Primary Pulmonary Paraganglioma: A Case Report and Review of Literature

Middle mediastinal paraganglioma: A case report and review of the literature

RATIONAL

Paragangliomas are rare and can occur in many places throughout the body, but mediastinal paragangliomas are even rarer, accounting for less than 0.3% of mediastinal masses. Extremely susceptible to misdiagnosis and mistreatment, which may lead to the death of the patient.

PATIENT CONCERNS

We report a case of a giant paraganglioma of the middle mediastinum. A 40-year-old woman was admitted to the hospital with a rib fracture and a chest computed tomography suggesting a giant occupying tumor in the middle mediastinum.

DIAGNOSIS

Immunohistochemistry revealed positive for S100 fraction and Syn, focally positive for CgA, while negative for CKp and succinate dehydrogenase complex iron sulfur subunit B gene, and Ki67index ≈ 5%. The imaging and immunohistochemical features suggested a final diagnosis of Paragangliomas.

INTERVENTIONS

This patient underwent lateral open heart surgery to remove a mediastinal mass.

OUTCOMES

One month after being discharged, the patient was contacted by phone for a follow-up visit and reported feeling OK. Unfortunately, as of the date of submission, the patient did not come to our hospital for review.

LESSONS

Mediastinal paraganglioma as a rare and potentially malignant tumor susceptible to misdiagnosis and mistreatment. Organ pathology examination is the gold standard for diagnosis, and surgery is an important treatment method. A clear diagnosis and thorough preoperative examination are important guarantees for the success of surgery.

An Unusual Histology for a Lung Nodule: A Case Report of Primary Pulmonary Paraganglioma

Introduction: Primary pulmonary paraganglioma is a rare tumor with few cases reported in literature and unspecific clinical presentation.

Case Presentation: A 49-year-old woman presented to our department with an incidental finding of a pulmonary mass at chest X-ray and no associated clinical symptom. The CT scan and the FDG-PET showed mild uptake of contrast, but a definitive diagnosis was only possible after surgery through histopathological examination.

Conclusion: Paragangliomas originating in the pulmonary tissue are generally non-functioning masses discovered incidentally in otherwise asymptomatic patients. Surgery appears to be the best treatment option, with only radiologic follow-up necessary afterwards.

Primary endobronchial paraganglioma with lymph node metastasis: a case report

A paraganglioma is an extra-adrenal tumor of the paraganglia often found in association with sympathetic and parasympathetic nerves. A primary pulmonary paraganglioma generally presents as multiple small tumors or a solitary mass; however, endobronchial involvement is extremely rare. A 49-year-old man was admitted to our hospital because of a chronic cough, intermittent dyspnea, and chest pain. Chest computed tomography revealed a rounded, high-density lesion in the left lower lung lobe. Fiberoptic bronchoscopy demonstrated an endobronchial mass characterized by smooth, hypervascularized mucosa. Transbronchial biopsy of the mass and immunohistochemistry results suggested a paraganglioma. The patient fully recovered after lobectomy and lymphadenectomy. Pulmonary paragangliomas are rarely reported. Complete surgical resection is considered the treatment of choice for pulmonary paragangliomas, and the long-term prognosis is generally good. However, life-long follow-up is mandatory because of the possibility of recurrence and metastasis. This case report adds valuable knowledge to the literature on pulmonary paragangliomas.

A rare neurendocrine tumor of the lung: sclerosing paraganglioma. A neoplasm that is difficult to diagnose and a source of dangerous pitfalls. A case report and literature review

An endobronchial obstructing neoformation was found in a 58-year-old man. The histology and immunohistochemical profile oriented the authors towards a diagnosis of paraganglioma, sclerosing variant. This very difficult diagnosis, especially in a pulmonary localization, may lead to erroneous conclusions both in terms of histogenetic interpretation and that of its biological behavior. The pulmonary localization of the paraganglioma is very rare and even more rare the sclerosing variant, recently reported. Differential diagnosis and literature are discussed.

