Primary retroperitoneal paraganglioma simulating a pancreatic mass: a case report and review of the literature. HPB Surg. 2010;2010:645728. [PMID: 21188160 PMCID: PMC3004405 DOI: 10.1155/2010/645728]

Visual analytics identifies key miRNAs for differentiating peripancreatic paraganglioma and pancreatic neuroendocrine tumors

Introduction

Paragangliomas (PGL), a type of neuroendocrine tumor, pose a significant diagnostic challenge due to their potential for unpredictable locations and asymptomatic presentation. Misdiagnosis of peripancreatic PGLs, particularly as pancreatic neuroendocrine tumors (PANNETs), is a pressing issue as it can negatively impact both pre- and post-treatment decision-making. The aim of our study was to identify microRNA markers for the reliable differential diagnosis of peripancreatic PGLs and PANNETs, addressing a crucial unmet need in the field and advancing the standard of care for these patients.

Methods

Morphing projections tool was used to analyze miRNA data from PGL and PANNET tumors present in the TCGA database. The findings were validated using two additional databases: GSE29742 and GSE73367.

Results

Our research uncovered substantial differences in the miRNA expression profiles of PGL and PANNET, leading to the identification of 6 key miRNAs (miR-10b-3p, miR-10b-5p, and the miRNA families miR-200c/141 and miR-194/192) that can effectively differentiate between the two types of tumors.

Discussion

These miRNA levels hold potential as biomarkers for improved diagnosis, offering a solution to the diagnostic challenge posed by these tumors and potentially improving the standard of care for patients.

Primary non-functional pancreatic paraganglioma: A case report and review of the literature

Primary pancreatic paragangliomas are rare. They are mainly non-functional tumours that lack typical clinical manifestations. Definite diagnosis relies on histopathology and immunohistochemistry, and the main treatment is surgery. We report here a case of primary, non-functional, pancreatic paraganglioma in a 49-year-old woman. The tumour was approximately 5.0 × 3.2 ×4.7 cm in size and located in the pancreatic neck and body. We undertook 3D laparoscopic complete resection of the tumour. The patient developed a pancreatic fistula (biochemical leak) post-surgery, but she recovered and was discharged from hospital 11 days after surgery. We describe this case study and briefly summarize previous related reports.

Preoperative Diagnosis of Abdominal Extra-Adrenal Paragangliomas with Fine-Needle Biopsy

Paragangliomas are rare, non-epithelial neuroendocrine neoplasms originating in paraganglia, for instance the adrenal medulla, or at extra-adrenal locations. The aim of this study was to review the literature regarding abdominal extra-adrenal paragangliomas diagnosed pre-operatively with fine-needle biopsy (FNA and/or FNB). The PubMed database was searched to identify such cases, using a specific algorithm and inclusion/exclusion criteria. An unpublished case from our practice was also added to the rest of the data, resulting in a total of 36 cases for analysis. Overall, 24 (67%) lesions were found in females, whereas 12 (33%) in males. Most (21/36; 58.33%) were identified around and/or within the pancreatic parenchyma. FNA and/or FNB reached or suggested a paraganglioma diagnosis in 17/36 cases (47.22%). Of the preoperative misdiagnoses, the most common was an epithelial neuroendocrine tumor (NET). Regarding follow-up, most patients were alive with no reported recurrence; however, 5/36 patients exhibited a recurrence or a widespread disease, whereas one patient died 48 months following her diagnosis. In two patients, transient hypertension was reported during the EUS-FNA procedure. In conclusion, this study showed that the preoperative diagnosis of these lesions is feasible and, while diagnostic pitfalls exist, they could significantly be avoided with the application of immunochemistry.

A retropancreatic celio-mesenteric paraganglioma

Paragangliomas are extra-adrenal pheochromocytomas that arise from chromaffin cells in the sympathetic or parasympathetic neural paraganglia. Surgery remains the only curative treatment, although prominent vascularity can make excision difficult. We have recently encountered a patient with a retropancreatic celio-mesenteric paraganglioma unusually located between celiac trunk (CT) and superior mesenteric artery.

