Mediastinal Paragangliomas: The Mayo Clinic Experience

Weakly supervised detection of pheochromocytomas and paragangliomas in CT using noisy data

Pheochromocytomas and Paragangliomas (PPGLs) are rare adrenal and extra-adrenal tumors that have metastatic potential. Management of patients with PPGLs mainly depends on the makeup of their genetic cluster: SDHx, VHL/EPAS1, kinase, and sporadic. CT is the preferred modality for precise localization of PPGLs, such that their metastatic progression can be assessed. However, the variable size, morphology, and appearance of these tumors in different anatomical regions can pose challenges for radiologists. Since radiologists must routinely track changes across patient visits, manual annotation of PPGLs is quite time-consuming and cumbersome to do across all axial slices in a CT volume. As such, PPGLs are only weakly annotated on axial slices by radiologists in the form of RECIST measurements. To ameliorate the manual effort spent by radiologists, we propose a method for the automated detection of PPGLs in CT via a proxy segmentation task. Weak 3D annotations (derived from 2D bounding boxes) were used to train both 2D and 3D nnUNet models to detect PPGLs via segmentation. We evaluated our approaches on an in-house dataset comprised of chest-abdomen-pelvis CTs of 255 patients with confirmed PPGLs. On a test set of 53 CT volumes, our 3D nnUNet model achieved a detection precision of 70% and sensitivity of 64.1%, and outperformed the 2D model that obtained a precision of 52.7% and sensitivity of 27.5% (p< 0.05). SDHx and sporadic genetic clusters achieved the highest precisions of 73.1% and 72.7% respectively. Our state-of-the art findings highlight the promising nature of the challenging task of automated PPGL detection.

Advanced imaging of cardiac Paraganglioma: A systematic review

Background and aims

Cardiac ParaGangliomas (PGLs) are rare extra-adrenal tumours that arise from chromaffin cells of the sympathetic ganglia. PGL are often diagnosed incidentally, with no symptoms or symptoms related to cardiovascular dysfunction.

Methods

Cardiac Computed Tomography (CCT) and Cardiac Magnetic Resonance (CMR) can detect the correct morphology and position of the lesion and provide proper tissue characterization.Nuclear medicine imaging, with Positron Emission Tomography (PET) or Single Photon Emission Computed Tomography (SPECT) with specific radiotracers, can evaluate the functionality of the PGL and to distinguish a secreting from a non-secreting tumour.

Results

In association with biochemical parameters, a multimodal imaging approach, not yet standardized, can be useful both in the diagnosis, in the monitoring and in the treatment planning.

Conclusions

In this systematic review, we aim to investigate the role of diagnostic imaging, in particular CCT, CMR, PET and SPECT in diagnosis, characterization and monitoring of cardiac PGLs.

Case of functional paraganglioma with intraoperative hypertensive crisis during robot-assisted thoracoscopic resection

BACKGROUND

Mediastinal paragangliomas are rare. Their dangerousness may unfold during surgery, especially if hormonal activity was previously unknown. We report our experience with this case in context to the incidence and localization of atypically located mediastinal paragangliomas in the literature.

CASE PRESENTATION

A 69-year-old female patient who was scheduled for thoracoscopic resection due to a posterior mediastinal tumor that had been progressing in size for several years and increasing symptoms. The induction of anesthesia, the ventilation of the lungs and the gas exchange after lung separation was uneventful. After initially stable circulatory conditions, there was a sudden increase in blood pressure up to 300/130 mmHg and tachycardia up to 130/min. This hypertensive phase was difficult to influence and required a rapid and consistent use of antihypertensive medication to bring down the blood pressure to reasonable values. The patient stabilized after tumor resection. The postoperative course was unremarkable. During the intraoperative blood pressure crisis, blood was drawn for analysis. These samples showed elevated concentrations of normetanephrine and metanephrine. The tumor subsequently presented as a catecholamine-secreting paraganglioma.

CONCLUSION

In order to avoid life-threatening blood pressure crises, hormone activity should be ruled out preoperatively in the case of mediastinal tumor, in which a paraganglioma could be considered in the differential diagnosis, especially if there are indications of hypertension in the medical history. Robotic-assisted thoracoscopic resection of the posterior mediastinal tumor was a feasible surgical method, even in the case of unexpected functional paraganglioma.

Paragangliomas and Anemia: Literature Review and Case Report

Paragangliomas are rare neuroendocrine tumors that arise from the extra-adrenal autonomic paraganglia, i.e., small organs consisting mainly of neuroendocrine cells that are derived from the embryonic neural crest and have the ability to secrete catecholamines. Paragangliomas can derive from either parasympathetic or sympathetic paraganglia. Most of the parasympathetic ganglia-derived paragangliomas are nonfunctional, and symptoms result from mass effect. Conversely, the sympathetic paragangliomas are functional and produce catecholamine. Although such patients could have symptoms similar to pheochromocytoma, mass effect symptoms, or non-specific symptoms, being benign tumors, they can also present with anemia, specifically iron-deficiency anemia. Considering that neoplastic pathology is chronically accompanied by moderate, normochromic, normocytic anemia, association between paragangliomas that are mostly benign but with a potential degree of malignancy and anemia is not as frequent as expected, with only 12 cases reported in the literature. We report a case of a 54-year-old female patient diagnosed with a paraganglioma of the carotid glomus accompanied by severe normochromic, normocytic anemia, which reached normal limits after excision of the paraganglioma.

