Total resection of a giant retroperitoneal and mediastinal ganglioneuroma-case report and systematic review of the literature

Spinal ganglioneuroma: a rare and challenging tumor in the pediatric population

BACKGROUND

"Spinal ganglioneuroma" is a rare entity of neuroblastic tumors, frequent among children, that has been sparsely reported in articles involving both the pediatric and adult populations. These tumors mostly arise from the sympathetic ganglia located in the paravertebral region, near the intervertebral foramina of the spine. This makes their extension into the spinal canal possible but quite rare, in a dumbbell fashion, producing radicular or medullary symptoms. We provide an extensive review of the pediatric cases found in the literature; while reporting a challenging case we have recently got to treat at the CHRU de Brabois in Nancy, France.

METHODS

We searched PubMed's database for articles and abstracts related to "spinal ganglioneuromas," from inception until June 1, 2024. We combined every case among patients under 18 years of age and divided them between the different spinal areas. We excluded those that originated from outside of the spine. We particularly focused our attention on the thoraco-lumbar region, which involved our case report, since the surgical management is completely different from other regions of the spine.

RESULTS

As per June 1, 2024, 21 patients aged between 3 and 17 years were identified with "spinal ganglioneuromas," with a predominance of females (81%). The thoracic region of the spine seems to be the area of predilection for these tumors (42.85%), although some have been found in the cervical (9.5%), cervico-thoracic (4.76%), thoraco-lumbar (19.04%), lumbar (19.04%), and sacral (4.76%) regions.

DISCUSSION

Our specific case included long-date abdominal pain and recent progressive paraparesis as the main symptoms, with radiological manifestations of renal atrophy and hydronephrosis, due to the compression and complete displacement of the kidney, as well as scoliosis. To our knowledge, this combination of symptoms has never been seen with spinal ganglioneuromas before in the pediatric population, given the gigantic size of the tumor, and its significant extension to both the spinal canal and the retroperitoneal space, which is quite uncommon.

CONCLUSION

Spinal ganglioneuromas are very rare, benign lesions, that should be included in the differential diagnosis of dumbbell tumors that can cause in the pediatric population, alongside neurological symptoms in the limbs and back pain, thoracic, abdominal, and even urinary symptoms.

Thoracic ganglioneuroma with extension into the epidural space

A patient in their 30s presented with chronic right upper quadrant abdominal pain, nausea, bloating, and constipation. Her clinical exam was unremarkable, and computed tomography (CT) of the chest and abdomen which showed a large right-sided thoracic mass with extension into the thoracic spinal canal. A needle biopsy revealed a diagnosis of ganglioneuroma, the patient then underwent a combined approach for excision the tumor. Ganglioneuroma is a neuroblastic tumor of a neural crest origin, it originates from paravertebral sympathetic chain ganglia of the posterior mediastinum or retroperitoneum. They usually extend through neuroforamina to involve the epidural space and surgical excision can be curative.

Combined unilateral biportal endoscopy and video-assisted thoracoscopic surgery for complete excision of a T3-T4 right ganglioneuroma

Ganglioneuroma (GN) is a rare solid neoplasm developing from neural crest cells of sympathetic ganglia or adrenal medulla. It usually presents as an asymptomatic mass in the retroperitoneal space and mediastinum. Resection through open surgery or minimal access is recommended. The video illustrates the case of a 23-year-old female with an incidental finding of thoracic GN. The authors performed a combined, staged approach to ensure complete resection, which involved unilateral T3-4 biportal endoscopy (UBE) for rhizotomy and nerve root decompression, followed by video-assisted thoracoscopic surgery (VATS) for complete excision. The procedure was uneventful, with full recovery and no postoperative complications. The video can be found here: https://stream.cadmore.media/r10.3171/2024.2.FOCVID23210.

Extralobar pulmonary sequestration: A case report and literature review

Pulmonary sequestration is a congenital malformation of lung development in which part of the lung tissue is separated from the normal lung during the embryonic phase and develops separately and receives blood supply from an aberrant systemic artery forming a nonrespiratory mass. In brief, early in embryonic development, certain tissues that should have atrophied and been gradually absorbed are left behind due to impairment of the atrophy process and form anomalous branches of the aorta, which pull parts of the lung tissue, isolating them from normal lung tissue and bronchi, and thus forming separate lung tissue. According to the relationship of the mass to the pleural covering, pulmonary sequestration can be divided into two types, intralobar pulmonary sequestration (ILS) and extralobar pulmonary sequestration (ELS), of which approximately 75% of cases are ILS, but ELS is less common. Symptoms are not obvious in either type, making diagnosis and differential diagnosis more difficult. Here we report a 33-year-old patient with only insignificant abdominal distension who was eventually diagnosed with retroperitoneal ELS.

