Extra-adrenal pheochromocytoma: Diagnosis and management

Renal and Genitourinary Ultrasound Evaluation in Emergency and Critical Care: An Overview

Renal and genitourinary ultrasound are fundamental resources employed by emergency and critical care healthcare providers to make prompt diagnoses and perform ultrasound-guided procedures. At the bedside, ultrasound can aid in the diagnosis of relevant pathologies, such as post-renal obstruction or kidney stones, and life-threatening conditions such as aortic dissection or hemoperitoneum. A narrative overview was performed, providing an updated review of renal and genitourinary ultrasound for emergency and critical care healthcare providers, emphasizing its advantages and the latest advances in the field. A thorough summary that can be utilized as a guide for emergency and critical care healthcare providers is presented. The daily hemodynamic management of critically ill patients involves the implementation of new protocols, such as VexUS or the evaluation of the renal resistance index. The role of ultrasound in managing acute nephropathy and genitourinary issues is increasingly crucial given its bedside availability, thus this imaging modality not only facilitates the initiation of therapeutic interventions but also provides swift prognostic insights that are vital to provide tailored patient care. As further advances in ultrasound will arise, it is important for healthcare providers to foster the use of these technologies capable of improving patient outcomes.

A rare case report of ectopic-adrenal paraganglioma with inferior vena cava infiltration. Case report and literature review

INTRODUCTION AND IMPORTANCE

Phaeochromocytomas are neuroendocrine neoplasms arising from chromaffin cells of the adrenal medulla and are known as intra-adrenal paragangliomas. On the contrary, paragangliomas are non-epithelial neuroendocrine neoplasms that produce other peptide hormones such as norepinephrine, epinephrine, and dopamine. In a setting with limited resources, such a condition may result in inaccurate diagnosis and treatment, which may lose a patient life if left untreated. In addition, PPGLs present a surgical challenge to many surgeons who are not thoroughly prepared.

CASE PRESENTATION

We describe a case of extra-adrenal paraganglioma in a 27-year-old female who presented with symptoms of heartbeat awareness for almost a year and abdominal swelling for three months. Physical examination revealed a palpable mass around the umbilicus. Abdominal pelvic CT scan revealed a well-circumscribed mass in the central retroperitoneum displacing the IVC laterally and abdominal aorta medially with no invasion of surrounding structures. Results for pheochromocytoma workup showed elevated levels of 24-h urine Vanillylmandelic acid (VMA), and 24-h metanephrine excretion. Laparotomy through extended midline incision was done with successful excision of the tumor. The blood pressure, which was initially high normalized after surgery.

DISCUSSION

The diagnosis of a malignant EAP is commonly made based on recurrence and the development of metastasis to lymph nodes or to other organs. Our patient presented with similar symptoms as pheochromocytoma. Compared to the commonly stated 10 % risk for pheochromocytomas, people with EAPs have been observed to have a 20 % to 50 % incidence of malignancy. EAPs account for at least 15 % of adult and 30 % of pediatric pheochromocytomas and are frequently found in the Zuckerkandl organ. Pheochromocytoma symptoms may manifest asymptomatically in patients with EAPs, or they may occur because of compression of nearby tissues. Surgical excision of the tumor is always the best option in managing EAP.

CONCLUSION

Extra-adrenal paragangliomas can be successfully managed surgically, provided there is a multidisciplinary team, and the tumor location is well recognized and can reduce the chance of tumor metastasis.

Composite Paraganglioma of the Celiac Trunk: A Case Report and a Comprehensive Review of the Literature

Introduction

Composite paragangliomas consist of two components, paraganglioma and ganglioneuroma, representing a rare subgroup of paragangliomas. The purpose of the study is to describe a case of composite paraganglioma of the celiac trunk and a brief review of the existing literature.

Case Presentation

A 64-year-old female patient with a history of epigastric abdominal pain and a 51 mm-diameter tumor found in a Computerized Tomography of the abdomen was admitted to our surgical department for further evaluation and treatment. After a brief preoperative surgical assessment, the patient underwent a mini-laparotomy for the excision of this tumor. After having the results of the pathology report, a comprehensive review of the international literature was carried out by applying the appropriate search terms.

Results

As it was found intraoperatively, the tumor was located at the cephalad aspect of the common hepatic artery, over the portal vein and the inferior vena cava. A negative-margin resection was achieved and the tumor was sent for pathology analysis. The final pathology report revealed a composite paraganglioma, with α paraganglioma and a ganglioneuroma component. Seventeen cases of extra-adrenal composite paraganglioma have been reported in the international literature so far. This case was the first one found in the area of the celiac trunk.

Conclusions

Composite paragangliomas comprise rare and potentially malignant tumors with variable prognosis. Establishing their diagnosis promptly is of vital significance. Due to the first-described location of the composite paraganglioma in our case, the differential diagnosis of tumors in this area should also include composite paragangliomas.

A patient with paraganglioma undergoing laparoscopic resection: A case report

Paraganglioma is a very rare extraadrenal nonepithelial tumor. The number of cases of laparoscopic surgery in Paraganglioma is small and controversial. This study encountered a case of successful transperitoneal laparoscopic surgery for a 56-mm paraganglioma in a 53-year-old female. Moreover, previous reports on laparoscopic surgery for paraganglioma are reviewed.