Pancreatic paraganglioma diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report and review of literature

BACKGROUND

Pancreatic paragangliomas (PPGL) are rare benign neuroendocrine neoplasms but malignancy can occur. PPGL are often misdiagnosed as pancreatic neuroendocrine tumor or pancreatic adenocarcinoma.

CASE SUMMARY

We reviewed 47 case reports of PPGL published in PubMed to date. Fifteen patients (15/47) with PPGL underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Only six (6/15) were correctly diagnosed as PPGL. All patients with PPGL underwent surgical resection except three (one patient surgery was aborted because of hypertensive crisis, two patients had metastasis or involvement of major vessels). Our patient remained on close surveillance as she was asymptomatic.

CONCLUSION

Accurate preoperative diagnosis of PPGL can be safely achieved by EUS-FNA with immunohistochemistry. Multidisciplinary team approach should be considered to bring the optimal results in the management of PPGL.

A rare case of retroperitoneal paraganglioma located in the neck of the pancreas: a case report and literature review

Paraganglioma (PGL) is an uncommon tumor located in the head, neck and abdomen. The majority of the tumor is benign and the patient has no obvious clinical symptoms. However, PGL located in the pancreas is rather rare and tends to mimic Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Herein, we reported a patient with PGL that occurred in the neck of the pancreas. A 75-year-old Chinese female presented to our hospital with a complaint of upper abdomen pain for two weeks and she had good past health. The laboratory findings and physical examination were all normal. Preoperative computed tomography (CT) and magnetic resonance imaging revealed a tumor located in the neck of the pancreas and a tentative diagnosis of Castleman's disease or PGL was made. We resected the tumor by laparoscopic surgery. Postoperative pathology and immunohistochemistry confirmed that the tumor was a PGL. The patient was recovered well after a postoperative follow-up of 6 months. PGL located in the neck of the pancreas is difficult to be diagnosed accurately and clinicians have difficulties in distinguishing PGL from Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Fifteen cases were listed to show the characters of PGL located in the pancreas and we also presented the difference among PGL, Castleman's disease and pancreatic neuroendocrine tumor. We showed our experience of treating such a rare tumor hoping to help clinicians correctly diagnose and treat PGL.

A rare case of retroperitoneal paraganglioma located in the neck of the pancreas: a case report and literature review

Paraganglioma (PGL) is an uncommon tumor located in the head, neck and abdomen. The majority of the tumor is benign and the patient has no obvious clinical symptoms. However, PGL located in the pancreas is rather rare and tends to mimic Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Herein, we reported a patient with PGL that occurred in the neck of the pancreas. A 75-year-old Chinese female presented to our hospital with a complaint of upper abdomen pain for two weeks and she had good past health. The laboratory findings and physical examination were all normal. Preoperative computed tomography (CT) and magnetic resonance imaging revealed a tumor located in the neck of the pancreas and a tentative diagnosis of Castleman's disease or PGL was made. We resected the tumor by laparoscopic surgery. Postoperative pathology and immunohistochemistry confirmed that the tumor was a PGL. The patient was recovered well after a postoperative follow-up of 6 months. PGL located in the neck of the pancreas is difficult to be diagnosed accurately and clinicians have difficulties in distinguishing PGL from Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Fifteen cases were listed to show the characters of PGL located in the pancreas and we also presented the difference among PGL, Castleman's disease and pancreatic neuroendocrine tumor. We showed our experience of treating such a rare tumor hoping to help clinicians correctly diagnose and treat PGL.

Non-functional retroperitoneal paraganglioma: A case report

Paragangliomas are extra-adrenal tumors of the autonomic nervous system and may be found within the skull base, neck, chest, and abdomen. When presenting within the abdominal cavity, they may arise as a primary retroperitoneal neoplasm and can mimic vascular malformations or other conditions related to specific retroperitoneal organs such as the pancreas, kidneys.^[1] They synthesize, store, and secrete catecholamines because of which they may present with headache, sweating, palpitation, and symptoms of hypertension (functional).^[2] In the absence of histological diagnosis and symptoms of catecholamine excess (non-functional), these may be mistaken for GISTs.^[3] We are reporting a case of a 36-year-old female who was clinically diagnosed as GIST, underwent excision, and postoperative histopathological examination was found to be paraganglioma.