Approach to Imaging of Mediastinal Masses

Mediastinal masses present a diagnostic challenge due to their diverse etiologies. Accurate localization and internal characteristics of the mass are the two most important factors to narrow the differential diagnosis or provide a specific diagnosis. The International Thymic Malignancy Interest Group (ITMIG) classification is the standard classification system used to localize mediastinal masses. Computed tomography (CT) and magnetic resonance imaging (MRI) are the two most commonly used imaging modalities for characterization of the mediastinal masses.

Diagnosis, Genetics, and Management of 24 Patients With Cardiac Paragangliomas: Experience From a Single Center

Context

Paragangliomas located within the pericardium represent a rare yet challenging clinical situation.

Objective

The current analysis aimed to describe the clinical characteristics of cardiac paragangliomas, with emphasis on the diagnostic approach, genetic background, and multidisciplinary management.

Methods

Twenty-four patients diagnosed with cardiac paraganglioma (PGL) in Peking Union Medical College Hospital, Beijing, China, between 2003 and 2021 were identified. Clinical data was collected from medical record. Genetic screening and succinate dehydrogenase subunit B immunohistochemistry were performed in 22 patients.

Results

The median age at diagnosis was 38 years (range 11-51 years), 8 patients (33%) were females, and 4 (17%) had familial history. Hypertension and/or symptoms related to catecholamine secretion were present in 22 (92%) patients. Excess levels of catecholamines and/or metanephrines were detected in 22 (96%) of the 23 patients who have completed biochemical testing. Cardiac PGLs were localized with 131I-metaiodobenzylguanidine scintigraphy in 11/22 (50%), and 99mTc-hydrazinonicotinyl-tyr3-octreotide scintigraphy in 24/24 (100%) patients. Genetic testing identified germline SDHx mutations in 13/22 (59%) patients, while immunohistochemistry revealed succinate dehydrogenase (SDH) deficiency in tumors from 17/22 (77%) patients. All patients were managed by a multidisciplinary team through medical preparation, surgery, and follow-up. Twenty-three patients received surgical treatment and perioperative death occurred in 2 cases. Overall, 21 patients were alive at follow-up (median 7.0 years, range 0.6-18 years). Local recurrence or metastasis developed in 3 patients, all of whom had SDH-deficient tumors.

Conclusion

Cardiac PGLs can be diagnosed based on clinical manifestations, biochemical tests, and appropriate imaging studies. Genetic screening, multidisciplinary approach, and long-term follow-up are crucial in the management of this disease.

Multimodality Imaging Appearance of Intrapericardial Paragangliomas

Paragangliomas are neuroendocrine tumors of the sympathetic and parasympathetic nervous system that originate from neural crest cells. Less than 1% of paragangliomas are found in the heart, originating from intrinsic cardiac ganglia cells in the posterior wall the atria, atrioventricular groove, and along the root of the great vessels. A 10-year review of our institution's database identified nine patients who had documented intrapericardial paragangliomas. We describe the multimodality imaging appearance of these tumors. The most common findings include embedment and wrapping around the great vessels and atrioventricular groove within the confines of the pericardium, markedly avid heterogeneous enhancement, distinct engorged neovascularization, and in large lesions, central low attenuation areas compatible with hemorrhage, necrosis, or cystic degeneration.

Tips and Tricks in Thoracic Radiology for Beginners: A Findings-Based Approach

This review has the purpose of illustrating schematically and comprehensively the key concepts for the beginner who approaches chest radiology for the first time. The approach to thoracic imaging may be challenging for the beginner due to the wide spectrum of diseases, their overlap, and the complexity of radiological findings. The first step consists of the proper assessment of the basic imaging findings. This review is divided into three main districts (mediastinum, pleura, focal and diffuse diseases of the lung parenchyma): the main findings will be discussed in a clinical scenario. Radiological tips and tricks, and relative clinical background, will be provided to orient the beginner toward the differential diagnoses of the main thoracic diseases.

Mediastinal Paraganglioma: A retrospective analysis of 51 cases

BACKGROUND

Paragangliomas are rarely found in the mediastinum, where they account for a small proportion of mediastinal masses. This study aimed to better characterize the presenting features and relevant aspects in optimizing the diagnosis and treatment of mediastinal paragangliomas.

METHODS

A computer-assisted search of electronic health records was performed to identify adult patients (≥18 years) who underwent evaluation for a primary mediastinal paraganglioma at Mayo Clinic between January 2000 and April 2022. Medical charts, laboratory tests and radiology images were reviewed to collect data.

