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

Primary Paraganglioma of the Spine: A Systematic Review of Clinical Features and Surgical Management in Cauda Equina vs Non-Cauda Equina Lesions

BACKGROUND

Primary spine paragangliomas are rare tumors. Surgical resection plays a role, but aggressive lesions are challenging. We reviewed the literature on primary spine paragangliomas.

METHODS

PubMed, Scopus, Web of Science, and Cochrane were searched upon the PRISMA guidelines to include studies on primary spine paragangliomas. Clinical-radiological features, treatments, and outcomes were analyzed and compared between cauda-equina vs non-cauda-equina tumors.

RESULTS

We included 143 studies comprising 334 patients. Median age was 46 years (range, 6-85). The most frequent symptoms were lower-back (64.1%) and radicular (53.9%) pain, and sympathetic in 18 patients (5.4%). Cauda-equina paragangliomas (84.1%) had frequently lumbar (49.1%) or lumbosacral (29%) locations. Non-cauda-equina tumors were mostly in the thoracic (11.4%), thoracolumbar (5.1%), and cervical (3.6%) spine. Median tumor diameter was 2.5cm (range, 0.5-13.0). Surgical resection (98.5%) was preferred over biopsy (1.5%). Decompressive laminectomy (53%) and spine fusion (6.9%) were also performed. Adjuvant radiotherapy was delivered in 39 patients (11.7%) with aggressive tumors. Post-treatment symptomatic improvement was described in 86.2% cases. Median follow-up was 19.5 months (range, 0.1-468.0), and 23 patients (3.9%) had tumor recurrences. No significant differences were found between cauda-equina vs non-cauda-equina tumors.

CONCLUSION

Surgical resection is effective and safe in treating primary spine paragangliomas; however, adjuvant treatments may be needed for aggressive lesions.

Spinal paraganglioma as unusual finding in von Hippel-Lindau disease

A 20-year-old patient with a history of von Hippel-Lindau disease reported on thoracic back pain radiating to the left shoulder for 10 weeks. Magnetic resonance imaging revealed a progressive contrast-enhancing tumor (14 × 21 × 28 mm) compressing the spinal cord and extending into the left neural foramen at T5/6. After embolization of supplying vessels, the tumor was completely resected via hemilaminectomy of T5. The postoperative course was uneventful without surgery related morbidity. The pathological examination disclosed a paraganglioma WHO grade I. We discuss the differential diagnoses and pitfalls of this unexpected finding in this patient with von Hippel-Lindau disease.

Surgical treatment of malignant paraganglioma with spinal invasion in a juvenile patient: A case report

RATIONALE

Paragangliomas are rare neuroendocrine tumors that originate in specialized cells derived from the neural crest with metastasis to the thoracic spine being among the rarest forms. Here, we are presenting a detailed analysis of a case of malignant paraganglioma in the thoracic spinal region in a 14-year-old boy. Our focus is to emphasize the importance of considering malignant paraganglioma as a diagnosis and guiding the perioperative management upon surgical treatment. The management of these unique cases has yet to be well-documented.

PATIENT CONCERNS

A 14-year-old boy presented with a 5-month history of continuous and progressive elevated blood pressure and back pain. The patient, who had been diagnosed of malignant paraganglioma in the left posterior mediastinum for 3 months, received surgical resection of paraganglioma in the left posterior mediastinum, which had involved the left intervertebral foramen of T4. However, the tumor was not completely resected during the first operation.

DIAGNOSES

Magnetic resonance imaging of spine and positron emission tomography-computed tomography showed spinal cord compression secondary to the epidural component of the T4 mass, with increased marrow infiltration of the left T4 intervertebral foramen, which was difficult to be removed. Postoperative pathology confirmed the diagnosis of spinal involvement of malignant paraganglioma.

INTERVENTIONS

The patient underwent biopsy and percutaneous vertebroplasty of T4 and paravertebral lesions, and needle-track cement augmentation via a posterior approach.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 10-month follow-up visit. There were no other complications associated with the operation during the follow-up period.

LESSONS

Combined efforts of specialists from orthopedics, neurosurgery, thoracic surgery, and medical oncology led to the successful diagnosis and management of this patient. Malignant paraganglioma of thoracic spine, although rare, should be part of the differential diagnosis when the patient has a history of paraganglioma and presents with back pain and radiculopathy. We recommend the posterior approach for spinal decompression of the malignant paraganglioma when the tumor has caused neurological deficits. Osteoplasty by cement augmentation is also a good choice for surgical treatment. However, we need to take the potential risk of complications in bone cement applications into full consideration.

