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Bolouri M, Veras P, Gupta S, Zayats Y, Allam E. Combined paraganglioma and IgG4-related retroperitoneal fibrosis. Radiol Case Rep 2024; 19:3240-3243. [PMID: 38800075 PMCID: PMC11126874 DOI: 10.1016/j.radcr.2024.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/14/2024] [Accepted: 04/20/2024] [Indexed: 05/29/2024] Open
Abstract
A paraganglioma is a neuroendocrine tumor that may secrete catecholamines and present with symptoms of sympathetic overload such as hypertension and diaphoresis. It is important that paragangliomas are identified, as they must often be treated by surgical excision. IgG4-related retroperitoneal fibrosis (IgG4-RPF) is a systemic inflammatory disease that results in the infiltration of IgG4-positive plasma cells in the retroperitoneum. Such fibrosis may adversely affect nearby organs and tissues. Here, we describe a case of combined paraganglioma and IgG4-RPF in a 47-year-old female patient. This case demonstrates the deleterious effect of these two conditions when they occur simultaneously.
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Affiliation(s)
- Maryam Bolouri
- Loyola University Medical Center and Loyola University Chicago, 2160 S First Ave, Maywood, IL 60153, USA
| | - Perry Veras
- Loyola University Medical Center and Loyola University Chicago, 2160 S First Ave, Maywood, IL 60153, USA
| | - Shashank Gupta
- Loyola University Medical Center and Loyola University Chicago, 2160 S First Ave, Maywood, IL 60153, USA
| | - Yuliya Zayats
- Loyola University Medical Center and Loyola University Chicago, 2160 S First Ave, Maywood, IL 60153, USA
| | - Emad Allam
- Loyola University Medical Center and Loyola University Chicago, 2160 S First Ave, Maywood, IL 60153, USA
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2
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Blinova NV, Ilovayskaya IA, Chikhladze NM, Lugovskaya AY, Britvin TA, Gurevich LE, Nefedova LN, Shikina VE, Chazova IE. [Diagnosis and management of patients with pheochromocytoma/paraganglioma: Consensus of experts of the Russian Medical Society for Arterial Hypertension and the Multidisciplinary Group for the Diagnosis and Treatment of Neuroendocrine Tumors]. TERAPEVT ARKH 2024; 96:645-658. [PMID: 39106507 DOI: 10.26442/00403660.2024.07.202779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 07/19/2024] [Indexed: 08/09/2024]
Abstract
The understanding of the nature of catecholamine-secreting tumors has changed significantly in recent years, affecting terminology and classification. Phaeochromocytoma/paraganglioma (PCC/PG) is a rare neuroendocrine tumor from chromaffin tissue that produces and secretes catecholamines. The incidence of PCC/PG is relatively low, with 2-8 cases per 1 million population per year; among patients with arterial hypertension, their prevalence is 0.2-0.6%. However, delayed diagnosis of PCC/PG is associated with a high risk of cardiovascular complications and a high mortality rate. The consensus presents the clinical manifestations of the disease with an emphasis on the course of arterial hypertension as the most common symptom in PCC/PG; modern ideas about the features of diagnosis, aspects of preoperative preparation, treatment, and follow-up of patients with PCC/PG are considered.
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Affiliation(s)
- N V Blinova
- Chazov National Medical Research Center of Cardiology
| | | | | | | | - T A Britvin
- Vladimirsky Moscow Regional Research Clinical Institute
| | - L E Gurevich
- Vladimirsky Moscow Regional Research Clinical Institute
| | | | - V E Shikina
- Vladimirsky Moscow Regional Research Clinical Institute
| | - I E Chazova
- Chazov National Medical Research Center of Cardiology
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3
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Chowdhury R, Moorthy M, Smith L, Mueller CA, Gong F, Rogers HJ, Papoutsaki MV, Syer T, Brembilla G, Singh S, Retter A, Parry T, Clemente J, Caselton L, Jeraj H, Bullock M, Mathew M, Chung TT, Akker S, Chapple P, Salsbury GA, Bainbridge A, Atkinson D, Gadian DG, Srirangalingam U, Punwani S. First-in-human in-vivo depiction of paraganglioma metabolism by hyperpolarised 13C-magnetic resonance. BJR Case Rep 2023; 9:20220089. [PMID: 37928705 PMCID: PMC10621573 DOI: 10.1259/bjrcr.20220089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/31/2023] [Accepted: 08/10/2023] [Indexed: 11/07/2023] Open
Abstract
Phaeochromocytomas (PCC) and paragangliomas (PGL), cumulatively referred to as PPGLs, are neuroendocrine tumours arising from neural crest-derived cells in the sympathetic and parasympathetic nervous systems. Predicting future tumour behaviour and the likelihood of metastatic disease remains problematic as genotype-phenotype correlations are limited, the disease has variable penetrance and, to date, no reliable molecular, cellular or histological markers have emerged. Tumour metabolism quantification can be considered as a method to delineating tumour aggressiveness by utilising hyperpolarised 13 C-MR (HP-MR). The technique may provide an opportunity to non-invasively characterise disease behaviour. Here, we present the first instance of the analysis of PPGL metabolism via HP-MR in a single case.
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Affiliation(s)
- Rafat Chowdhury
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Myuri Moorthy
- Department of Endocrinology, University College London Hospital, London, UK
| | - Lorna Smith
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | | | - Fiona Gong
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Harriet J Rogers
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | | | - Tom Syer
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Giorgio Brembilla
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Saurabh Singh
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Adam Retter
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Thomas Parry
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Joey Clemente
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Lucy Caselton
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Hassan Jeraj
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Max Bullock
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Manju Mathew
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - Teng Teng Chung
- Department of Endocrinology, University College London Hospital, London, UK
| | - Scott Akker
- Department of Endocrinology, St Bartholomew’s Hospital, London, UK
| | - Paul Chapple
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Grace A Salsbury
- Department of Endocrinology, University College London Hospital, London, UK
| | - Alan Bainbridge
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Atkinson
- Centre for Medical Imaging, Division of Medicine, University College London, London, UK
| | - David G Gadian
- UCL Great Ormond Street Institute of Child Health, London, UK
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4
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Ballard S, Le Roux JJ, Wakabayashi K, Labuschagne HC, Jooma Z. The Silent Killer Seeks Young Blood: A Case Report on the Perioperative Anesthetic Management of a Paraganglionoma in Pregnancy. Cureus 2023; 15:e44025. [PMID: 37746444 PMCID: PMC10517734 DOI: 10.7759/cureus.44025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Pheochromocytomas and paraganglionomas are rare neuroendocrine tumors. The multisystem effects of these tumors on the pregnant woman and fetus, the timing of surgery in relation to the pregnancy, and the pharmacological treatment have several anesthetic implications. Case reports on elective cesarean section followed by postpartum resection of the tumor are scarce. A case is presented of a 31-year-old nulliparous female where an antenatal diagnosis of a paraganglionoma was made at 19 weeks gestation for whom an elective cesarean section was performed at 31 weeks gestation under graded lumbar epidural anesthesia, followed by an elective open surgical removal of the tumor six weeks postpartum.
