Anterior and middle mediastinum paraganglioma: complete resection is the treatment of choice

Aortic transection for resection of middle mediastinal tumor

BACKGROUND

Visceral mediastinal tumors are rare with challenging surgical approaches due to their location in close proximity with the great vessels and the pulmonary trunk. The aim of this paper is to discuss surgical strategies for complex cases of primary mediastinal tumors.

METHODS

We present two cases of patients with middle mediastinal tumor, one synovial sarcoma and one paraganglioma. For both patients, surgical access was performed through a sternotomy with beating heart cardio-pulmonary bypass and aortic transection, allowing optimal exposure of the carina, of the common pulmonary artery and its bifurcation. Both tumors were resected 'en-bloc'. The postoperative course was uneventful and the two patients had a 3 months postoperative follow-up CT-scan showing no evidence of recurrence.

RESULTS

Surgery remains the cornerstone of treatment for synovial sarcoma and for paraganglioma of the visceral mediastinum and this location may be difficult to deal with. Many different surgical accesses exist and our approach of ascending aortic transection allows optimal exposure to the pulmonary artery, but also provides access to the upper airways.

CONCLUSION

For visceral mediastinal tumor with close contact with vascular and respiratory structures, aortic transection allows an excellent exposure and control of the tumor with oncological resection.

Surgical and non-surgical management of thoracic and cervical paraganglioma

Thoracic and cervical paragangliomas (PGLs) are rare neuroendocrine tumors arising from chromaffin cells of the neural crest progenitors located outside the adrenal gland. We describe our current protocol as a multidisciplinary team for the management of cervical and thoracic PGLs. Surgery is generally considered the treatment of choice as it offers the best chance for cure. For resection of thoracic PGLs, video-assisted thoracoscopic surgery (VATS) is the main surgical approach, while open thoracotomy is preferred in case of tumors > 6cm, lacking confirmation of a plane of separation with adjacent structures, or with technical difficulties during VATS. In cervical PGLs, the surgical approach should be individualized according to location, mainly based on the Glasscock-Jackson and the Fisch-Mattox classifications. Surgery is the treatment of choice for most cervical and thoracic PGLs, but radiotherapy or observation could be more suitable options in unresectable cervical and thoracic PGLs or when resection has been incomplete.

Combined left thoracoscopic and median sternotomy approach to resect aortopulmonary mediastinal paraganglioma following feeding artery embolization: a case report

Background

Aortopulmonary mediastinal paragangliomas are rare. Complete resection of the tumor is desirable regardless of tumor size in view of the risk of sudden death induced by adjacent organ compression and poor prognosis after partial resection or untreated observation. Due to the hypervascularity of the tumor, the risk of intraoperative bleeding is significant, and cardiopulmonary bypass is often required for complete resection.

Case presentation

The patient was diagnosed as having bilateral carotid body tumors and supposedly an aortic body tumor at the age of 43 and eventually underwent resections of bilateral carotid body tumors at the age of 52. The pathology of the carotid body tumors was compatible with paraganglioma on both sides. A familial succinate dehydrogenase subunit D mutation was subsequently identified. Five years later, a contrast-enhanced computed tomography scan showed an enlarged tumor of 45 mm in size in the aortopulmonary mediastinum. Based on the previously known genetic mutation, the tumor was thought to be a paraganglioma. After confirming with an endocrinologist that the aortic body tumor was non-functional, radiologists performed preoperative embolization of the feeding vessels. Subsequently, a surgical team consisting of thoracic and cardiovascular surgeons resected the aortic body tumor using a video-assisted small left thoracotomy approach combined with a median sternotomy approach. The procedure was completed without cardiopulmonary bypass or blood transfusion. The patient was discharged home on postoperative day 9 uneventfully.

Conclusions

After conduction of preceding interventional embolization of multiple feeding vessels, we employed a video-assisted thoracoscopic surgical approach to dissect the aspects of the tumor adjacent to the esophagus, descending thoracic aorta, and left pulmonary artery, followed by a median sternotomy approach to dissect the other aspects of the tumor adjacent to the ascending aorta, aortic arch, right pulmonary artery, and trachea. There have been no reports on scheduled preoperative embolization of feeding vessels to an aortopulmonary mediastinal paraganglioma. Multidisciplinary approach was effective for complete resection of this challenging rare mediastinal tumor.