Severe Hypertension Leading to Hemorrhagic Stroke in Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1), also known as von Recklinghausen’s disease, is an autosomal dominant multisystem genetic disorder affecting one in 2,600 individuals. It is caused by a mutation of the NF-1 gene located on chromosome 17q11.2. It is characterized by various cutaneous findings, including cafe-au-lait spots and axillary freckling. Hypertension is a commonly reported finding in adult patients with NF-1 but may also develop during childhood. In most cases, hypertension in NF-1 patients is primary in nature; however, secondary hypertension has been more frequently reported in NF-1 patients due to the association of NF-1 with an increased incidence of pheochromocytomas, bilateral renal artery stenosis, and coarctation of the abdominal aorta. This case reports the consequences of uncontrolled hypertension in a 23-year-old female with NF-1, illustrating the importance of screening for hypertension in children diagnosed with NF-1, and emphasizing the higher incidence of both primary and secondary causes of hypertension in the NF-1 patient population. In this case, no secondary causes of hypertension were found; therefore, a diagnosis of primary hypertension was made and the appropriate therapy was initiated to prevent further complications.

Abdominal paraaortic paraganglioma: Management of intraoperative hemodynamic emergencies during elective resection procedures (A case presentation)

Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.

Non-adrenal tumors of the adrenal area; what are the pitfalls?

Discovery of an adrenal mass is nowadays a frequent situation. While adrenal tumors can cause a variety of symptoms, more often than not they are diagnosed incidentally on imaging exams such as CT-scan or MRI performed for another purpose. However, any retroperitoneal supra-renal mass can have an extra-adrenal origin. Indeed, operated non-adrenal masses initially but wrongly diagnosed as an adrenal disease represent about 3.5% of adrenalectomies. These differential diagnoses principally include retroperitoneal tumors that are malignant in two thirds of cases (lymphomas, sarcomas, neurogenic or germinal tumors), and more rarely vascular anomalies or congenital malformations, which are most frequently left-sided due to the wide variety of anatomical structures surrounding the left adrenal gland. Several lesions can originate from the adrenal gland or be located near the gland (paraganglioma, ganglioneuroma). Even though unilateral adrenalectomy is associated with low morbidity, ignorance of these differential diagnoses can cause ill-adapted management; overly conservative surgery in case of sarcoma is one example. Some of these lesions have characteristic clinical or imaging features (cystic lymphangioma, angiomyolipoma…). In other cases, assessment of hormonal secretion is required and additional exams (MRI, percutaneous biopsy, PET-scan with 18-Fluorodeoxyglucose) can correct an erroneous diagnosis. The above diagnostic approach allows appropriate management (with or without surgery). The purpose of this review was to highlight the main differential diagnoses of adrenal masses, to describe their characteristics, and to discuss their therapeutic management.

Retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuromas: our technique and clinical outcomes

OBJECTIVE

To report our experience of retroperitoneoscopic technique in semi-lateral decubitus position for the retroperitoneal nonadrenal ganglioneuromas in 18 patients, and to evaluate its clinical outcomes.

MATERIALS AND METHODS

From January 2012 to May 2016, 18 patients with retroperitoneal nonadrenal ganglioneuromas underwent retroperitoneoscopic resection. With the patients in semi-lateral decubitus position, a 4-port retroperitoneal approach was used. Data were collected on the tumor size, tumor location, perioperative outcomes, pathology, and lastknown disease status. We reviewed the operative videos to identify surgical tips and tricks.

RESULTS

All procedures were carried out successfully without converting to open surgery. The tumors had an average size of 5.2cm. The mean operative time was 86.5 min, with a mean estimated blood loss of 85.4mL. There were three patients suffering from intraoperative complications. Postoperatively, all patients achieved an uneventful recovery; the mean postoperative hospital stay was 5.5 days. The postoperative pathology revealed to be retroperitoneal ganglioneuromas. With a mean follow-up of 39.5 months, all patients were recurrence free. The review of the operative videos revealed several tips and tricks, including keeping peritoneum and posterior Gerota fascia intact to provide a favorable operative exposure of tumors, and placing the harmonic scalpel through different ports during tumor dissection.

CONCLUSIONS

With the patient in semi-lateral decubitus position and a 4-port retroperitoneal approach, retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuroma is a feasible, effective, and safe procedure. This approach has distinct advantages including direct access to the tumor, optimal exposure of tumor and less intraperitoneal interference.

Retro-peritoneal paraganglioma, diagnosis and management

INTRODUCTION

Paragangliomas, defined as extra-adrenal chromaffin-cells tumors, are rarely located in the retro-peritoneum. Clinical presentation is similar to pheochromocytoma, and mainly depends on the producing character of the tumor. Positive diagnosis requires plasmatic and urinary hormonal assays. Radiological and isotopic explorations are essential before surgery. The only curative therapeutic strategy is surgical, associated to peri-operative prevention and monitoring of the frequently reported hemodynamic and cardiovascular disorders. Outcome depends of the metastatic character of the tumor, the presence of tumor remnant after surgical resection. Genetic study is recommended; the risk of recurrence and association to other neoplasm is more described in genetic forms.