RESULTS

The study included 51 patients, each with a single mediastinal paraganglioma. The median age was 47 years (IQR: 39-67), 67% females. Symptoms of catecholamine excess were manifest in 39% of patients, and 14% presented with mass effect, while the remaining 47% had no paraganglioma-related symptoms. Genetic testing was performed in 35 patients; 66% harbored a pathogenic variant in the succinate dehydrogenase enzyme complex. Most paragangliomas (71%) were in the middle mediastinum and showed uptake of intravenous contrast on chest imaging. Biopsies were performed in 30 (59%) patients; 27% were inconclusive and 10% resulted in major complications. Surgical resection occurred in 75%, primarily for relief of symptoms (50%) followed by proximity to critical structures (45%). Perioperative complications were common (66%), but there were no cases of local tumor recurrence during the follow-up period (median 8 years; IQR: 4-13).

CONCLUSION

Mediastinal paragangliomas are most located in the middle mediastinum and can often be diagnosed noninvasively using a combination of clinical, biochemical, and radiological features.

Intracardiac paraganglioma with a cough as the first symptom

BACKGROUND

Cardiac paragangliomas (PGLs) are clinically rare, with hypertension and metabolic changes as the main symptoms. The tumor is highly related to gene mutation, and surgery is presently the effective treatment. Medical history and clinical manifestations of the patient, routine laboratory examinations and imaging examinations, and pathological examination can help the final diagnosis.

CASE PRESENTATION

The present study presents a 31-year-old male patient with a left atrial mass. The initial symptom was cough. Cardiac enlargement was found during the chest X-ray. The follow-up imaging examination revealed a left atrial occupying lesion, and the possibility of malignant occupying lesions was not ruled out. The patient underwent surgical resection of the mass. The final pathological result revealed paraganglioma. The thoracic computed tomography review two months after the operation revealed that the original occupying lesion disappeared, and no new lesion was found.

CONCLUSIONS

Pheochromocytomas and paragangliomas (PPGLs) are a kind of neuroendocrine tumors. PPGLs can cause secondary hypertension, and lead to a series of clinical syndromes, including myocardial injury, metabolic changes, and so on. The occurrence of PPGIs is related to gene mutation. Biochemical detection, imaging examination, and genetic testing can help diagnose. The tumor should be surgically removed as soon as possible after the diagnosis. As a functional tumor, PPGLs should be fully prepared before surgery to avoid anesthesia and huge fluctuations in blood pressure during and after surgery, or the occurrence of fatal hypertensive crisis and intractable hypotension after tumor resection. Adequate preoperative preparation directly affects the prognosis of patients after surgery. Therefore, multidisciplinary cooperation before, during, and after the operation is extremely important.

Catecholamine crisis after endoscopic ultrasound-guided fine-needle biopsy: A case report

RATIONALE

The function and use of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has developed in recent years, particularly in distinguishing malignant from benign masses. It is a generally safe method that can be completed without any uncommon complications. Here, although no complications from EUS-FNB were noted, we report about an unexpected catecholamine crisis that occurred after EUS-FNB.

PATIENTS CONCERNS

A 60-year-old man visited an outpatient clinic with an incidental diagnosis of a retroperitoneal mass on his last abdominopelvic computed tomography (APCT) scan taken at the time of a previous liver abscess treatment. On presentation, the patient showed no symptoms.

DIAGNOSES

A retroperitoneal mass was incidentally discovered on APCT, and risk for lymphoma, gastrointestinal tumor, or neuroendocrine tumor was noted on the APCT reading.

INTERVENTIONS

EUS-FNB was performed on retroperitoneal mass.

OUTCOMES

The procedure was completed without any complications; however, the patient's condition deteriorated due to hemodynamic instability and cardiovascular collapse. During intensive care unit (ICU) treatment, the biopsy results were found to be paraganglioma. Catecholamine crisis occurred after biopsy of paraganglioma.

LESSONS

The case presented here gives a caution of complication that may occur after EUS-FNB. Although EUS-FNB is known to be relatively safe, careful evaluation is required when performing biopsy of lesions around the aorta.

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.

Multimodality imaging appearance of intrapericardial paragangliomas

Paragangliomas are neuroendocrine tumours of the sympathetic and parasympathetic nervous systems originating from neural crest cells. Less than 1% of paragangliomas in the heart originate from intrinsic cardiac ganglia cells in the posterior wall of the atria, atrioventricular groove, and along the root of the great vessels. We describe the tumour characteristics, patient demographics, presentation, means of diagnosis, pathology correlation, management, and outcome in 11 patients with intrapericardial paragangliomas. To the authors' knowledge, this is the largest case series reported, with emphasis on multimodality imaging findings.

Middle mediastinal paraganglioma enclosing the left anterior descending artery: A case report

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.

Rare and complicated functional posterior mediastinal paraganglioma

Functional mediastinal paragangliomas (PGs) are rare, catecholamine-secreting tumours. Surgical resection is the preferred treatment, but it can be complicated by catecholamine-related symptoms, involvement of cardiac structures and/or tumour supply from major blood vessels. We report a case of a man in his 30s with a subcarinal functional PG complicated by all three factors. The PG had arterial supplies from the right coronary and bronchial arteries, with mass effect on the left atrium. Given the high risk of intraoperative bleeding, catecholamine surges and injury to right coronary artery, we attempted a minimally invasive strategy that incorporates best practices from the few published cases on functional PGs. We show that a multidisciplinary approach involving alpha/beta blockade, preoperative embolisation of tumour blood supply, robotic-assisted tumour mobilisation and, if needed, open resection with cardiopulmonary bypass can be a safe strategy in the treatment of functional mediastinal paragangliomas adherent to cardiac structures.