Treatment and outcome of metastatic paraganglioma of the spine

BACKGROUND

Spinal metastatic paraganglioma (MPG) is rare and only reported in individual case reports. The low incidence makes it difficult to define appropriate therapy and prognosis. Our study illustrated the largest series to discuss the possible treatment and outcomes of patients with spinal MPG.

METHODS

A retrospective study of 15 patients with spinal MPG who were surgically treated between 2005 and 2014 was performed. Three surgical modalities were applied, and radiotherapy and chemotherapy were utilized as adjuvant therapy.

RESULTS

The mean patients age was 40.9 (range 23-58) years. The period between primary surgery and spinal metastasis averaged 8.2 (0.5-15) years. Lesions were mainly located in cervical spine (2), thoracic spine (8), lumbar spine (3), and sacrum (2). The mean follow-up period was 35.0 months. Lesion progression was detected in nine patients, whereas five patients (33.3%) passed away. For solitary spine, multiple bone and both bone and nonosseous metastasis cases, the mean progression-free survival was 41 (range 9-56), 22.5 (range 12-38) and 8.3 (range 3-18) months, respectively.

CONCLUSIONS

The cases presented in the current study highlight the crucial role of surgery. Total en bloc for solitary spinal MPG could result in a satisfying prognosis and piecemeal total resection with postoperative radiotherapy could be an alternative therapy. Radiotherapy and chemotherapy were advocated, especially for the multiple metastasis.

Clinical characteristics and surgical treatment of spinal paraganglioma: A case series of 18 patients

BACKGROUND AND OBJECTIVES

Paraganglioma rarely develops in the spine. With few cases reported, little knowledge about this disease was known. The objective of this study is to illustrate the clinical features, imaging manifestations, pathological appearances and long-term outcomes of the consecutive surgeries by literature review.

METHODS

The clinical and follow-up data of 18 patients who were diagnosed of spinal paraganglioma and treated with surgeries in our hospitals from 2003 to 2014 were retrospectively analyzed.

RESULT

A total of fourteen patients radiographed of intra-spinal tumor underwent extra-capsular tumor resection. Of five patients with obvious vertebral bone damage, four cases underwent piecemeal resection, and the left one with sacral tumor underwent en bloc tumor excision. Spinal reconstruction was performed in all cases. Follow-up lasted for 16-96 months (44.1 months on average). There was no local recurrence or distant metastasis in cases without obvious bone invasion. Of those five cases with vertebral bone damage, one case suffered and survived from the repeat relapse of T1 vertebral body tumor. Local recurrence was not observed in one case with T10 vertebral tumor after tumor resection, but the tumor metastasized to T2 attachment during the follow-up and was finally eradicated by re-operation. No tumor recurrence was observed in the left three cases.

CONCLUSION

Paraganglioma, usually benign, rarely occurs. Surgical resection, especially complete surgical resection, is preferred to treat spinal paraganglioma. Chemotherapy, radiotherapy, use of octreotide and other somatostatin are selected as adjuvant therapies, but their effects remain unknown.

Secretory paraspinal paraganglioma of thoracolumar spine: Case report and review of literature

Background:

Pheochromocytomas are catecholamine secreting tumors of the adrenal medulla chromaffin cells, however, when present extra-adrenally they are called paragangliomas. Paragangliomas rarely produce catecholamine in excess, which is evident by clinical symptoms, urine, and blood biochemistry. Total resection of these tumors can lead to complete clinical and biochemical resolution. This case report presents the clinical features, radiological findings, and neurological outcome in a middle-aged female with a secretory paraganglioma.

Case Description:

We present the case of a 34-year-old female who presented with a 2-year history of dizziness, flushing, headache, palpitations, and hypertension. Her blood workup showed raised urinary catecholamine levels. Magnetic resonance imaging (MRI) and iodine-123-meta-iodobenzylguanidine (MIBG) scans demonstrated a retroperitoneal mass located anterolateral to T11-T12 vertebral bodies reaching up to T12-L1 intervertebral disc. The patient was otherwise neurologically intact. She underwent resection of the tumor after alpha-adrenergic and beta-adrenergic blockade. En bloc resection was achieved without neurological complications. Postoperatively, the patient was initially hypotensive and subsequently became normotensive, and on follow-up, the patient had resolution of her symptoms and was stable.

Conclusion:

Secretory paraganglioma of the dorsal spine are rare and difficult to excise, needs preoperative preparation with pharmacological intervention, good operative technique, and postoperative care.