Pulmonary artery transection for resection of a middle mediastinal paraganglioma

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.

Mesenchymal Tumors of the Mediastinum: An Update on Diagnostic Approach

Mesenchymal tumors of the mediastinum are a heterogenous group of rare tumors with divergent lineages. Mediastinal mesenchymal tumors are diagnostically challenging due to their diversity and morphologic overlap with nonmesenchymal lesions arising in the mediastinum. Accurate histologic diagnosis is critical for appropriate patient management and prognostication. Many mediastinal mesenchymal tumors affect distinct age groups or occur at specific mediastinal compartments. Neurogenic tumors, liposarcoma, solitary fibrous tumor, and synovial sarcoma are common mesenchymal tumors in the mediastinum. Herein, we provide an update on the diagnostic approach to mediastinal mesenchymal tumors and a review of the histologic features and differential diagnosis of common benign and malignant mesenchymal tumors of the mediastinum.

Incomplete Carney Triad, a surgical case of a rare syndrome

This report describes a 36-year-old woman with multiple gastric gastrointestinal stromal tumors, hepatic and lymphatic metastasis, and a mediastinal paraganglioma as a presentation of an incomplete Carney triad. Our purpose is to present our therapeutic approach, with emphasis on the surgical and oncological specificities of this syndrome.

Diaphragmatic paraganglioma protruding into the right thoracic cavity

Paragangliomas in the diaphragm are extremely rare. We report the case of a 27‐year‐old woman with a nonfunctioning paraganglioma protruding superiorly from the right diaphragm. The patient underwent an anterior thoracotomy, and a supradiaphragmatic tumor (70 mm in diameter), which compressed the inferior vena cava and the right hepatic vein, was completely resected by combined partial resection of the right diaphragm and pericardium. To our knowledge, this is the first report of a paraganglioma situated both on the diaphragm and close to the inferior vena cava and hepatic vein.

Key points

A 46-Year-Old Woman With a Mediastinal Mass

CASE PRESENTATION

A 46-year-old otherwise healthy woman visited the ED twice over a period of 4 days for chest discomfort, midback pain, and dyspnea. The pain was localized, constant, nonpleuritic in nature, moderate in severity, and was not relieved by over-the-counter medications.

Paraganglioma of the middle mediastinum

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.

Aorticopulmonary Paraganglioma With Symptomatic Postoperative Bradycardia

Aorticopulmonary paragangliomas are rare middle mediastinal masses that are often treated with surgery. In addition to the technical challenge of resection due to location near critical structures, these paragangliomas can have postoperative complications due to resection of cardiac sympathetic innervation. We present a patient with a nonfunctional aorticopulmonary paraganglioma who suffered from postoperative hypotension and heart block, with inability to tolerate his prior alpha and beta blockade on discharge.

Pulmonary and mediastinal paragangliomas: rare endothoracic malignancies with challenging diagnosis and treatment

Background

Pulmonary and mediastinal paragangliomas are rare tumors that may have neuroendocrine activity or be non-functional, incidental, in asymptomatic patients, or causing mass effect symptoms. Although being low-grade tumors, they can display an aggressive behaviour, developing local infiltration and distant metastases. We report our experience with three endothoracic paragangliomas and a Literature review, to point out diagnostic difficulties and problems related to surgical treatment.

Methods

From 2009 to 2017, we treated 3 patients with histological diagnosis of paraganglioma: 2 pulmonary, 1 mediastinal. No one presented catecholamine-secreting syndromes; pulmonary cases were asymptomatic, while the mediastinal one had aspecific cough and dyspnea. Imaging diagnosis was based on chest computerized tomography (CT) and magnetic resonance imaging (MRI) scan. No patient had preoperative histological diagnosis. Intraoperative pathological examination was suggestive for malignancy: in pulmonary cases, wedge resection and lobectomy were performed; the middle mediastinal mass was completely removed after challenging dissection, isolation and section of numerous vascular pedicles.

Results

Postoperative course was uneventful in all cases. No patient received adjuvant treatments. At a median follow-up of 47 months (range, 6-102 months), two patients are alive, without local or distant recurrence; one patient died 6 months after surgery, due to disease progression.