Thoracoscopic resection of posterior mediastinal paraganglioma: perioperative management and surgical tips

Posterior mediastinal paraganglioma (PM-PGL) is a rare disease that is difficult to diagnose. If PM-PGL is misdiagnosed preoperatively, surgeons may encounter severe tachycardia and hypertension and easy bleeding from the tumor during the operation. Therefore, it is essential to include PGL as a differential diagnosis for mediastinal tumors. We herein describe a 73-year-old Japanese man with a PM-PGL that was diagnosed preoperatively and resected safely by video-assisted thoracic surgery. Preoperative management of hypertension with doxazosin mesylate, soft coagulation of the peritumor area, and careful clipping of feeding arteries were effective for hemostasis. The patient’s vital signs were stable during and after the operation.

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.

A Case Report of Resection of a Mediastinal Paraganglioma: Why All the Fuss?

Mediastinal paragangliomas are rare tumors that have only been reported in individual cases or limited case series. Surgical resection of these tumors can be challenging, as they are highly vascular and intimately related to the great vessels. Surgery is usually performed via median sternotomy with or without cardiopulmonary bypass. We present the case of a mediastinal paraganglioma that was resected via a left-sided posterolateral thoracotomy. Histopathology revealed a completely resected 38-mm paraganglioma with a positive station 5 lymph node, indicative of locally aggressive disease. Hereditary paragangliomas are associated with malignant transformation; therefore, genetic testing is important. These tumors do not respond well to chemoradiotherapy, and consequently lifelong surveillance for early detection of recurrence is recommended.

A case of cervico-mediastinal paraganglioma mimicking an ectopic goiter

Introduction and importance

Mediastinal paragangliomas are rare neuroendocrine tumors that originate from extra-adrenal paraganglia, occasionally secreting catecholamines. Nonfunctional mediastinal paragangliomas present nonspecific clinical and radiological features and represent a diagnostic challenge.

Case presentation

A 53-year old woman presented with cough and dyspnea increasing over time. CT-scan and ultrasonography showed a large vascularized cervico-mediastinal mass, consistent with an intrathoracic ectopic goiter. Preoperative angiography showed a blood supply from neck vessels. The lesion was completely removed through a cervical approach. The diagnosis of paraganglioma was a histological surprise. The patient is alive without recurrence 30 months after surgery.

Clinical discussion

When preoperatively diagnosed, the treatment of choice of a mediastinal paraganglioma is surgical excision. However, a preoperative diagnosis of mediastinal paraganglioma is difficult to obtain, especially in cases of nonfunctional lesions. Distinction between an intrathoracic goiter and a nonfunctional paraganglioma can be extremely difficult and, given the rarity of the latter, an ectopic goiter is suspected in first instance. CT-scan and ultrasonography are of little use in the differential diagnosis. However, scintigraphy with ¹²³I-metaiodobenzylguanidine can be an useful diagnostic tool when a paraganglioma is suspected. In case of vascularized cervico-mediastinal mass, such as paragangliomas or intrathoracic goiter, preoperative angiography should be performed to study the blood supply and orient the surgical approach.

Conclusion

Although uncommon, paragangliomas should be considered in the differential diagnosis of mediastinal masses, especially when an ectopic goiter is suspected.

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Clinical diagnosis of mediastinal nonfunctioning paragangliomas is challenging.

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Mediastinal paragangliomas can mimic intrathoracic goiters.

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If a clinical suspicion of paraganglioma is raised, ¹²³I-MIBG can be useful.

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In case of a vascularized cervico-mediastinal mass, an angiography is recommended.

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Angiography can detect the blood supply and guide the surgical approach.

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.

Cardiac paraganglioma: stent in right coronary artery prior to surgery resection

Cardiac paragangliomas are extremely rare. Sometimes surgical resection is a challenge owing to the proximity of vital structures and coronary arteries involvement. We report a case of a 34-year-old man with cardiac paragangliomas located between right atrium and right ventricle with a feeding blood supply from collaterals of the right coronary artery. In this case, we implanted a covered single stent (PK Papyrus®) in the right coronary artery with the objective of embolizing collateral branches and to reinforce the coronary artery wall. Although tumour mass was not reduced, vascularization was minimized, and this hybrid strategy made the surgery easier and safer.

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

Paraganglioma in the posterior mediastinum: a case report

Background

Paragangliomas are tumors that arise from extra-adrenal chromaffin cells. Herein, we present a rare case of a functional paraganglioma in the posterior mediastinum.

Case presentation

A 36-year-old man presented with paroxysms of chest pain and headache. At presentation, the patient’s blood pressure was 190/120 mmHg. Chest computed tomography and magnetic resonance imaging revealed a left paravertebral mass in the posterior mediastinum. ¹²³I-metaiodobenzylguanidine scanning revealed focally high tracer uptake in the left paravertebral area. The metanephrine level in the urine was elevated, confirming a rare, catecholamine-producing, functional paraganglioma in the posterior mediastinum. Before surgery, the patient was prepared by orally administering α- and β-adrenergic blockers. The mass was then resected via a lateral thoracotomy. The metanephrine level in urine was normal 24 h after surgery.