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Affiliation(s)
- Samantha Ballard
- Department of Anesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Johannes J Le Roux
- Department of Anesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Koji Wakabayashi
- Department of Anesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Hendrik C Labuschagne
- Department of Radiology, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Zainub Jooma
- Anesthesia and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
- Department of Anesthesia, University of the Witwatersrand, Johannesburg, Johannesburg, ZAF
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5
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Cao Y, Wang Z, Ren J, Liu W, Da H, Yang X, Bao H. Differentiation of retroperitoneal paragangliomas and schwannomas based on computed tomography radiomics. Sci Rep 2023; 13:9253. [PMID: 37286581 DOI: 10.1038/s41598-023-28297-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/16/2023] [Indexed: 06/09/2023] Open
Abstract
The purpose of this study was to differentiate the retroperitoneal paragangliomas and schwannomas using computed tomography (CT) radiomics. This study included 112 patients from two centers who pathologically confirmed retroperitoneal pheochromocytomas and schwannomas and underwent preoperative CT examinations. Radiomics features of the entire primary tumor were extracted from non-contrast enhancement (NC), arterial phase (AP) and venous phase (VP) CT images. The least absolute shrinkage and selection operator method was used to screen out key radiomics signatures. Radiomics, clinical and clinical-radiomics combined models were built to differentiate the retroperitoneal paragangliomas and schwannomas. Model performance and clinical usefulness were evaluated by receiver operating characteristic curve, calibration curve and decision curve. In addition, we compared the diagnostic accuracy of radiomics, clinical and clinical-radiomics combined models with radiologists for pheochromocytomas and schwannomas in the same set of data. Three NC, 4 AP, and 3 VP radiomics features were retained as the final radiomics signatures for differentiating the paragangliomas and schwannomas. The CT characteristics CT attenuation value of NC and the enhancement magnitude at AP and VP were found to be significantly different statistically (P < 0.05). The NC, AP, VP, Radiomics and clinical models had encouraging discriminative performance. The clinical-radiomics combined model that combined radiomics signatures and clinical characteristics showed excellent performance, with an area under curve (AUC) values were 0.984 (95% CI 0.952-1.000) in the training cohort, 0.955 (95% CI 0.864-1.000) in the internal validation cohort and 0.871 (95% CI 0.710-1.000) in the external validation cohort. The accuracy, sensitivity and specificity were 0.984, 0.970 and 1.000 in the training cohort, 0.960, 1.000 and 0.917 in the internal validation cohort and 0.917, 0.923 and 0.818 in the external validation cohort, respectively. Additionally, AP, VP, Radiomics, clinical and clinical-radiomics combined models had a higher diagnostic accuracy for pheochromocytomas and schwannomas than the two radiologists. Our study demonstrated the CT-based radiomics models has promising performance in differentiating the paragangliomas and schwannomas.
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Affiliation(s)
- Yuntai Cao
- Department of Radiology, Affiliated Hospital of Qinghai University, Tongren Road No.29, Xining, 810001, People's Republic of China.
| | - Zhan Wang
- Department of Biomedical Engineering, Tsinghua University, Beijing, People's Republic of China
| | - Jialiang Ren
- Department of Pharmaceuticals Diagnosis, GE Healthcare, Beijing, People's Republic of China
| | - Wencun Liu
- Department of Radiology, Chongqing Jiulongpo People's Hospital, Chongqing, People's Republic of China
| | - Huiwen Da
- Department of Radiology, Affiliated Hospital of Qinghai University, Tongren Road No.29, Xining, 810001, People's Republic of China
| | - Xiaotong Yang
- Department of Radiology, Affiliated Hospital of Qinghai University, Tongren Road No.29, Xining, 810001, People's Republic of China
| | - Haihua Bao
- Department of Radiology, Affiliated Hospital of Qinghai University, Tongren Road No.29, Xining, 810001, People's Republic of China.
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6
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Stevens CM, Malone K, Wadhwa RD, Rinehouse NA, Saad Aldine A, Sangster G. Paraganglioma in a Young Adult Female Patient: A Case Report. Cureus 2023; 15:e36963. [PMID: 37131552 PMCID: PMC10149090 DOI: 10.7759/cureus.36963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
Abstract
Paragangliomas are catecholamine-secreting neuroendocrine tumors that originate from the chromaffin cells of the sympathetic ganglia. Roughly 10% of paragangliomas are malignant, resulting in a rare occurrence of 90-95 cases per 400 million people. Herein, we report a case of a 29-year-old female patient who presented with nausea, vomiting, and bloating and was found to have a large left retroperitoneal tumor upon imaging. The tumor was successfully removed, and subsequent histological analysis was compatible with the presence of a paraganglioma. This case serves as a reminder that despite its rarity, paragangliomas should never be dismissed as a differential diagnosis if correlating symptoms and diagnostic findings are consistent with that of paraganglioma etiology.
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Lollert A, Miederer M, Russo A, Staatz G. [Pheochromocytoma and paraganglioma during childhood and adolescence]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:1043-1049. [PMID: 35948798 DOI: 10.1007/s00117-022-01048-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pheochromocytoma and paraganglioma belong to the group of rare catecholamine-producing tumours during childhood and adolescence. They occur most frequently in patients with tumour predisposition syndromes. Imaging is essential to assess tumour stage and to plan therapy initiation. OBJECTIVE The aim of this review is a summary of the most important characteristics of the aforementioned tumour entities with a special focus on imaging. In particular, magnetic resonance imaging (MRI) as well as nuclear medicine techniques are presented. MATERIALS AND METHODS Diagnostic methods in patients with pheochromocytoma and paraganglioma are presented based on the literature and own case reports. RESULTS The radiologic modality of choice for the staging of catecholamine-producing tumours during childhood and adolescence is MRI, due to the lack of ionizing radiation and high soft tissue contrast. In addition, 123-I-meta-iodo-benzyl-guanidine (MIBG) scintigraphy and positron emission tomography/computer tomography (PET/CT) are performed. Whole-body MRI is particularly important as a screening tool in patients with a tumour predisposition syndrome. CONCLUSIONS Radiologic imaging and nuclear medicine techniques are important for the assessment of disease stage and therapy planning in patients with catecholamine-producing tumours. Detection of metastatic disease is essential, as there are no known histopathologic markers, which can predict the metastatic potential of the tumours.
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Affiliation(s)
- André Lollert
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Sektion Kinderradiologie, Universitätsmedizin der Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Matthias Miederer
- Klinik und Poliklinik für Nuklearmedizin, Universitätsmedizin der Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Alexandra Russo
- Zentrum für Kinder- und Jugendmedizin, Universitätsmedizin der Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Gundula Staatz
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Sektion Kinderradiologie, Universitätsmedizin der Johannes Gutenberg-Universität, Langenbeckstr. 1, 55131, Mainz, Deutschland
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8
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Hsu YC, Lee CH, Chen CY, Hung CJ. Left adrenal aldosteronism coexisting with left paraaortic paraganglioma presenting as bilateral adrenal and left paraaortic tumors- comprehensive adrenal evaluation aiding perfect management: a case report. BMC Endocr Disord 2022; 22:279. [PMID: 36371163 PMCID: PMC9652807 DOI: 10.1186/s12902-022-01181-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 10/18/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Coexistence of a catecholamine-secreting tumor and an adrenal cortical tumor is quite rare which makes both diagnosis and management challenging. The purpose of this article is to describe the presence of this condition, share a stepwise approach for preoperative evaluation, and review the related literature. CASE PRESENTATION A 44-year-old male patient had a history of hypertension and aggravating hypokalemia for years. Abdominal computed tomography incidentally found concomitant bilateral adrenal and left para-aortic tumors. Comprehensive adrenal hormone tests revealed a high aldosterone renin ratio and mildly elevated 24-h urine vanillylmandelic acid and norepinephrine levels. Subsequently, a metaiodobenzylguanidine scan showed uptake over the left para-aortic tumor, and NP-59 adrenal scintigraphy showed uptake over the left adrenal tumor. Further confirmatory tests, including captopril suppression, irbesartan suppression, and saline infusion, all confirmed the diagnosis of hyperaldosteronism. Adrenal venous sampling following 2 months of preparation with an alpha blocker demonstrated a left aldosterone-producing adrenal adenoma. Combining hormonal analysis, imaging studies, and adrenal venous sampling, the patient was diagnosed with left adrenal aldosteronoma, right adrenal nonfunctional tumor, and left para-aortic paraganglioma (PGL). Accordingly, laparoscopic left adrenalectomy and left PGL excision were performed smoothly under alpha blocker maintenance. The pathology report confirmed left adrenal cortical adenoma and left para-aortic PGL. Postoperatively, the blood pressure, biochemical tests, and adrenal hormone assays returned to normal, and related symptoms disappeared and were relatively stable during the follow-up period of two years. CONCLUSIONS This is the first case of left para-aortic PGL coexisting with an ipsilateral aldosterone-producing adenoma presenting as a left para-aortic tumor associated with bilateral adrenal tumors. Awareness of the rarity of this coexistence can avoid unexpected disasters during the process of evaluation and management.