Pitfalls of Frozen Section Diagnosis for Paraganglioma: A Clinicopathologic Analysis and Review of the Literature

Few paraganglioma (PG) cases include frozen section diagnoses, and therefore, the accuracy of frozen section diagnosis for PG remains unknown. To better understand the histologic characteristics and pitfalls of frozen section findings for PG, 15 PG cases with frozen section diagnoses were selected from 12 articles through PubMed (1984-2015). In addition, we included 3 cases of PG for which intraoperative consultations were requested during a 5-year period (2012-2016) in 2 hospitals. Seven PGs were from the thyroid; 2 from the pancreas; 4 from the mediastinum, retroperitoneum, or mesentery; 1 from the middle ear; and 4 from the urinary bladder (UB). Out of 18 PGs, correct diagnoses were rendered in only 2 cases, and no thyroid or UB PGs were correctly diagnosed on intraoperative consultation. Thyroid PGs were frequently misdiagnosed as medullary thyroid carcinomas (4/7, 57%) and UB PGs were frequently misdiagnosed as malignancies.

Diagnosis and surgical treatment of retroperitoneal paraganglioma: A single-institution experience of 34 cases

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.

Pancreatic Paraganglioma: A Case Report

Background: Paraganglionic neoplasms that originate in the adrenal medullas are referred to as pheochromocytomas, but if they arise from other paraganglia scattered throughout the body, they are referred to as paragangliomas. Pancreatic paragangliomas are an extremely rare entity as only 20 cases have been reported in the literature. They tend to be nonfunctional and typically occur in the fourth to fifth decade of life without a gender predilection. We describe in this study a case of a pancreatic paraganglioma and its CT appearance. Case Presentation: A 62-year-old woman undergoing presurgical evaluation for an olfactory groove meningioma resection was incidentally found to have a pancreatic mass. Multiple fine needle aspirations of the mass through endoscopic ultrasound yielded only atypical epithelial cells. The mass demonstrated avid enhancement on serial CTs with mild interval growth over a period of 5 years. No lymphadenopathy was ever found. The patient's complete blood count, complete metabolic panel, and plasma carcinoembryonic antigen levels were all within normal limits. Urine catecholamine metabolite levels were never checked as the patient demonstrated no symptoms of catecholamine excess. The patient underwent a laparoscopic distal pancreatectomy and splenectomy, and the mass was eventually diagnosed as a pancreatic paraganglioma through pathology. While the patient tolerated the surgery well, she did require a biliary sphincterotomy and placement of a pancreatic duct stent postoperatively for treatment of a pancreatic duct leak, which completely resolved. She showed no evidence of disease recurrence on multiple subsequent CTs and continues to do well. Conclusion: Pancreatic paragangliomas are usually incidentally discovered and typically demonstrate avid homogenous enhancement on contrast-enhanced CT or MR. Aggressive surgical resection is necessary to maximize the chances of disease-free survival. Pancreatic paragangliomas are similar histologically, whether benign or malignant, to paragangliomas that occur anywhere else in the body, with ∼70% in the abdomen and 30% in the chest.

