Ganglioneuroma: computed tomography and magnetic resonance features

Adrenal ganglioneuroma with nodal metastases on 123I-MIBG SPECT/CT and 18F-FDG PET/CT

Ganglioneuroma is a well-differentiated tumor originating from neural crest cells of the sympathetic nervous system. Although benign, a few cases have been reported that ganglioneuroma can metastasize to other sites. We report a case of adrenal ganglioneuroma with para-aortic nodal metastases with low FDG and MIBG uptake. In order to avoid unnecessary wide excision or aggressive medication, it is important to consider the possibility of ganglioneuroma preoperatively even if with metastases.

Retroperitoneal Peripancreatic Ganglioneuroma Encasing the Celiac Trunk and Superior Mesenteric Artery

A retroperitoneal ganglioneuroma is an exceptionally rare surgical entity, even more so in pancreaticoduodenal tumors. These well-differentiated neuroepithelial tumors originate in the neural crest, emerge in the sympathetic nervous system, and consist of ganglion cells and stromal Schwann cells. Generally, these tumors, despite being mostly benign, may be associated with venous or arterial vascular involvement. The symptomatology presented will depend on the mass effect due to tumor growth, and surgical excision is the only therapeutic option offered today to these patients. However, encapsulation of the main vessels represents a great surgical complexity. Various surgical approaches have been employed throughout history; however, the current preferred method is an open midline laparotomy, involving an extensive Kocher maneuver and an artery-first approach, aiming for an R0 resection of the tumor with total vascular preservation to the greatest extent possible. We present a case of an R2 resection involving a 95 mm x 85 mm retroperitoneal peripancreatic ganglioneuroma with double vascular involvement (celiac trunk and superior mesenteric artery). The procedure utilized an artery-first approach with total vascular preservation in a 17-year-old woman who had long-standing gastrointestinal symptoms due to the mass effect.

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.

A giant lobular thoracic ganglioneuroma cause skeletal erosion: A case report and literature review

RATIONALE

Ganglioneuroma (GN) is a rare tumor that originates from neural crest cells and can manifest in any location along the sympathetic chain. It typically exhibits a circular or oval shape and does not invade the surrounding tissue destructively and the enormous lobular appearance and erosion of adjacent skeletal tissues are extremely infrequent among GN.

PATIENT CONCERNS

A 15-year-old girl presented to our thoracic surgery clinic with a large intrathoracic mass that was incidentally discovered on a chest X-ray. Further imaging with computed tomography and magnetic resonance imaging revealed a lobular profile and an aggressive growth pattern of the tumor, which destroyed the vertebral and rib bones. A tissue sample obtained by needle biopsy was subjected to histopathological analysis, which confirmed the diagnosis of a GN.

DIAGNOSIS

Thoracic (posterior mediastinal) GN and Hashimoto's thyroiditis.

INTERVENTIONS

After thoracoscopic exploration, a thoracotomy was performed to excise the mass.

OUTCOMES

The patient recovered well after surgery, had no major complications, and was discharged without any issues. Further follow-up is necessary to clarify the medium to long-term outcome.

LESSONS

Based on existing reports, thoracic GN rarely erodes adjacent bone tissue. By examining previously reported cases, we speculate that the lobular morphology of the tumor may be linked to the more aggressive biological behavior of GN. We also discovered that female patients may be more susceptible to bone erosion. However, further research and additional cases are required to confirm these potential associations.

Cervical ganglioneuroma arising from the dorsal root ganglion: illustrative case

BACKGROUND

Ganglioneuroma is a benign and well-differentiated tumor derived from neural crest cells, which occurs infrequently, with most patients being female and adolescents. While predilection sites are the posterior mediastinum and retroperitoneal cavity, ganglioneuroma originating from the dorsal root ganglion is very rare. Here the authors report a case with C2 dorsal root ganglion-derived ganglioneuroma with some literature review.

OBSERVATIONS

A 45-year-old male patient complained of persistent right-side throbbing occipital headache for more than a year. Magnetic resonance imaging (MRI) of the cervical spine revealed a dumbbell-shaped intradural extramedullary tumor from the C2 posterior surface of the odontoid to right C1-2 intervertebral foramen with high T2- and low T1-weighted signal intensities. The tumor displayed homogeneous contrast enhancement by MRI. The authors suspected schwannoma and performed a tumorectomy for both diagnosis and treatment purposes. Intraoperative findings showed that the tumor originated from the dorsal root ganglion, and pathological examination revealed ganglioneuroma. Immediately after the tumorectomy, the throbbing occipital headache disappeared and the patient was discharged from the hospital without major complications.

LESSONS

Although ganglioneuroma derived from the dorsal root ganglion is very rare, a differential diagnosis of the ganglioneuroma should be made, when schwannoma is suspected.

Adrenal Ganglioneuroma: A Case Report

Adrenal ganglioneuroma (AGN) are sympathetic differentiated tumors that originate from neural crest cells. It is a rare benign tumor in children and young adults. These lesions are usually asymptomatic and tend to be hormonally silent. Their discovery is fortuitous in imaging examinations.

Preoperative diagnosis remains difficult, and the gold standard treatment is adrenalectomy. There is a good prognosis after surgery without recurrence. We herein report a case of adrenal ganglioneuroma in a 40-year-old man who benefited from an abdominal CT scan in the face of a complaint of abdominal discomfort and as part of the extension assessment of his colonic adenocarcinoma. Abdominal CT scan with contrast showed a left retroperitoneal mass of triangular shape within the adrenal lodge of tissue density, containing some calcifications not enhanced after injection of contrast product, measuring 90 x 62 mm in diameter (AP x T) with a relative washout calculated at 30%. Biopsy and histological examination of the mass suggested an adrenal ganglioneuroma.