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Affiliation(s)
- Yu-Chen Hsu
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, Taiwan
| | - Cheng-Han Lee
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, Taiwan
| | - Chen-Yu Chen
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, Taiwan
| | - Chung-Jye Hung
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, Taiwan.
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9
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Shroff GS, Wu CC, Ocazionez D, Carter BW, Shivaprasad A, Chai T, Supsupin EP, Truong MT, Shroff S. It's Not All in Your Head: Thoracic Manifestations of Neurologic Diseases and Disorders. Acad Radiol 2022; 29:736-747. [PMID: 32622741 PMCID: PMC7329291 DOI: 10.1016/j.acra.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/15/2022]
Abstract
Myriad conditions may affect both the neurologic system and the thorax, while other diseases primarily affecting the thorax may manifest with neurologic abnormalities. Correlation of signs, symptoms, and imaging findings in the neurological system with those in the thorax can help diagnose certain conditions and/or guide further diagnostic work-up and treatment. We will review and illustrate the imaging appearance of several systemic/neurological diseases with thoracic manifestations as well as discuss conditions in the thorax that can lead to neurologic symptoms.
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Affiliation(s)
- Girish S Shroff
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX.
| | - Carol C Wu
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Brett W Carter
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Thomas Chai
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
| | | | - Mylene T Truong
- MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1478, Houston, TX
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10
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Qamar Y, Gulzar M, Qamar A, Rasheed N, Syed I. A Carotid Body Tumour Mimicking Richter’s Transformation of Chronic Lymphocytic Leukaemia. Cureus 2022; 14:e24262. [PMID: 35607576 PMCID: PMC9123347 DOI: 10.7759/cureus.24262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 11/05/2022] Open
Abstract
Carotid body tumours (CBT), also called carotid paragangliomas, are highly vascular glomus tumours that originate from paraganglionic cells of the carotid body. They are frequently asymptomatic, insidious, and non-secretory in nature. They typically present as a large, non-tender, pulsatile neck mass. Careful evaluation of a neck mass, with the aid of imaging, is necessary to avoid a misdiagnosis. We herein describe a case of a 77-year-old gentleman with a background of chronic B-cell lymphocytic leukaemia, who was found to have a rapidly enlarging, asymptomatic neck mass along with multiple enlarged lymph nodes in the axillae. Given his past medical history, the preliminary diagnosis was Richter’s transformation. However, the characteristic splaying of the internal and external carotid arteries on imaging prompted us to consider the diagnosis of a CBT. The patient was referred to vascular surgeons for surgical excision of the tumour. Histology confirmed that the neck mass was indeed a CBT. Ultrasound-guided core biopsy of the axillary lymph nodes revealed a concomitant Hodgkin-like Richter’s transformation. This case exemplifies how we were able to differentiate between a CBT and nodal mass with the aid of various imaging modalities. An accurate diagnosis allows clinicians to deliver the appropriate management; the treatment for CBT is surgical excision, whereas chemotherapy is the first-line treatment for Richter’s transformation.
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11
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Rzepka E, Kokoszka J, Grochowska A, Ulatowska-Białas M, Lech M, Opalińska M, Przybylik-Mazurek E, Gilis-Januszewska A, Hubalewska-Dydejczyk A. Adrenal bleeding due to pheochromocytoma - A call for algorithm. Front Endocrinol (Lausanne) 2022; 13:908967. [PMID: 35992110 PMCID: PMC9389316 DOI: 10.3389/fendo.2022.908967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Adrenal hemorrhage is a rare, usually life-threating complication. The most common neoplasm resulting in spontaneous adrenal bleeding is pheochromocytoma and it accounts for nearly 50% of cases. Currently, the recommendations for the diagnosis and management of patients with adrenal bleeding due to pheochromocytoma are unavailable. MATERIALS AND METHODS We performed a database search for all pheochromocytoma patients, diagnosed and treated from 2005 to 2021 in tertiary endocrinology center. 206 patients were identified, 183 with complete data were included in the analysis. We investigated clinicopathological characteristics, treatment and outcomes of hemorrhagic pheochromocytoma cases and characterize our approach to perioperative diagnosis and medical management. Finally our experiences and data from previously published articles concerning adrenal hemorrhage were analyzed to propose a diagnostic and therapeutic algorithm for hemorrhagic pheochromocytomas. RESULTS In the whole group, seven patients (4 men and 3 women) with adrenal bleeding were found, (3.8%). Median patient's age was 49 years (range: 36-78 years). The most common manifestation of adrenal bleeding was acute abdominal pain (5/7). Two patients developed shock. Hormonal assessment was performed in five patients, based on 24-hour urinary fractionated metanephrines with urinary 3-methoxytyramine. Normetanephrine was elevated in all patients, metanephrine and 3-methoxytyramine - in four cases (4/5). Most patients (6/7) had symptoms suggesting pheochromocytoma before hemorrhage - most commonly paroxysmal hypertension (4/7). One patient died, before the diagnosis of adrenal bleeding was made. Diagnostic imaging performed in six out of seven patients revealed adrenal tumor, with median largest diameter equal to 7.4 cm (range: 5-11 cm). Five patients had elective surgery, in one case an urgent surgery was performed. In all cases the diagnosis of pheochromocytoma was confirmed in postoperative histopathology or in autopsy. The perioperative survival rate was 85.7%. CONCLUSIONS Diagnosis of pheochromocytoma should be always considered in patients with adrenal bleeding, especially with accompanying abdominal pain, hemodynamic shock and previous history of pheochromocytoma-associated symptoms. Lack of proper diagnosis of pheochromocytoma before surgery is associated with an additional perioperative risk. To improve the decision making in this life-threatening clinical situation, based on our results and literature data, we proposed a diagnostic and treatment algorithm.
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Affiliation(s)
- Ewelina Rzepka
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Cracow, Poland
| | - Joanna Kokoszka
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Cracow, Poland
| | - Anna Grochowska
- Department of Radiology, University Hospital, Cracow, Poland
| | | | - Martyna Lech
- Department of Pathomorphology, Jagiellonian University Medical College, Cracow, Poland
| | - Marta Opalińska
- Nuclear Medicine Unit, Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Cracow, Poland
| | | | - Aleksandra Gilis-Januszewska
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Cracow, Poland
- *Correspondence: Aleksandra Gilis-Januszewska,
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12
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Badawy M, Gaballah AH, Ganeshan D, Abdelalziz A, Remer EM, Alsabbagh M, Westphalen A, Siddiqui MA, Taffel MT, Itani M, Shaaban AM, Elsayes KM. Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings. Br J Radiol 2021; 94:20210753. [PMID: 34464549 DOI: 10.1259/bjr.20210753] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.
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Affiliation(s)
- Mohamed Badawy
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ayman H Gaballah
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | | | - Amr Abdelalziz
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | - Erick M Remer
- Department of Radiology, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Mustafa Alsabbagh
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | - Antonio Westphalen
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Mohammed A Siddiqui
- Department of Radiology, University of Missouri Health care, Columbia, MO, United States
| | - Myles T Taffel
- Department of Radiology, NYU Langone Medical Center, New York, NY, United States
| | - Malak Itani
- Department of Radiology, University of Washington, Seattle, WA, United States
| | - Akram M Shaaban
- Department of Diagnostic Imaging, University of Utah, Salt Lake City, UT, United States
| | - Khaled M Elsayes
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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13
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Li SJ, Lee J, Hall J, Sutherland TR. The inferior vena cava: anatomical variants and acquired pathologies. Insights Imaging 2021; 12:123. [PMID: 34460015 PMCID: PMC8405820 DOI: 10.1186/s13244-021-01066-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/07/2021] [Indexed: 01/05/2023] Open
Abstract
The inferior vena cava (IVC) is the largest vein in the body, draining blood from the abdomen, pelvis and lower extremities. This pictorial review summarises normal anatomy and embryological development of the IVC. In addition, we highlight a wide range of anatomical variants, acquired pathologies and a common pitfall in imaging of the IVC. This information is essential for clinical decision making and to reduce misdiagnosis.