Conclusions

Endothoracic paragangliomas, rare and often asymptomatic tumors, are of difficult diagnosis and should be considered malignant tumors, due to the potential aggressive behaviour of cases with high mitotic index and the frequent possibility of recurrence and metastases. Surgical resection is the treatment of choice and careful intraoperative manipulation is recommended, due to the high vascularity of these tumors, to prevent complications. After complete excision, long-term prognosis is generally good. However, even after surgical removal, a close, periodical and life-long follow-up is mandatory.

Robotic resection of a middle mediastinal mass

Aorto-pulmonary paraganglioma is an exceptionally rare condition, and its diagnosis and treatment are a challenge for the general thoracic surgeon. We describe the case of a 35 years old man who was incidentally diagnosed with a visceral mediastinal mass, deeply encased in the aorto-pulmonary window. To our knowledge this is the first case of its kind to be successfully treated with the adoption of a minimally invasive technique. We conclude that the dissection was made easier by the robotic instrumentation and by the camera system, and a minimally invasive approach would have been more difficult by traditional thoracoscopy.

Mediastinal paragangliomas related to SDHx gene mutations

Introduction

Paragangliomas (PGLs) related to hereditary syndromes are rare mediastinal tumors. Paragangliomas are caused by mutations in genes encoding subunits of succinate dehydrogenase enzyme (SDH).

Aim

To evaluate clinical, anatomical and functional characteristics of mediastinal paragangliomas related to SDHx gene mutations.

Material and methods

Retrospective analysis of 75 patients with confirmed SDHx gene mutations (24 patients with SDHB, 5 SDHC, 46 with SDHD mutations) was performed. Patients underwent evaluation using computed tomography (CT), somatostatin receptor scintigraphy (SRS) (^99mTc-[HYNIC,Tyr3]-octreotide), ¹²³I mIBG scintigraphy and urinary excretion of total methoxycatecholamines.

Results

Out of 75 patients, 16 (21%) patients (1 SDHB, 15 SDHD mutations) had 17 PGLs localized in the mediastinum. Fourteen PGLs were localized in the middle mediastinum (intrapericardial) and 3 PGLs in the posterior mediastinum. The median diameter of paragangliomas measured on the axial slice was 24.3 mm (interquartile range (IQR): 14.7–36.6), and the median volume was 2.78 ml (IQR: 0.87–16.16). Twelve out of 16 patients (75%) underwent SRS, and 11 of them (92.3%) had pathological uptake of the radiotracer. Eleven (68.75%) out of 16 patients underwent 123 I mIBG, with only 3 positive results. Symptoms of catecholamine excretion were observed in 3 patients with PGLs localized in the posterior mediastinum. All PGLs were benign except in 1 patient with the SDHB mutation and PGL detected in the posterior mediastinum, who had a metastatic disease.

Conclusions

Most mediastinal paragangliomas were related to SDHD gene mutations. They were asymptomatic, localized in the medial mediastinum, intrapericardially.

Mesenchymal tumours of the mediastinum--part II

This is the second part of a two-part review on soft tissue tumours which may be encountered in the mediastinum. This review is based on the 2013 WHO classification of soft tissue tumours and the 2015 WHO classification of tumours of the lung, pleura, thymus and heart and provides an updated overview of mesenchymal tumours that have been reported in the mediastinum.

Hypertension in pregnancy: An unresectable mediastinal pheochromocytoma

Hypertension is a relatively common occurrence during pregnancy, which usually has a benign course with an excellent prognosis. However, physicians caring for pregnant women should have a high index of suspicion for underlying medical conditions that could lead to a more perilous outcome. Herein, we present the case of a pregnant woman who was found to have uncontrollable hypertension late in her pregnancy, secondary to a mediastinal pheochromocytoma, which was deemed unresectable at the time of exploration after her delivery.

Successful Removal of Giant Intrapericardial Paraganglioma via Posterolateral Thoracotomy

Intrapericardial paraganglioma remains a surgical challenge because of its hypervascular nature and firm adhesion to adjacent mediastinal structures. Here, we describe a 63-year-old female with a giant nonfunctioning intrapericardial paraganglioma tightly adhered to the left atrium. Marginal but complete resection of the tumor was achieved via right posterolateral thoracotomy. At the time of dissection between the tumor and the left atrial wall, we encountered massive hemorrhage leading to cardiac arrest. We were able to repair the wall laceration with minimal time under an optimal operative field, which avoids air embolism. She was discharged without complications and is currently in good health with no recurrence or metastasis for 15 months. Based on our experience, cardiopulmonary bypass should be considered, if surgeons are able to secure suitable sites for arterial and venous cannulations while right posterolateral thoracotomy is employed.