Comparison of two Schwann Cell-Containing Orbital Tumors: Schwannoma and Ganglioneuroma

Orbital tumors comprise a variety of diseases, although tumors of the peripheral nerves are rare. Of these, schwannoma is considered the most common entity, consisting histopathologically almost exclusively of Schwann cells. Another benign tumor containing Schwann cells is ganglioneuroma. Here, ganglion cells are histopathologically apparent in addition to the Schwann cell-containing stroma. Ganglioneuroma belongs to the group of neuroblastic tumors and can occur anywhere in the pathway of sympathetic ganglion cells. In this report, we present the disease courses as well as the findings of two patients with different orbital tumors. In both cases, the diagnosis was only confirmed by histopathological examination. The first patient had a schwannoma with cystic degeneration and the second patient had a ganglioneuroma, both tumor entities which occur only rarely in the orbit. Commonalities and differences are discussed.

Adrenal incidentaloma. Part 2. Modern concepts of computed tomography semiotics of adrenal gland incidentalomas: algorithm of differential diagnosis

While accidentally detecting an adrenal gland lesion (incidentaloma) during a routine computed tomography (CT) scan, the radiologist should correctly interpret revealed changes. The most common lesion is adenoma with high lipid content, but a lipid poor adenoma, pheochromocytoma, adrenocortical cancer, metastasis and other less common adrenal diseases are also worth of attention and require detailed knowledge of their CT semiotics. The article presents criteria of differential diagnosis of the adrenal incidentalomas on the basis of which an algorithm of differential diagnosis was proposed for the most common adrenal lesions.

A Rare Case of Giant Mediastinal Ganglioneuroma in A 3-year-old

Ganglioneuroma is a rare, differentiated, and benign neurogenic tumor that could grow into a huge size with minimal or no symptoms at all. Ganglioneuroma is typically found in older children or adults and is commonly detected within the posterior mediastinum (other than retroperitoneal). Here, we present a case of a 3-year-old patient with shortness of breath, and radiological examination showed a giant mediastinal tumor which proved to be a ganglioneuroma after histopathological examination. This study highlights the possibility of ganglioneuroma occurring in younger children and the role of imaging in assessing ganglioneuroma as a posterior mediastinal tumor.

Pancreatic/peripancreatic neurogenic tumor; little known masses not to be missed

BACKGROUND

Retroperitoneal neurogenic tumors are extremely rare pathological entities; therefore, few clinical features and natural courses, especially originating from the pancreatic/peripancreatic regions, have been reported. This study aimed to investigate the clinicopathological features of pancreatic and peripancreatic neurogenic tumors and assess the diagnostic value of computed tomography (CT) and endoscopic ultrasound-guided fine needle biopsy (EUS-FNB).

METHODS

Between 2006 and 2018, patients who were diagnosed with neurogenic tumors were included. In total, 90 histologically confirmed cases of neurogenic tumors located in the pancreatic/peripancreatic regions were selected for analysis.

RESULTS

The mean age was 49.2 ± 13.1 years. There were no differences in sex distribution of the tumors. Schwannomas (44.4%) and paragangliomas (41.1%) were the most common neurogenic tumors. The sensitivity of CT was 62.2% in 90 cases. EUS-FNB was performed in 30 cases and the sensitivity of it was 83.3%. The diagnosis of neurogenic tumors with EUS-FNB or CT was not significantly associated with tumor location and size. Surgical resection was performed in 78 cases. Of the 12 patients who did not undergo surgery, 10 cases were followed-up without any increase in tumor size.

CONCLUSIONS

Through the present study, we verified radiological, pathological, and clinical aspects of the pancreatic/peripancreatic neurogenic tumors which little known before, therefore, this study can serve as the basis for research to present an optimal diagnosis and treatment of neurogenic tumors. In addition, EUS-FNB is useful in the diagnosis of pancreatic/peripancreatic neurogenic tumors with relatively high sensitivity and can help establish therapeutic plans before the surgery.

Radiologic-Pathologic Correlation of Primary Retroperitoneal Neoplasms

An earlier incorrect version of this article appeared in print. The online version is correct.

Presentation and outcomes of adrenal ganglioneuromas: A cohort study and a systematic review of literature

OBJECTIVE

To describe the presentation and outcomes of patients with adrenal ganglioneuromas (AGNs).

DESIGN

Single-centre retrospective cohort study (1 January 1995 to 31 December 2019) and systematic review of literature (1 January 1980 to 19 November 2019).

PATIENTS

Diagnosed with histologically confirmed AGN.

MEASUREMENTS

Baseline clinical, imaging and biochemical characteristics, recurrence rates and mortality. Subgroup analysis was performed on tumours with histologic elements of ganglioneuroma and pheochromocytoma (ie composite tumours).

RESULTS

The cohort study included 45 patients with AGN, 20 (44%) of which had composite tumours. Compared to pure AGN, patients with composite tumour were older (median age, 62.5 vs. 35 years, p < .001), had smaller tumours (median size, 3.9 vs. 5.7 cm, p = .016) and were discovered incidentally less frequently (65% vs. 84%, p = .009). No recurrences or ganglioneuroma-specific mortality occurred during follow-up (range, 0-266 months). The systematic review included 14 additional studies and 421 patients. The mean age of diagnosis was 39 years, and 47% were women. AGNs were discovered incidentally in 72% of patients, were predominantly unilateral (99%) and had a mean diameter of 5.8 cm and an unenhanced computed tomography (CT) attenuation of -118 to 49 Hounsfield units (HU). On imaging, 69% of AGNs were homogenous, 41% demonstrated calcifications, and 40% were lobulated.

CONCLUSIONS

AGNs are rare benign tumours that present with variable imaging features including large size, unenhanced CT attenuation >20 HU, calcifications and lobulated shape. Imaging characteristics can assist in establishing a diagnosis and avoiding an unnecessary adrenalectomy. The association of pheochromocytomas with AGNs is frequent. Diagnosis should include biochemical testing.

