Paraganglioma of the duodenum: a case report with radiological findings and literature review

A rare case of multiple paragangliomas in the head and neck, retroperitoneum and duodenum: A case report and review of the literature

Pheochromocytomas and paragangliomas (PGLs) are rare non-epithelial neuroendocrine neoplasms of the adrenal medulla and extra-adrenal paraganglia respectively. Duodenal PGL is quite rare and there are only two previous reports. Herein, we report a case of multiple catecholamines (CAs)-producing PGLs in the middle ear, retroperitoneum, and duodenum, and review the literature of duodenal PGLs. A 40-year-old man complained right-ear hearing loss, and an intracranial tumor was suspected. Magnetic resonance imaging of the head revealed a 3-cm mass at the right transvenous foramen, which was surgically resected following preoperative embolization. The pathological diagnosis was a sympathetic PGL of the right middle ear. Six years later, family history of PGL with germline mutation of succinate dehydrogenase complex iron sulfur subunit B, SDHB: c.268C>T (p.Arg90Ter) was clarified. The patient had elevated levels of plasma and urine CAs again. Abdominal computed tomography scanning revealed two retroperitoneal tumors measuring 30-mm at the anterior left renal vein and 13-mm at near the ligament of Treitz. The larger tumor was laparoscopically resected, but the smaller tumor was not identified by laparoscopy. After the operation, the patient remained hypertensive, and additional imaging tests suggested a tumor localized in the duodenum. The surgically resected tumor was confirmed to be a duodenal PGL. After that, the patient remained hypertension free, and urinary levels of noradrenaline and normetanephrine decreased to normal values. No recurrence or metastasis has been found at 1 year after the second operation. CAs secretion from PGLs in unexpected location, like the duodenum of our patient, may be overlooked and leads to a hypertensive crisis. In such cases, comprehensive evaluation including genetic testing, fluorodeoxyglucose-positron emission tomography scanning, and measurement of CAs will be useful for detecting PGLs. Most previous reports on duodenal PGL were gangliocytic PGL which has been renamed composite gangliocytoma/neuroma and neuroendocrine tumor, and defined the different tumor from duodenal PGL. We reviewed and discussed duodenal PGLs in addition to multiple PGLs associated with SDHB mutation.

Periampullary Gangliocytic Paraganglioma

BACKGROUND

Gangliocytic paraganglioma (GP) is rare and difficult to be differentiated from other periampullary neoplasms. The clinical characteristics and optimal treatment of periampullary GPs have not been clarified.

METHODS

The data pool for the analysis comprised of cases of periampullary GP encountered in our institution and sporadic cases reported in the English literature.

RESULTS

A total of 117 cases with periampullary GP were studied, including 2 from our institute, and among them, duodenal GP was the most common (53.0%). GP size ranged from 0.7 to 19.0 cm, with a median of 2.2 cm. The most common presenting symptom for overall periampullary GPs was epigastric pain in 49.5% cases, followed by gastrointestinal bleeding in 35.4% cases. Most (84.1%) of the periampullary GPs were benign, whereas 15.9% were malignant. Metastasis was noted in 26.3% of periampullary GPs, with 14.5% showing lymph node metastasis and 1.8% showing liver metastasis. Of the periampullary GP cases included, 30.1% were treated with pancreaticoduodenectomy, 40.6% with local excision, and 17.7% with endoscopic resection.

CONCLUSIONS

Periampullary GP should be considered as a tumor with malignant potential. Endoscopic resection is the treatment of choice for most of the duodenal GPs, whereas pancreaticoduodenectomy is recommended for GPs with possible malignancy, such as large size, with submucosal invasion, or pancreatic GP.

Surgical management of endoscopically unresectable duodenal gangliocytic paraganglioma in a patient with partial upper gastrointestinal obstruction

Context:

Gangliocytic paragangliomas are unusual and often misunderstood tumors that occur almost exclusively in the second portion of the duodenum, although they have been described in other sites such as the urinary bladder, spermatic cord, prostate, urethra, uterus and scalp. We describe our experience with the surgical management of an endoscopically unresectable gangliocytic paraganglioma located in the third part of the duodenum causing a partial upper gastrointestinal obstruction.