An unusual case of mediastinal mass and bilateral nodules

A 23-year-old woman presented with a mediastinal paraganglioma and multiple pulmonary chondromas following antral gastric resection for gastrointestinal stromal tumor. These tumors form the Carney triad, a rare disorder of unknown genetic background. First described in 1977, approximately 120 cases have been documented in the literature. The tumors do not harbor the specific c-kit or PDGFRA gene mutations often found in sporadic gastrointestinal stromal tumor. In most cases, gastric gastrointestinal stromal tumor is the first tumor to be detected, with secondary tumors appearing years later. Even if it is rare, Carney triad should be suspected in young patients with history of gastrointestinal stromal tumor.

Mediastinal paraganglioma: complete resection using video-assisted thoracoscopic surgery

Mediastinal paragangliomas are very rare neuroendocrine tumors. Complete resection is the standard treatment of a paraganglioma because of the tumor's potential malignancy and poor response to chemo- or radiotherapy. However, the highly vascular nature of the tumor and its characteristic anatomic location make complete resection difficult. We report a case of an anterior mediastinal paraganglioma, which was incidentally found on a chest computed tomography scan for chronic cough work-up of a 55-year-old woman. Complete resection was accomplished using video-assisted thoracoscopic surgery, and the patient recovered without any complications.

Superior mediastinal paraganglioma associated with von Hippel-Lindau syndrome: report of a case

Extra-adrenal pheochromocytomas are termed paragangliomas. Paragangliomas in the mediastinum, especially the superior mediastinum, are extremely rare. It is known that paragangliomas or pheochromocytomas occur in combination with von Hippel-Lindau syndrome. We present the case of a non-functional superior mediastinal paraganglioma in a patient with von Hippel-Lindau syndrome, without a familial history suggestive of the condition. This case highlights that we should be aware of possible sporadic von Hippel-Lindau syndrome in patients with a mediastinal paraganglioma.

Resection of an intrapericardial paraganglioma under cardiopulmonary bypass

We describe the case of a 52-year-old woman with a non-functional middle mediastinal paraganglioma. Radiologic diagnosis of paraganglioma was confirmed by multidetector computed tomography and (18)F-fluorodeoxyglucose positron-emission tomography, without biopsy. Surgical resection was performed via a median sternotomy, and cardiopulmonary bypass was required for complete resection of the tumor because of invasion to the intrapericardial pulmonary artery. Preoperative pathological diagnosis of mediastinal paraganglioma by biopsy is dangerous due to bleeding, and should be avoided.

Anterior mediastinal paraganglioma: a case for preoperative embolization

Background

Paraganglioma is a rare but highly vascular tumor of the anterior mediastinum. Surgical resection is a challenge owing to the close proximity to vital structures including the heart, trachea and great vessels. Preoperative embolization has been reported once to facilitate surgical treatment.

Case presentation

We report a case of anterior mediastinal paraganglioma that was embolized preoperatively, and was resected without the need for cardiopulmonary bypass and without major bleeding complications.

Conclusion

We make a case to further the role of preoperative embolization in the treatment of mediastinal paragangliomas.

Paraganglioma of the mediastinum: challenges in diagnosis and surgical management

Mediastinal paraganglioms are rare, highly vascularized tumors arising from chromaffin tissue located in the para-aortic ganglia. Tumors tend to invade bordering structures and may also form metastasis. Up to 50% of patients are asymptomatic and diagnosis is incidental. Presenting symptoms are related to catecholamine hypersecretion or to a mass effect. Complete surgical resection remains the standard of care due to malignant potential of the tumor and poor response to chemotherapy or radiation. Strategic location of the tumor in proximity to great vessels, trachea, and recurrent laryngeal nerve poses challenge for the surgeon. We report a case of a 59-year old asymptomatic female who was incidentally diagnosed with a middle mediastinal mass on a positron-emission tomography (PET-CT) scan performed as part of breast cancer surveillance. Complete resection of the tumor was achieved using cardiopulmonary bypass. The patient recovered uneventfully and in a ten-month follow up there is no evidence of recurrence.