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Affiliation(s)
- Simon J Li
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - Jean Lee
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jonathan Hall
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Tom R Sutherland
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
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14
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Wei YY, Li Y, Shi YJ, Li XT, Sun YS. Primary extra-pancreatic pancreatic-type acinar cell carcinoma in the right perinephric space: A case report and review of literature. World J Clin Cases 2021; 9:5637-5646. [PMID: 34307619 PMCID: PMC8281426 DOI: 10.12998/wjcc.v9.i20.5637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/30/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Primary extra-pancreatic pancreatic-type acinar cell carcinoma (ACC) is a rare malignancy, and has only been reported in the gastrointestinal tract, liver, and lymph nodes until now. Extra-pancreatic pancreatic-type ACC in the perinephric space has not been reported. Herein, we report the first case of ACC in the perinephric space and describe its clinical and imaging features, which should be considered when differentiating perinephric space neoplasms.
CASE SUMMARY A 48-year-old man with a 5-year history of hypertension was incidentally found to have an asymptomatic right retroperitoneal mass during a routine health check-up. Laboratory tests were normal. Abdominal computed tomography and magnetic resonance imaging showed an oval hypervascular mass with a central scar and enhanced capsule in the right perinephric space. After surgical resection of the neoplasm, the diagnosis was primary extra-pancreatic pancreatic-type ACC. The patient was alive without recurrence or metastasis during a 15-mo follow-up.
CONCLUSION This is the first report of an extra-pancreatic ACC in right perinephric space, which should be considered as a possible diagnosis in perinephric tumors.
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Affiliation(s)
- Yi-Yuan Wei
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ying Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yan-Jie Shi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Xiao-Ting Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Ying-Shi Sun
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Radiology, Peking University Cancer Hospital & Institute, Beijing 100142, China
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15
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Kamada M, Shimamoto A, Mori M, Tsutsui S, Zaizen Y, Fukuda M, Matsumoto K, Nagayasu T, Ashizawa K. Tracheal Paraganglioma: A Case report and Review of the Pertinent Literature. Intern Med 2021; 60:2275-2283. [PMID: 33583885 PMCID: PMC8355390 DOI: 10.2169/internalmedicine.5705-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The trachea is a sporadic origin of paraganglioma. The purpose of the present study was to identify the features of tracheal paraganglioma and reveal the effectiveness of computed tomography (CT) and magnetic resonance imaging (MRI) by reviewing both previous and current cases. In cases of tracheal tumors, we need to consider the bleeding risk associated with a biopsy, as the tumor may be paraganglioma, which is hypervascular. If a biopsy is not available, then CT and MRI can aid in making a pre-operative diagnosis. MRI in particular is useful for long-term observations.
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Affiliation(s)
| | - Aya Shimamoto
- Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Mio Mori
- Department of Clinical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Shin Tsutsui
- Department of Radiology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Yoshiaki Zaizen
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Minoru Fukuda
- Clinical Oncology Center, Nagasaki University Hospital, Japan
| | - Keitaro Matsumoto
- Department of Surgical Oncology, Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kazuto Ashizawa
- Clinical Oncology Center, Nagasaki University Hospital, Japan
- Department of Clinical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Japan
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16
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Landreth S, Bhamidipati C, Muralidaran A, Sauer D, Goldner B, Fuss C. Mediastinal Mass: An Unusual Location for a Paraganglioma. Radiol Cardiothorac Imaging 2021; 3:e210063. [PMID: 34235449 DOI: 10.1148/ryct.2021210063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/16/2021] [Accepted: 04/22/2021] [Indexed: 11/11/2022]
Abstract
A 50-year-old man presented to the hospital for workup of a symptomatic inguinal hernia. At presurgical workup, findings from a contrast material-enhanced CT of the chest, abdomen, and pelvis revealed a large, well-defined and enhancing middle mediastinal mass arising from the right ventricular outflow tract. The mass was ultimately deemed resectable due to preserved fat planes between the mass and other mediastinal structures and the preservation of the right and left coronary arteries. The tumor was diagnosed as a mediastinal paraganglioma at histologic assessment. Keywords: Adults, Angiography, CT-Angiography, MR-Angiography, Cardiac, Neoplasms-Primary ©RSNA, 2021.
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Affiliation(s)
- Scott Landreth
- Department of Diagnostic Radiology (S.L., C.F.), Department of Surgery, Division of Cardiothoracic Surgery (C.B., A.M.), and Department of Pathology (D.S.), Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098; and Department of Radiology, University of California, Davis, Sacramento, Calif (B.G.)
| | - Castigliano Bhamidipati
- Department of Diagnostic Radiology (S.L., C.F.), Department of Surgery, Division of Cardiothoracic Surgery (C.B., A.M.), and Department of Pathology (D.S.), Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098; and Department of Radiology, University of California, Davis, Sacramento, Calif (B.G.)
| | - Ashok Muralidaran
- Department of Diagnostic Radiology (S.L., C.F.), Department of Surgery, Division of Cardiothoracic Surgery (C.B., A.M.), and Department of Pathology (D.S.), Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098; and Department of Radiology, University of California, Davis, Sacramento, Calif (B.G.)
| | - David Sauer
- Department of Diagnostic Radiology (S.L., C.F.), Department of Surgery, Division of Cardiothoracic Surgery (C.B., A.M.), and Department of Pathology (D.S.), Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098; and Department of Radiology, University of California, Davis, Sacramento, Calif (B.G.)
| | - Brian Goldner
- Department of Diagnostic Radiology (S.L., C.F.), Department of Surgery, Division of Cardiothoracic Surgery (C.B., A.M.), and Department of Pathology (D.S.), Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098; and Department of Radiology, University of California, Davis, Sacramento, Calif (B.G.)
| | - Cristina Fuss
- Department of Diagnostic Radiology (S.L., C.F.), Department of Surgery, Division of Cardiothoracic Surgery (C.B., A.M.), and Department of Pathology (D.S.), Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098; and Department of Radiology, University of California, Davis, Sacramento, Calif (B.G.)
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17
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Zhang Z, Tu Z, Lv Z, Luo Y, Yuan J. Case Report: Totally Laparoscopic Resection of Retroperitoneal Paraganglioma Masquerading as a Duodenal Gastrointestinal Stromal Tumor. Front Surg 2021; 8:586503. [PMID: 33768109 PMCID: PMC7985177 DOI: 10.3389/fsurg.2021.586503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/04/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Retroperitoneal paraganglioma (RPGL) is a rare clinical tumor derived from the retroperitoneal sympathetic paraganglion tissue. Since RPGLs are locate deeply and have no specific symptoms and imaging manifestations at the early stage, which easily causes missed diagnosis or misdiagnosis. In addition, reports on totally laparoscopic resection of RPGLs are scarce due to their close proximity to large vessels, giant size, uncertain location, and unknown malignant status. Case Presentation: We present here the case of totally laparoscopic resection of a 6.4 × 5.4 cm RPGL that was discovered during a workup for discomfort and upper abdominal pain in a 68-year-old female patient, mimicking a gastrointestinal stromal tumor (GIST) of the duodenum, Which was confirmed as a RPGL based on the histopathological and immunohistochemical findings. Conclusions: RPGL is a rare tumor, and the transperitoneal laparoscopic approach for the RPGL is a safe, applicable method with less trauma and quick recovery, which is worth clinical popularizing and application. Moreover, the survival prognosis of RPGL patients are related to metastasis, and lifelong follow-up should be emphasized.
