1
|
Kanj AN, Young WF, Ryu JH. Mediastinal Paraganglioma: A retrospective analysis of 51 cases. Respir Med 2023:107296. [PMID: 37257785 DOI: 10.1016/j.rmed.2023.107296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Amjad N Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA.
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
2
|
Itagaki K, Notsuda H, Suzuki T, Tanaka R, Kamada H, Omata K, Tezuka Y, Ota H, Okada Y, Saiki Y. Combined left thoracoscopic and median sternotomy approach to resect aortopulmonary mediastinal paraganglioma following feeding artery embolization: a case report. Surg Case Rep 2022; 8:176. [PMID: 36138281 PMCID: PMC9500140 DOI: 10.1186/s40792-022-01534-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/16/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
Collapse
|
3
|
Naser JA, van Zyl M, Gruber LM, Gulati R, Friedman PA, Young WF, Hemmati P, Foley TA, Schaff HV, Crestanello JA, Pislaru SV. Role of Multimodality Imaging and Preoperative Management in Intrapericardial Paragangliomas. JACC Case Rep 2022; 4:871-877. [PMID: 35912325 PMCID: PMC9334143 DOI: 10.1016/j.jaccas.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/28/2022]
Abstract
Intrapericardial paragangliomas are rare, highly vascular tumors that frequently adhere to adjacent structures and blood vessels, making surgical resection challenging. In this case series, we discuss the role of multimodality imaging and preoperative embolization in the management of 3 patients presenting with intrapericardial paragangliomas. (Level of Difficulty: Advanced.)
Collapse
Affiliation(s)
- Jwan A. Naser
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Martin van Zyl
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Lucinda M. Gruber
- Department of Endocrinology and Metabolism, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - William F. Young
- Department of Endocrinology and Metabolism, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Pouya Hemmati
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Thomas A. Foley
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Hartzell V. Schaff
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Sorin V. Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Address for correspondence: Dr Sorin V. Pislaru, Division of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota 55905, USA. @SorinVPislaru
| |
Collapse
|
4
|
Pheochromocytomas and Abdominal Paragangliomas: A Practical Guidance. Cancers (Basel) 2022; 14:cancers14040917. [PMID: 35205664 PMCID: PMC8869962 DOI: 10.3390/cancers14040917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare. They can be discovered incidentally by imaging with computed tomography or magnetic resonance imaging and during hormonal surveillance in patients with known genetic variants that are associated with PPGLs. As most PPGLs are functioning, a hormonal work-up evaluating for catecholamine excess is recommended. Classical symptoms, such as tachycardia, hypertension and headache, can be present, but when the PPGL is discovered as an incidentaloma, symptoms may be lacking or be more discrete. PPGLs carry malignant potential, and patients should undergo close surveillance, as recurrence of disease or metastasis may develop. Genetic susceptibility for multifocal disease has gained more attention, and germline variants are commonly detected, thus facilitating detection of hereditary cases and afflicted family members. Any patient with a PPGL should be managed by an expert multidisciplinary team consisting of endocrinologists, radiologists, surgeons, pathologists and clinical geneticists. Abstract Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare tumors arising from the adrenal medulla or the sympathetic nervous system. This review presents a practical guidance for clinicians dealing with PPGLs. The incidence of PPGLs has risen. Most cases are detected via imaging and less present with symptoms of catecholamine excess. Most PPGLs secrete catecholamines, with diffuse symptoms. Diagnosis is made by imaging and tests of catecholamines. Localized disease can be cured by surgery. PPGLs are the most heritable of all human tumors, and germline variants are found in approximately 30–50% of cases. Such variants can give information regarding the risk of developing recurrence or metastases as well as the risk of developing other tumors and may identify relatives at risk for disease. All PPGLs harbor malignant potential, and current histological and immunohistochemical algorithms can aid in the identification of indolent vs. aggressive tumors. While most patients with metastatic PPGL have slowly progressive disease, a proportion of patients present with an aggressive course, highlighting the need for more effective therapies in these cases. We conclude that PPGLs are rare but increasing in incidence and management should be guided by a multidisciplinary team.
Collapse
|
5
|
Greason KL. Commentary: Management of cardiac paraganglioma is a team sport. J Thorac Cardiovasc Surg 2020; 164:167-168. [PMID: 33220967 DOI: 10.1016/j.jtcvs.2020.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
6
|
Rijken JA, de Vos B, Leemans CR, Zwezerijnen GJCB, de Graaf P, Hensen EF, Dreijerink KMA, Dickhoff C, Symersky P. Management of Multiple Secreting Paragangliomas in a Succinate Dehydrogenase Subunit D (SDHD) Variant Carrier. Ann Thorac Surg 2019; 109:e87-e90. [PMID: 31279790 DOI: 10.1016/j.athoracsur.2019.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 05/07/2019] [Indexed: 12/01/2022]
Abstract
Management of functional intrathoracic sympathetic paragangliomas in succinate dehydrogenase subunit D (SDHD) mutation carriers is challenging, and there is no uniform guideline for treatment to date. The risks of potential malignant behavior and long-term cardiovascular morbidity have to be weighed against the risks of treatment complications. We report the multidisciplinary and shared decision-making approach that resulted in successful surgical removal of 3 paragangliomas in a SDHD mutation carrier.
Collapse
Affiliation(s)
- Johannes A Rijken
- Department of Otolaryngology/Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands.
| | - Berry de Vos
- Department of Otolaryngology/Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - C René Leemans
- Department of Otolaryngology/Head and Neck Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - G J C Ben Zwezerijnen
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Pim de Graaf
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Erik F Hensen
- Department of Otolaryngology/Head and Neck Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen M A Dreijerink
- Department of Endocrinology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Chris Dickhoff
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Petr Symersky
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| |
Collapse
|
7
|
Liu XP, Miao Q, Liu XR, Zhang CJ, Ma GT, Liu JZ. Outcomes of surgery for functional cardiac paragangliomas: A single-center experience of 17 patients. J Thorac Cardiovasc Surg 2019; 157:1556-1564. [DOI: 10.1016/j.jtcvs.2018.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 11/26/2022]
|