CT and MR Imaging Findings of Pancreatic Paragangliomas: A Case Report

Previous studies on pancreatic paraganglioma, a rare neoplasm, have primarily reported its ultrasound and routine and contrast-enhanced computed tomography (CT) findings. To our knowledge, we are the first to report the contrast-enhanced magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) sequence findings of pancreatic paraganglioma. A male patient, ages 41 years, was admitted to our hospital due to a pancreatic space-occupying lesion that had been present for more than 10 days. The patient had no obvious discomfort. He had a history of hypertension and hyperthyroidism. Physical examination revealed upper abdominal tenderness without a palpable mass. Routine and contrast-enhanced abdominal CT showed a soft tissue mass at the pancreatic head/uncinate process, with patchy calcification within the lesion. On a contrast-enhanced CT scan, severe enhancement of the mass in the arterial phase was noted, as was slightly reduced but still marked enhancement in the venous phase. The celiac trunk and superior mesenteric artery segment were wrapped by the tumor. Thickened, tortuous vessels were observed at the lesion edges, around which there were multiple enlarged lymph nodes. The main pancreatic duct was markedly dilated. Routine and contrast-enhanced pancreatic MRI demonstrated an abnormal nodular signal in the pancreatic head/uncinate process that was approximately 4.3 × 6.4 cm² in size. T1-weighted imaging (T1WI) revealed hypointensity, whereas T2-weighted imaging (T2WI) revealed nonhomogeneous, slight hyperintensity. Patchy hypointensity on both T1WI and T2WI was observed within the lesion. DWI showed slight hyperintensity. Grossly heterogeneous enhancement of the mass was observed on a contrast-enhanced MRI scan, with the tumor wrapped around the adjacent vasculature, and multiple enlarged lymph nodes were observed peripherally. After preoperative preparation, the patient underwent pancreatoduodenectomy. Histopathology and immunohistochemistry of the resected tumor indicated pancreatic paraganglioma. After surgery, the patient recovered well, without presenting any recurrence or metastasis during short-term follow-up. For hypervascular pancreatic tumors on contrast-enhanced CT or MRI, and particularly those occurring in the pancreatic head, with a clear display of draining veins, the possibility of pancreatic paraganglioma should be considered. These tumors usually exhibit necrosis or cystic changes and are occasionally accompanied by calcification.

Pancreatic paraganglioma with draining vessels

A pancreatic paraganglioma is a rare neoplasm that is difficult to distinguish from a pancreatic neuroendocrine tumour. Here we present a case of pancreatic paraganglioma that was surgically resected following preoperative diagnosis of a pancreatic neuroendocrine tumour. Careful evaluation of the endoscopic ultrasonography findings revealed abundant draining vessels, which could have led to a correct preoperative diagnosis of pancreatic paraganglioma.

Retroperitoneal paraganglioma presenting with pancytopenia: A rare case with rare manifestation

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Retroperitoneal paragangliomas are mostly benign with good prognosis.

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Complete surgical excision is the treatment of choice for extra-adrenal paragangliomas.

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Reactive thrombocytosis is a common cause of thrombocytosis after splenectomy.

Introduction

Paragangliomas are tumors that arise from extraadrenal chromaffin cells and most of them are asymptomatic presenting with painless mass. Retroperitoneal paragangliomas are mostly benign with good prognosis; however, they can present with abdominal pain, palpable mass, or hypertensive episodes. Surgical resection is still the main treatment and necessary for histological assessment.

Case report

A 41 year old female patient presented with 6 months of loss of appetite, weight loss, weakness and breathlessness on exertion.. The patient’s initial blood examination showed marked anemia, reduced leukocyte count with neutropenia and lymphopenia and a marked reduction in the platelet count. The patient was admitted for evaluation of her pancytopenia. Magnetic resonance imaging revealed a 8 × 7 × 8 cm sized mass closed to the pancreatic tail invading splenic hilum. A large mass was identified retroperitoneally, closed to the tail of pancreas with a splenic hilum invasion. Total mass resection and splenectomy was performed.

Discussion

Complete surgical excision is the treatment of choice for extra-adrenal paragangliomas as well as for recurrent or metastatic neoplasms. Reactive thrombocytosis is a common cause of thrombocytosis. Splenectomy was found to be one of the main causes of extreme reactive thrombocytosis. Reactive thrombocytosis is a predictable finding after splenectomy and management of the thrombocytosis and prevention of complications should be initiated.

Retroperitoneal paragangliomas: Report of 4 cases

We reviewed the data of all patients managed for retroperitoneal paragangliomas (PGLs) between June 2010 and June 2011 to present our experience concerning this uncommon entity to highlight diagnostic and therapeutic challenges of retroperitoneal PGLs. All patients were admitted to the department of general and hepatobiliary surgery in the regional hospital of Jendouba, Tunisia. The size of the tumor was taken at its largest dimension, as determined in a computed tomography (CT) scan and pathological reports. There were 4 patients (all women) with a median age of 48 years (range 46-56 years). Abdominal pain was the commonest presentation. CT showed and localized the tumors which were all retroperitoneal. All patients had successful surgical resection of the tumors under invasive arterial blood pressure monitoring. One patient underwent surgery for a presumed tumor of the pancreatic head. The fresh-mount microscopic study of the peroperative biopsy yielded inflammatory tissue without malignancy and no resection was performed. Final histological examination of the biopsy concluded PGL. A second laparotomy was performed and the tumor was entirely resected. The diagnosis was made after surgery by histology in all patients. The control of the blood pressure was improved after surgery in 3 patients. Paragangliomas are rare tumors. The retroperitoneal localization is uncommon. Complete surgical resection remains the only curative treatment but it is often challenging as these tumors are located near multiple vital blood vessels.

