A rare paraganglioma with skull and brain metastasis

Metastatic paraganglioma presenting as ajunctional scotoma

PURPOSE

To report a unique case of metastatic paraganglioma presenting as a junctional scotoma.

OBSERVATIONS

A 38-year-old Caucasian man with a history of abdominal paraganglioma presented with minimally blurred vision 20/25 visual acuity in the left eye. The patient was found to have a junctional scotoma upon visual field testing. Cranial MRI revealed a large peri-clival mass compressing the pre-chiasmal optic nerves and other loci of metastatic disease. Intracranial masses, including metastases, can present with a relatively intact central acuity and nonspecific visual symptoms.

CONCLUSIONS AND IMPORTANCE

To the best of our knowledge, this is the first report of metastatic paraganglioma causing a junctional scotoma. In cases with junctional scotoma, careful neuro-ophthalmic assessment and imaging are of paramount importance, even in patients with excellent visual acuity.

Malignant pheochromocytoma with cerebral and skull metastasis: A case report and literature review

BACKGROUND

Malignant pheochromocytoma with cerebral and skull metastasis is a very rare disease. Combining our case with 16 previously reported cases identified from a PubMed search, an analysis of 17 cases of malignant cerebral pheochromocytoma was conducted. This literature review aimed to provide information on clinical manifestations, radiographic and histopathological features, and treatment strategies of this condition.

CASE SUMMARY

A 60-year-old man was admitted with a progressive headache and enlarging scalp mass lasting for 3 mo. Radiographic images revealed a left temporal biconvex-shaped epidural mass and multiple lytic lesions. The patient underwent a left temporal craniotomy for resection of the temporal tumor. Histopathological analysis led to identification of the mass as malignant pheochromocytoma. The patient's symptoms were alleviated at the postoperative 3-mo clinical follow-up. However, metastatic pheochromocytoma lesions were found on the right 6th rib and the 6th to 9th thoracic vertebrae on a 1-year clinical follow-up computed tomography scan.

CONCLUSION

Magnetic resonance spectroscopy and histopathological examination are necessary to make an accurate differential diagnosis between malignant cerebral pheochromocytoma and meningioma. Surgery is regarded as the first choice of treatment.

Leptomeningeal Metastasis in Carotid Body Paraganglioma: Findings on 68Ga DOTANOC PET-CT

Carotid body paragangliomas are mostly benign tumors with very rare propensity to metastasize to lymph nodes, bones, liver, and lungs. Leptomeningeal metastasis from a carotid body paraganglioma is a very rare phenomenon. We describe Ga-DOTANOC PET-CT findings of a 33-year-old man, a known case of metastatic paraganglioma who underwent scan for response assessment to everolimus therapy.

En Bloc Resection and Reconstruction Using a Frozen Tumor-Bearing Bone for Metastases of the Spine and Cranium from Retroperitoneal Paraganglioma

BACKGROUND

Paragangliomas are neuroendocrine tumors that originate from autonomic nervous system-associated paraganglia and are rare tumors accounting for only 0.3% of all neoplasms. Malignant paragangliomas frequently spread to the skeleton. The authors present a case of malignant paraganglioma with bone metastases to the spine and cranium, as well as excellent local control achieved with en bloc tumor resection and reconstruction using frozen tumor-bearing bone for the sites of the metastases.

CASE

The patient was a 61-year-old woman who underwent retroperitoneal paraganglioma resection 12 years previously. Nine years after the primary surgery, she began to experience back pain. Magnetic resonance imaging revealed an isolated metastasis in T6, and the following evaluation detected another metastasis in the left temporal bone. We performed curative surgeries for the metastases, including total en bloc spondylectomy of T6, partial craniectomy for the cranial metastasis, and spinal and cranial reconstruction using frozen tumor-bearing bone for the sites of the metastases. At the 24-month follow-up examination, bone fusion was achieved between the frozen bone and the adjacent healthy bone in the spine and cranium. At 36 months postoperatively, an asymptomatic metastatic lesion was found in the pelvis. Nevertheless, no local recurrences at the surgical sites were detected. Her quality of life and performance in activities of daily living were well preserved. To the author's knowledge, this is the first report to present a case of cranioplasty achieved using a liquid nitrogen frozen, tumor-bearing autologous bone flap in a single-stage operation.

Metastatic paraganglioma presenting as a primary shoulder mass

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

Paraganglioma with intracranial metastasis: a case report and review of the literature

Paragangliomas are rare neuroendocrine tumors of neural crest origin. They are mostly benign, however; malignant tumors with aggressive behavior and distant metastasis can also occur. Intracranial involvement is extremely rare and has been sporadically reported in the literature. Here we report a case who presented with progressive neurologic deficits due to multiple intracranial lesions found to be metastasis from an occult retroperitoneal malignant paraganglioma.

Delayed intracranial and bony metastasis of paraganglioma

Background:

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

Case Description:

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

Conclusions:

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