MATERIAL AND METHODS

Authors report 5cases of retro-peritoneal paraganglioma, operated in the department of urology of Hospital, between 2013 and 2017. Observations are about 2men and 3women. Clinical presentation is not always specific and paraganglioma may be discovered fortuitously. Two patients have been operated by coelioscopic approach, midline incision was performed in two other cases, and dorsal lumbotomy associated to a Rutherford-Morrison incision in a patient.

RESULTS

Two patients presented resistant hypertension and palpitation associated to suspect retro-peritoneal masses in imagery and elevated urinary methoxylated derivates before surgery. One patient was asymptomatic and the tumor was discovered in imagery. Per-operative hypertensive crisis and sinus tachycardia occurred in a case. The average follow-up period is 22.8months. Hypertension and palpitation disappeared after surgery. There was no recurrence for all the operated patients.

CONCLUSION

Retro-peritoneal paraganglioma is a rare condition. Symptoms are not specific and clinical presentation may be similar to pheochromocytoma. Abdominal CT-scan and MRI, in association with MIBG scintigraphy are strongly evocative. Histological examination ensures diagnosis. Per-operative cardio-vascular disorders are to consider and must prevented and managed by anesthesiologists. Complete surgical resection is the only curative treatment and avoids recurrences.

Peritoneal carcinomatosis from ovarian paraganglioma: Report of a rare case and systematic review of the literature

Paraganglioma is one of the rarest neoplasms involving the ovary, with only 10 previous reports. We present a case of peritoneal carcinomatosis from primary ovarian paraganglioma and a systematic review of the literature. Clinical information was retrieved from medical records, and a systematic review of the literature was performed according to meta-analysis of observational studies in epidemiology guidelines. A 33-year-old woman presented with a 12-month history of hypertension and weight loss. She was diagnosed with ovarian paraganglioma and was treated with extensive debulking surgery to no residual disease after three cycles of neoadjuvant chemotherapy. She recurred after 6 months and was started on somatostatin-analogue. Following further disease progression with bone metastasis (treated with palliative radiotherapy), a trial with Sunitinib was started. The patient died 30 months after initial diagnosis. Of the cases reported to date, only one had peritoneal metastasis at presentation but none of them had such an ominous prognosis. Ovarian paraganglioma is an extremely rare condition. We report the first case of primary malignant ovarian paraganglioma with an exceptionally aggressive behavior. Clinicopathological correlation with immunohistochemistry is essential to avoid misdiagnosis. A standard treatment is not recommended yet but cytoreductive surgery seems to be a favorable approach to prolong survival.

Primary functioning hepatic paraganglioma mimicking hepatocellular carcinoma: A case report and literature review

INTRODUCTION

Hepatic paraganglioma (HPGL) originates from the sympathetic nervous tissue in the liver, and is an extremely rare type of the sympathetic paragangliomas. Till now, only 11 HPGL cases have been reported.

CASE PRESENTATION

A 49-year-old woman presented to our hospital with a lesion in the right lobe of the liver, which grew from 2 to 6 cm in 2 years. In addition, she had a 6-year history of diabetes. The patient was initially diagnosed as hepatocellular carcinoma and hepatectomy was performed. Surgical resection of the liver lesion was successful, but the blood pressure rose and fell sharply when the lesion was being removed. The pathological examination of the liver lesion showed that it was HPGL. After the operation, the patient recovered uneventfully. Follow-up examination showed the blood glucose level went back to the normal range in 20 days after the operation, and MRI and I-MIBG scan showed that there was no evidence of recurrence and metastasis in >2 years.

CONCLUSION

By means of reporting this case and reviewing 11 reported cases, we conclude that the incidence of HPGLs is extremely low and the clinical and radiological characteristics of HPGLs are nonspecific; thus, it is hard to diagnose HPGLs correctly. Surgical resection is curative therapy for HPGLs, whereas the removing of HPGLs may cause the releasing of catecholamine, and then lead to hypertension crisis and arrhythmia. Thus, antihypertensive therapy is necessary during the operation. Follow-ups after the operation are important for HPGL patients, for pathological examinations are not sufficient to differ malignant HPGLs from benign ones, and follow-ups are helpful for HPGL patients to find the recurrent foci or metastases timely.

Fat-containing Retroperitoneal Lesions: Imaging Characteristics, Localization, and Differential Diagnosis

The complex anatomy of the retroperitoneum is reflected in the spectrum of neoplastic and nonneoplastic conditions that can occur in the retroperitoneum and appear as soft-tissue masses. The presence of fat within a retroperitoneal lesion is helpful in refining the differential diagnosis. Fat is easily recognized because of its characteristic imaging appearance. It typically is hyperechoic at ultrasonography and demonstrates low attenuation at computed tomography (-10 to -100 HU). Magnetic resonance imaging is a more ideal imaging modality because it has better soft-tissue image contrast and higher sensitivity for depicting (a) microscopic fat by using chemical shift imaging and (b) macroscopic fat by using fat-suppression techniques. Whether a lesion arises from a retroperitoneal organ or from the soft tissues of the retroperitoneal space (primary lesion) is determined by examining the relationship between the lesion and its surrounding structures. Multiple imaging signs help to determine the organ of origin, including the "beak sign," the "embedded organ sign," the "phantom (invisible) organ sign," and the "prominent feeding artery sign." Adrenal adenoma is the most common adrenal mass that contains microscopic fat, while myelolipoma is the most common adrenal mass that contains macroscopic fat. Other adrenal masses, such as pheochromocytoma and adrenocortical carcinoma, rarely contain fat. Renal angiomyolipoma is the most common fat-containing renal mass. Other fat-containing renal lesions, such as lipoma and liposarcoma, are rare. Fatty replacement of the pancreas and pancreatic lipomas are relatively common, whereas pancreatic teratomas are rare. Of the primary retroperitoneal fat-containing lesions, lipoma and liposarcoma are common, while other lesions are relatively rare. (©)RSNA, 2016.