Conclusions

Paragangliomas in the posterior mediastinum are very rare, but more than half of all cases are functional. The associated symptoms are curable with complete resection, and long-term follow-up for recurrence is important.

Utility of immunohistochemical staining for the diagnosis of Extra-adrenal mediastinal paraganglioma

Extra-adrenal, mediastinal paraganglioma are rare tumors that origin from sympathetic ganglia. Common diagnostic steps include CT, MRI and PET-Scan. We present a case where immunohistochemical staining was an essential step for final diagnosis in a patient without symptoms of endocrine activity and an uncommon location of this tumor entity. In combination with clinical particularities on the origin of the tumor and characteristic morphology, the immunohistochemical staining of tumor tissue is a necessary diagnostic tool for paraganglioma.

Intracardiac paragangliomas: surgical approach and perioperative management

Intracardiac paragangliomas most commonly arise from the left atrium and are often infiltrative and densely adherent to surrounding structures. Given their rarity, only scattered reports exist in the literature and standardized perioperative and surgical management is not well established. We describe a case of a 60-year-old woman with a mildly functioning intracardiac paraganglioma in which division of the superior vena cava improved exposure and enabled a complex limited resection. Further, we provide an overview of the diagnostic workup, perioperative medical management, surgical approach, and surveillance strategy in patients with these challenging tumors.

Clinicopathological, immunophenotypic and genetic studies of mediastinal paragangliomas†

OBJECTIVES

Paragangliomas have unique features in the mediastinum, in part due to their location. Because of their paucity, they have not been thoroughly investigated. We studied the clinical, pathological, immunohistochemical and molecular features of mediastinal paragangliomas.

METHODS

Immunohistochemistry, next-generation sequencing mutation panel and the Oncoscan assay were performed.

RESULTS

Twenty-four patients with mediastinal paraganglioma (7 men, 29.2%) had a median age of 45.5 years (19.8-72.2). Twenty-one (87.5%) paragangliomas were completely resected. Six (of 24, 25.0%) tumours were considered metastatic. Mitotic activity occurred in 11 (of 24, 45.8%) paragangliomas. Programmed death-ligand 1 (PD-L1) (n = 23) was expressed in 6 (26%) patients in 10% (n = 2) and 1% (n = 4) of tumour cells, respectively. SDHB expression was lost in 19 (of 22, 86.4%) cases. ATRX expression was lost in 11 (of 23, 47.8%) cases. Next-generation sequencing revealed a single pathogenic mutation in 10 (of 19) specimens including SDHB (n = 4), SDHD (n = 6), SDHC (n = 1), ATRX (n = 1), and ≥2 mutations in 2 cases [SDHC and TERT (n = 1); SDHB, ATRX and TP53 (n = 1)]. Germline mutation analysis revealed the same succinate dehydrogenase mutation (or lack thereof) as identified in the paraganglioma in 11 (of 12) cases. During a median follow-up (n = 21) of 4.8 years (0.8-14.9), 3 patients developed metastases; 4 patients died, at least 1 of disease.

CONCLUSIONS

Mediastinal paragangliomas can be associated with morbidity and mortality. Many mediastinal paragangliomas have been reported to be associated with syndromes such as multiple endocrine neoplasia, von Hippel-Lindau or succinate dehydrogenase syndrome with mutation profiles dominated by alterations in genes associated with these syndromes.

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.

Paragangliomas Throughout the Body: Hereditary Syndromes and Imaging Features Including 3D Cinematic Rendering

Paragangliomas are highly vascular neuroendocrine tumors that arise from embryonic neural crest cells. They may either be hormonally active (sympathetic) or silent (parasympathetic). Approximately one-third are hereditary, and patients may develop multiple paragangliomas. Presurgical planning involves medical management as well as interventional and/or surgical techniques that must address vascular supply. Contrast-enhanced CT is the best initial anatomical study and shows the hypervascularity and feeding vessels. 3D cinematic rendering using multiplanar light sources can highlight spatial relationships of a mass to adjacent structures and help in surgical planning. This article will review the clinical presentation of paragangliomas, genetic syndromes, presurgical management, and tumor behavior and imaging appearance by location with a particular emphasis on 3D cinematic rendering.

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.

Surgical management of mediastinal paraganglioma: All hands on deck!

Mediastinal paragangliomas are very uncommon neuroendocrine neoplasms. Due to their tissue of origin (sympathetic ganglia of the great vessels), they tend to arise deep within pericardial space and, more importantly, intimately attached to great vessels, which makes surgical resection, even with cardiopulmonary bypass, very challenging. This commentary accompanies the case report describing complex surgical management of a paraganglioma located in the anterior mediastinum that was initially thought to be a thymoma.

Aortopulmonary paraganglioma masquerading as an anterior mediastinal mass: A fine line between confusion and chaos!

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.