Pathologic features and clinical course of a non-functioning primary pulmonary paraganglioma: A case report

Introduction

Paragangliomas (PGGL) are rare neuroendocrine tumors arising from non-epithelial extra-adrenal chromaffin cells. They have been described in different sites: abdomen, pelvis, head, neck and thorax. Incidence is very low, occurring in less than 2–8/million per year. PGGL's of the lung are extremely rare, they have a slow growth and present as painless lesions. Biopsy is the method of choice for diagnosis and prognosis.

Presentation of case

This is a 70-year-old woman with chronic cough, with a CT-scan showing a 3.3-cm mass in the left lower lobe. After video-assisted thoracic surgery, histologic findings confirmed a non-functioning pulmonary paraganglioma. We present the clinical, radiological, pathological findings and clinical course.

Discussion

Primary pulmonary PGGL's are extremely rare neuroendocrine tumors with low-grade malignancy, difficult to distinguish from other pulmonary tumors relying only on imaging techniques. In this case, PGGL presented as an incidentaloma during the evaluation of chronic cough. After histological diagnosis, genetic testing are ideally performed to identify somatic or germline mutations that may condition a higher risk of malignancy and metastasis.

Conclusion

PGGL's must be considered when other diagnoses are unlikely due to immunohistochemistry findings. Larger studies in this field are needed to determine the risk factors for its development and to determine which populations have the greatest potential for malignant transformation

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Paragangliomas are rare neuroendocrine tumors derived from non-epithelial extra-adrenal chromaffin cells.

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Paragangliomas from the lung are rare, they have a slow growth and present as non-painful lesions.

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Complete surgical resection is the diagnostic method of choice for solitary primary pulmonary paragangliomas.

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Genetic testing is important to identify somatic or germline mutations.

Current Management of Pheochromocytoma/Paraganglioma: A Guide for the Practicing Clinician in the Era of Precision Medicine

Pheochromocytomas and paragangliomas (PCC/PGLs) are rare, mostly catecholamine-producing neuroendocrine tumors of the adrenal gland (PCCs) or the extra-adrenal paraganglia (PGL). They can be separated into three different molecular clusters depending on their underlying gene mutations in any of the at least 20 known susceptibility genes: The pseudohypoxia-associated cluster 1, the kinase signaling-associated cluster 2, and the Wnt signaling-associated cluster 3. In addition to tumor size, location (adrenal vs. extra-adrenal), multiplicity, age of first diagnosis, and presence of metastatic disease (including tumor burden), other decisive factors for best clinical management of PCC/PGL include the underlying germline mutation. The above factors can impact the choice of different biomarkers and imaging modalities for PCC/PGL diagnosis, as well as screening for other neoplasms, staging, follow-up, and therapy options. This review provides a guide for practicing clinicians summarizing current management of PCC/PGL according to tumor size, location, age of first diagnosis, presence of metastases, and especially underlying mutations in the era of precision medicine.

Asymptomatic left posterior mediastinal functional paraganglioma: A case report

RATIONALE

Paraganglioma refers to a set of neuroendocrine tumors derived from the chromaffin cells of the adrenal diplomatic ganglion. Paragangliomas can be classified as functional or nonfunctional based on the ability to synthesize and release catecholamines.

PATIENT CONCERNS

We report a 47-year-old man with a functional paraganglioma in the left posterior mediastinum and highlight the key elements of management of mediastinal paragangliomas.

DIAGNOSES

A left posterior mediastinal mass was found by computed tomography (CT) scan and Chest-enhanced CT. Preoperative ultrasound-guided biopsy suggested the possibility of a paraganglioma. A diagnosis of paraganglioma was established by immunohistochemistry.

INTERVENTIONS

The patient underwent single-stage resection of the lesion via left thoracotomy after preoperative oral α-adrenoceptor (phenoxybenzamine) therapy and intravenous fluid resuscitation for two weeks.

OUTCOMES

The postoperative period was uneventful. The patient exhibited no abnormal blood pressure or recurrence during the 12-month follow-up period.

LESSONS SUBSECTIONS AS PER STYLE

Pathological examination alone cannot determine whether it was a benign or malignant paraganglioma, which can be determined by pathological examination combined with distant metastasis. Long-term follow-up is required to assess the treatment effect.