Laparoscopic resection of a large paraganglioma arising in the organ of Zuckerkandl: Report of a case and review of the literature

Paragangliomas are catecholamine-secreting neuroendocrine tumours arising from chromaffin tissue at extra-adrenal sites. The commonest site for a paraganglioma is the organ of Zuckerkandl. Traditional treatment of paraganglioma of organ of Zuckerkandl (POZ) involves open surgical resection, and only a few cases of laparoscopic approach to this pathology have been reported. We report the successful laparoscopic resection of a large POZ in a 22-year-old woman and review the previous cases reporting a laparoscopic approach to this rare tumour.

CT and MR Imaging Findings of Pancreatic Paragangliomas: A Case Report

Previous studies on pancreatic paraganglioma, a rare neoplasm, have primarily reported its ultrasound and routine and contrast-enhanced computed tomography (CT) findings. To our knowledge, we are the first to report the contrast-enhanced magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) sequence findings of pancreatic paraganglioma. A male patient, ages 41 years, was admitted to our hospital due to a pancreatic space-occupying lesion that had been present for more than 10 days. The patient had no obvious discomfort. He had a history of hypertension and hyperthyroidism. Physical examination revealed upper abdominal tenderness without a palpable mass. Routine and contrast-enhanced abdominal CT showed a soft tissue mass at the pancreatic head/uncinate process, with patchy calcification within the lesion. On a contrast-enhanced CT scan, severe enhancement of the mass in the arterial phase was noted, as was slightly reduced but still marked enhancement in the venous phase. The celiac trunk and superior mesenteric artery segment were wrapped by the tumor. Thickened, tortuous vessels were observed at the lesion edges, around which there were multiple enlarged lymph nodes. The main pancreatic duct was markedly dilated. Routine and contrast-enhanced pancreatic MRI demonstrated an abnormal nodular signal in the pancreatic head/uncinate process that was approximately 4.3 × 6.4 cm² in size. T1-weighted imaging (T1WI) revealed hypointensity, whereas T2-weighted imaging (T2WI) revealed nonhomogeneous, slight hyperintensity. Patchy hypointensity on both T1WI and T2WI was observed within the lesion. DWI showed slight hyperintensity. Grossly heterogeneous enhancement of the mass was observed on a contrast-enhanced MRI scan, with the tumor wrapped around the adjacent vasculature, and multiple enlarged lymph nodes were observed peripherally. After preoperative preparation, the patient underwent pancreatoduodenectomy. Histopathology and immunohistochemistry of the resected tumor indicated pancreatic paraganglioma. After surgery, the patient recovered well, without presenting any recurrence or metastasis during short-term follow-up. For hypervascular pancreatic tumors on contrast-enhanced CT or MRI, and particularly those occurring in the pancreatic head, with a clear display of draining veins, the possibility of pancreatic paraganglioma should be considered. These tumors usually exhibit necrosis or cystic changes and are occasionally accompanied by calcification.

Retroperitoneal Laparoscopic Management of Paraganglioma: A Single Institute Experience

OBJECTIVES

To explore the feasibility and safety of retroperitoneal laparoscopic resection of paraganglioma (RLPG) in a large study population.

METHODS

In a six-year period, 49 patients with primary retroperitoneal paragangliomas (PG) underwent retroperitoneal laparoscopic surgery in a single center. Medical records were reviewed, and collected the following data, which were clinical characteristics, perioperative data (operative time, estimated blood loss, intraoperative hemodynamic changes, intraoperative and postoperative complications, and open conversions), and follow-up data (recurrence or distant metastases).

RESULTS

All PGs were removed with negative tumor margin confirmed by postoperative histopathology. The operative time of RLPG was 101.59±31.12 minutes, and the estimated blood loss was 169.78±176.70ml. Intraoperative hypertensive and hypotensive episodes occurred in 25 cases and 27 cases, respectively. Two open conversions occurred. Two intraoperative complications occurred but were successfully managed endoscopically. Postoperative complications were minor and unremarkable. No local recurrence or distant metastasis were observed during the follow-up period.

CONCLUSIONS

Our experience indicates the feasibility and safety of resection of PGs in a relatively large study population.

Multifocal Extra-Adrenal Paraganglioma - Case Report

Paraganglioma is a rare neoplasm originating from extra-adrenal pheochromocytes of the sympathetic and parasympathetic nervous system. It is usually benign and the treatment method of choice is a complete resection of the tumour. The authors present a case of 66-year-old female patient with a multifocal benign retroperitoneal paraganglioma, which was completely removed during surgery.