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Affiliation(s)
- Zhi Zhang
- Department of General Surgery, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Zhengbin Tu
- Department of General Surgery, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Zhiqiang Lv
- Department of General Surgery, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Yang Luo
- Department of General Surgery, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
| | - Jianmao Yuan
- Department of General Surgery, Suzhou Ninth People's Hospital, Affiliated Wujiang Hospital of Nantong University, Suzhou, China
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18
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From Diagnosis to Therapy-PET Imaging for Pheochromocytomas and Paragangliomas. Curr Urol Rep 2021; 22:2. [PMID: 33403502 DOI: 10.1007/s11934-020-01021-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Pheochromocytoma and paraganglioma (PPGLs) are neuroendocrine tumors with diverse clinical presentations. PPGLs can be sporadic but often are associated with various syndromes, which can have variable clinical presentations. A thorough workup is therefore critical for staging, treatment, and follow-up. Imaging is an essential part of the workup and diagnosis of PPGLs. RECENT FINDINGS Improvements in cross-sectional imaging with radionuclides have increased specificity and sensitivity for identifying and treating PPGLs. Furthermore, a variety of targets on PPGLs has allowed for optimal imaging with radionuclides that can be used for staging and treatment. Currently, radionuclides are being evaluated for staging and treatment of PPGLs. Developing novel radionuclides that can identify disease sites and target them simultaneously provides a potential for improving survival and outcomes in patients with PPGLs. Given the clinical diversity among PPGLs, expanding the therapeutic arsenal against locally advanced or metastatic PPGLs can allow clinicians to evaluate and treat PPGLs thoroughly.
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19
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Magnelli L, Pierre K, Sharma P. Tumors presenting in both pediatric and adult patients: a case-based review of pathology and imaging features for the radiologist. Abdom Radiol (NY) 2020; 45:3831-3837. [PMID: 32322909 DOI: 10.1007/s00261-020-02541-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Various pathologic neoplasms present in both childhood and adulthood. Multiple environmental and genetic factors with different targets at different ages have been implicated in prior literature. These tumors include Multi-Locular Cystic Renal Tumors (MCRT), Adrenocortical Carcinomas, Paragangliomas, Hepatic Hemangiomas, and Medullary Renal Cell Carcinomas. The pertinent imaging, pathological, and clinical features of these select entities are discussed to assist the General and Pediatric Radiologist in accurate interpretation and treatment planning.
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Affiliation(s)
- Laura Magnelli
- Divisions of Pediatric and Abdominal Imaging, Department of Radiology, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100374, Gainesville, FL, 32608-0374, USA
- University of Florida Department of Radiology, Gainesville, FL, USA
| | - Kevin Pierre
- Divisions of Pediatric and Abdominal Imaging, Department of Radiology, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100374, Gainesville, FL, 32608-0374, USA
| | - Priya Sharma
- Divisions of Pediatric and Abdominal Imaging, Department of Radiology, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100374, Gainesville, FL, 32608-0374, USA.
- University of Florida Department of Radiology, Gainesville, FL, USA.
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20
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Patel D, Phay JE, Yen TWF, Dickson PV, Wang TS, Garcia R, Yang AD, Solórzano CC, Kim LT. Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine/Head and Neck Disease-Site Work Group. Part 1 of 2: Advances in Pathogenesis and Diagnosis of Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2020; 27:1329-1337. [PMID: 32112212 PMCID: PMC8655649 DOI: 10.1245/s10434-020-08220-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 08/02/2023]
Abstract
This first part of a two-part review of pheochromocytoma and paragangliomas (PPGLs) addresses clinical presentation, diagnosis, management, treatment, and outcomes. In this first part, the epidemiology, prevalence, genetic etiology, clinical presentation, and biochemical and radiologic workup are discussed. In particular, recent advances in the genetics underlying PPGLs and the recommendation for genetic testing of all patients with PPGL are emphasized. Finally, the newer imaging methods for evaluating of PPGLs are discussed and highlighted.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Roberto Garcia
- Division of Surgical Oncology, National Cancer Institute of Panama/Paitilla Medical Center, Panama City, Panama
| | - Anthony D Yang
- Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
| | - Lawrence T Kim
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC, USA
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21
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Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors that secrete excess catecholamines leading to secondary hypertension and cardiovascular morbidity. Once biochemical testing with either 24-hour urinary fractioned metanephrines or plasma free metanephrines confirms the diagnosis, patients are optimized with adequate hydration to maintain their intravascular volume and the appropriate antihypertensive medications are initiated for optimal blood pressure control. Genetic testing and imaging is performed to determine the extent of adrenalectomy and the optimal surgical approach. Surgical approaches include transabdominal or retroperitoneal minimally invasive approaches, and transabdominal open approaches. Factors that influence the surgical approach include germline genetic test results, the size of the tumor, body mass index, surgeon experience, and the likelihood of malignancy. The extent of adrenalectomy is based on germline genetic findings. Patients with syndromes such as von Hippel Lindau (VHL) or multiple endocrine neoplasia 2 (MEN 2) benefit from cortical-sparing adrenalectomy to avoid chronic steroid replacement and the risk of Addisonian crisis. Postoperative management includes hemodynamic monitoring and assessment for signs of hypoglycemia. Outcomes after surgery show improved blood pressure control in most patients and normalization of blood pressure in about a third of patients. Long-term follow-up is required for all patients to assess for recurrence.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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22
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Wang B, Qiu J. Progress in the diagnosis and treatment of paraganglioma. Transl Cancer Res 2019; 8:2624-2635. [PMID: 35117020 PMCID: PMC8797373 DOI: 10.21037/tcr.2019.10.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/24/2019] [Indexed: 11/09/2022]
Abstract
Neuroendocrine tumors derived from the adrenal medulla and the adrenal gland are called pheochromocytoma (PHEO) and paraganglioma (PGL), respectively. PGLs are neuroepithelial cell clusters associated with sympathetic or parasympathetic nerves, and are scattered throughout the body. According to the World Health Organization, the presence of distant metastases indicates malignant PGL. Most PGLs are benign, but their high secretion of catecholamines in the blood is associated with high blood pressure, cardiovascular disease, and death. Further research on PGL is required to provide a theoretical basis for clinical diagnosis and treatment. This article reviews the genetics, clinical manifestations, benign and malignant forms, current major diagnostic methods, and progress in the treatment of PGL.
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Affiliation(s)
- Ben Wang
- Xi’an Medical University, Xi’an 710068, China
| | - Jian Qiu
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, China
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23
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Lin CS, Hsu YH. A primary paraganglioma of the liver mimicking hepatocellular carcinoma. Tzu Chi Med J 2019; 31:286-288. [PMID: 31867261 PMCID: PMC6905243 DOI: 10.4103/tcmj.tcmj_230_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/02/2018] [Accepted: 11/27/2018] [Indexed: 11/09/2022] Open
Abstract
Paragangliomas occurring primarily in the liver parenchyma are extremely rare. The radiological features mimic hepatocellular carcinoma. Herein, we describe a case with a presurgical diagnosis of hepatocellular carcinoma, which was pathologically confirmed as hepatic paraganglioma after surgery. A 41-year-old woman visited our hospital for evaluation of a hepatic mass detected incidentally in a health examination 7 years previously. Triple-phase computed tomography of the liver showed a homogeneous and strongly arterial enhancing mass, followed by portovenous washout at the posterior segment of the right lobe. In view of the enhancement pattern and highly vascular nature, the hepatocellular carcinoma was included in the differential diagnosis. Anatomical resection of segment VII was carried out. Grossly, the mass was encapsulated and soft. Microscopically, it had a typical “Zellballen pattern.” Immunohistochemical staining for CD56 was positive, and sustentacular cells at the periphery of the tumor cell nests were also demonstrated by S-100 protein. Therefore, the diagnosis of primary paraganglioma of the liver was confirmed. In conclusion, hepatic paraganglioma should be considered in the differential diagnosis in cases of hepatic masses displaying “early enhancement, early washout.”