Trans-arterial Onyx Embolization of a Functional Thoracic Paraganglioma

Paragangliomas are rare tumors of the endocrine system. They are highly vascular and in some cases hormonally active, making their management challenging. Although there is strong evidence of the safety and effectiveness of preoperative embolization in the management of spinal tumors, only five cases have been reported in the setting of thoracic paragangliomas. We present the case of a 19-year-old man with a large, primary, functional, malignant paraganglioma of the thoracic spine causing a vertebral fracture and spinal cord compression. To our knowledge this is the first report of preoperative trans-arterial balloon augmented Onyx embolization of a thoracic paraganglioma.

Metastatic paraganglioma of the spine: case report and review of the literature

Paragangliomas are relatively rare tumors, accounting for only about 0.3% of all neoplasms. Most paragangliomas are defined as benign in nature, but 10-20% possess metastatic potential. There have been scattered reports of metastatic paraganglioma in the literature, but in rare circumstances, paragangliomas can metastasize to the spinal column causing destruction or compression of the spinal cord, clinically manifesting as pain or neurological deficit. We report a case of metastatic paraganglioma in which a 47-year-old man had spinal metastasis from a primary abdominal paraganglioma and was found to be positive for SDHB mutation, portraying negative implications for prognosis. Long-term follow-up is reported. In addition, we review the literature on the topic of metastatic paraganglioma, management of paragangliomas involving spine, and touch on the importance of the presence of SDHB mutations in these cases.

[Mediastinal paragangliomas: a report of 2 cases]

Paragangliomas are neuroendocrine tumors derived from chromaffin cells of the extraadrenal sympathetic system; mediastinal paragangliomas are rare. We illustrate and describe the imaging findings in two cases of mediastinal paraganglioma, one nonfunctional aorticopulmonary paraganglioma and one locally aggressive functional aorticosympathetic paraganglioma first observed as a mediastinal mass on chest plain-film radiographs.

Part I: Spinal-cord neoplasms—intradural neoplasms

Intradural spinal-cord tumours are an uncommon but important consideration in the differential diagnosis of patients with back pain, radicular pain, sensorimotor deficits, or sphincter dysfunction. Intradural spinal tumours can be divided into intramedullary and extramedullary spinal-cord tumours on the basis of their anatomical relation to the spinal parenchyma. The heterogeneous cell composition of the intradural compartment allows the formation of neoplasms, arising from glial cells, neurons, and cells of spinal vasculature. Additionally, developmental tumours, metastases, and intradural extension of extradural tumours are represented. In this Review, we discuss the published work on intradural spinal-cord tumours in terms of epidemiological, radiographic, and histological characteristics. Surgical and adjuvant treatment strategies are also reviewed.

Thoracic extradural paragangliomas: a case report and review of the literature

STUDY DESIGN

Case report.

OBJECTIVES

To report on a case of paraganglioma presenting in an uncommon extradural thoracic localization.

SETTING

Department of Neurosurgery, Florence, Italy.

CASE REPORT

A 43-year-old woman with a thoracic lesion extending into the extradural space along four levels, T(1)-T(4), presented with sudden spastic incomplete paraplegia and paresthesia at the lower limbs.

RESULTS

The neoplasm was surgically resected 'en bloc' and histological findings corresponded to paraganglioma. One year after surgery, the patient was walking without assistance, a T(3)-T(4) hypoesthesia was still present and an magnetic resonance imaging (MRI) study showed no signs of focal recurrence.

CONCLUSIONS

The imaging features of thoracic paragangliomas may be misleading and an advanced malignant lesion could be primarily suspected; thus, a histological study is always needed. Total resection is the gold standard therapy. Owing to the risk of recurrence or multicentric growth, follow-up must be prolonged and accurate.

Paraganglioma of the filum terminale

Paraganglioma of the filum terminale is rare. The authors report a case of paraganglioma of the filum terminale presenting with paraparesis on a background of spastic quadriparesis. The clinical presentation, radiological findings and current literature are presented.

Paraganglioma of the cauda equina: A case report and literature review

A 26-year-old man presented with left leg pain and progressive paraparesis. Imaging revealed a large intradural tumour compressing the cauda equina. The lesion was radically resected and histological analysis revealed it to be a paraganglioma. The clinical features of this rare tumour are described with a review of the literature.

Thoracic paraganglioma presenting with spinal cord compression and metastases

We report a case of a 41-year-old man with a primary thoracic spine paraganglioma presenting with spinal cord compression and distant metastasis. Paragangliomas arising within the spinal canal are rare and when they occur are usually found in the intradural, extramedullary compartment and in the lumbosacral region. Thoracic paragangliomas are very rare, with only five prior cases reported in the literature and with distant metastasis seen in only one of these. In this case, the tumor was entirely extradural and produced extensive sclerosis of the surrounding vertebrae. The clinical, radiographic, and pathologic features of this case are detailed and the relevant literature is reviewed.