Total laparoscopic excision of retroperitoneal ganglioneuroma: A case report

Introduction

Ganglioneuromas are rare benign tumors originating from neural crests and typically affect young adults. The most frequent locations are the posterior mediastinum, retroperitoneum and adrenal gland. In general, retroperitoneal ganglioneuromas are discovered incidentally or by mass effect. In the literature, the number of retroperitoneal masses reported is quite limited. We report a case of laparoscopic excision of a retroperitoneal ganglioneuroma.

Presentation of case

The patient was a 40-year-old woman who visited a nearby clinic with anorexia and vomiting. She was referred to our hospital after the detection of an abdominal mass.

Enhanced computed tomography(CT) showed a lobule mass of 107 × 42 mm in size, with internal inhomogeneity and mild delayed enhancement on the retroperitoneal side of the left abdominal lesion. Magnetic resonance imaging(MRI) showed a mass with low intensity and partial high intensity on T2 weighted Image (T2WI). In addition, positron emission tomography CT(PET-CT) detected slight fluorodeoxyglucose (FDG) accumulation (standardized uptake value(SUV) max: 3.01) in the same lesion. Based on these findings, we suspected a retroperitoneal tumor. Laparoscopic excision was performed via 5 ports. The extracted tissue was a well-defined mass of 110 × 70 mm. The tumor in our case exceeded 10 cm.

The pathological diagnosis was ganglioneuroma, with no obvious malignancy.

Discussion

It was suggested that adaptation of laparoscopic surgery should be considered based on the observation of organ invasion or vessel invasion and adhesion around the tumor, rather than based on the diameter of the tumor.

Conclusion

This approach is less invasive than conventional laparotomy methods and achieves good cosmetic outcomes. Thus, totally laparoscopic procedures should be considered more often for the treatment of retroperitoneal tumors.

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Retroperitoneal tumor of >10 cm in size is usually treated by laparotomy surgery.

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However, totally laparoscopic approach can be performed with good outcomes.

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Adaptation of laparoscopic surgery should be considered based on organ or vessel invasion and adhesion around the tumor.

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This approach is less invasive and achieves good cosmetic outcomes.

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Totally laparoscopic surgery should be considered for retroperitoneal tumor excisions.

Continuous and progressive 'wash-in' without 'wash-out' of contrast in adrenal mass: a useful feature of ganglioneuroma

Computed tomography (CT) scan is a useful and widely performed diagnostic modality to evaluate adrenal masses. Nature of the mass determines the degree of attenuation both in unenhanced and in different phases of contrast enhancement. Benign neurogenic tumours like ganglioneuroma mimicks pheochromocytoma and adrenocortical carcinoma in non-contrast CT scan. The 'adrenal protocol' routinely calculates the wash-out pattern at delayed venous phase (DVP) (15 min) following contrast administration to differentiate majority of benign masses from the malignant ones. Ganglioneuromas typically exhibit continuous wash-in of contrast where enhancement gradually increases to attain its peak in DVP. Such wash-in pattern is different from the wash-out pattern observed in pheochromocytomas or adrenocortical adenomas or carcinomas. Presence of this wash-in pattern provides a useful clue to the clinician for underlying ganglioneuroma in hormonally inactive adrenal masses with suspicious morphological appearances. This wash-in pattern also effectively rules out any malignant potential of ganglioneuroma, and thus helps in preoperative decision-making.

Robotic and standard surgical intervention as adjunct therapies for retroperitoneal ganglioneuroma resection: a case report

Background

Ganglioneuroma (GN) is ranked by the International Neuroblastoma Pathology Classification as a benign tumor. It can occur anywhere along the sympathetic nerve chain and surgical excision is the treatment of choice.

Case presentation

An 18-year-old female patient sought medical assistance after 6 months of constant dorsal and back pain radiating from the thoracic region to the right abdominal flank. Magnetic resonance imaging revealed a solid nodular lesion with heterogeneous post-contrast enhancement and lobulated contours, centered on the right foramina of D12–L1, with a projection to the intracanal space, which compressed and laterally displaced the dural sac and had a right paravertebral extension between the vertebral bodies of D11 and superior aspect of L2. Ganglioneuroma was diagnosed using immunohistochemical analysis. It was decided to use a surgical approach in two stages: robot assisted for the anterior/retroperitoneal mass and a posterior hemilaminectomy/microsurgical approach to attempt total resection, avoiding the traditional anterior thoracoabdominal surgical incision and optimizing the patient’s postoperative outcomes. No postoperative adverse events were noted, and the patient was discharged on postoperative day 5.

Conclusion

This retroperitoneal GN presentation was peculiar because it originated at the D12 nerve root, which extended to the retroperitoneal space and inside the spinal canal. We hope that our case report can assist future decisions in similar circumstances.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01146-x.

A Common Tumor with an Unusual Finding: Mature Cystic Teratoma Containing a Ganglioneuroma

BACKGROUND

Ganglioneuromas (GNs) arise from peripheral or central areas of the autonomic nervous system, being benign lesions of neuroblastic origin.

CASE

A 19-year-old Greek female patient was admitted to our clinic with symptoms of periodic lower abdominal pain and irritation since some months ago. Ultrasonography revealed a mass of 72 × 68 mm originating from the left ovary giving the characteristics of a typical dermoid cyst. Laparoscopic ovarian cystectomy was done. The histological diagnosis revealed a mature cystic teratoma with a small hidden GN.

SUMMARY AND CONCLUSION

Histology remains the gold standard for their confirmation. The coexistence of GN within a mature cystic teratoma happens extremely rarely. This is one of the few cases reported in the literature.

Computed tomography characteristics of adrenal ganglioneuroma: a retrospective analysis of 30 pathologically-confirmed cases

Objective

To investigate the computed tomography (CT) characteristics of adrenal ganglioneuromas (AGNs) and to determine the ability of CT scanning to distinguish between large (>3 cm) and small (≤3 cm) AGNs.