Thoracotomy of an asymptomatic, functional, posterior mediastinal paraganglioma: A case report

BACKGROUND

Paragangliomas in the mediastinum are rare, accounting for only 1%-2% of all paragangliomas and < 0.3% of all mediastinal tumors. Most paragangliomas are nonfunctional, therefore, asymptomatic functional paragangliomas in the left posterior mediastinum are extremely rare. Perioperative management including preoperative preparation, careful intraoperative procedures, and strict postoperative care is important, and one-stage surgical resection should be performed only after appropriate perioperative measures are undertaken. Because those tumors are rare, it is necessary to report known cases to raise awareness regarding them.

CASE SUMMARY

We report the case of a 47-year-old male who was admitted to our hospital with the chief complaints of intermittent tearing pain on the left side of the chest and back for more than 10 mo. A chest contrast-enhanced computed tomography scan revealed a round, solid mass in the left posterior mediastinum, with low-density cystic lesions in the middle, and no enlarged lymph nodes in the hilum or mediastinum (Figure 1). After the diagnosis of paraganglioma, the patient was preoperatively given an oral adrenoceptor blocking drug (phenoxybenzamine), and intravenous fluid resuscitation for two weeks, subsequently the patient underwent a one-stage resection of lesions via left thoracotomy. The patient’s blood pressure increased to 220/120 mmHg when the tumor was touched, which could be relieved by symptomatic treatment such as accelerating liquid transfusion or other intervention to lower blood pressure. The patient recovered uneventfully after surgery, with no abnormal blood pressure or recurrence during one year of follow-up visits.

CONCLUSION

Surgical resection is the preferred treatment for asymptomatic functional paragangliomas.

Primary Pulmonary Paraganglioma Revealed by FDG PET/CT

Primary pulmonary paraganglioma is a rare type of extra-adrenal paragangliomas arising from neuroectodermal-derived paraganglionic tissue. We report herein the case of a 49-year-old woman with a round-like well-defined nodule in the right middle lobe detected by chest CT. FDG PET/CT also revealed this homogeneous nodule with increased FDG accumulation. Finally, the patient underwent right middle lobe resection, and the pathological findings demonstrated the diagnosis of pulmonary paraganglioma.

The Diagnosis and Clinical Significance of Paragangliomas in Unusual Locations

Paragangliomas are neuroendocrine neoplasms, derived from paraganglia of the sympathetic and parasympathetic nervous systems. They are most commonly identified in the head and neck, being most frequent in the carotid body, followed by jugulotympanic paraganglia, vagal nerve and ganglion nodosum, as well as laryngeal paraganglia. Abdominal sites include the well-known urinary bladder tumors that originate in the Organ of Zuckerkandl. However, other unusual sites of origin include peri-adrenal, para-aortic, inter-aortocaval, and paracaval retroperitoneal sites, as well as tumors in organs where they may not be expected in the differential diagnosis of neuroendocrine neoplasms, such as thyroid, parathyroid, pituitary, gut, pancreas, liver, mesentery, lung, heart and mediastinum. The distinction of these lesions from epithelial neuroendocrine neoplasms is critical for several reasons. Firstly, the determination of clinical and biochemical features is different from that used for epithelial neuroendocrine tumors. Secondly, the genetic implications are different, since paragangliomas/pheochromocytomas have the highest rate of germline susceptibility at almost 40%. Finally, the characterization of metastatic disease is unique in these highly syndromic lesions. In this review, we summarize updated concepts by outlining the spectrum of anatomic locations of paragangliomas, the importance of morphology in establishing the correct diagnosis, the clinical implications for management, and the impact of genetics on the distinction between multifocal primary tumors compared with malignant disease.

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.

Imaging of Intrathoracic Paragangliomas

Intrathoracic paragangliomas are uncommon and only represent 1%-2% of paragangliomas. They are most commonly found in mediastinal compartments (aortopulmonary window or posterior mediastinum). Computed tomography, magnetic resonance, and specific nuclear medicine radiotracers are routinely used to characterize these lesions and help exclude other more common conditions. Selective angiography is currently used for preoperative embolization and mapping of the vascular supply before surgical resection, rather than for diagnostic purposes alone.