Cross-sectional Imaging Features of Primary Retroperitoneal Tumors and Their Subsequent Treatment

Basically malignant tumors in the retroperitoneal region arise from a heterogeneous group of tissues: mesodermal, neurogenic, germ cell, and lymphoid. Although rare, benign tumors and cystic masses can be also encountered in retroperitoneal space. Developments in computed tomography (CT) and magnetic resonance imaging (MRI) have contributed to both diagnosis and staging of the retroperitoneal tumors. High spatial resolution and superiority in calcification make CT indispensable; on the other hand, MRI has a better soft-tissue contrast resolution which is essential for the assessment of vascular invasion and tissue characterization. The aim of this article is to review the CT and MRI features of retroperitoneal tumors and their subsequent management.

Malignant paraganglioma in a cougar (Puma concolor)

A 7½-yr-old male cougar (Puma concolor) was presented with a 2-wk history of progressive hindlimb abnormalities. An abdominal mass was palpated on physical examination. Computed tomography of the abdomen showed a mass surrounding the left ureter. A postmortem diagnosis of paraganglioma was established.

Non-functioning Aortocaval Paraganglioma Masquerading as Celiac Lymphnodal Metastasis

An extra-adrenal paraganglioma is a rare tumour derived from chromaffin cells of sympathetic ganglia. This report documents a rare case of a non-functional aortocaval paraganglioma in a 24-year-old woman with persistent abdominal pain. Computed tomography revealed a solid mass, measuring 2.5x3cms, localized between the celiac trunk and superior mesenteric artery in aortocaval location along with right ovarian cystic mass. A clinical diagnosis of malignant ovarian tumour with celiac nodal metastasis was made. Excision and pathological analysis of both revealed an aortocaval extra-adrenal paraganglioma and benign ovarian cyst. On serial follow-up the patient was in a good health, asymptomatic and without evidence of tumour recurrence. This case emphasizes the necessity of including extra-adrenal paraganglioma in the differential diagnosis and management of retroperitoneal tumours, despite its rarity.

Primary Retroperitoneal Inter-aorto-Caval Paraganglioma of the Organ of Zuckerkandl

Tumour that arise from chromaffin cells at extra-adrenal locations are termed paragangliomas which are rare tumour. The organ of Zuckerkandl located along aortic bifurcation is the most common site of their occurrence. Herein, we report a case of 20-year-old male with large abdomino-pelvic paraganglioma of the organ of zuckerkandl with multiple pedicles to abdominal aorta. On exploratory laparotomy it revealed a large retroperitoneal mass with variable consistency with surfaces covered with tortuous vessels. This mass was adhered to the retroperitoneum with multiple arterial pedicles to abdominal aorta. Histopathologic evaluation revealed features of extra-adrenal paraganglioma with characteristic Zellballen appearance. Postoperative course was uneventful.

Primary Retroperitoneal Inter-aorto-Caval Paraganglioma of the Organ of Zuckerkandl

Tumour that arise from chromaffin cells at extra-adrenal locations are termed paragangliomas which are rare tumour. The organ of Zuckerkandl located along aortic bifurcation is the most common site of their occurrence. Herein, we report a case of 20-year-old male with large abdomino-pelvic paraganglioma of the organ of zuckerkandl with multiple pedicles to abdominal aorta. On exploratory laparotomy it revealed a large retroperitoneal mass with variable consistency with surfaces covered with tortuous vessels. This mass was adhered to the retroperitoneum with multiple arterial pedicles to abdominal aorta. Histopathologic evaluation revealed features of extra-adrenal paraganglioma with characteristic Zellballen appearance. Postoperative course was uneventful.

Management and follow up of extra-adrenal phaeochromocytoma

Introduction

The prevalence of phaeochromocytoma (PCC) in patients with hypertension is 0.1–0.6% and about 10% of PCCs are detected in extra–adrenal tissue. The diagnosis and therapy of this rare disease detected as a retroperitoneal tumor mass can be difficult for clinicians.

Material and methods

A PubMed database was searched for the peer–reviewed articles, the listed articles until Dec 2012 were included. Following key words were used: “extra–adrenal phaeochromocytoma”, “paraganglioma”, “diagnosis”, “therapy”, “surgery”, “genetic analysis”, and “SDH mutation”.

Results

Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) are first choice imaging tools for PCC (sensitivity 90–100%). For the validation of the diagnosis or follow up, the functional imaging 123I–metaiodobenzylguanidine (MIBG) or Fluorine–18–L–dihydroxyphenylalanine (18F–DOPA) positron emission tomography (excellent specificity and sensitivity of 90–100% in detection of small tumors >1–2 cm) are used. Laparoscopic surgery with complete resection is a safe and a first choice approach. The conversion (about 5%) to direct open operation was needed for large lesions (>8 cm) with the suspicion of malignancy. Currently, there are no histological criteria for distinguishing benign and malignant tumors. The genetic testing (Sanger DNA sequencing) for hereditary syndromes (von Hippel–Lindau, neurofibromatosis, etc.) is used for prediction of malignancy and recurrence. All patients should get individual and risk–adapted genetic analysis and consultation, including family members. The rate of malignancy in ePCC is about 30% (PCC about 5–10%). In patients with proven SDHB germline mutations, higher malignancy rate, multiple PCCs and recurrences are likely. A stringent lifelong clinical follow–up is recommended in these cases. Patients with syndromic hereditary forms should be screened for other often associated neoplasms.