Methods

This retrospective study searched the electronic medical record system of a hospital between January 2008 and July 2019 in order to identify patients with pathologically-confirmed AGNs that underwent three phases of CT scanning. The CT features were compared between large and small AGNs.

Results

A total of 30 patients with pathologically-confirmed AGNs were included in the study. The majority of patients (76.7%; 23 of 30) were asymptomatic and there were nonspecific symptoms in seven patients. The ‘pointed peach’ sign appeared in more than half of the patients (53.3%; 16 of 30). The CT value of the arterial phase, progressive enhancement, morphology and calcification in the CT images were found to be significantly different between large and small AGNs. Progressive enhancement was more likely to occur in small AGNs. Most large AGNs had irregular shapes, while small AGNs were likely to be round or oval with a smooth border. Calcifications were noted in large AGNs (42.9%; six of 14).

Conclusion

CT scanning can show many of the key imaging characteristics of AGNs used to distinguish between large and small AGNs.

Adrenal schwannoma: a case report

Retroperitoneum is an uncommon site for Schwannoma tumors and among adrenal incidentaloma the Schwannoma is rare. This condition lacks of a specific clinical and radiological features, but correct diagnosis before pathological examination should be very important for clinical management and surgical decision. We describe a case of voluminous retroperitoneal incidental mass, that was proved to be an adrenal Schwannoma.

Occurrence of paratesticular ganglioneuroma 18 years after concurrent adrenal ganglioneuroma and papillary thyroid carcinoma - a case report

BACKGROUND

Ganglioneuromas (GNs) are composed of mature ganglion cells and Schwann cells with a fibrous stroma; GNs are most often observed in children and young adults. The majority of non-cranial GNs are located in the retroperitoneum and posterior mediastinum. Other reported rare sites include the adrenal gland, small intestine, colon and urinary bladder. However, para-testicular GNs are even more rare.

CASE PRESENTATION

Herein, we report the case of a patient with concurrent adrenal GN and thyroid papillary carcinoma who developed paratesticular GN eighteen years later.

CONCLUSIONS

We conclude that there is an association among papillary thyroid carcinoma, GN and MEN2 syndromes. This case report may provide important information for the proposed association. However, further studies are required.

Cause of postprandial vomiting - a giant retroperitoneal ganglioneuroma enclosing large blood vessels: A case report

BACKGROUND

Ganglioneuroma (GN) is a rare neurogenic tumor that accounts for about 0.1%-0.5% of all tumors of the nervous system. It originates from neural crest cells. GN has no specific clinical symptoms or laboratory findings, which leaves it easily overlooked and misdiagnosed as other tumors. Retroperitoneal GN with very large volume and vascular penetration is extremely rare.

CASE SUMMARY

We present the imaging and pathological findings of a giant retroperitoneal GN in a child. A 4-year-old boy had suffered from postprandial vomiting for more than 6 mo with no precipitating factors. Abdominal computerized tomographic examination showed a giant cystic mass in the retroperitoneal area. After injection of contrast agent, the mass showed heterogeneous enhancement. Surgery with local excision of the mass was performed to address the embedded abdominal blood vessels, and the histopathological and immunohistochemical diagnosis of the mass was GN. Postprandial vomiting was relieved, and no complications occurred after the operation.

CONCLUSION

In the diagnosis of giant retroperitoneal hypodense masses in children, GN should be considered if the mass presents delayed enhancement, punctate calcification, and vascular embedding but no invasion. Pathology is the golden standard for the diagnosis of GN, and surgical excision is the optimal treatment for GN.

Imaging Analysis of Ganglioneuroma and Quantitative Analysis of Paraspinal Ganglioneuroma

BACKGROUND This study evaluated the imaging features of ganglioneuroma (GN) and assessed the diagnostic value of the enhancement rate (ER) of CT for GN. MATERIAL AND METHODS We retrospectively reviewed records of 49 patients with histopathologically confirmed GN who underwent preoperative contrast-enhanced CT or MRI between 2010 and 2018. The independent samples t test and chi-square test were used. Receiver operating characteristic (ROC) curves were generated to analyze the diagnostic sensitivity (SE) and specificity (SP). Positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS The CT values were 32.59±3.61 Hounsfield units (HU) for plain scans, 38.87±5.09 HU for the arterial phase, and 54.26±8.14 HU for the venous phase, and the incidence of calcification and cysts was 32.6% and 10.2%, respectively. There was no significant difference in CT results and clinical parameters between mediastinal ganglioneuroma (MGN) and retroperitoneal ganglioneuroma (RGN) (p>0.05). The area under the curves (AUCs) for the arterial enhancement rate (AER), venous enhancement rate (VER), and AER/VER combined index in diagnosing GN were 0.735, 0.980, and 0.990, respectively. The VER of 0.2819 exhibited the SE and SP at 92.9% and 92.9%, respectively, to characterize the GN, whereas the AER of 0.1779 had SE and SP of 52.4% and 90.5%, respectively. The SE and SP for the combined index were 88.1% and 100%, respectively. The GN showed hypointensity on T1WI, hyperintense, or slightly high signal on T2WI with the linear hypointensity, and hyperintense on DWI. CONCLUSIONS A hypodense mass was observed for GN on plain scan and presented delayed enhancement on contrast enhancement. VER or AER/VER combination is more accurate than AER for the diagnosis of paravertebral GN.

Retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuromas: our technique and clinical outcomes

OBJECTIVE

To report our experience of retroperitoneoscopic technique in semi-lateral decubitus position for the retroperitoneal nonadrenal ganglioneuromas in 18 patients, and to evaluate its clinical outcomes.

