MEDIASTINAL NONCHROMAFFIN PARAGANGLIOMA

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.

Surgical excision with left atrial reconstruction of a primary functioning retrocardiac paraganglioma

About 2% of all paragangliomas are located in the chest, and a few have been described to be found in the heart. Primary cardiac paragangliomas are extremely uncommon tumors and surgical experience with this neoplasm is limited. Treatment strategies described in the literature have included simple excision, excision with reconstruction, autotransplantation after excision of the tumor and even orthotopic cardiac transplantation, depending on the extent of disease. A primary retrocardiac paraganglioma catecholamine-productive was identified in an asymptomatic 49–year old female associated to familial pheochromocytoma-paraganglioma syndrome caused by germline mutation of the gen which codifies for the subunit B of succinate dehydrogenase enzyme (SDHB). The neoplasm was surgically excised from the posterior surface of the left atrium via median sternotomy using cardiopulmonary bypass. Direct ligation of feeding vessels of the tumor along with left atrial reinforcement using a pericardial patch was performed. The post-operative course was uneventful, with normalization of catecholamine secretion and no recurrence at three-month follow-up. We review the current literature about this exceptional cardiac tumor, pathophysiological conditions and options for surgical management.

A rare case of cardiac paraganglioma presenting as anginal pain: a case report

INTRODUCTION

Primary cardiac paraganglioma is a very rare tumor with less than sixty reported cases in the literature. The clinical presentation is variable, but is most commonly manifested by hypertension and symptoms related to the catecholamine excess.

CASE REPORT

We report a case of a 35 year old man who presented with anginal pain and hypertension. He was found to have a cardiac mass on the computed tomographic scan and echocardiogram. He underwent surgical exploration of the mass which on biopsy was found to be a 'Cardiac Paraganglioma'. Surgical resection of the tumor was successfully done and the patient is doing well five years after the surgery without any evidence of recurrence. His blood pressure, however, failed to normalize and needed single agent antihypertensive therapy.

CONCLUSION

Cardiac paragangliomas have a relatively favorable outcome if diagnosed and resected in time. We briefly review the literature regarding the diagnosis, treatment and prognosis of this rare tumor.

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

Paraganglioma of the mediastinum is described to be an indolent and slow-growing tumor. After a patient presented to our center, we reviewed the world literature to evaluate the prognosis of this tumor. This review showed that paragangliomas are locally invasive and have a high local recurrence rate (44/79 or 55.7%) with a true metastatic capacity (21/79 or 26.6%). The overall survival is 62.0% (49/79), but only 36.7% (29/79) of patients could be considered as free of disease, with survival time of 98.2 +/- 11.7 months (mean +/- standard error). The survival with a complete resection is 84.6% (125.7 +/- 18.7 months) versus 50.0% (71.5 +/- 13.8 months) for patients with a biopsy or a partial excision and adjuvant treatment (p < 0.01). We acknowledge the limitation of this retrospective study, but a prospective trial is not possible because of the rarity of the tumor. We want to emphasize that paraganglioma of the anterior and middle mediastinum is an aggressive tumor, and complete surgical resection, using cardiopulmonary bypass if necessary, is highly recommended.

Mediastinal paragangliomas. A clinicopathologic and immunohistochemical study of 16 cases

BACKGROUND

Paragangliomas of the mediastinum are rare neoplasms. Because of their rarity, the spectrum of morphologic and immunohistochemical features and biologic behavior of these tumors in this location has not been delineated.

METHODS

A retrospective study of 16 cases of mediastinal paragangliomas was undertaken to evaluate their clinicopathologic and immunohistochemical features.

RESULTS

The patients were 10 men and 6 women whose ages ranged from 16-69 years of age (mean, 42.5 years). Twelve tumors were located in the posterior mediastinum, and three tumors were located in the anterior mediastinum. In one case, the exact location of the tumor within the mediastinum was not available. Microscopically, the nesting pattern (zellballen) was the most commonly encountered. Areas of stromal hyalinization were also frequent and were marked in two tumors. In two cases there was a prominent spindle cell component, and two cases showed granular cell changes in the cytoplasm of the tumor cells. Cellular pleomorphism was observed in the majority of cases. Occasional mitoses were seen in a few cases. Immunohistochemical studies in 10 cases showed chromogranin reactivity in 10 of 10 cases, S-100 protein in 9 of 10 cases, leu-enkephalin in 6 of 10 cases, and neurofilament protein in 5 of 10 cases. Keratin was negative in all cases studied. All patients underwent surgical resection of their tumors, and one patient underwent adjuvant radiation therapy. Follow-up information ranging from 1-168 months (mean, 84.5 months) was obtained in 12 patients. Nine patients (75%) were alive and well at last follow-up. In one patient the tumor metastasized to spinal space and bone marrow, and another patient died with metastases to lymph node, lung, and pelvis 14 years after initial diagnosis.