Laparoscopic resection of ganglioneuroma from the hepatoduodenal ligament: A case report

INTRODUCTION AND IMPORTANCE

Ganglioneuromas are extremely rare, slow-growing, benign tumors that arising from Schwann cells, ganglion cells, and neuronal or fibrous tissue. Their malignant degeneration occurs very rarely, complete surgical removal is recommended to eliminate possible symptoms or to prevent possible malignant transformation. Reviewing the literature, there is currently insufficient data available on laparoscopic resection of retroperitoneal ganglioneuromas.

CASE PRESENTATION

20-year-old young woman with no previous medical history or regular medication use complaints of abdominal pain. Abdominal CT scan found a cystic mass measuring up to 50 mm in diameter with a thick fluid density and no contrast accumulation, was identified in the porta hepatis region extrahepatically. Ultrasound-guided biopsy was performed, histopathological finding revealed mature benign neurogenic tumor tissue consisting of mature ganglion cells, mature Schwann cells, and branching stroma.

CLINICAL DISCUSSION

A laparoscopic surgery was performed, the 5 cm large tumor was excised from the hepatoduodenal ligament. The tumor was removed from the region of the inferior caval vein, portal vein, and the common and proper hepatic arteries. Final histological diagnosis is ganglioneuroma of the hepatoduodenal ligament. After uneventful postoperative period, the patient was discharged home on the 6th day.

CONCLUSIONS

Retroperitoneal tumors were previously excised during laparotomy. However, in recent decades, with the development of laparoscopic surgical techniques and tools, laparoscopic removal of some retroperitoneal tumors seems to be the ideal approach. The use of laparoscopy improves visibility of the relationship of the tumor to the surrounding, often vital, structures. Based on a review of the international literature and our own experience, laparoscopic ganglioneuroma resection is the recommended procedure with careful patient selection, as well as appropriate preoperative imaging and diagnostics, and with adequate expertise.

A case report of multimodal ultrasound imaging in the diagnosis of giant retroperitoneal ganglioneuroma

Retroperitoneal ganglioneuroma is a rare benign tumor that is challenging in terms of clinical diagnosis. Computed tomography and magnetic resonance imaging are usually performed for diagnosis rather than convenient and inexpensive ultrasonography. Here, we present the case of a 21-year-old female patient who was diagnosed by multimodal ultrasound imaging and whose diagnosis was confirmed by ultrasound-guided core needle biopsy before surgery. We hope that this rare case will help clinicians and radiologists realize the advantages of multimodal ultrasound imaging in the diagnosis of retropeitoneal solid tumors, and reduce misdiagnosis.

Ganglioneuroma presenting as subpulmonic effusion-a differential to consider?

Ganglioneuroma is a benign, slow-growing neurogenic tumor arising from neural crest cells. It is extremely rare (1/1,000,000) and is located most commonly in the posterior mediastinum (41.5%), retroperitoneum (37.5%), and adrenal glands (21%). We present a case of a 62-year-old lady who had complaints of shortness of breath on exertion and dyspnea for the past 3 months. She had no other significant history. Computerised tomography (CT) scan of the thorax suggested left-sided loculated subpulmonic pleural effusion, 14 × 12 cm in dimension. She underwent assisted video-assisted thoracoscopic surgery (VATS) exploration of the thorax with debridement and drainage of subpulmonic collection that was abutting the diaphragm, along with release of trapped lung. Histopathological examination showed multiple ruptured cystic masses with nodules; microscopical evidences of Schwann cells, ganglion cells, and spindle cells-all these along with immunohistochemistry-revealed features consistent with ganglioneuroma. Postoperative recovery was uneventful, and the patient did not have any complaints or other limitations to daily life activities at 6 months' follow-up. Ganglioneuroma is essentially benign in nature, asymptomatic, and rare. A systematic review of the literature has shown that giant-sized ganglioneuromas (size more than 10 cm) have rarely been reported. Surgical excision and clearance is the treatment modality of choice. In our case, due to large size and difficulty in access and mobilisation of the mass adherent to the diaphragm, assisted VATS had to be performed. We increased the size of the utility port from 5 to 10 cm and used a rib retractor for better surgical negotiation. This could have been more challenging, as there have been incidences where ganglioneuromas have extended both into the thoracic and abdominal cavities and even involved vital organs and vessels. Regular follow-up is essential, as late recurrence and slow progression potential is a known complication.