Aorticopulmonary paraganglioma with severe obstruction of the pulmonary artery: successful combined treatment by stenting and surgery

Aorticopulmonary paraganglioma is a rare tumor of the middle mediastinum. Complete surgical resection is the only effective treatment, even when it may pose a surgical challenge due to the proximity of the tumor to the heart and great vessels, often rendering complete resection difficult to achieve. We report the case of a 30-year-old woman with an aorticopulmonary paraganglioma who presented with severe pulmonary hypertension due to obstruction of the pulmonary artery. In the first step, stenting of the pulmonary artery was performed and 2 months later a radical resection of the tumor using cardiopulmonary bypass under circulatory arrest and deep hypothermia was carried out. In addition, the ascending aorta and aortic arch were replaced by a prosthesis. The patient is in optimal condition and has now been disease-free for almost 7 years. We believe that this is the first description in the English literature of a successful combined management strategy in view of such an unusual manifestation of aorticopulmonary paraganglioma.

Mediastinal paragangliomas: association with mutations in the succinate dehydrogenase genes and aggressive behavior

Extra-adrenal pheochromocytomas, otherwise known as paragangliomas (PGLs), account for about 20% of catecholamine-producing tumors. Catecholamine excess and mutations in the genes encoding succinate dehydrogenase subunits (SDHx) are frequently found in patients with PGLs. Only 2% of PGLs are found in the mediastinum, and little is known about genetic alterations in patients with mediastinal PGLs, catecholamine production by these tumors, or their clinical behavior. We hypothesized that most mediastinal PGLs are associated with germ line SDHx mutations, norepinephrine and/or dopamine excess, and aggressive behavior. The objective of this study was to characterize genetic, biochemical, and clinical data in a series of ten patients with mediastinal PGLs. All ten primary mediastinal PGL patients had germ line SDHx mutations, six in SDHB, and four in SDHD genes. Chest or back pain were the most common presenting symptoms (five patients), and catecholamines and/or their metabolites were elevated in seven patients. Additional tumors included head and neck PGLs in four patients, pheochromocytoma in one patient, and bladder PGL in another. Metastatic disease was documented in six patients (60%), and a concurrent abdominal mass was found in one patient. We conclude that mediastinal PGLs are strongly associated with SDHB and SDHD gene mutations, noradrenergic phenotype, and aggressive behavior. The present data suggest that all patients with mediastinal PGLs should be screened for SDHx gene mutations, regardless of age.

Management of an anterior mediastinal pheochromocytoma causing tracheomalacia

Thoracic paragangliomas are rare tumors that arise from extra-adrenal chromaffin cells and have the capacity to secrete catecholamines. Surgical excision is the optimal treatment of these tumors as they are resistant to chemotherapy and radiation therapy. Although these tumors are most commonly found in the abdomen, 10% of paraganagliomas are located in the thorax, usually in the posterior mediastinum. Occasionally these tumors present in the anterior mediastinum, which can pose a significant surgical challenge due to the proximity of the great vessels and airway. In this report we describe the treatment of an anterior mediastinal pheochromocytoma that presented with tracheal obstruction and required pulmonary artery reconstruction and airway stenting.

A 25-year-old woman with a gastric GIST and a PET-positive epicardial tumor

BACKGROUND

A 25-year-old woman presented with a history of abdominal pain. Endoscopy of the upper gastrointestinal tract revealed a tumor that protruded into the prepyloric antrum. After resection, a 'high-risk' gastrointestinal stromal tumor was histologically confirmed.

INVESTIGATIONS

Endoscopy, endoscopic ultrasound, hemigastrectomy, [(18)F]-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT scan, histological examination, immunohistochemistry, cardiac MRI, high-resolution CT with electrocardiogram gating, CT angiography, and cardiac surgery.

DIAGNOSIS

Gastrointestinal stromal tumor, epicardial paraganglioma, and Carney's syndrome.

MANAGEMENT

Abdominal ultrasound and endoscopy combined with endoscopic ultrasound, annual FDG-PET/CT scan.