Conclusions

New imaging tools and genetic analysis are crucial to improve the diagnosis and prognosis of phaeochromocytoma.

Paraganglioma presenting with marked proteinuria: a case report

Paragangliomas are rare neuroendocrine tumors that arise from sympathetic and parasympathetic paraganglia. In children, most of them are functional tumors. Presenting symptoms such as sustained or paroxysmal elevations in blood pressure, headache, sweating, and palpitations are related to catecholamine hypersecretion. A previously healthy 8-year-old boy presented with marked proteinuria, hypertension, and heart murmur. Imaging revealed an 81×43×45 mm sized solid mass extending from right retroaortic area to left suprarenal region. Measurements of catecholamines suggested the diagnosis of paraganglioma. Pathologic examination confirmed the diagnosis. Complete tumor resection was performed. Proteinuria, hypertension, and cardiac signs resolved after surgery. Proteinuria has been described as a rare manifestation of paragangliomas in adult patients. This is the first case of a paraganglioma presenting with massive proteinuria in a child.

Metastatic paraganglioma presenting as a primary shoulder mass

Paragangliomas uncommonly metastasize, including to the bones, wherein these tumors are designated as malignant paragangliomas. A 56-year-old man presented with pain and immobility in his right arm for 1 year. He had a history of controlled hypertension and diabetes mellitus for 2 years. He had also been taking anti-anxiety medications for 25 years. His shoulder imaging revealed an expansile, lytic, destructive lesion in the glenoid cavity, measuring 4.6 × 3.9 × 3.2 cm, involving the adjacent bones and soft tissues. A whole-body PET-CT scan revealed a hypermetabolic destructive mass in the right glenoid cavity and another lesion in his abdomen in the aortocaval region. Initial biopsy and subsequent scapular resection microscopically revealed a multinodular tumor with polygonal cells arranged in a nesting and diffuse pattern, in a vascularized and sclerotic stroma. Tumor cells displayed moderate to abundant, eosinophilic to clear cytoplasm, fine nuclear chromatin, focal intranuclear inclusions, and scattered mitotic figures. Immunohistochemically, tumor cells were positive for vimentin, synaptophysin, chromogranin, and CD56 and negative for AE1/AE3, CK, EMA, CD10, SMA, Melan A, HMB-45, desmin, and S100-P. Biopsy of the abdominal mass revealed foci of tumor cells resembling the scapular tumor. Diagnosis of a malignant paraganglioma was finally offered. The patient's post-operative blood pressure is controlled. Currently, his urinary vanillylmandelic acid and metanephrine levels are normal. He is asymptomatic 11 months post-surgery and is on follow-up. This unusual case is presented to increase a diagnostic index of suspicion for a malignant paraganglioma, including at unconventional musculoskeletal sites. The diagnostic challenge and therapeutic implications are discussed herewith.

An unusual combination of extra-adrenal pheochromocytoma and arteriovenous malformation of the ureter in a young adult

We present a case of a 24-year-old gentleman who presented with painless pan haematuria for 2 weeks. During the workup, he was diagnosed to have a retrocaval mass after a CT scan while cystoscopy revealed a polypoidal pulsating lesion in the left ureter. After surgical manipulation of the retrocaval mass, the blood pressure of the patient raised to 260/130 mm Hg. It was completely resected and diagnosed as extra-adrenal pheochromocytoma (paraganglioma) after histopathology. The lesion in the ureter was completely excised and fulgurated and diagnosed as an arteriovenous malformation. To the best of our knowledge, this is the first patient to be presented in the literature with this unusual combination.

Retroperitoneal composite pheochromocytoma-ganglioneuroma : a case report and review of literature

Abstract

Composite pheochromocytoma/paraganglioma is a rare tumor with elements of pheochromocytoma/paraganglioma and neurogenic tumor. Most were located in the adrenal glands, and extra-adrenal composite pheochromocytoma is extremely rare. Only 4 cases in the retroperitoneum have been described in the online database PUBMED. Here, we report a case of retroperitoneal extra-adrenal composite pheochromocytoma and review the related literature.

Virtual slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1700539911908679

Retroperitoneal paraganglioma presenting as a chest pain: a case report

Paragangliomas are very rare tumors derived from neuroendocrine cells of autonomic nervous system. Extra-adrenal paragangliomas account for only 10 to 15% of all paragangliomas and may present incidentally as a mass. Typical triad of fluctuating hypertension, headache, and sweating is not always present which makes the diagnosis difficult sometimes. Definitive diagnosis is usually made with histologic findings and surgery is the treatment of choice. We report a case of a 53-year-old male who presented with chest pain and vomiting.

