Long-term follow-up after en bloc resection and reconstruction of a solitary paraganglioma metastasis in the first lumbar vertebral body: a case report

Surgical Treatment of Spinal Metastatic Pheochromocytoma and Paraganglioma: A Single Institutional Cohort of 18 Patients

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To describe surgeries and treatment outcomes of metastatic pheochromocytomas and paragangliomas (PPGLs) on the spine.

METHODS

We reviewed a cohort of 18 patients with spinal PPGLs who were consecutively treated in our spinal center. Their clinical data was reviewed. The survival period and its relevant factors was then analyzed.

RESULTS

The cohort included ten cases of pheochromocytomas and eight paragangliomas. The local pain and neurological deficits were the two most common symptoms. One third of the spinal PPGLs were diagnosed as functional tumors, arousing secondary hypertension. The imaging features were consistent with those of osteolytic lesions. The surgical strategies for the cohort included percutaneous vertebroplasty, neurological decompression and partial tumor resection, and total en-bloc resection. The postoperative courses were uneventful except 1 patient developed heart failure. The adjuvant therapies were implemented in 6 patients with 131I-MIBG, five with radiotherapy, two with chemotherapy, and 1 with target therapy. The median survival period was 39 months, and the overall survival rate of 1 year was 77.8% (14/18). The patients' Karnofsky performance scores were positively correlated with the survival period (P < .05).

CONCLUSION

Surgery is indicated for intractable local pain and neurological impairment in the patients with spinal PPGLs. Palliative surgical strategies, including neurological decompression and partial tumor resection, could bring fair outcomes, especially for the patients in poor physical conditions.

Metastatic Paraganglioma of the Spine With SDHB Mutation: Case Report and Review of the Literature

BACKGROUND

Paragangliomas (PGLs) are rare neuroendocrine tumors that can arise from any autonomic ganglion of the body. Most PGLs do not metastasize. Here, we present a rare case of metastatic PGL of the spine in a patient with a germline pathogenic succinate dehydrogenase subunit B (SDHB) mutation.

METHODS

In addition to a case report we provide a literature review of metastatic spinal PGL to highlight the importance of genetic testing and long-term surveillance of these patients.

RESULTS

A 45-year-old woman with history of spinal nerve root PGL, 17 years prior, presented with back pain of several months' duration. Imaging revealed multilevel lytic lesions throughout the cervical, thoracic, and lumbar spine as well as involvement of the right mandibular condyle and clavicle. Percutaneous biopsy of the L1 spinal lesion confirmed metastatic PGL and the patient underwent posterior tumor resection and instrumented fusion of T7-T11. Postoperatively the patient was found to have a pathogenic SDHB deletion.

CONCLUSIONS

Patients with SDHx mutation, particularly SDHB, have increased risk of developing metastatic PGLs. Consequently, these individuals require long-term surveillance given the risk for developing new tumors or disease recurrence, even years to decades after primary tumor resection. Surgical management of spinal metastatic PGL involves correcting spinal instability, minimizing tumor burden, and alleviating epidural cord compression. In patients with metastatic PGL of the spine, genetic testing should be considered.

Secretory Paravertebral Paraganglioma of the Lumbar Spine: A Case Report and Review of Literature

Introduction:

Paragangliomas are relatively rare group of well-vascularized tumor having an origin from the embryonic neural crest cells. They arise from extra-adrenal autonomic paraganglia and have neuroendocrine cells that can secrete catecholamines. Most head and neck paragangliomas are parasympathetic type and are non-functional. They are located near the skull base and along the vagus nerve. Paragangliomas of the thoracoabdominal regions are sympathetic type and known to secrete catecholamines. It is an important cause for episodic hypertension. Triad of episodic hypertension, sweating, and palpitations is included in the classical triad for the catecholamine secreting tumors. Rarely, the paraganglioma can show features of malignancy in 10–15% of cases.

Case Report:

We present here a 34-year-old female who came to us with back pain, episodic hypertension associated with palpitations, and sweating. Back pain was not associated with other neurological symptoms and neuroclaudication. She was treated with en bloc resection of the tumor with L1 corpectomy posterior instrumentation and anterior reconstruction.

Conclusion:

Secretory paravertebral paraganglioma of the lumbar spine is infrequently reported. Its management requires multidisciplinary approach with optimization of perioperative blood pressure and meticulous handling of the tumor mass. In cases, where the vertebral body is destroyed, it requires anterior column reconstruction for stabilization.

Paratesticular Paraganglioma with Metastasis to D1 Vertebra- A Case Report and Review of Literature

INTRODUCTION

Paragangliomas are relatively rare tumors, accounting for only about 0.3% of all neoplasms. Most paragangliomas are defined as benign in nature, but 10-% possess metastatic potential. There have been scattered reports of metastatic paraganglioma in the literature, but in rare circumstances, paragangliomas can metastasize to the spinal column causing destruction or compression of the spinal cord, clinically manifesting as pain or neurological deficit.

CASE REPORT

We present a case of a 43-year-old man who presented with paresthesia and paraparesis and was found to have pathologic fracture involving D1 vertebra as a manifestation of metastasis from a non-secretory right paratesticular paraganglioma.

CONCLUSIONS

We will review the literature on the topic of metastatic paraganglioma, management of paragangliomas involving spine, and touch on the importance of angioembolization, staged procedures, and a team approach.

Treatment and outcome of metastatic paraganglioma of the spine

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULT

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

CONCLUSION

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

Molecular and therapeutic advances in the diagnosis and management of malignant pheochromocytomas and paragangliomas

Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare catecholamine-secreting tumors derived from chromaffin cells originating in the neural crest. These tumors represent a significant diagnostic and therapeutic challenge because the diagnosis of malignancy is frequently made in retrospect by the development of metastatic or recurrent disease. Complete surgical resection offers the only potential for cure; however, recurrence can occur even after apparently successful resection of the primary tumor. The prognosis for malignant disease is poor because traditional treatment modalities have been limited. The last decade has witnessed exciting discoveries in the study of PCCs and PGLs; advances in molecular genetics have uncovered hereditary and germline mutations of at least 10 genes that contribute to the development of these tumors, and increasing knowledge of genotype-phenotype interactions has facilitated more accurate determination of malignant potential. Elucidating the molecular mechanisms responsible for malignant transformation in these tumors has opened avenues of investigation into targeted therapeutics that show promising results. There have also been significant advances in functional and radiological imaging and in the surgical approach to adrenalectomy, which remains the mainstay of treatment for PCC. In this review, we discuss the currently available diagnostic and therapeutic options for patients with malignant PCCs and PGLs and detail the molecular rationale and clinical evidence for novel and emerging diagnostic and therapeutic strategies.