Preoperative embolization followed by surgical excision of an intrapericardial pheochromocytoma

A teenager with palpitations and hypertension was found to have an intrapericardial pheochromocytoma of the left atrium with multiple feeding collaterals. Radiologic embolization was carried out on the major feeding arteries to the tumor preoperatively with good angiographic result. Surgery was carried out the following day through a median sternotomy approach and cardiopulmonary bypass. Minimal bleeding was observed due to prior embolization. The patient made a rapid postoperative recovery and was discharged 7 days later.

Aortico-pulmonary paraganglioma: case report and Japanese review

Aortico-pulmonary paraganglioma (APPG) is a rare middle mediastinal tumor. We experienced a case of APPG in a 52-year-old man. Chest computed tomography and magnetic resonance imaging revealed a multi-cystic mass in the subaortic area. A left thoracotomy was performed without definitive preoperative diagnosis. The tumor was strongly adherent to the pericardium and the surrounding large vessels, but a complete resection was undertaken. Histological and immunohistochemical examination revealed that it was a malignant paraganglioma with a microscopically positive surgical margin. After radiotherapy of 50 Gy for the mediastinum, the patient almost recovered from his hoarseness by thyroplasty. We also reviewed nine Japanese cases of APPG reported previously. Though APPG is rare, we must consider that a middle mediastinal tumor may be APPG, and preoperative examination and preoperative planning are necessary to prevent massive bleeding and microscopic residual tumor.

A case of the Carney triad

OBJECTIVE

To report a case of mediastinal paraganglioma in the setting of the Carney triad (gastric leiomyosarcoma, extra-adrenal paraganglioma, and pulmonary chondroma).

METHODS

A case of the Carney triad is presented, and the related literature is discussed.

RESULTS

A 47-year-old woman with a history of gastric leiomyosarcoma and retroperitoneal paraganglioma sought medical attention because of progressive shortness of breath. She was found to have a mediastinal mass in the aortopulmonary window. The patient had normal blood pressure and normal urinary catecholamines, but metaiodobenzylguanidine scintigraphy showed an intense uptake in the region of the mass, consistent with paraganglioma. She subsequently underwent resection of the mediastinal mass, and the surgical pathology report indicated paraganglioma.

CONCLUSION

Patients with the Carney triad can have multicentric paragangliomas. Metaiodobenzylguanidine scanning may be helpful in the diagnostic workup.

Paraganglioma de mediastino com metástases pulmonares

Descrevemos uma paciente de 27 anos que se apresentou com paraganglioma de mediastino anterior e médio e nódulos pulmonares bilaterais. O tratamento consistiu na ressecção das lesões pulmonares através de toracotomia anterior bilateral transesternal e retirada do paraganglioma com auxílio de circulação extracorpórea. Como tratamento neoadjuvante foram usadas radioterapia e quimioterapia. A evolução pós-operatória foi satisfatória, e catorze meses depois a paciente encontrava-se assintomática.

First reported case of esophageal paraganglioma. A review of the literature of gastrointestinal tract paraganglioma including gangliocytic paraganglioma

Paraganglioma and the variant gangliocytic paraganglioma are rare gastrointestinal tumors. We present the first reported case of an esophageal paraganglioma and a review of the literature. From this review it seems that these tumors can occur at any age and usually present with acute or chronic bleeding with or without abdominal pain. The majority of reported cases originated in the foregut, most commonly the second part of the duodenum. Macroscopically the tumor may be pedunculated, sessile or ulcerated and have been described up to 10 cm in size. There are no reported cases of gut paragangliomas shown to be producing clinically significant amounts of catecholamines. The majority of reported tumors have been benign, only 7% malignant at presentation and all with lymph node metastases. One case developed bone metastases 3 years after excision and another recurred locally. There has been no benefit seen from radiotherapy or chemotherapy to date and it is recommended that all of these tumors are widely excised together with a lymph node resection if possible.

Nonfunctioning paraganglioma of the aortopulmonary window

Aortopulmonary paraganglioma is a rare tumor of the mediastinum. The only effective treatment is complete resection, which may pose a surgical challenge because of its proximity to the heart, great vessels, and trachea, often rendering a complete resection difficult to achieve. We report a case in which the tumor was excised under cardiopulmonary bypass and resulted in massive bleeding only controlled by means of packing the pleural cavity during 48 hours, known as damage control strategy. The patient survived and has been disease-free for 2 years.