Large retroperitoneal paraganglioma concurrent with periampullary adenocarcinoma

Paragangliomas are tumors that originate from extra-adrenal medullary neural crest derivatives. They are rarely located in retroperitoneal space. These tumors are often discovered incidentally during imaging studies performed for other reasons. Periampullary cancers include adenocarcinomas arising from the pancreas, ampulla of Vater, duodenum or distal common bile duct. The exact site of origin of periampullary tumors is often difficult to ascertain pre-operatively. We report the case of a patient who had a retroperitoneal non-functional paraganglioma, concurrent with periampullary adenocarcinoma. An 81-year-old woman was admitted with progressive abdominal fullness. There was an upper paramedian, left sided, large, palpable mass on the physical examination. Laboratory investigations showed an increase in liver enzyme levels. On abdominal computed tomography the patient found to have a large retroperitoneal mass and dilation in biliary tract, which was confirmed by magnetic resonance cholangiopancreatography. She had a tumoral papi in Endoscopic Retrograde cholangiopancreatography. Which biopsy revealed adenocarcinoma. She underwent surgery for excision of abdominal mass and pancreaticoduodenectomy. And pathologic study showed paraganglioma. This is the first ever reported case of concurrent paraganglioma and periampullary adenocarcinoma.

Malignant extra-adrenal pancreatic paraganglioma: case report and literature review

Background

Pancreatic paragangliomas are rare tumors, with only 16 reported cases to date. One of these cases demonstrates metastasis to lymph node, while another case was functional, however, none of these cases showed malignant and large, pancreatic paraganglioma with marked invasion. Also another unique feature was the age of our patient compared to the average reported ages in published literature (42–85 years).

Case presentation

A 19-year-old woman presented with a one-year history of intermittent abdominal pain. Physical examination showed a palpable mass in the right upper abdomen, but initial laboratory results were within normal ranges; tumor markers (CEA, AFP, and CA19-9) were negative. An abdominal and pelvic computed tomography (CT) scan showed a well-defined retroperitoneal para-aortic mass. The CT scan revealed that the surrounding lymph nodes were not enlarged, but the liver showed evidence of parenchymal infiltration. Intraoperatively, a large, firm tumor originating from the head of pancreas was found pushing on the caudate hepatic lobe and the inferior vena cava (IVC). The tumor was resected through a pancreaticoduodenectomy, involving segment VI of the liver and a small segment of the IVC. The blood pressure spiked (>220 mm Hg) when the tumor was manipulated during the operation. The final pathology report showed a 9-cm tumor with lymphovascular invasions; immunohistochemistry was positive for synaptophysin and chromogranin. All resection margins were negative and 1/15 lymph nodes was positive for metastasis. Post-operative recovery was unremarkable. One month after discharge, the patient was re-admitted with abdominal pain and found to have an abdominal collection at the resection site, which was drained under CT guidance. She received a therapeutic dose of I¹³¹-metaiodobenzylguanidine (MIBG). Follow-ups showed the absence of recurrence, and she has remained disease free.

Conclusion

This patient was an extraordinary example of a rare tumor. Even more remarkable was that the tumor was malignant with lymph node invasion. To our knowledge, a case similar to that presented here has not been previously reported in the literature.

Hypercortisolaemia due to ectopic adrenocorticotropic hormone secretion by a nasal paraganglioma: a case report and review of the literature

BACKGROUND

Adrenocorticotropic hormone-producing extraadrenal paragangliomas are extremely rare. We present a case of severe hypercortisolemia due to ectopic adrenocorticotropic hormone secretion by a nasal paraganglioma.