MATERIALS AND METHODS

From January 2012 to May 2016, 18 patients with retroperitoneal nonadrenal ganglioneuromas underwent retroperitoneoscopic resection. With the patients in semi-lateral decubitus position, a 4-port retroperitoneal approach was used. Data were collected on the tumor size, tumor location, perioperative outcomes, pathology, and lastknown disease status. We reviewed the operative videos to identify surgical tips and tricks.

RESULTS

All procedures were carried out successfully without converting to open surgery. The tumors had an average size of 5.2cm. The mean operative time was 86.5 min, with a mean estimated blood loss of 85.4mL. There were three patients suffering from intraoperative complications. Postoperatively, all patients achieved an uneventful recovery; the mean postoperative hospital stay was 5.5 days. The postoperative pathology revealed to be retroperitoneal ganglioneuromas. With a mean follow-up of 39.5 months, all patients were recurrence free. The review of the operative videos revealed several tips and tricks, including keeping peritoneum and posterior Gerota fascia intact to provide a favorable operative exposure of tumors, and placing the harmonic scalpel through different ports during tumor dissection.

CONCLUSIONS

With the patient in semi-lateral decubitus position and a 4-port retroperitoneal approach, retroperitoneoscopic resection of retroperitoneal nonadrenal ganglioneuroma is a feasible, effective, and safe procedure. This approach has distinct advantages including direct access to the tumor, optimal exposure of tumor and less intraperitoneal interference.

Magnetic resonance neurography in the diagnosis of a retroperitoneal ganglioneuroma: Case report and literature review

Magnetic resonance neurography is a technique for identifying anatomy and pathologic lesions of nerves, and has emerged as a helpful technique for localizing lesions and elucidating the underlying etiology. Ganglioneuromas are highly differentiated benign tumors. This lesion is rare and exhibits undetermined symptoms, the features of using the magnetic resonance neurography are a great ally to determine its diagnosis. The authors illustrate a case of retroperitoneal ganglioneuroma emphasizing its image characteristics using magnetic resonance neurography with the diagnosis confirmed by histopathological examination.

Intradural Ganglioneuroma Mimicking Lumbar Disc Herniation: Case Report

BACKGROUND

Ganglioneuroma (GN) is a slow-growing tumor originating from the neural crest-derived cells, which form the sympathetic nervous system. These tumors can affect anywhere along the peripheral autonomic ganglion sites and are most commonly found in the mediastinum and retroperitoneum. Spinal GNs are extremely rare and, so far, only 1 case arising from a lumbar nerve root has been reported in the English literature. GNs are often asymptomatic, and the majority of them are found incidentally in healthy subjects. Because of their slow growth, symptoms may result from the compressive effect of the tumor.

CASE DESCRIPTION

A 40-year-old man presented with a right sciatica episode accompanied by global muscle weakness and tingling pain. Findings of the neurologic examination displayed positive Lasegue test and sensory deficit over L5-S1 dermatomes. Magnetic resonance imaging of the lumbar spine without contrast showed a well-circumscribed longitudinal lesion arising from L5-S1 disc space, moving us toward a diagnosis of lumbar disc herniation. During surgery, we observed a mass well-encapsulated and oval-shaped inside S1 right root. The patient underwent subtotal resection. Histopathologic examination showed clusters of ganglion mature cells with neuromatous stroma, consistent with a ganglioneuroma.

CONCLUSIONS

We report a case that illustrates the clinical, radiologic, and histopathologic features of a ganglioneuroma mimicking a lumbosciatica syndrome and review related literature and similar cases.

Extensive spinal extradural ganglioneuroma of the lumbar spine: mimicking lymphoma

BACKGROUND

Ganglioneuromas are rare, benign, well-differentiated tumors arising from neural crest cells that commonly occur in the posterior mediastinum, retroperitoneum, cervical spine, and adrenal gland. We report an unusual case of an extensive spinal extradural ganglioneuroma, circumferentially and longitudinally affecting the extradural space of the lumbar spine and continuously invading bilateral psoas muscles.

CASE DESCRIPTION

A 32-year-old man presented with a 1-week history of abdominal pain and diarrhea. Radiographs revealed scalloping of the posterior surfaces of the L2 and L3 vertebral bodies and widening of L2-3 and L3-4 bilateral intervertebral foramina. Computed tomography scans and magnetic resonance imaging showed a well-defined lobulated extradural mass from L1 to L4 and a continuously forming mass in the psoas muscles through L2-3 bilateral neural foramina. The mass demonstrated homogeneously isointense signal on T1-weighted images, inhomogeneously hyperintense-to-isointense signal on T2-weighted images, and inhomogeneous enhancement on fat-suppressed contrast-enhanced T1-weighted images. Radiologic diagnosis included spinal epidural lymphoma. Percutaneous biopsy with sonographic guidance was performed, and the mass was diagnosed on pathological examination as a ganglioneuroma.

CONCLUSIONS

This is the first known reported case in the literature of a spinal extradural ganglioneuroma with circumferentially and longitudinally extensive involvement of the extradural space and a large psoas mass.

Imaging of Nonmalignant Adrenal Lesions in Children

The adrenal glands in children can be affected by a variety of benign lesions. The diagnosis of adrenal lesions can be challenging, but assessment of morphologic changes in correlation with the clinical presentation can lead to an accurate diagnosis. These lesions can be classified by their cause: congenital (eg, discoid adrenal gland, horseshoe adrenal gland, and epithelial cysts), vascular and/or traumatic (eg, adrenal hemorrhage), infectious (eg, granulomatous diseases), enzyme deficiency disorders (eg, congenital adrenal hyperplasia [CAH] and Wolman disease), benign neoplasms (eg, pheochromocytomas, ganglioneuromas, adrenal adenomas, and myelolipomas), and adrenal mass mimics (eg, extralobar sequestration and extramedullary hematopoiesis). Multimodality cross-sectional imaging helps to define the origin, extent, and relationship of these lesions to adjacent structures, as well as to guide treatment management. The anatomic and functional imaging modalities used to evaluate pediatric adrenal lesions include ultrasonography, computed tomography (CT), magnetic resonance imaging, and iodine 123 metaiodobenzylguanidine scintigraphy. Identifying the imaging features of nonmalignant adrenal lesions is helpful to distinguish these lesions from malignant adrenal neoplasms. Identifying characteristic imaging findings (eg, enlarged adrenal glands, with cerebriform surface, and stippled echogenicity in CAH; a T2-hyperintense mass with avid contrast enhancement in pheochromocytoma; low CT attenuation [<10 HU] and signal intensity drop on opposed-phase chemical shift images in adenoma; and enhancing suprarenal mass supplied by a systemic feeding artery in extralobar sequestration) can aid in making the correct diagnosis. In addition, clinical features (eg, ambiguous genitalia in CAH and hypertension in pheochromocytoma) can also guide the radiologist toward the correct diagnosis. ^©RSNA, 2017.