Lessons to be learned: a case study approach. Paraganglioma of the urinary bladder

Primary paraganglioma arises infrequently in the urinary bladder. We present here the clinicopathological, immunohistochemical and ultrastructural findings in a 23-year-old Saudi female. She was hospitalised because of gross haematuria over the previous seven days. The intravenous urogram revealed a filling defect in the urinary bladder. Cystoscopy disclosed a non-papillary tumour arising from the roof of the bladder neck. Transurethral resection was, accordingly, performed--but marked fluctuation in blood pressure was observed during the procedure. The histopathological findings of trabeculae and small nests of plump oval to spindle cells with a clear to acidophilic cytoplasm, forming an organoid pattern and demonstrating inconspicuous mitotic activity, were diagnostic of paraganglioma of the urinary bladder, the diagnosis was confirmed by means of immunohistochemical and ultrastructural studies. The endocrine markers chromogranin A and neuron-specific enolase were positive in chief cells; sustentacular cells at the periphery of neoplastic cell clusters were positive for S-100 protein. Neurosecretory granules were identified by electron microscopic examination. It is emphasised that, currently, there are no anatomico-pathological criteria to distinguish benign and malignant forms of the disease. Post-surgical recovery was uneventful in this case. Recurrence and metastases, though infrequent, have been reported in the literature; therefore, radiation therapy may be an important adjunct--and long-term follow-up is mandatory.

Sudden death in a child due to an intrathoracic paraganglioma

A 12-year-old boy under treatment for asthma was found dead in his home. The autopsy revealed a large posterior mediastinal mass that completely compressed the upper lobe of the right lung and the associated airways. This mass extended from the right costovertebral sulcus into the thoracic spinal canal through the spinal foramen and compressed the spinal cord. It was located in the epidural space and was adherent to a nerve root. The histologic and immunocytochemical features were that of a paraganglioma. Although neurogenic tumors are the most common posterior mediastinal masses in the pediatric population, paragangliomas are rare, and spinal involvement has not been described in children. In addition, sudden death has not been reported in association with any of the 13 cases of posterior mediastinal paraganglioma described in the literature as involving the spine. This case illustrates an unusual cause of sudden death in a pediatric patient due to a benign neoplasm.

Severe progressive osteoporotic spine deformity with cardiopulmonary impairment in a young patient. A case report

STUDY DESIGN

This report describes a young patient with a rapidly progressive kyphosis caused by collapse of a severely osteoporotic thoracolumbar spine, which led to impairment of cardiopulmonary function.

OBJECTIVES

To highlight the treatment strategy, difficulty of diagnosis, operative stabilization, and outcome.

SUMMARY OF BACKGROUND DATA

Little is known about natural history, treatment options, and results of this condition.

METHODS

The magnitude of bone loss was measured by dual-energy x-ray absorptiometry, and the deformity was visualized by computed tomography and magnetic resonance imaging. Laboratory investigations also were performed before and during halotraction in an attempt to establish a diagnosis. These data constituted the preoperation information required to assess later results of medical and surgical intervention.

RESULTS

An extensive evaluation of possible underlying etiologies failed to identify a specific etiology. Before and during halotraction, bone mineral substitutes were given, partially correcting the bone mineral content as measured on repeated dual-energy x-ray absorptiometry scans. In addition, the thoracic kyphosis was partially corrected, from 100 degrees to 70 degrees Cobb's angle. Subsequently, a combined anterior and posterior stabilization was performed from C7 to S1 using a vascularized fibula graft, a double Isola rod system (AcroMed, Cleveland, OH), and a carbonate apatite cancellous bone cement to reinforce the pedicle screws. At follow-up assessment 40 months surgery, the patient was asymptomatic and fully mobilized, with radiographs showing complete incorporation of the grafts and no loosening of the fixation device.

CONCLUSIONS

The diagnostic and therapeutic difficulties of progressive spine deformity caused by severe osteoporosis in young patients emphasizes the importance of a thoroughly planned treatment strategy. Halotraction is recommended to stop progression of the deformity, or even partially correct it, and to allow time to search for the diagnosis and bone mineral substitution. Surgical treatment using vascularized fibular strut grafts and a strong fixation device was successful. Biocompatible carbonated apatite cancellous bone cement was successfully used to reinforce pedicle screw fixation.

Schwannoma of posterior mediastinum: a case report and concise review

In the vast majority of cases, schwannoma (neurilemmoma) of the posterior mediastinum arises from 1 of the intercostal nerves and most often is manifested by an asymptomatic solitary mass on a radiograph. This case report emphasizes the importance of new imaging studies in the diagnosis of this classic tumor of the mediastinum, with special regard to the differential diagnosis of such a tumor.