Overreliance on Radiological Findings Leading to Misdiagnosed Giant Retroperitoneal Ganglioneuroma: A Case Report and Literature Review

Ganglioneuroma is a rare, benign, well-differentiated neurogenic tumor most commonly located in the posterior mediastinum or retroperitoneum. Giant ganglioneuromas are even less common; this is only the 19th reported case in literature to date. We present a case of a giant retroperitoneal ganglioneuroma in a five-year-old child, which on imaging mimicked a mesenteric cyst and posed various challenges in its management. Histopathology later confirmed our misdiagnosis and revealed the tumor to be a ganglioneuroma. This unique case serves as a lesson for clinicians to not operate before receiving histopathological confirmation of their diagnosis.

Imaging of Ganglioneuroma: A Literature Review and a Rare Case of Cystic Presentation in an Adolescent Girl

Retroperitoneal ganglioneuroma is a rare neuroectodermal tumor with a benign nature. We performed a literature review among 338 studies. We included 9 studies, whose patients underwent CT and/or MRI to characterize a retroperitoneal mass, which was confirmed to be a ganglioneuroma by histologic exam. The most common features of ganglioneuroma are considered to be a solid nature, oval/lobulated shape, and regular margins. The ganglioneuroma shows a progressive late enhancement on CT. On MRI it appears as a hypointense mass in T1W images and with a heterogeneous high-intensity in T2W. The MRI-"whorled sign" is described in the reviewed studies in about 80% of patients. The MRI characterization of a primitive retroperitoneal cystic mass should not exclude a cystic evolution from solid masses, and in the case of paravertebral location, the differential diagnosis algorithm should include the hypothesis of ganglioneuroma. In our case, the MRI features could have oriented towards a neurogenic nature, however, the predominantly cystic-fluid aspect and the considerable longitudinal non-invasive extension between retroperitoneal structures, misled us to a lymphatic malformation. In the literature, it is reported that the cystic presentation can be due to a degeneration of a well-known solid form while maintaining a benign character: the distinguishing malignity character is the revelation of immature cells on histological examination.

Combined exploratory laparotomy, transpsoas, and thoracic approach to resection of a giant spinal ganglioneuroma: illustrative case

BACKGROUND

Ganglioneuromas are rare peripheral nervous system tumors of neural crest origin. Most are often asymptomatic and incidentally found, but large tumors can cause mass effect. Herein, the authors report a case of a giant ganglioneuroma that arose from the lumbar foramina into the retroperitoneal and thoracic cavities.

OBSERVATIONS

A 62-year-old female presented with low back pain, left lower extremity swelling, and increased sensation of an abdominal mass. Surgical treatment options were reviewed with the patient and coordinated care was planned by surgical oncological specialists. The patient opted for multistage exploratory laparotomy for abdominal mobilization, diaphragm resection, and en bloc resection with neuromonitoring. After surgery, the patient experienced significant improvement in symptoms.

LESSONS

A combined surgical exposure involving gastrointestinal, thoracic, and neurological surgeons can be important in the safe resection of ganglioneuromas that span multiple body cavities. Hence, a thorough preoperative assessment could help plan surgery accordingly.

Ganglioneuroma on fine needle aspiration cytology: Case series and review of the literature

We report two cases of an uncommon benign lesion, retroperitoneal ganglioneuroma, first diagnosed on fine needle aspiration (FNA) cytology. Our first case presented with nausea, constipation, vomiting, and neutropenia after three cycles of chemotherapy for breast cancer treatment, while our second patient presented with seemingly unprovoked abdominal pain and progressive neuropathy. Both underwent computed tomography (CT) scans, in which a soft tissue mass was found in the retroperitoneal space in each patient. An endoscopic ultrasound guided (EUS) FNA was performed on both patients, and as a result, the masses were diagnosed as retroperitoneal ganglioneuromas. As retroperitoneal ganglioneuromas have low incidence of proliferation, invasive surgery was avoided in favor of routine follow-up imaging. Cytologically, both masses showed large, scattered ganglion cells with abundant cytoplasm and large nuclei against a background of wavy spindle cells with elongated nuclei. Histologically, both were positive for S-100. When an EUSFNA is performed and quality material is collected, a diagnosis of retroperitoneal ganglioneuroma may be established, preventing invasive surgery and its accompanying risks in favor of routine follow-up imaging.

Retroperitoneal ganglioneuroma presenting as an obstructive pyelonephritis: a case report

Ganglioneuroma is a nerve tumor arising from the sympathetic neural crest. It is a rare benign tumor. Retroperitoneum is its second location after the posterior mediastinum. Usually asymptomatic, it is discovered incidentally on imaging. Surgical resection is the sole treatment. The prognosis is good if the diagnosis is made early with quality R0 surgical excision. We report a case in a 14-year-old female admitted to the emergency department for obstructive pyelonephritis. Imaging features found a retroperitoneal mass with characteristics suggestive of a retroperitoneal ganglioneuroma, which was confirmed by histological study. Ganglioneuroma should be a part of differential diagnoses for any retroperitoneal mass in children and young adults.