Adrenal ganglioneuroma: The Padua Endocrine Surgery Unit experience

BACKGROUND

Adrenal ganglioneuroma (AGN) is a rare tumor that originates from the gangliar cells of the sympathetic nervous system. It represents less than 5% of all adrenal masses. AGN occurs as a large mass, with benign behavior and no relevant symptoms and hormonal secretion, but it is often misdiagnosed because the preoperative radiological diagnosis is generally challenging. The aim of the present paper is to report the experience of a tertiary referral academic center regarding the management of AGN and review the relevant literature.

METHODS

The demographic, diagnostic, surgical, and pathological findings of 666 consecutive patients who were adrenalectomized at the Padua Endocrine Surgery Unit between 1990 and 2015 were retrospectively reviewed in order to focus on AGN.

RESULTS

The pathology confirmed AGN in 10 patients (1.5% of cases; median age 35 years, range 19-73). The diagnosis was incidental and never available before surgery. Eight patients were asymptomatic, two presented lower back and abdominal pain. The mass was non-secreting in all cases. Preoperative imaging techniques were inconclusive about the nature of the mass in all cases. The median size of the tumor was 55 mm (range 30-80). The laparoscopic approach was performed in 60% of cases. No recurrences occurred after surgery at a median follow-up of 10 years (range 1.7-18.2).

CONCLUSION

The diagnosis of AGN may be challenging and most often occurs after surgery, since it is frequently confirmed by histological examination. Radical excision may be achieved by laparoscopic adrenalectomy, with a subsequent definitive cure and excellent prognosis at long term follow up.

Synchronous Ganglioneuroma and Schwannoma Mistaken for Carotid Body Tumor

Ganglioneuromas are a very rare benign neural tumor, commonly derived from the ganglia of the sympathetic system, and are composed of mature Schwann cells, ganglion cells, and nerve fibres. They may arise anywhere from the base of the skull to the pelvis along the paravertebral sympathetic plexus. We report a rare case of synchronous ganglioneuroma and schwannoma, mistaken for carotid body tumor. The coexistence of these two entities in head and neck region is very rare.

Clinicopathological Features of Ganglioneuroma Originating From the Adrenal Glands

BACKGROUND

Ganglioneuromas are benign tumors that rarely develop from adrenal glands. In this study, we present our clinical experience of patients with adrenal ganglioneuroma (AGN).

METHODS

Demographic, diagnostic, surgical, and pathologic findings of patients who were adrenalectomized as a result of AGN were retrospectively reviewed from the database of a tertiary referral hospital.

RESULTS

Among 1784 patients who underwent an adrenalectomy between 2002 and 2015, 35 (1.9 %; 14 males, 21 females) were diagnosed with AGN. Mean age was 33.4 ± 18.7 years (0-84). Twenty-nine (82.9 %) were asymptomatic, four (11.4 %) complained of abdominal discomfort, and two (5.7 %) had abdominal distension. Preoperative computed tomography (CT) reported AGN in 22 (62.9 %) cases. Precontrast Hounsfield units, increased postcontrast phase attenuation, and well-defined borders were characteristic CT features of AGN. Mean tumor size was 6.3 ± 3.3 cm (range, 1.5-16.0). No recurrence occurred during a median follow-up period of 19 months (range, 1-120).

CONCLUSION

AGN was asymptomatic in most cases and diagnosis may be challenging. Adrenalectomy is a safe treatment modality for AGN and ensures favorable outcomes when diagnosed.

Ganglioneuroma of the External Auditory Canal and Middle Ear

Objective

We report an extremely rare case of ganglioneuroma involving the external auditory canal and middle ear.

Case Report

Ganglioneuromas are rare benign mature tumors thought to originate from sympathetic ganglions, with the highest incidence in the retroperitoneum, adrenal medulla, and posterior mediastinum. We present a case of ganglioneuroma of the external auditory canal and middle ear. At the age of 12 months, the patient was diagnosed with neuroblastoma stage IV with metastasis to the squamous temporal bone, bone marrow, and skull base. He received a high-risk protocol regimen resulting in complete remission. The patient later presented with recurrent right ear discharge at the age of six years and was diagnosed with ganglioneuroma of external auditory canal and middle ear after appropriate investigations. We report in this article the clinical presentation, investigations, surgical intervention, and follow-up.

Conclusion

After the literature review and to our knowledge, this is the first reported case of its kind. Ganglioneuroma maturing from neuroblastoma is one of the theories describing pathophysiology of the disease. Ganglioneuroma should be considered in the differential diagnosis of patients presenting with recurrent ear discharge and decreased hearing in treated cases of neuroblastoma with metastases to temporal bone.

An unusual case of fatty posterior mediastinal ganglioneuroma

Ganglioneuromas, which arise from neural crest cells, are typically seen in adolescent and young adults. We describe an unusual case of posterior mediastinal ganglioneuroma with a large fatty component in a middle-aged male. This imaging feature has only been reported in five published manuscripts in the English literature.

