cardiothoracic Surgery, The Essex Cardiothoracic Centre, Basildon University Hospital, Nether Mayne, Basildon, UK
| | - Nina Al-Saadi
- Department of Cardiothoracic Surgery, The Essex Cardiothoracic Centre, Basildon University Hospital, Nether Mayne, Basildon, UK
| | - Robert Leatherby
- Department of Cardiothoracic Surgery, The Essex Cardiothoracic Centre, Basildon University Hospital, Nether Mayne, Basildon, UK
| | - Diamantis Xylas
- Department of Cardiothoracic Surgery, The Essex Cardiothoracic Centre, Basildon University Hospital, Nether Mayne, Basildon, UK
| | - Samir Shah
- Department of Cardiothoracic Surgery, The Essex Cardiothoracic Centre, Basildon University Hospital, Nether Mayne, Basildon, UK
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10
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CT-based mediastinal compartment classifications and differential diagnosis of mediastinal tumors. Jpn J Radiol 2018; 37:117-134. [DOI: 10.1007/s11604-018-0777-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/10/2018] [Indexed: 12/25/2022]
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11
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Asa SL, Ezzat S, Mete O. The Diagnosis and Clinical Significance of Paragangliomas in Unusual Locations. J Clin Med 2018; 7:E280. [PMID: 30217041 PMCID: PMC6162705 DOI: 10.3390/jcm7090280] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/06/2018] [Accepted: 09/10/2018] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Sylvia L Asa
- Department of Pathology, University Health Network, Toronto, ON M5G 2C4, Canada.
- Endocrine Oncology Site, Princess Margaret Cancer Center, Toronto, ON M5G 2MG, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada.
| | - Shereen Ezzat
- Endocrine Oncology Site, Princess Margaret Cancer Center, Toronto, ON M5G 2MG, Canada.
- Department of Medicine, Division of Endocrinology, University Health Network, Toronto, ON M5G 2C4, Canada.
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada.
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON M5G 2C4, Canada.
- Endocrine Oncology Site, Princess Margaret Cancer Center, Toronto, ON M5G 2MG, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada.
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Lu L, Yang Z, Zhang G, An B, Lin Y, Zheng X. Challenges in the surgical treatment of undiagnosed functional paragangliomas: A case report. Medicine (Baltimore) 2018; 97:e12478. [PMID: 30235746 PMCID: PMC6160181 DOI: 10.1097/md.0000000000012478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Paragangliomas (PGs) or extra-adrenal pheochromocytomas are rare neuroendocrine neoplasms of ubiquitous distribution. Those that produce excess catecholamine are categorized as functional, and those that do not are categorized as nonfunctional. Although modern medical technology is becoming more widespread, there are still substantial risks of misdiagnosis or missed diagnosis of PGs. CASE PRESENTATION A 38-year-old woman who lived in an autonomous region of inner Mongolia presented complaining of having experienced coughing for approximately the past month. Chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion on the right side of thoracic vertebra 5-8 of approximately 66 mm × 54 mm, and it was deemed to be a mediastinal tumor that required surgical treatment. The patient exhibited severe hemodynamic instability during the operation, resulting in substantial challenges and risks with regard to anesthesia management. CONCLUSION When a patient is suspected having PG, whether the surgery should be continued or not depends on their overall condition and whether hemodynamic fluctuation can be controlled to within the normal range. Both are factors that should be considered during intraoperative management. Communication between the surgeon and anesthesiologist is necessary, in order to accurately assess the risks associated with the operation. The combination of central venous pressure and the Flotrac/Vigileo system may provide precise guidance for complementary liquid therapy and reduce cardiopulmonary complications. After the operation, hemodynamic changes should be monitored continuously in the intensive care unit, and vasoactive drugs are required to avoid postoperative hypotension. Dramatic hemodynamic changes are certainly a challenge for patients and anesthesiologists, regardless of their origin, and sufficient attention should be paid to avoid serious consequences.
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Ocazionez D, Shroff GS, Vargas D, Dicks D, Chaturvedi A, Nachiappan AC, Murillo H, Baxi A, Restrepo CS. Imaging of Intrathoracic Paragangliomas. Semin Ultrasound CT MR 2017; 38:584-593. [PMID: 29179898 DOI: 10.1053/j.sult.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intrathoracic paragangliomas are uncommon and only represent 1%-2% of paragangliomas. They are most commonly found in mediastinal compartments (aortopulmonary window or posterior mediastinum). Computed tomography, magnetic resonance, and specific nuclear medicine radiotracers are routinely used to characterize these lesions and help exclude other more common conditions. Selective angiography is currently used for preoperative embolization and mapping of the vascular supply before surgical resection, rather than for diagnostic purposes alone.