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Affiliation(s)
| | - Yung-Hsiang Hsu
- Department of Pathology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
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24
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Zongo N, Koama A, Kambou/Tiemtoré BMA, Nde/Ouédraogo NA, Zida M, Ouédraogo MNL, Ouangré E, Sanou A, Lompo OM, Diallo O, Lougué/Sorgho C, Cissé R. Ectopic pheochromocytoma or paraganglioma of the ZUCKERKANDL organ: A case report and review of the literature. Int J Surg Case Rep 2019; 60:120-122. [PMID: 31220678 PMCID: PMC6584908 DOI: 10.1016/j.ijscr.2019.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/01/2019] [Accepted: 06/07/2019] [Indexed: 12/02/2022] Open
Abstract
EPIDEMIOLOGY: paraganglioma of the ZUCKERKANDL organ is a rare neuroendocrine tumour but must be known. DIAGNOSIS: The typical presentation which is the Menard Triad of symptoms, associating headaches, sweating and palpitation. Preoperative diagnosis can be difficult in pauci-symptomatic cases. The Clinical signs, Abdominal-pelvic CT scan and biology are the steps of the preoperative diagnosis. TREATMENT: Treatment is surgical. Preoperative medical preparation is aimed at reducing risks of peroperative hemodynamic instability. The anesthetist should therefore prepare himself to manage blood pressure peaks during the tumour’s dissection, but also the possible low blood pressure at the end of exeresis. Surgery remains the key element of treatment and consists in exeresis of the paragaglioma. PROGNOSIS: paraganglioma of the ZUCKERKANDL organ is often a benign tumor. The resuscitation determines the patient’s prognosis.
Introduction Paraganglioma of the ZUCKERKANDL organ are rare. Diagnosis is based on clinical, radiological and biological arguments. We report a case to describe our surgical procedure and insist on the necessity of preoperative diagnosis. Presentation of case BA, 52-years-old male patient was seen in consultation for left hypochondrium pains. The clinical examination had revealed a painful tumefaction in the left flank and the left hypochondrium. A deep mass was observed, but was difficult to be assessed, due to pain. Abdominal-pelvic CT scan with contrast injection had revealed a tissue mass, suggesting a tumor of the tail of the pancreas. Laparotomy showed this mass was not attached to the tail of the pancreas, and was along the abdominal aorta up to the aortic bifurcation. Upon touching the mass, blood pressure raised up to 240 mmHg. A least mobilization of the mass and the use of nicardipine helped maintain blood pressure below 180mmhg. Dissection was carried out from the aortic bifurcation to the TREITZ’s angle and the mass was removed. The follow-ups were characterized by low blood pressure a few minutes following the resection of the mass. Discussion Pheochromocytoma is rare. The Clinical signs, Abdominal-pelvic CT scan and biology are the steps of the preoperative diagnosis. The surgery consists a lumpectomy. The resuscitation determines the patient’s prognosis. Conclusion Pheochromocytoma is an unusual mass. Preoperative diagnosis can be difficult in pauci-symptomatic cases. One should consider this in the face of any abdominal mass, so as to improve planning of resuscitation which determines the patient’s prognosis.
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Affiliation(s)
- Nayi Zongo
- Visceral Surgery at Yalgado Ouedraogo University Hospital Centre (CHUYO), Burkina Faso.
| | - Adjirata Koama
- Radiology and Medical Imaging Department, University Hospital Centre (CHU) of Bogodogo, Ouagadougou, Burkina Faso.
| | | | - Nina A Nde/Ouédraogo
- Radiology and Medical Imaging Department, University Hospital Centre (CHU) of Bogodogo, Ouagadougou, Burkina Faso.
| | - Maurice Zida
- Visceral Surgery at Yalgado Ouedraogo University Hospital Centre (CHUYO), Burkina Faso.
| | - Marie N L Ouédraogo
- Visceral Surgery at Yalgado Ouedraogo University Hospital Centre (CHUYO), Burkina Faso.
| | - Edgard Ouangré
- Visceral Surgery at Yalgado Ouedraogo University Hospital Centre (CHUYO), Burkina Faso.
| | - Adama Sanou
- Visceral Surgery at Blaise Compaoré National Hospital (HNBC), Burkina Faso.
| | | | - Ousséni Diallo
- Souro Sanou University Hospital Centre of Bobo Dioulasso (CHU SS), Burkina Faso; Radiology and Medical Imaging Department, University Hospital Centre (CHU) of Yalgado, Ouagadougou, Burkina Faso.
| | - Claudine Lougué/Sorgho
- Souro Sanou University Hospital Centre of Bobo Dioulasso (CHU SS), Burkina Faso; Radiology and Medical Imaging Department, University Hospital Centre (CHU) of Yalgado, Ouagadougou, Burkina Faso.
| | - Rabiou Cissé
- Souro Sanou University Hospital Centre of Bobo Dioulasso (CHU SS), Burkina Faso; Radiology and Medical Imaging Department, University Hospital Centre (CHU) of Yalgado, Ouagadougou, Burkina Faso.
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25
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Arıkan AA. Ruptured Abdominal Aortic Aneurysm with a Suprarenal Tumor. Braz J Cardiovasc Surg 2019; 33:522-524. [PMID: 30517262 PMCID: PMC6257529 DOI: 10.21470/1678-9741-2017-0166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/18/2017] [Indexed: 12/13/2022] Open
Abstract
This paper presents a case study of a patient that underwent surgery for a
ruptured abdominal aneurysm. The postoperative course was complicated by
resistant hypertension and tachycardia. A suprarenal mass was detected in the
computed tomography scan with radiological suspicion of pheochromocytoma. Few
cases of pheochromocytoma coexisting with aneurysms have been reported.
Management of cardiovascular stability is crucial in such cases. Despite the
lack of evidence, pheochromocytomas might have a role in the etiology of aortic
aneurysms.
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Affiliation(s)
- Ali Ahmet Arıkan
- Department of Cardiovascular Surgery, Muş State Hospital, Muş, Turkey
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Parmar K, Chandna A, Kumar S. Retroperitoneal paraganglioma: a chameleon masquerading as an adrenal pheochromocytoma. Ann R Coll Surg Engl 2018; 101:e62-e65. [PMID: 30371110 DOI: 10.1308/rcsann.2018.0193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Retroperitoneal paragangliomas are rare tumours arising from neural crest cells located near or in the autonomic nervous system; right from the skull bass to the pelvic floor. Often called the great masqueraders, their diagnosis and treatment is often difficult and fraught with danger, considering the close proximity of these tumours to important retroperitoneal organs. A 29-year-old woman presented to the outpatient department with complaints of paroxysms of headache, sweating and palpitations for one year. She was found to have elevated urinary metadrenalines (metanephrines) and a suprarenal mass on contrast-enhanced computed tomography of the abdomen, which demonstrated increased tracer activity on I-131 iodine-123 meta-iodobenzylguanidine scintigraphy. Adrenal pheochromocytoma was diagnosed and she underwent laparoscopic adrenalectomy after stabilisation of her blood pressure. Laparoscopy revealed a large suprarenal mass with dense adhesions to the inferior vena cava that was carefully separated from the vein and surrounding structures. The cut section revealed a heterogeneous mass encasing a normal adrenal gland and histopathology confirmed the same, confirming the final diagnosis of retroperitoneal paraganglioma.