Cell loss and autophagy in the extra-adrenal chromaffin organ of Zuckerkandl are regulated by glucocorticoid signalling

Neuroendocrine chromaffin cells exist in both intra- and extra-adrenal locations; the organ of Zuckerkandl (OZ) constitutes the largest accumulation of extra-adrenal chromaffin tissue in mammals. The OZ disappears postnatally by modes that are still enigmatic but can be maintained by treatment with glucocorticoids (GC). Whether the response to GC reflects a pharmacological or a physiological role of GC has not been clarified. Using mice with a conditional deletion of the GC-receptor (GR) gene restricted to cells expressing the dopamine β-hydroxylase (DBH) gene [GR(fl/fl) ; DBHCre abbreviated (GR(DBHCre) )], we now present the first evidence for a physiological role of GC signalling in the postnatal maintenance of the OZ: postnatal losses of OZ chromaffin cells in GR(DBHCre) mice are doubled compared to wild-type littermates. We find that postnatal cell loss in the OZ starts at birth and is accompanied by autophagy. Electron microscopy reveals autophagic vacuoles and autophagolysosomes in chromaffin cells. Autophagy in OZ extra-adrenal chromaffin cells is confirmed by showing accumulation of p62 protein, which occurs, when autophagy is blocked by deleting the Atg5 gene (Atg5(DBHCre) mice). Cathepsin-D, a lysosomal marker, is expressed in cells that surround chromaffin cells and are positive for the macrophage marker BM8. Macrophages are relatively more abundant in mice lacking the GR, indicating more robust elimination of degenerating chromaffin cells in GR(DBHCre) mice than in wild-type littermates. In summary, our results indicate that extra-adrenal chromaffin cells in the OZ show signs of autophagy, which accompany their postnatal numerical decline, a process that is controlled by GR signalling.

Intraoperative diagnosis of functional retroperitoneal multiple paraganglioma: A case report

Paragangliomas are extra-adrenal chromaffin tumors that arise from neuroectodermal cells of the autonomous nervous system. It is difficult to make an accurate preoperative clinical diagnosis of silent paraganglioma. The best choice of treatment is complete surgical resection. However, it is important to note that in patients with functional paragangliomas, the tumor's ability to produce catecholamines may cause abrupt changes in blood pressure. Thus, surgery may induce life-threatening complications. In the present study, we present a case of functional retroperitoneal multiple paraganglioma in a 39-year-old male patient who was diagnosed during surgery. Four years after the operation, the patient remains asymptomatic and free of disease.

Navigation with the use of intraoperative ultrasonography in videoscopic adrenal surgery

The aim of the study was to assess the efficacy of intraoperative ultrasonography during videoscopic adrenalectomy.

MATERIAL AND METHODS

The study was conducted in patients undergoing extraperitoneal videoscopic adrenalectomy for adrenal tumours in the Department of Endocrine, General and Vascular Surgery of the Medical University in Łódź in 2008-2011.

RESULTS

The active group consisted of 20 patients in whom navigation with the use of intraoperative ultrasonography (IOUS) was used in the course of surgery. The comparison group consisted of 46 patients operated without the use of IOUS. In the active group, we managed to obtain a shorter time of surgery by almost 20 min (89.44 ± 27.11 min vs 109.12 ± 33.88 min; p=0.034) and a shorter lesion access time by more than 15 min (28.61 ± 14.93 min vs 45.98 ± 20.44 min; p=0.002). Intraoperative blood loss was also significantly lower in the active group (86.11 ± 157 ml vs 169.27 ± 201.04 ml; p=0.037). In contrast, the use of IOUS did not affect the hospitalisation time (4.39 ± 3.27 days vs 3.83 ± 3.67 days; p=0.227), the rate of intraoperative complications (0/18 vs 2/41; p=1) and the conversion rate (2/20 - 10% vs 5/46 - 10.87%; p=1).

CONCLUSIONS

1. Intraoperative ultrasonography is useful for determining the tumour relationship with the surrounding anatomical structures. 2. Intraoperative ultrasonography is a useful technique in the assessment of adrenal tumour infiltration of the surrounding tissues. 3. This technique facilitates finding the pathological lesion, shortening the time of access to the tumour and procedure duration (thus reducing the burden for the patient). 4. Reduced blood loss was also obtained owing to the use of IOUS.

Malignant abdominal paraganglioma presenting as a giant intra-peritoneal mass

INTRODUCTION

Paraganglioma is a malignant tumor that arises from the extra adrenal paraganglionic cells of the sympathetic or parasympathetic systems. Herein, we present a case of abdominal mass of unknown histology that underwent a very difficult surgical mass resection. Its final histologic diagnosis was non-functional paraganglioma that was presented as a huge intra-peritoneal mass.

PRESENTATION OF CASE

The patient was a 55-year-old Iranian lady who referred to our center with a giant abdominal mass. Fine needle aspiration (FNA) biopsy showed undifferentiated carcinoma. After laparotomy for mass resection pathology evaluation revealed; malignant paraganglioma, non-metastatic type. Further post-operative patients evaluations showed that the tumor was sporadic in nature and the subsequent patient's natural history was uneventful.

DISCUSSION

Pathologic evaluations have key roles in the exact diagnosis of abdominal masses with unidentified sources. For the paragangliomas, all of them should be regarded malignant until proved otherwise. However, combined use of biochemical markers, immunohistochemical techniques (IHC), and genetic analysis have key roles in the diagnosis and treatment of paragangliomas. Additionally, surgical removal is the proved curative way of paraganglioma treatment.

CONCLUSION

Asymptomatic intra-peritoneal paraganglioma is very rare, especially its malignant variety. This case emphasizes that full pathologic investigation would reveal the exact nature of idiopathic abdominal masses, especially in the state of absence of typical clinical and para-clinical symptoms.