CONCLUSIONS

The only parameter found to correlate with aggressive behavior was the extent of circumscription and/or local infiltration of the tumor at initial resection. No clinical, histologic, or immunohistochemical features were otherwise found to separate aggressive from indolent clinical behavior. Regular follow-up is recommended in these patients due to the potential for these tumors to metastasize.

Nonchromaffin paraganglioma in the nose and paranasal sinuses

Nonchromaffin paraganglioma occurring in the nose and paranasal sinuses are extremely rare. The authors have experienced a case of nonchromaffin paraganglioma of nasal cavity which extended to the epipharynx. To our knowledge, this reported case is the fourth case that has appeared in the world literature. The patient, a 31-year-old female, had complained of a right nasal obstruction and mucopurulent rhinorrhea for two years. The right nasal cavity was filled with a polypoid mass showing no bleeding tendency or necrosis. Radiographs revealed a homogeneous shadow which occupied the entire nasal cavity and paranasal sinuses. Histopathological studies revealed that the tumor showed typical findings of nonchromaffin paraganglioma and neurosecretory granules in cytoplasm were observed by electron microscopic study. Subsequently, the tumor recurred at on the posterior epipharyngeal wall after a duration of one year and three months, and was removed completely. Since then, there was no recurrence of the tumor until the present time.

Tracheal paraganglioma: a case report with review of the literature

Only three cases of tracheal paraganglioma have been reported in the literature. This paper describes an additional case, which showed pharmacological and ultrastructural evidence of hormone secretion. It is suggested that this tumor is derived from true paraganglia located in the trachea and not from misplaced or aberrant paraganglionic tissue. Hemoptysis was the only presenting symptom in two of the four reported cases and significant bleeding occurred during biopsy in the other two cases. The long-term prognosis appears good if complete resection is possible.

Aortico-pulmonary paraganglioma: report of a case with ultrastructural study and review of the literature

The light microscopic and ultrastructural features of an aortico-pulmonary paraganglioma (A-PP) are presented. The tumor was characterized by organoid clustering of neoplastic chief cells to form Zellballen. Argyrophilic granules were demonstrated within chief cell cytoplasm using a modified Grimelus technique. Ultrastructurally, three distinct cell types were present within the tumor: endothelial cells, pericytes and neoplastic chief cells. Membrane-bound neurosecretory granules were present and measured 100 to 2000 nm in diameter. "Light" and "dark" chief cells were less distinct than previously reported in other head and neck paragangliomas. Analysis of the 36 documented A-PP reported in the English literature reveals that the tumor has been either incompletely excised or has been considered unresectable in one-third of the cases. The reported surgical mortality is 9%, or approximately equal to the incidence of malignant behavior. The treatment of choice is surgical resection but when this is not possible, radiation may be a useful adjunct in therapy.

Mediastinal paragangliomas (aortic body tumor): a report of four cases and a review of the literature

Four cases of paraganglioma originating in the supra-aortic or aortico-pulmonary bodies are described. A review of the reported examples of aortic body tumors and a study of these four cases indicate that there is a high incidence of aggressive tumor growth in the mediastinum, with resultant important morbidity or death in 16 of 35 cases. The morphologic features of aortic body tumors are identical to those of paragangliomas of other locations, and the occurrence of invasive growth and/or metastasis cannot be predicted on histologic grounds.

Carotid body tumour. Exicsion with resection of carotid arteries

A case of carotid body tumour is reported and the salient features of its histopathology have been described. Its excision with resection of the carotid arteries can be safely undertaken if the tumour is of long duration, the angiography shows marked displacement of the carotid arteries and if the blood pressure is maintained during surgery by regulating the blood transfusion and lowering the head end of the patient, thereby preventing fatal brain hypoxia. The fact that it is a potentially malignant and radioresistant tumour, makes its excision with or without ligation of the carotid arteries almost imperative.

Neurogenic tumours with an intrathoracic localization

This paper is a clinicopathological review of patients suffering from intrathoracic neurogenic tumours.