Laparoscopic Resection of Periadrenal Paraganglioma: A Report of 2 Cases

[Minimally invasive surgery of retroperitoneal paragangliomas : Synopsis of personal experiences]

Retroperitoneal paragangliomas are rare tumors with the characteristics of adrenal pheochromocytomas. They may occur sporadically or in conjunction with hereditary syndromes. Diagnostic methods in paragangliomas include testing of catecholamine secretion and imaging procedures. The first choice treatment is surgical removal, which in the author's opinion is preferably by minimally invasive approaches. Infrarenal paragangliomas should be excised using a laparoscopic transabdominal procedure. For suprarenal tumors the retroperitoneoscopic approach should be used.

Retroperitoneoscopic resection of primary paraganglioma: single-center clinical experience and literature review

BACKGROUND AND PURPOSE

Paraganglioma (PG) is a rare neuroendocrine entity. Surgical resection is recommended as the mainstay of treatment due to the uncontrolled hypertension, close proximity to major vessels, variable location, and higher potential malignancy. With rapid development of minimally invasive techniques during the past decade, laparoscopic resection of retroperitoneal PG has been reported with successful results. There are only a few publications describing retroperitoneal access, however. In the present study, we proposed to summarize our experience on retroperitoneal laparoscopic resection in 10 patients and systematically review relevant publications to evaluate its safety and efficacy.

PATIENTS AND METHODS

From June 2009 to October 2013, 10 patients with PG who were treated with retroperitoneoscopy were included in the study. Minimal effective dosage α-blockade with phenoxybenzamine was routinely used. Preoperative, intraoperative, and postoperative baseline data were collected and analyzed. Meanwhile, two reviewers independently searched and identified 8 retrospective studies and 23 case reports in the Medline, Embase, and Science Citation Index between 1998 and 2013.

RESULTS

Operations in 9 of 10 patients were successfully completed without conversion; one case was converted to open surgery because of left accessory renal artery injury. Mean operative time, blood loss, and postoperative hospital stay were 97.8±20.6 minutes, 44.4±8.2 mL, and 4.8±3.5 days, respectively. There were three complications in this series, including accessory renal artery injury, renal vein injury, and chylorrhea.

CONCLUSIONS

Retroperitoneoscopic resection is feasible, effective, and safe in the treatment of patients with PG according to our preliminary clinical experience and has distinct advantages including direct access to the tumor, less intraperitoneal interference, precise dissection, and minimal invasiveness.

Paraganglioma mimicking adrenal incidentaloma

Paragangliomas can be confused with adrenal incidentalomas because of their proximity to the adrenal glands. A 71-year-old man presented with left-sided abdominal pain. A computed tomography scan showed a large cystic mass with a solid component arising from the left adrenal gland (Figure 1).

Laparoscopic resection of periadrenal paraganglioma mimicking an isolated adrenal hydatid cyst

The authors conclude that paraganglioma can mimic the appearance of an isolated adrenal hydatid cyst.

We present the case of a 64-year-old female with a periadrenal paraganglioma. The mass was diagnosed during abdominal ultrasonography performed to investigate right flank pain. Magnetic resonance imaging showed a lesion 48mm in diameter with an irregular hyperintense central margin, thickened septa, centrally located cystic component, and contrast enhancing peripheral portions. These findings made us think it was an isolated adrenal hydatid cyst. The mass was excised via laparoscopy without complications. Histopathological examination was consistent with periadrenal paraganglioma. We believe that the paraganglioma can mimic the radiological appearance of an isolated adrenal hydatid cyst, which should be taken into consideration during diagnosis.

Abdominal Paragangliomas: Analysis of Surgeon's Experience

Abdominal paraganglioma is a rare endocrine tumor associated with genetic mutations, however, the ability to predict long-term risk of metastasis has not been clarified. The aim of this study was to examine the clinicopathological features and outcomes in patients undergoing surgery for an abdominal paraganglioma. A retrospective analysis was performed for all patients undergoing surgery for abdominal paragangliomas from one surgical department between 1998 and 2010. Clinical presentation, hormone secretion and clinical outcomes were examined. A total of 23 patients underwent surgery for abdominal paraganglioma with the most common presentation being hypertension. Median time to metastasis was 32 months with all patients developing disease progression having a rise in urine catecholamines. Patients with capsular invasion or predisposing genetic conditions are at a higher risk of having more aggressive disease. All patients with a diagnosis of paraganglioma should be screened for predisposing genetic abnormalities and postoperative follow-up must include routine urinary catecholamine assessment.

Local-regional recurrence of sporadic or syndromic abdominal extra-adrenal paraganglioma: incidence, characteristics, and outcome

BACKGROUND

Operative excision of abdominal extra-adrenal paragangliomas (EAPs) does not preclude the late development of local-regional recurrence. We describe the incidence, characteristics, and outcome of this rarely reported feature.

METHODS

Retrospective analysis of local-regional recurrence that occurred during follow-up of 51 consecutive patients operated for a sporadic (n = 26) or hereditary (n = 25) EAP.

RESULTS

Seven patients with a sporadic or syndromic EAP (n = 4: von Hippel-Lindau syndrome and SDHB, SDHC, and SDHD gene mutations) underwent reoperation for a local-regional recurrence after a median time of 46 months (interquartile range [IQR], 16-100). The Kaplan-Meier estimated incidence of local-regional recurrence (+/- standard error of the mean) reached 15% +/- 7% at 5 years and 23% +/- 9% after 10 years. Recurrent EAPs were all secreting and 38% provoked clinical symptoms. New lesions were smaller than the primary EAP (P = .01) and more often associated with lymph node metastases (43% vs 4%, P = .01). Operative excision seemed complete in 5 patients. Clinical remission was maintained in 4 patients after a median follow-up of 57 months (IQR, 22-102).

CONCLUSION

Local-regional recurrence of sporadic and syndromic EAPs is frequent and may be delayed beyond 10 years, requiring lifelong follow-up after the initial operation. When technically feasible, operative excision can lead to prolonged remission.

Retroperitoneal paragangliomas in obese patients

Obesity, the most significant metabolic problem in the world today, is associated with a wide range of diseases, including endocrine disorders. Paraganglioma is a rare chromaffin cell tumor that develops from the neural crest cells of the neuroendocrine system. Retroperitoneal paragangliomas can represent a surgical challenge due to their close relation to large vessels. We report two cases of functioning retroperitoneal paraganglioma in type-I obese patients (case 1: female; weight, 77 kg; body mass index, 30.1 kg/m(2); case 2: male; weight, 92 kg; body mass index, 31.1 kg/m(2)) who underwent elective endocrine surgery. The tumors (one interaortocaval and the other above the iliac artery) were completely excised by laparotomy without postoperative complications.