Left subdiaphragmatic paraganglioma supplied by contralateral right renal artery

INTRODUCTION

Paragangliomas are neuroendocrine tumors of the autonomic nervous system that arise from neural crest cells. Paragangliomas are typically extra-adrenal, non-functional and can be discovered incidentally, posing diagnostic and therapeutic challenges.

PRESENTATION OF CASE

We present the unusual case of a young man who presented with an acute abdomen secondary to small bowel obstruction, and was found to have an incidental left-sided subdiaphragmatic paraganglioma supplied by a branch of the contralateral right renal artery.

DISCUSSION

Emergent laparotomy revealed an internal hernia as the source of the small bowel obstruction. Initial attempts to remove an incidental left subdiaphragmatic mass were aborted because of bleeding. Subsequently, after preoperative superselective embolization of the feeding vessel arising from the right renal artery, the mass was successfully resected. Pathology was consistent with a paraganglioma.

CONCLUSION

This report highlights the rarity of the location and blood supply of an incidental left subdiaphragmatic paraganglioma found in the setting of a small bowel obstruction.

Clinical and imaging overview of functional adrenal neoplasms

Adrenal adenoma, adrenocortical carcinoma, pheochromocytoma and neuroblastoma are four discrete adrenal neoplasms that have the potential for functional activity. Functional adrenal neoplasms can secrete cortisol, aldosterone, sex hormones or catecholamines. These heterogeneous groups of tumors show varied biological behavior and clinical outcomes. These neoplasms are encountered with increasing clinical frequency as a result of an expansion in the volume of medical imaging carried out. The clinical presentation, including prognosis and treatment options, and the imaging features of these neoplasms are discussed. The key radiological observations of each of these neoplasms are shown using multimodality images. Familiarity with the clinical and imaging features of these neoplasms improves diagnosis, and facilitates appropriate clinical decision-making and patient management.

Laparoscopic resection of extra-adrenal pheochromocytoma in paediatric age

Today, in the era of minimally invasive surgery, paediatric laparoscopy has become widely popular. Extra-adrenal pheochromocytoma is a very rare entity, especially in the paediatric age group and utility of the laparoscopic approach is not established in this population. Early diagnosis and surgical excision are integral part of treatment of childhood pheochromocytoma. We present a case study of a child with hormonally active extra-adrenal pheochromocytoma that was resected laparoscopically. Laparoscopic approach provides excellent exposure with magnification and allows proper identification of the tumour and its relation to surrounding structures; complete resection of tumour was achieved with adequate vascular control. With our initial experience, we suggest laparoscopic resection is an appropriate and feasible tool in such cases.

Delayed intracranial and bony metastasis of paraganglioma

Background:

Paragangliomas are tumors of neural crest origin that arise from the extra-adrenal paraganglia. In contrast with the often quoted 10% rule of malignancy for pheochromocytomas, the rate of malignancy as defined by local invasion or distant metastasis has been reported to be from 20% to as high as 50% in some case series with the most common sites of distant metastases being the liver, lungs, and bones. Here we present the case of a patient who presented with a rare case of intracranial metastasis from abdominal paraganglioma.

Case Description:

Our patient was a 48-year-old male with a distant history of multiple resections of abdominal paraganglioma in 1975 who presented with left shoulder, and left occipital metastasis 35 years after his original paraganglioma operations.

Conclusions:

Intracranial metastasis of paraganglioma is rare. There are unfortunately no known criteria to assess the risk of metastatic potential and given the long possible latency period between the resection of the primary tumor and the discovery of metastatic disease, patients with paragangliomas require lifelong monitoring. The optimal interval of monitoring has not been elucidated but follow-up every 5–10 years seems warranted.

An Unusual Case of Gastrointestinal Bleeding

A 10-year-old boy presented with a 3-day history of worsening abdominal pain, fever, emesis and melena. Abdominal ultrasound revealed a right upper quadrant mass that was confirmed by computed tomography angiogram (CTA), which showed an 8 cm well-defined retroperitoneal vascular mass. ¹²³Iodine metaiodobenzylguanidine (¹²³MIBG) scan indicated uptake only in the abdominal mass. Subsequent biopsy revealed a paraganglioma that was treated with chemotherapy. This case represents an unusual presentation of a paraganglioma associated with gastrointestinal (GI) bleeding and highlights the utility of CTA and ¹²³MIBG in evaluation and treatment.

Risky endoscopic ultrasonography-guided fine-needle aspiration for asymptomatic retroperitoneal tumors

Paraganglioma, a sporadically occurring rare tumor should be included in the differential diagnosis of retroperitoneal tumors, such as malignant lymphomas, gastrointestinal stromal tumors, sarcoma and carcinoma of unknown primary site. A 58-year-old Japanese woman presented with a large retroperitoneal tumor detected by ultrasonography (US). She had no medical history of hypertension. Computed tomography showed a mass, 7 cm in diameter, located between the pancreas and the inferior vena cava. It was unclear whether the mass originated from the duodenum or the mesentery. Endoscopic ultrasonography (EUS) demonstrated a large solid paraduodenal mass. Doppler US revealed sparse vascularity in the tumor. With the differential diagnosis of retroperitoneal tumor, we carried out EUS-FNA. At the time of the third needle puncture, transient severe hypertension was noted, with a blood pressure measurement of 269/130 mmHg. Data obtained from urine and blood examinations after EUS-fine-needle aspiration indicated a diagnosis of paraganglioma.