CASE PRESENTATION

A 70-year-old Caucasian woman, was emergently admitted to our department with supraventricular tachycardia, oedema of face and extremities and hypertensive crisis. Initial laboratory evaluation revealed severe hypokalemia and hyperglycemia without ketoacidosis, although no diabetes mellitus was previously known. Computed tomography revealed a large tumor obliterating the left paranasal sinus and a left-sided adrenal mass. After cardiovascular stabilisation, a thorough hormonal assessment was performed revealing marked adrenocorticotropic hormone-dependent hypercortisolism. Due to the presence of a cardiac pacemaker magnetic resonance imaging of the hypophysis was not possible. [68Ga-DOTA]-TATE-Positron-Emission-Tomography was performed, showing somatostatin-receptor expression of the paranasal lesion but not of the adrenal lesion or the hypophysis. The paranasal tumor was resected and found to be an adrenocorticotropic hormone-producing paraganglioma of low-proliferative rate. Postoperatively the patient became normokaliaemic, normoglycemic and normotensive without further need for medication. Genetic testing showed no mutation of the succinatdehydrogenase subunit B- and D genes, thus excluding hereditary paragangliosis.

CONCLUSION

Detection of the adrenocorticotropic hormone source in Cushing's syndrome can prove extremely challenging, especially when commonly used imaging modalities are unavailable or inconclusive. The present case was further complicated by the simultaneous detection of two tumorous lesions of initially unclear biochemical behaviour. In such cases, novel diagnostic tools - such as somatostatin-receptor imaging - can prove useful in localising hormonally active neuroendocrine tissue. The clinical aspects of the case are discussed and relevant literature is reviewed.

Retropancreatic Retroperitoneal Tumors: A 30-year Experience with 38 Cases

Retropancreatic retroperitoneal tumors (RRTs) are seldom encountered in clinical practice. The lack of characteristics on clinical presentation and imaging make preoperative diagnosis difficult and surgical management remains a challenge. This retrospective report surveys the presenting diagnosis and surgical management of 38 patients with RRTs presenting at our center between August 1981 and May 2012. Six patients were misdiagnosed on the basis of computerized tomography and one each by magnetic resonance imaging and magnetic resonance cholangiopancreatography. Tumors were localized posterior to the pancreatic head and uncinate process (n = 18); posterior to the neck and body of the pancreas (n = 9); or posterior to the body and tail of the pancreas (n = 11). Thirty-three patients underwent surgical resections. Operative approaches were chosen on the basis of tumor size and localization. The tumors were mostly commonly originating from neurogenic tissue (n = 16). There were 25 benign neoplasms (65.8%), 10 malignant tumors (26.3%), and three undefined tumors. The morbidity of postsurgical complications was 21 per cent (eight of 38). The number of patients who underwent follow-up was 21, and the mean follow-up time was 35 months (range, 2 to 90 months). Three patients died during follow-up. The morbility of local recurrence was 10.5 per cent (four of 38). Definitive diagnosis of RRTs is made at laparotomy. Complete resection remains the fundamental objective of disease management. Different operative approaches should be used according to tumor localization and size.

Retroperitoneal paraganglioma presenting as a chest pain: a case report

Paragangliomas are very rare tumors derived from neuroendocrine cells of autonomic nervous system. Extra-adrenal paragangliomas account for only 10 to 15% of all paragangliomas and may present incidentally as a mass. Typical triad of fluctuating hypertension, headache, and sweating is not always present which makes the diagnosis difficult sometimes. Definitive diagnosis is usually made with histologic findings and surgery is the treatment of choice. We report a case of a 53-year-old male who presented with chest pain and vomiting.

Intraoperative diagnosis of functional retroperitoneal multiple paraganglioma: A case report

Paragangliomas are extra-adrenal chromaffin tumors that arise from neuroectodermal cells of the autonomous nervous system. It is difficult to make an accurate preoperative clinical diagnosis of silent paraganglioma. The best choice of treatment is complete surgical resection. However, it is important to note that in patients with functional paragangliomas, the tumor's ability to produce catecholamines may cause abrupt changes in blood pressure. Thus, surgery may induce life-threatening complications. In the present study, we present a case of functional retroperitoneal multiple paraganglioma in a 39-year-old male patient who was diagnosed during surgery. Four years after the operation, the patient remains asymptomatic and free of disease.