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Affiliation(s)
- K Parmar
- Post Graduate Institute of Medical Education and Research, Advanced Urology Centre Nehru Hospital, Pgimer , Chandigarh , India
| | - A Chandna
- Post Graduate Institute of Medical Education and Research, Advanced Urology Centre Nehru Hospital, Pgimer , Chandigarh , India
| | - S Kumar
- Post Graduate Institute of Medical Education and Research, Advanced Urology Centre Nehru Hospital, Pgimer , Chandigarh , India
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Drenthen LCA, Roerink SHPP, Mattijssen V, de Boer H. Bilaterally enlarged adrenal glands without obvious cause: need for a multidisciplinary diagnostic work-up. Clin Case Rep 2018; 6:729-734. [PMID: 29636949 PMCID: PMC5889220 DOI: 10.1002/ccr3.1340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/21/2017] [Accepted: 11/28/2017] [Indexed: 12/28/2022] Open
Abstract
Bilateral enlarged adrenal glands are rare, and as diagnostic delay may have serious consequences for the patient, we recommend a multidisciplinary approach of specialists in the field of endocrinology, oncology, radiology, and clinical chemistry prior to the start of the diagnostic work‐up.
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Affiliation(s)
- Linda C A Drenthen
- Department of Internal Medicine Rijnstate Hospital Arnhem the Netherlands
| | - Sean H P P Roerink
- Department of Internal Medicine Rijnstate Hospital Arnhem the Netherlands
| | - Vera Mattijssen
- Department of Internal Medicine Rijnstate Hospital Arnhem the Netherlands
| | - Hans de Boer
- Department of Internal Medicine Rijnstate Hospital Arnhem the Netherlands
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Hu H, Huang B, Zhao J, Yuan D, Yang Y, Xiong F. En Bloc Resection with Major Blood Vessel Reconstruction for Locally Invasive Retroperitoneal Paragangliomas: A 15-Year Experience with Literature Review. World J Surg 2017; 41:997-1004. [PMID: 27896404 DOI: 10.1007/s00268-016-3846-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Retroperitoneal paragangliomas (PGs) are a rare subgroup of neuroendocrine tumors that are commonly located alongside the abdominal aorta. Complete tumor resection is thought to be restricted in patients with major blood vessel involvement. However, no study has specifically focused on aggressive surgical treatment in such patients. We evaluated the value of en bloc resection with major blood vessel reconstruction for locally invasive retroperitoneal PGs. METHODS Twenty-nine patients with retroperitoneal PGs with major blood vessel involvement were included in this retrospective study. Survival was compared between patients who underwent en bloc resection with major blood vessel reconstruction and those who underwent medical treatment. Prognostic predictors were analyzed in patients who underwent en bloc resection with major blood vessel reconstruction. RESULTS All 11 patients who underwent medical treatment obtained a pathological diagnosis by computed tomography-guided percutaneous needle biopsy. All 18 patients who underwent en bloc resection with major blood vessel reconstruction achieved complete tumor resection. Overall survival was higher in patients who underwent complete tumor resection than in those who underwent medical treatment (p < 0.05). No perioperative mortality occurred in patients who underwent complete tumor resection. Patients with no metastasis, no organ invasion, R0 resection, a Ki-67 index of ≤3%, and a tumor diameter of ≤11.7 cm showed better tumor-free survival (p < 0.05). CONCLUSIONS En bloc resection with major blood vessel reconstruction can be successfully performed and provide satisfactory outcomes for patients with locally invasive retroperitoneal PGs. This technique may become a standard surgical strategy for properly selected patients.
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Affiliation(s)
- Hankui Hu
- Department of Vascular Surgery, West China Hospital of Sichuan University, Guoxue Road No. 37, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Guoxue Road No. 37, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital of Sichuan University, Guoxue Road No. 37, Wuhou District, Chengdu, 610041, Sichuan Province, China.
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital of Sichuan University, Guoxue Road No. 37, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Guoxue Road No. 37, Wuhou District, Chengdu, 610041, Sichuan Province, China
| | - Fei Xiong
- Department of Vascular Surgery, West China Hospital of Sichuan University, Guoxue Road No. 37, Wuhou District, Chengdu, 610041, Sichuan Province, China
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Abstract
PURPOSE OF REVIEW The purpose of this manuscript is to review the progress in the field of therapeutics for malignant pheochromocytomas and sympathetic paraganglioma (MPPG) over the past 5 years. RECENT FINDINGS The manuscript will describe the clinical predictors of survivorship and their influence on the first TNM staging classification for pheochromocytomas and sympathetic paragangliomas, the treatment of hormonal complications, and the rationale that supports the resection of the primary tumor and metastases in patients with otherwise incurable disease. Therapeutic options for patients with bone metastasis to the spine will be presented. The manuscript will also review chemotherapy and propose a maintenance regimen with dacarbazine for patients initially treated with cyclophosphamide, vincristine, and dacarbazine. Finally, the manuscript will review preliminary results of several phase 2 clinical trials of novel radiopharmaceutical agents and tyrosine kinase inhibitors. MPPGs are very rare neuroendocrine tumors. MPPGs are usually characterized by a large tumor burden, excessive secretion of catecholamines, and decreased overall survival. Recent discoveries have enhanced our knowledge of the pathogenesis and phenotypes of MPPG. This knowledge is leading to a better understanding of the indications and limitations of the currently available localized and systemic therapies as well as the development of phase 2 clinical trials for novel medications.
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Ji XK, Zheng XW, Wu XL, Yu ZP, Shan YF, Zhang QY, Zeng QQ. Diagnosis and surgical treatment of retroperitoneal paraganglioma: A single-institution experience of 34 cases. Oncol Lett 2017; 14:2268-2280. [PMID: 28789448 PMCID: PMC5530091 DOI: 10.3892/ol.2017.6468] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 04/21/2017] [Indexed: 12/30/2022] Open
Abstract
The present study aimed at identifying the clinical, radiological and pathological characteristics of retroperitoneal paragangliomas, and determining the association between the tumor features and the prognosis of patients following surgery. A total of 34 patients with retroperitoneal paragangliomas, who underwent resection between November 1999 and December 2015, were included in the present retrospective study. The patients' demographics, clinical symptoms and signs, tumor functional status, surgical procedure, intraoperative results, tumor pathology, radiological results, and postoperative survival time were recorded and analyzed. Of the 34 patients, the most common type of presenting symptom was abdominal mass (46%), followed by hypertension (39%) and abdominal pain (32%). Functional tumors occurred in 20 patients (59%). Computed tomography (CT) and magnetic resonance imaging revealed soft-tissue masses, with marked enhancement in the arterial phase, indicative of retroperitoneal paragangliomas. The preoperative CT diagnostic accuracy rate between 2010 and 2015 was markedly improved, compared with that between 1999 and 2009. The tumors were primarily located close to the renal arteries and veins surrounding the abdominal aorta and inferior vena cava. With the exception of one malignant paraganglioma, the majority of paragangliomas were positive for chromogranin A, S-100 protein, vimentin and heat-shock protein 90, and exhibited decreased expression of Ki-67 antigen and insulin-like growth factor 2. All tumors were completely removed by surgery. Distant metastasis, but not tumor size, functional status and local invasion, was markedly associated with survival. The preoperative diagnostic accuracy rate of retroperitoneal paragangliomas may be improved by focusing on the predilection sites and CT characteristics. In addition, immunohistochemical markers were useful to determine tumor malignancy. Complete surgical resection was appropriate for all patients and postoperative survival time was identified to be associated with tumor metastasis.