Dumbbell Scoring System: A New Method for the Differential Diagnosis of Malignant and Benign Spinal Dumbbell Tumors

STUDY DESIGN

Retrospective diagnostic analysis.

OBJECTIVE

The aim of the study was to establish a new scoring system, the dumbbell scoring system (DSS), for preoperative evaluation of the malignant potential of spinal dumbbell tumors (SDTs).

SUMMARY OF BACKGROUND DATA

Among SDTs, benign tumors such as schwannomas occur frequently, whereas malignant SDTs, including malignant peripheral nerve sheath tumors, are uncommon. No scoring system has been developed to preoperatively diagnose the malignant potential of SDTs.

METHODS

We retrospectively reviewed the records of 59 consecutive patients with SDTs. The following imaging features were recorded: tumor size, tumor shape, tumor boundary, pattern of enhancement of intratumoral lesions (homogeneous or heterogeneous), cyst formation in the tumors on magnetic resonance imaging, and enlargement of neural foramina and scalloping or osteolytic destruction of surrounding bones on computed tomography. The prevalence of characteristic imaging features in malignant and benign SDTs were evaluated, and appropriate cut-off points for the DSS score were obtained using receiver operating characteristics.

RESULTS

Twenty cases were confirmed to be malignant tumors. Pathological diagnoses of the malignant SDTs were as follows: 11 cases of malignant peripheral nerve sheath tumor; 3 cases of malignant lymphoma; and 1 case each of extraskeletal Ewing sarcoma, hemangiopericytoma, hemangioendothelioma, malignant myoepithelioma, neuroblastoma, and plasmacytoma. The DSS was based on four characteristic imaging features confirmed as significant predictors of malignant SDTs, namely, maximal diameter greater than 5 cm, irregularly lobulated tumor, tumor boundary indistinguishable from surrounding tissues, and osteolytic bone destruction. Malignant SDTs showed a higher DSS score (median 5.5 points) than did benign SDTs (median 0 point). The optimum cut-off value for the DSS score was 3 points, and the sensitivity and specificity for the diagnosis of malignant SDTs were 90% and 84.6%, respectively.

CONCLUSION

This scoring system may be helpful for preoperative decision making. If the DSS score is equal to or higher than 3, biopsies was recommended to confirm the histological diagnosis.

LEVEL OF EVIDENCE

4.

Organ Preservation in a Case of Retroperitoneal Ganglioneuroma: A Case Report and Review of Literature

The retroperitoneum is a closed space harbouring vital organs including the great vessels, kidneys and adrenal glands, ureters, and the ascending and descending colon. Surgical management of retroperitoneal pathologies may need multiorgan resection in order to achieve complete surgical resection while preservation of surrounding organs should be attempted, especially in case of benign tumors. We present a case of 15-year-old girl with an 11 × 6 × 5 cm retroperitoneal ganglioneuroma displacing the right kidney, renal vein, and ureter and abutting the IVC which was excised in toto preserving the right kidney and ureter with careful dissection around the great vessels. We also attempt to review the various surgical options available while dealing with these benign retroperitoneal tumors which are often detected incidentally and usually surround important retroperitoneal organs and vessels.

Retroperitoneal paravertebral ganglioneuroma: a multidisciplinary approach facilitates less radical surgery

Background

Ganglioneuroma (GN) of the adult is a rare benign tumour originating from neural crest-derived cells. In most cases, GN is found in the mediastinum or retroperitoneum incidentally and may present with unspecific symptoms caused by space-occupying effects. The correct diagnosis of a retroperitoneal mass is still a challenge. Nevertheless, a preoperatively confirmed diagnosis of GN may support the concept of a less radical approach and may help to prevent unnecessary morbidity or loss of function.

Case presentation

We report a case of a symptomatic retroperitoneal paravertebral GN in a 33-year-old woman. She has been referred with abdominal discomfort, lancinating pain in the right leg, headache and nausea. Magnetic resonance imaging revealed a solid paravertebral tumour adjacent to the psoas muscle. Computed tomography-guided core needle biopsy yielded the diagnosis of GN. The tumour was resected completely via a laparotomy. Immunohistopathological examinations confirmed a benign GN.

Conclusions

Diagnostic studies and therapeutic interventions of retroperitoneal GN are discussed. In our case, a core needle biopsy preceding complete resection was helpful to prevent too extensive surgical approach.

Incidental ganglioneuromas: a presentation of 14 surgical cases and literature review

BACKGROUND AND AIMS

Ganglioneuromas are benign tumors which originate from the neural crest. This tumor affects mainly young patients rather than adult ones, and its most frequent localizations are mediastinum, retroperitoneum, adrenal glands and cervical region. Usually, ganglioneuromas are discovered as incidentalomas since they are often asymptomatic, even if they could present sympathetic or mass-related symptoms. To obtain a definitive diagnosis, histological exam is necessary since CT scan and MRI are not capable of distinguishing ganglioneuromas from other tumors, such as neuroblastomas or pheocromocytomas. The surgical excision is the chosen treatment and it offers an excellent prognosis.

METHODS

We conducted a retrospective analysis of our cases of ganglioneuroma from 2004 to 2014; this study aims to compare our experience with literature review (2000-2014). Data about patients' features, tumor localization, symptoms, treatment and follow-up were analyzed and reported in detailed tables.

RESULTS

Between 2004 and 2014 we treated 14 patients affected by ganglioneuroma. For all of them the diagnosis was incidental; 9 out of 12 (64.3 %) patients presented an adrenal mass; in 2 patients (14.3 %) the tumor was localized in cervical region; in other 2 patients (14.3 %) the tumor was in the retroperitoneum and one patient (7.1 %) presented a ganglioneuroma in the costo-vertebral space. All our patients underwent surgical removal and none of them present surgery-related complications or recurrences to date.