Left subdiaphragmatic paraganglioma supplied by contralateral right renal artery

INTRODUCTION

Paragangliomas are neuroendocrine tumors of the autonomic nervous system that arise from neural crest cells. Paragangliomas are typically extra-adrenal, non-functional and can be discovered incidentally, posing diagnostic and therapeutic challenges.

PRESENTATION OF CASE

We present the unusual case of a young man who presented with an acute abdomen secondary to small bowel obstruction, and was found to have an incidental left-sided subdiaphragmatic paraganglioma supplied by a branch of the contralateral right renal artery.

DISCUSSION

Emergent laparotomy revealed an internal hernia as the source of the small bowel obstruction. Initial attempts to remove an incidental left subdiaphragmatic mass were aborted because of bleeding. Subsequently, after preoperative superselective embolization of the feeding vessel arising from the right renal artery, the mass was successfully resected. Pathology was consistent with a paraganglioma.

CONCLUSION

This report highlights the rarity of the location and blood supply of an incidental left subdiaphragmatic paraganglioma found in the setting of a small bowel obstruction.

Functional 'composite' pheochromocytoma-ganglioneuroma presenting as a pancreatic mass

Pheochromocytomas rarely have 'composite' forms in which they demonstrate histologic features of a typical paraganglioma in combination with those of a neural component. Extra-adrenal 'composite' pheochromocytomas are distinctly uncommon. We describe herein a unique case of a 34-year-old female patient with type 1 neurofibromatosis who presented with abdominal pain and paroxysmal hypertension. Imaging revealed a pancreatic mass with biliary and pancreatic ductal dilatation and a hormonal assay led to the diagnosis of functional pheochromocytoma. She underwent surgical resection and histopathology revealed a composite paraganglioma-ganglioneuroma. Clinical, biochemical and radiological aspects of this rare tumor and its association with neurofibromatosis and other hereditary cancer syndromes are discussed.

Peripancreatic paraganglioma: a potential diagnostic challenge in cytopathology and surgical pathology

Paragangliomas are rare neuroendocrine neoplasms arising in extra-adrenal chromaffin cells of the autonomic nervous system. In rare instances, paragangliomas present around and involve the pancreas, thereby mimicking one of the more common primary pancreatic lesions. These neoplasms present considerable diagnostic difficulty not only for the clinician and radiologist but also for the pathologist. We have collected a series of 9 peripancreatic paragangliomas clinically simulating a primary pancreatic lesion. The paragangliomas were diagnosed in 4 men and 5 women with an age range of 37 to 78 years (mean, 50 y). Patients presented clinically either with diffuse epigastric and abdominal pain (7 of 9, 78%) or with an incidental mass (2 of 9, 22%) discovered on routine radiographic imaging. All patients were found to have mass lesions suspicious for a primary pancreatic neoplasm on radiographic examination. The lesions were predominantly located in the body of the pancreas (5 of 9, 56%) and ranged in size from 5.5 to 17.0 cm (mean, 10.0 cm). Five of 9 (56%) neoplasms also demonstrated cystic change. Fine-needle aspiration (FNA) was performed on 6 cases; however, the diagnostic accuracy was low, with 3 of 6 (50%) neoplasms misdiagnosed as pancreatic neuroendocrine tumor (PanNET) (n=1), spindle cell neoplasm (n=1), or pseudocyst (n=1). In addition, 2 of 8 (25%) surgically resected tumors were misdiagnosed by the referring pathologist as a PanNET. Immunohistochemistry was performed on all cases, confirming the characteristic 2-cell populations: chief cells (synaptophysin positive and chromogranin A positive) and sustentacular cells (S-100 protein positive). Follow-up information was available for all patients and ranged from 2 months to 11.6 years (mean, 2.7 y). Three of 9 (33%) patients developed metastatic disease, and 2 of these 3 died of their disease at 2.8 and 4.6 years after diagnosis. In summary, in unsuspected cases, interpretation of FNA and surgical pathology resections can be diagnostically challenging. Awareness and proper recognition of this entity, including differential diagnosis, are imperative in establishing the correct diagnosis. Further, close follow-up of these cases should be considered because of the significant risk of metastatic disease.