Innovative approach to a functional mediastinal paraganglioma with anomalous coronary supply: a case report

Background

Mediastinal paragangliomas (PGs) are rare and particularly challenging neuroendocrine tumours. Clinical presentation is heterogeneous and tumour resection can be challenging due to bleeding and the risk of catecholamine surges in functional tumours.

Case Summary

A 36-year-old man with multiple cardiovascular risk factors was admitted with subacute heart failure. Investigations revealed a large non-metastatic functional mediastinal PG irrigated mainly by a left circumflex coronary anomalous feeder branch. The surgical risk was deemed very high due to patient comorbidities, tumour vascularization, and close relation to major thoracic structures. A multidisciplinary team decided to perform embolization of the anomalous coronary branch followed by peptide-receptor radionuclide therapy with 177-LuDOTATE aiming to decrease tumour size and perioperative risk. Follow-up studies showed a reduction in tumour vascularization, size, and hormonal production.

Discussion

The innovative strategy of combining embolization of the anomalous feeder branch with radionuclide therapy proved to be a promising approach.

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review

Cardiac masses are rare, but remain an important component of cardio-oncology practice. These include benign tumors, malignant tumors (primary and secondary) and tumor-like conditions (e.g., thrombus, Lambl’s excrescences, and pericardial cyst). The advent of multimodality imaging has enabled identification of the etiology of cardiac masses in many cases, especially in conjunction with information from clinical settings. This paper provides a comprehensive review of the epidemiology, clinical presentation, imaging, diagnosis, management, and outcomes of cardiac masses.

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Cardiac tumors are rare and should be considered as part of the differential diagnosis of any space-occupying mass noted on cardiovascular and/or thoracic imaging modalities.

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It may be possible to get close to a diagnosis without biopsy using a structured imaging approach.

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The prognosis and treatment of each tumor is different, although early diagnosis is usually associated with a better outcome.

Robotic approach to a subcarinal functional paraganglioma

Intro

Functional mediastinal paragangliomas arise from extra-adrenal tissues and are rare. These cases create challenges related to diagnosis, peri-operative management, and surgical management. We present a case that demonstrates a planned robot-assisted thoracoscopic resection of a mediastinal paraganglioma that ultimately required a trans-sternal resection of the tumor off the left atrium.

Case report

Our patient is a 42-year-old male with a prolonged history of refractory hypertension, palpitations, headaches, and diaphoresis, which led to the discovery of a subcarinal functional mediastinal paraganglioma. The patient was brought to the operating room for a right robotic-assisted thoracoscopic subcarinal dissection with attempted resection of the mass. Subsequently, the patient's paraganglioma was successfully resected off the left atrium using a trans-sternal approach, cardiopulmonary bypass, and cardioplegic arrest. He was successfully transitioned to minimal anti-hypertensive medication post-operatively.

Discussion

Pheochromocytomas are neural-crest derived tumors that typically arise from the adrenal medulla. Rarely, paragangliomas arise in the thoracic cavity, at an approximate incidence of 2%. Our sequential approach offered the potential for a minimally invasive resection, and though initially unsuccessful, safely elucidated the feasibility of resection using cardiopulmonary bypass after confirming no invasion of the airway, esophagus, or other mediastinal structures.

Imaging Features of Succinate Dehydrogenase-deficient Pheochromocytoma-Paraganglioma Syndromes

Pheochromocytoma (PC) and paraganglioma (PGL) are rare neuroendocrine tumors that occur throughout the body from the base of the skull to the pelvis. Sympathetic catecholamine-secreting tumors may be associated with hyperadrenergic symptoms and long-term morbidity if they are untreated. Typically biochemically silent, head and neck PGLs may result in cranial nerve palsies and symptoms due to localized mass effect. Tumors can arise sporadically or as part of an inheritable PC-PGL syndrome. Up to 40% of tumors are recognized to be associated with germline mutations in an increasing array of susceptibility genes, including those that appear to arise sporadically. Most commonly, up to 25% of all PC-PGLs are associated with mutations in one of the succinate dehydrogenase (SDH) enzyme subunit genes. The resulting familial PC-PGL syndrome varies according to the affected enzyme subunit (most commonly SDHB and SDHD mutations) with respect to tumor prevalence, location, age of onset, and risk of malignancy. Patients with SDH enzyme mutations have increased lifetime risk of developing multifocal tumors and malignancy. Early recognition of individuals at high risk, genetic testing, screening of family members, and lifelong surveillance programs are recommended, but not without health, economic, and psychologic implications. Anatomic and functional imaging is key to diagnosis, staging, treatment planning, and lifelong surveillance of these individuals. Radiologists must be aware of the imaging appearance of these varied tumors.^©RSNA, 2019.

Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine/Head and Neck Disease-Site Work Group. Part 1 of 2: Advances in Pathogenesis and Diagnosis of Pheochromocytoma and Paraganglioma

This first part of a two-part review of pheochromocytoma and paragangliomas (PPGLs) addresses clinical presentation, diagnosis, management, treatment, and outcomes. In this first part, the epidemiology, prevalence, genetic etiology, clinical presentation, and biochemical and radiologic workup are discussed. In particular, recent advances in the genetics underlying PPGLs and the recommendation for genetic testing of all patients with PPGL are emphasized. Finally, the newer imaging methods for evaluating of PPGLs are discussed and highlighted.