Case Report:

A fifty-two-year-old male presented to the Geisinger clinic with a four-year history of postprandial projectile vomiting associated with epigastric discomfort. Computed tomography scan revealed an oval-shaped filling defect in the third part of the duodenum. Endoscopic ultrasonography showed a 22 × 16 × 35 mm submucosal mass that was not amenable to an endoscopic resection. Exploratory laparotomy revealed an absence of extraduodenal involvement. A long-stalked tumor was successfully excised and extruded through a longitudinal duodenotomy. The pathology report showed a gangliocytic paraganglioma with negative lymph nodes.

Conclusions:

In patients presenting with prolonged recurrent attacks of vomiting, diagnostic workup to exclude anatomic causes is mandatory. Gangliocytic paraganglioma must be considered in the differential diagnosis of an intraduodenal tumor.

Hypervascular subepithelial gastrointestinal masses: CT-pathologic correlation

Although the vast majority of gastrointestinal (GI) masses are epithelial neoplasms, a variety of subepithelial masses are infrequently encountered during endoscopic or radiologic examination. A subepithelial mass, which was previously called a submucosal mass, is defined as a mass covered with normal-appearing mucosa, whether the underlying process is intramural or extramural in origin. At contrast material-enhanced computed tomography (CT), hypervascular subepithelial masses are usually detected more easily than isoattenuating or hypovascular masses. Entities that appear as intramural hypervascular subepithelial lesions include neuroendocrine tumors, GI stromal tumor, glomus tumor, hemangioma, angiosarcoma, Kaposi sarcoma, nerve sheath tumors, hypervascular metastases, heterotopic tissues, and vascular structures. Entities that appear as extramural hypervascular subepithelial lesions include Castleman disease, solitary fibrous tumor, inflammatory myofibroblastic tumor, and actinomycosis. Some rare gastric cancers resemble subepithelial tumors. In comparison with endoscopic ultrasonography, CT is of limited value in differentiating the layers of the GI wall and determining the origin of mass lesions. However, recent advances in multidetector CT with multiplanar reformation allow one to determine whether a GI mass is of epithelial, intramural subepithelial, or extramural subepithelial origin. Furthermore, the full extent of tumors can be delineated, and local invasion and distant metastases can be identified. Familiarity with the characteristic CT appearances of hypervascular subepithelial masses of the GI tract will help radiologists make a more confident diagnosis.

Endoscopic resection of nonadenomatous ampullary neoplasms

The safety and effectiveness of endoscopic management of ampullary adenomas is well known. However, data on the endoscopic treatment and long-term outcome of nonadenomatous ampullary neoplasms are lacking. We describe our experience with the endoscopic management and the follow-up of 4 patients with nonadenomatous ampullary neoplasms viz, ampullary carcinoid, gangliocytic paraganglioma, ampullary hamartoma in patients with Peutz-Jegher syndrome and Cowdens syndrome.

First reported case of esophageal paraganglioma. A review of the literature of gastrointestinal tract paraganglioma including gangliocytic paraganglioma

Paraganglioma and the variant gangliocytic paraganglioma are rare gastrointestinal tumors. We present the first reported case of an esophageal paraganglioma and a review of the literature. From this review it seems that these tumors can occur at any age and usually present with acute or chronic bleeding with or without abdominal pain. The majority of reported cases originated in the foregut, most commonly the second part of the duodenum. Macroscopically the tumor may be pedunculated, sessile or ulcerated and have been described up to 10 cm in size. There are no reported cases of gut paragangliomas shown to be producing clinically significant amounts of catecholamines. The majority of reported tumors have been benign, only 7% malignant at presentation and all with lymph node metastases. One case developed bone metastases 3 years after excision and another recurred locally. There has been no benefit seen from radiotherapy or chemotherapy to date and it is recommended that all of these tumors are widely excised together with a lymph node resection if possible.

Hemodynamic activity associated with a paraganglioma of the cauda equina. Case report

A 53-year-old man presented with a paraganglioma of the cauda equina that caused significant hemodynamic instability during removal. The clinical implications of this phenomenon are discussed.

Ganglioneuroma of the duodenum. Report of a case and literature review

A 43-year-old male presented with upper gastro-intestinal bleeding. A polypoid tumor mass in the second part of the duodenum was found by endoscopic examination. Pathology revealed an extremely rare case of ganglioneuroma. The surgical local resection of the tumor was a sufficient procedure because of a lack of malignant potential. This is the fourth case since the first case was reported by Dahl et al in 1957 (1). We review the literature concerning duodenal paragangliomas, and discuss the histogenesis.