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Affiliation(s)
- Xiao-Ke Ji
- Department of General Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Xiang-Wu Zheng
- Radiological Department, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Xiu-Lin Wu
- Department of Pathology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Zheng-Ping Yu
- Department of General Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Yun-Feng Shan
- Department of General Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Qi-Yu Zhang
- Department of General Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
| | - Qi-Qiang Zeng
- Department of General Surgery, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, P.R. China
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31
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Ramachandran R, Rewari V. Factors affecting the haemodynamic behaviour of patients undergoing pheochromocytoma and paraganglioma removal: A review. Cardiovasc Endocrinol 2017; 6:73-80. [PMID: 31646123 PMCID: PMC6768518 DOI: 10.1097/xce.0000000000000090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/24/2016] [Indexed: 12/19/2022] Open
Abstract
Pheochromocytoma and paraganglioma are catecholamine-secreting tumours associated with major haemodynamic upheavals. The cardiovascular and other organ-related morbidity and even mortality has been ascribed to the major haemodynamic effects of these tumours. Many factors affect the nature and intensity of these haemodynamic changes. The rarity of these tumours as well as their extremely varied clinical presentation preclude conduct of randomized-controlled trials that may provide evidence in terms of these factors and the ways to predict and control them. Many retrospective studies and case reports, however, do provide some insight into their haemodynamic behaviour. Factors such as tumour pathology, associated genetic syndromes, anatomical attributes and perioperative drug therapy affect the haemodynamics of patients with these unique tumours. Knowledge of these factors and their presumed and known association with haemodynamic behaviour of the patients is important during the perioperative care of these patients. The review focuses on the tumour-related, patient-related and the perioperative care-related factors that affect the haemodynamic behaviour of these patients during the surgical removal of these tumours.
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Affiliation(s)
- Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, Delhi, India
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, Delhi, India
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32
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Abstract
Neuroendocrine tumors which have the potential to secrete catecholamines are either associated with sympathetic adrenal (pheochromocytoma) or nonadrenal (paraganglioma) tissue. Surgical removal of these tumors is always indicated to cure and prevent cardiovascular and other organ system complications associated with catecholamine excess. Some of these tumors have malignant potential as well. The diagnosis, localization and anatomical delineation of these tumors involve measurement of catecholamines and their metabolic end products in plasma and urine, 123I-metaiodobenzylguanidine scintigraphy, computed tomography, and/or magnetic resonance imaging. Before surgical removal of the tumors, the optimization of blood pressure, as well as intravascular volume, is an important measure to avoid and suppress perioperative adverse hemodynamic events. Preoperative preparation includes the use of alpha-adrenergic antagonists, beta-adrenergic antagonists with or without other antihypertensive agents, fluid therapy as well as insulin therapy for hyperglycemia if required. Due attention should be given to type and dose of alpha-receptor antagonists to be used and the duration of this therapy to achieve an optimal level of preoperative "alpha-blockade." Despite this preoperative preparation, many patients will have hypertensive crises intraoperatively which need to be promptly and carefully managed by the anesthesia team which requires intensive and advanced monitoring techniques. The most common complication after tumor removal is hypotension which may require fluid therapy and vasopressor support for a few hours. With advancement in surgical and anesthetic techniques, the incidence of severe morbidity and mortality associated with the surgery is low in high volume centers.
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Affiliation(s)
- Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Nicholas RS, Quddus A, Topham C, Baker D. Resection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat. BMJ Case Rep 2015; 2015:bcr-2014-208271. [PMID: 25883251 DOI: 10.1136/bcr-2014-208271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 39-year-old man was referred to the vascular surgeons with a right-sided cervical mass, palpitations, headaches and sweating. He had presented with abdominal discomfort 12 months earlier. Investigations had revealed a gastrointestinal stromal tumour (GIST) and left adrenalectomy. CT of the neck with contrast demonstrated a large right carotid paraganglioma, extending superiorly from below the carotid bifurcation to encase the internal carotid artery. Genetic screening confirmed the diagnosis of Carney-Stratakis syndrome, an SDH-D germline mutation leading to GIST and multifocal paragangliomas. Successful surgical excision required considerable multidisciplinary teamwork between neuroendocrinologists, anaesthetists and surgeons. The tumour was highly vascular and involved the right carotid body, hypoglossal and vagus nerves. Access was challenging and maxillofacial surgical expertise were required for division of the mandible. The patient made a good recovery following speech and swallowing rehabilitation.
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Affiliation(s)
| | - Ayyaz Quddus
- Department of Vascular Surgery, Royal Free Hospital, London, UK
| | | | - Daryll Baker
- Department of Vascular Surgery, Royal Free Hospital, London, UK
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34
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Carr JC, Spanheimer PM, Rajput M, Dahdaleh FS, Lal G, Weigel RJ, Sugg SL, Liao J, Howe JR. Discriminating pheochromocytomas from other adrenal lesions: the dilemma of elevated catecholamines. Ann Surg Oncol 2013; 20:3855-61. [PMID: 23884753 DOI: 10.1245/s10434-013-3142-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Screening tests for pheochromocytoma involve measuring levels of catecholamines in the urine or plasma, which have significant false-positive rates. We reviewed patients with adrenal masses and elevated levels of catecholamines to determine the value of different preoperative tests in diagnosing pheochromocytomas. METHODS A retrospective chart review identified patients who underwent adrenalectomy between 1997 and 2011 with elevation of urine or serum catecholamines. A database of clinicopathologic factors was created including preoperative urine and plasma metanephrines, normetanephrines, vanillylmandelic acid, and fractionated catecholamines, and tumor dimensions on imaging and pathology. RESULTS A total of 70 patients underwent adrenalectomy because of presence of an adrenal mass and elevation of catecholamines or normetanephrines or metanephrines. Of these, 46 had pathologically confirmed pheochromocytomas. To improve our ability to discriminate between pheochromocytoma and other pathology, we examined different combinations of clinicopathologic factors and catecholamine levels and found the best test was a scoring system. Points are awarded for a hierarchy of elevated normetanephrine, norepinephrine, metanephrines, with additional points received for age <50 and size on imaging >3.3 cm. A score of 2 is suggestive of pheochromocytoma, with a positive predictive value of 86-87%, while a score of 4 is diagnostic with positive predictive value of 100%. CONCLUSION We found that urine/serum normetanephrine levels were the most valuable screening tool; however, a score examining the size of adrenal mass on preoperative CT, age, and either plasma or urine norepinephrine, metanephrine, and normetanephrine values leads to a higher positive predictive value, making this scoring system superior to individual lab tests.
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Affiliation(s)
- Jennifer C Carr
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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35
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Pichler R, Heidegger I, Klinglmair G, Kroiss A, Uprimny C, Gasser RW, Schäfer G, Steiner H. Unrecognized paraganglioma of the urinary bladder as a cause for basilar-type migraine. Urol Int 2013; 92:482-7. [PMID: 23735539 DOI: 10.1159/000348829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 01/25/2013] [Indexed: 11/19/2022]
Abstract
Extra-adrenal paraganglioma with isolated localization in the urinary bladder is a rare neuroendocrine tumor. Although the typical symptoms like headache, nausea, weight loss, flushing, heart palpitation or paroxysmal hypertension during micturition are well established, we present an unusual case of bladder paraganglioma, 'misdiagnosed' with basilar-type migraine due to headache for the past 8 years. As urologists linked the presence of a tumor (by CT) and symptoms connected with micturition, no cystoscopy and no transurethral resection of the bladder was performed prior to detailed diagnostic workup. After diagnosis of an extra-adrenal paraganglioma, the patient was scheduled for open partial cystectomy. In consideration of the fact that bladder paraganglioma is an infrequent genitourinary cancer, this case report clearly points out the importance of an exact anamnesis and clinical examination to minimize the probability of misdiagnosis with possible fatal consequences in any case with clinical suspicion of bladder paraganglioma.
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Affiliation(s)
- Renate Pichler
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria
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36
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Han EJ, Lee SH, Song IU, Chung YA, Maeng LS. Simultaneous adrenal pheochromocytoma and carotid body paraganglioma in a woman. Nucl Med Mol Imaging 2012; 47:67-8. [PMID: 24895513 DOI: 10.1007/s13139-012-0179-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 08/21/2012] [Accepted: 10/02/2012] [Indexed: 12/21/2022] Open
Affiliation(s)
- Eun Ji Han
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sang-Hoon Lee
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - In Uk Song
- Department of Neurology, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Yong-An Chung
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 665 Bupyeong-dong, Bupyeong-gu, Incheon, South Korea 403-720
| | - Lee-So Maeng
- Department of Clinicopathology, College of Medicine, The Catholic University of Korea, Incheon, South Korea
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