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Affiliation(s)
- Daniel Ocazionez
- Department of Diagnostic and Interventional Imaging, The University of Texas Medical School at Houston, Houston, TX.
| | - Girish S Shroff
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Vargas
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Demetrius Dicks
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT
| | | | - Arun C Nachiappan
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | | | - Ameya Baxi
- Department of Diagnostic Radiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Carlos S Restrepo
- Department of Diagnostic Radiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX
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Petrella F, Iacono GL, Monaco F, Pirola S, Alamanni F, Rizzo S, Spaggiari L. Mediastinal Aortopulmonary Paraganglioma. Am Surg 2017. [DOI: 10.1177/000313481708300503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Francesco Monaco
- Department of Thoracic Surgery European Institute of Oncology Italy
| | - Sara Pirola
- Department of Pathology European Institute of Oncology Italy
| | - Francesco Alamanni
- Cardiovascular Section Department of Clinical Sciences and Community Health University of Milan—IRCCS Centro Cardiologico Monzino Italy
| | - Stefania Rizzo
- Department of Radiology European Institute of Oncology Italy
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery European Institute of Oncology Italy; and Department of Oncology and Hemato-Oncology University of Milan, Italy
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15
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Muñoz-Largacha JA, Glocker RJ, Moalem J, Singh MJ, Litle VR. Incidental posterior mediastinal paraganglioma: The safe approach to management, case report. Int J Surg Case Rep 2017; 35:25-28. [PMID: 28427002 PMCID: PMC5397129 DOI: 10.1016/j.ijscr.2017.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/29/2017] [Accepted: 03/29/2017] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Paragangliomas are neuroendocrine tumors arising from chromaffin cells located in sympathetic paraganglia. Mediastinal paragangliomas are extremely rare and can be classified as functional or non-functional according to their ability for secreting catecholamines. Patients can be asymptomatic and the diagnosis is usually incidental. Complete surgical resection remains the standard of care for paragangliomas. PRESENTATION OF CASE We present a 44-year-old woman with a functional mediastinal paraganglioma incidentally found during the perioperative imaging workup for a diagnosed breast carcinoma. Chest radiograph and computed tomography (CT) showed a well-defined lesion in the posterior mediastinum suspicious for an esophageal malignancy. Endoscopic and CT-guided biopsies were performed confirming the diagnosis of a neuroendocrine tumor. Laboratory studies showed elevated catecholamines and chromogranin A levels, consistent with a paraganglioma. Appropriate pre-operative management was done and successful surgical resection without catecholamine related complications was achieved. DISCUSSION The workup and treatment of incidentally discovered adrenal and extra-adrenal lesions are controversial. Because of the absence of symptoms and the wider differential diagnosis of extra-adrenal lesions, an attempt for biopsying and surgically remove these lesions prior to biochemical testing is not an uncommon scenario, although this could be potentially harmful. Surgeons should have an index of suspicion for catecholamine-secreting tumors and hormonal levels should be assessed prior to biopsy or surgical resection. CONCLUSION Surgeons should consider paragangliomas as a differential diagnosis for extra-adrenal lesions. Biochemical testing with catecholamines and chromogranin A levels should be performed prior to biopsy or surgical removal in order to avoid catastrophic complications.
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Affiliation(s)
- Juan A Muñoz-Largacha
- Department of Surgery, Division of Thoracic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Roan J Glocker
- Department of Surgery, Divisions of Vascular Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jacob Moalem
- Department of Surgery, Division of Endocrine Surgical Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael J Singh
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburg, PA, USA
| | - Virginia R Litle
- Department of Surgery, Division of Thoracic Surgery, Boston University School of Medicine, Boston, MA, USA.
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Abstract
OBJECTIVE Thoracic neurogenic neoplasms may be a diagnostic challenge both clinically and radiologically, ranging from benign, incidentally discovered tumors to aggressive, symptomatic malignancies. These tumors may originate from any nervous structure within the chest and are derived from cells of the nerve sheath, autonomic ganglia, or paraganglia. The nervous anatomy of the thorax is complex, and neurogenic tumors may be found in any mediastinal compartment or in the chest wall. Furthermore, neurogenic tumors may indicate one of many syndromes, particularly when they are multiple. CONCLUSION This article illustrates the complex anatomy of the nervous system within the chest and details important epidemiologic and pathophysiologic features as an approach to neurogenic tumors of the thorax. Key imaging features of neurogenic tumors occurring in the chest are identified, focusing on distinguishing characteristics and the relative advantages of available imaging modalities to further refine a differential diagnosis.
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