Preoperative embolization in the management of a mediastinal paraganglioma

Parangliomas are rare and highly vascular tumors of neuroendocrine cell origin which are treated by complete surgical resection. Preoperative embolization to reduce perioperative bleeding complications, although described in paragangliomas of the neck and carotid body, has never before been described in the case of a mediastinal paraganglioma. The following is a presentation of such a case of mediastinal paraganglioma, in which embolization was used successfully before surgical resection.

Unusual primary tumors of the heart

Primary tumors of the heart, with the exception of atrial myxomas, occur rarely; tumors metastatic to or directly invasive of the heart are far more common. About 75% of primary tumors are benign, and 75% of these are atrial myxomas. The benign tumors include rhabdomyomas, fibromas, papillary fibroelastomas, hemangiomas, pericardial cysts, lipomas, hamartomas, teratomas, mesotheliomas, and paragangliomas or pheochromocytomas. The last 3 may also be malignant. The malignant tumors consist of various sarcomas: myxosarcoma, liposarcoma, angiosarcoma, fibrosarcoma, leiomyosarcoma, osteosarcoma, synovial sarcoma, rhabdomyosarcoma, undifferentiated sarcoma, reticulum cell sarcoma, neurofibrosarcoma, and malignant fibrous histiocytoma. Cardiac tumors produce a large variety of symptoms through any of 4 mechanisms. Their mass can obstruct intracardiac blood flow or interfere with valve function. Local invasion can lead to arrhythmias or pericardial effusions with tamponade. Bits of tumor can embolize, causing systemic deficits when the tumors are on the left side of the heart. Finally, the tumors may cause systemic or constitutional symptoms. Some tumors, of course, produce no symptoms and become evident as incidental findings. The most useful diagnostic tool is the echocardiogram, which in almost all cases precisely locates the tumor and defines its extent. The echocardiographic appearance may also allow quite accurate prediction of the tumor type and whether it is malignant or benign. Magnetic resonance imaging serves as the next most important test where the density of T1 and T2 images may allow tumor cell type identification. With few exceptions, these tumors require operative excision. Most benign tumors can be resected completely; a few, because of their large size, cannot be, and only tumor debulking may be possible. Heart transplantation should be considered for these patients. Many of the malignant tumors cannot be resected completely, either because of the extent of local spread and invasion or because of the frequent distant metastases. Transplantation may also be an option for those with extensive local disease. The long-term results for resected benign tumors are excellent; the long-term results for sarcomas are very poor, and there are few survivors. For patients with unresectable sarcomas, radiation and chemotherapy may be used, but without great expectation of successful results.

Resection of multiple mediastinal paragangliomas with cardiopulmonary bypass

The case of a patient who underwent simultaneous resection of two separate mediastinal paragangliomas is presented. The tumors were located in the aortopulmonary window and in the right atrioventricular groove. The patient had previously undergone resection of a glomus vagale tumor. The mediastinal lesions were removed with the aid of cardiopulmonary bypass, and the patient is doing well postoperatively.

Nonfunctioning malignant paraganglioma of the posterior mediastinum with spinal cord compression. A case report

STUDY DESIGN

Case report and review of the literature.

OBJECTIVE

To present a case with an uncommon nonfunctioning malignant paraganglioma of the posterior mediastinum with compression of the spinal cord. An update survey is given with respect to diagnostic, histopathologic, and therapeutic aspects of paragangliomas.

SUMMARY OF BACKGROUND DATA

Paragangliomas in the posterior mediastinum are uncommon and rarely may produce spinal cord compression. To illustrate the low incidence, only two cases of paraganglioma of the posterior mediastinum were reported by the Mayo Clinic, Rochester, Minnesota, during a 40-year period.

METHOD

Case report and review of the literature.

RESULT

The diagnosis was made by modern imaging techniques (computed tomography, magnetic resonance imaging, and metaiodobenzylguanidine scan) and verified by computed tomography guided per thoracic puncture. A wide local resection was performed; the patient is disease-free 1 year after surgery.

CONCLUSION

The uncertainty of prognosis and possibility of local recurrence of paragangliomas even after a long period emphasizes the importance of wide local surgical resection with or without adjuvant therapy and makes long-term follow-up and continued surveillance of the patient mandatory.