Extended resection of a cardiac paraganglioma-A rare neuroendocrine manifestation of the heart

BACKGROUND

Cardiac paragangliomas are rare tumors that develop from neural crest cells. They account for about 2% of all paragangliomas and there is only limited evidence of malignant transformation.

CASE PRESENTATION

We present a young woman with atypical symptoms, which are related to the mass effect of the 40 × 49mm cardiac tumor on top of the left atrium. The patient underwent an extensive resection of the tumor including the root of the pulmonary trunk, the ascending aorta, and the left main artery.

CONCLUSIONS

The present case is of great importance showing the need for multidisciplinary approach in the management of cardiac tumors that infiltrate multiple anatomic structures.

Paraganglioma of the carotid body and intrapericardium

A 65-year-old Japanese woman with an intrapericardial tumor and neck tumor was admitted to our hospital. Intrapericardial tumor had not been resected because of massive bleeding from the hypervascular tumor and its invasion into the pericardium, ascending aorta, and pulmonary artery. The neck tumor had been successfully resected, and paraganglioma was pathologically diagnosed. Abnormal accumulation in the intrapericardial tumor was seen with ¹²³I-metaiodobenzylguanidine scintigraphy. Moreover, gene mutation of succinate dehydrogenase type D was found. Finally, paraganglioma of the carotid body and intrapericardium was diagnosed. <Learning objective: Cardiac paraganglioma (PGL) and simultaneous carotid body and cardiac PGL is exceedingly rare. We experienced a case of intrapericardial tumor and carotid body tumor, evaluated by histological examination of the surgical specimen of the carotid body tumor and multimodal imaging including ¹²³I-metaiodobenzylguanidine scintigraphy, and genetic analysis of the succinate dehydrogenase gene. The final diagnosis was type 1 PGLs of both the carotid body and intrapericardium.>.

Minimally invasive robotic-assisted excision of an aortopulmonary mediastinal paraganglioma

Aortopulmonary paragangliomas are rare, neural crest-derived tumours that arise in the aortopulmonary window and present a significant surgical challenge due to their proximity to major vessels. In the relatively few cases reported in the study, thoracotomy and video-assisted thorascopic surgery (VATS) approaches have been utilized for the treatment of such masses. In this report, we describe the application of a totally endoscopic robotic-assisted VATS approach for the excision of an aortopulmonary paraganglioma.

Cardiac Paraganglioma: Advantages of Cardiovascular Multimodality Imaging

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Cardiac paragangliomas are infrequent tumors.

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The most common location is in the left atrium.

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Cardiovascular morbidity and mortality without treatment are high.

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Different imaging techniques help determine the relation with adjacent structures.

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Multimodal cardiovascular imaging is an essential tool for diagnosis and therapy.

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.

Postpartum Diagnosis of Cardiac Paraganglioma: A Case Report

BACKGROUND

Extra-adrenal pheochromocytomas, or paragangliomas, originate from neural crest chromaffin cells and can be found anywhere along the sympathetic chain from head to toe.

CASE REPORT

A 34-year-old female presented 4 days postpartum with episodes of palpitations, hypertension, and shortness of breath. Two episodes in the emergency department confirmed hypertension and supraventricular tachycardia (SVT). A mediastinal mass was noted during workup for pulmonary embolus and was subsequently diagnosed as a cardiac paraganglioma. Our patient underwent surgical resection and was doing well 3 months postoperatively. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case represents a rare presentation of mediastinal paraganglioma with episodic SVT and hypertension postpartum, diagnosed during workup for pulmonary embolus. Although exceedingly rare, emergency physicians should consider paragangliomas in the differential of pregnant or postpartum women who present with episodic hypertension, palpitations, headache, and sweating.

Paradoxical hypertension

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain predominantly. A 48-year-old female patient presented to ER with complaints of breathlessness and developed sudden painless loss of vision while eliciting history. The patient had a heart rate of 104/min and accelerated hypertension (BP of 220/120 mm of Hg). MRI Brain showed subcortical white matter T2/Fluid-attenuated inversion recovery hyperintensities, suggestive of PRES. The patient regained vision completely over 5 days after nitroglycerin infusion and calcium channel blockers. Beta blocker was started in view of increased BP and anxiety. Blood pressure paradoxically increased from 170/90 mm of Hg to 200/100 mm of Hg. Urine and plasma metanephrines were elevated. Contrast-enhanced computerized tomography abdomen showed locally infiltrative, retroperitoneal mass in left para-aortic prevertebral region diagnosed as paraganglioma. The patient improved with alpha blockers and surgical removal of paraganglioma. 0.1% of hypertensive patients harbor a pheochromocytoma or paraganglioma and its presentation as PRES is very rare.

Resection of Intrathoracic Paraganglioma With and Without Cardiopulmonary Bypass

BACKGROUND

Intrathoracic paragangliomas (PGLs) are rare tumors. Approximately 50% originate from and around cardiac structures.

METHODS

A retrospective review was made of the perioperative course of patients with intrathoracic PGL resection from 2000 through 2015 at Mayo Clinic in Rochester, Minnesota.

RESULTS

Twenty-two patients underwent PGL resection. Sixteen patients (73%) had functioning tumors (11, noradrenergic; 4, mixed noradrenergic and dopaminergic; 1, dopaminergic). Patients with functioning tumors received preoperative adrenergic blockade: 15 (68%), α_1,2-adrenergic receptor antagonist; 4 (18%), α₁-adrenergic receptor antagonists; and 13 (59%) metyrosine. Six patients with nonfunctioning tumors had no adrenergic blockade. Twelve patients had tumor resection without cardiopulmonary bypass-9 for PGL associated with the great vessels, 2 for PGL with pericardial involvement, and 1 for PGL in right atrioventricular groove. Ten patients required cardiopulmonary bypass; for 9, the tumor involved cardiac structures and for 1, it involved ascending aorta and proximal aortic arch. Of these, 1 patient had uncontrollable bleeding and died intraoperatively. Other than this single death, there were no inhospital major cardiac or pulmonary complications. Median follow-up was 8.2 years (range, 2.1 to 17.2). Six patients subsequently had metastatic disease, and of them, 1 died 6 years after the operation.

CONCLUSIONS

In this series, 73% of intrathoracic PGLs were functional and involved noradrenergic, mixed noradrenergic and dopaminergic, or pure dopaminergic secretion. Cardiac and pericardial paraganglioma resection may require cardiopulmonary bypass. Although intraoperative bleeding in most complex cases may be uncontrollable, as for 1 of our patients, those who survived hospital discharge had favorable long-term outcomes.

Unusual cardiac paraganglioma mimicking an atypical carcinoid tumor of the lung

We present a case of unusual cardiac paraganglioma (PG) initially misdiagnosed as atypical carcinoid tumor of the lung and discuss key clinical and pathologic characteristics that guide surgical management of these rare chromaffin cell tumors. A 64-year-old female with persistent cough and back pain was found to have a 4 cm × 3 cm mass abutting multiple cardiopulmonary structures. A biopsy was performed at an outside institution and pathology reported "atypical neuroendocrine carcinoma, consistent with carcinoid". The patient was transferred to our institution and pericardial resection with right pneumonectomy was performed to excise the tumor. Histology of the mass was that of PG with multiple ethanol embolizations. Immunohistochemical examination revealed that type I (chief) cells were positive for neuroendocrine markers (chromogranin A and synaptophysin), while type II (sustentacular) cells were positive for S100. There was no evidence of atypical carcinoid tumor in the lung. PG is an entity of chromaffin cell tumors that often affects the adrenal glands and carotid body. PG rarely occurs in the thoracic region, accounting for just 1-2% of all PG. Proper diagnosis of cardiac PG is challenging owing to its rare prevalence, subtle symptoms of presentation, and the neuroendocrine histopathological features it shares with atypical carcinoids. These tumors are typically benign and are best treated by surgical resection. Our report examines the approach to appropriate diagnosis of cardiac PG vs. atypical carcinoid, preoperative management, and surgical treatment by describing successful resection through thoracotomy without the use of cardiopulmonary bypass.

Castleman Disease of the Thorax: Clinical, Radiologic, and Pathologic Correlation: From the Radiologic Pathology Archives

Castleman disease is a complex lymphoproliferative disease pathologically divided into two subtypes, the hyaline vascular variant (HVV) and the plasma cell variant (PCV). The HVV is the most common, is thought to represent a benign neoplasm of lymph node stromal cells, and is treated with surgical resection. It is most commonly found in the mediastinum, where it classically appears as a unicentric, avidly enhancing mass at computed tomography (CT) and magnetic resonance imaging. This appearance can mimic other avidly enhancing mediastinal masses, and location, clinical history, laboratory data, and nuclear medicine single photon emission CT (SPECT) and positron emission tomography (PET) studies can help narrow the differential diagnosis. Multicentric Castleman disease (MCD), which in the majority of cases is composed of the PCV, is an aggressive lymphoproliferative disorder associated with human herpesvirus infection, interleukin 6 dysregulation, and other systemic disorders. While it can be difficult to differentiate MCD from lymphoma, the presence of avidly enhancing lymph nodes can suggest the diagnosis. The purpose of this article is to review the clinical, immunologic, and pathologic findings associated with both unicentric Castleman disease and MCD and discuss how the imaging findings correlate with the pathophysiology of the disease.

Left Atrial and Carotid Body Paraganglioma

We report a rare case of left atrial paraganglioma with a synchronous carotid body paraganglioma in a 30-year-old man with succinate dehydrogenase B gene mutation. The patient initially presented with a neck mass and palpitations. Laboratory test results showed elevated catecholamine levels. A cardiac paraganglioma was identified by computed tomography, meta-iodobenzylguanidine scintigraphy, and magnetic resonance imaging. Surgical resection of both paragangliomas were performed on two separate occasions. Serum and urine catecholamine levels returned to normal range. On follow-up, there was no recurrence of the cardiac paraganglioma. Radiotherapy was subsequently initiated for recurrence in the carotid body paraganglioma.