CONCLUSIONS

Our data widen the knowledge about ganglioneuroma and confirm that the surgical approach has an excellent prognosis with very low incidence of surgery-related complications and recurrences.

Morphological differences between schwannomas and ganglioneuromas in the mediastinum: utility of the craniocaudal length to major axis ratio

OBJECTIVE

To evaluate the diagnostic value of the craniocaudal length (CC) to major axis ratio (CC/M R) for differentiating between schwannoma and ganglioneuroma in the mediastinum on CT/MRI.

METHODS

22 schwannomas (Group A: 7 schwannomas in the posterior mediastinum; Group B, 15 schwannomas located in the chest wall or regions of the mediastinum other than the posterior mediastinum) and 14 ganglioneuromas in the posterior mediastinum (Group C) were evaluated. For each tumour, the major and minor axes on the largest transaxial image and the CC were measured on CT/MRI. The CC/M R was calculated, and differences among the three groups were analysed.

RESULTS

The major axis, minor axis and CC measurements and CC/M R ranged from 23 to 52mm (mean, 37 mm), 15 to 38mm (28 mm), 25 to 62mm (42mm) and 0.66 to 1.4mm (1.1 mm), respectively, in Group A; from 18 to 97mm (37 mm), 10 to 71mm (28 mm), 18 to 80mm (35mm) and 0.59 to 1.3mm (0.95 mm), respectively, in Group B; and from 20 to 70mm (49 mm), 15 to 60mm (32 mm), 30 to 110mm (74mm) and 1.0 to 2.6mm (1.5 mm), respectively, in Group C. The mean CC/M R of Group C was significantly higher than those of the other two groups (p,0.005). There was no difference between the mean CC/M R of Groups A and B.

CONCLUSION

Ganglioneuromas display higher mean CC/M R than schwannomas. The CC/M R is a useful index for differentiating between these neurogenic tumours.

ADVANCES IN KNOWLEDGE

The CC/M R is a practical and effective index for differentiating between ganglioneuromas and schwannomas.

Pituitary adenoma with gangliocytoma: Report of two cases

Worldwide, cases of pituitary adenoma with gangliocytoma are rarely reported. The current study reports the cases of two 47-year-old females who presented with masses in the sellar region following a general examination and radiological imaging. The two patients underwent sellar region tumor resection via the trans-naso-sphenoid approach. The histopathological examination confirmed the diagnosis of a hormone-free pituitary adenoma with gangliocytoma. The two patients were in good condition and experienced no specific discomfort subsequent to the follow-up after surgery. Gangliocytoma is a slowly growing and non-metastasizing tumor. A biopsy is required to differentiate a gangliocytoma from a malignant neuroblastoma, and excision is usually curative.

Myxoid adrenocortical adenoma: magnetic resonance imaging and pathology correlation

We report a case of a 74-year-old female with myxoid adrenocortical adenoma which showed different magnetic resonance imaging findings compared to those of a typical adrenocortical adenoma. The myxoid change in the adrenocortical adenoma is a rare form of degeneration. It presents a considerable diagnostic challenge to both radiologists and clinicians because it can mimic other adrenal tumor types on imaging. The MRI findings of the presented case included a high signal intensity on T2-weighted images similar to that of fluid and delayed progressive enhancement.

Adrenal ganglioneuroma: features and outcomes of 27 cases at a referral cancer centre

BACKGROUND

Adrenal ganglioneuroma (AGN) is a rare neurogenic tumour that can mimic other adrenal neoplasms. Limited information, mostly derived from small cases series, is available for AGN.

METHODS

A retrospective review for AGNs seen at a tertiary referral centre describing important features to distinguish AGN from other adrenal neoplasms.

RESULTS

Of 53 ganglioneuromas, 27 were AGNs. Median age was 31 years (range, 1·7-64 years) and median tumour size was 8 cm (range, 1·5-20 cm). Seventeen AGNs (63%) were detected incidentally and nine patients (33%) presented with abdominal/back discomfort. Catecholamine levels, available for 21 patients, were normal. On computed tomography (CT), most AGNs were homogenous and well circumscribed with a median density of 32·5 Hounsfield units (HU) on unenhanced CT; 40 HU on postcontrast venous phase; and 66·5 HU on delayed postcontrast phase. On magnetic resonance imaging (MRI), AGNs had hypo-intense signal on T1-weighted images with heterogeneous hyperintense signal on T2-weighted images. In four patients, there was no tumour growth during median follow-up of 48 months (range, 21-60 months). One patient had malignant peripheral nerve sheath tumour arising from AGN. Thirteen patients with resected AGN had no recurrence during a median follow-up of 50 months (range, 2-135 months).

CONCLUSIONS

We herein describe the largest AGN series reported to date. Isolated AGNs do not produce catecholamines and have CT imaging characteristics that can help in distinguishing them from other adrenal and para-adrenal neoplasms. The natural history of AGNs is usually benign, although local extra-adrenal extension or malignant transformation can rarely occur.

Incidentally found retroperitoneal ganglioneuroma in an adult

The ganglioneuroma is a very rare tumor arising from sympathetic nerve system. An asymptomatic retroperitoneal ganglioneuroma was found incidentally in a 35-year-old woman. Ultrasonography, computed tomography, and magnetic resonance imaging showed a retroperitoneal mass extending to the left adrenal gland, and surrounding abdominal aorta, celiac axis, left renal and adrenal arteries, and veins. The tumor was resected and histologic examination showed ganglioneuroma.

Hormone-secreting large adrenal ganglioneuroma in an adult patient: a case report and review of literature

BACKGROUND. Ganglioneuromas (GNs) are neural crest cell-derived tumors and rarely occur in the adrenal gland. They are usually asymptomatic and hormonally silent. The majority of cases are detected incidentally during work-up for unrelated conditions. Hormone-secreting pure adrenal GNs in adults are extremely rare. To date, only four cases have been reported in the English literature. CASE REPORT. We describe an adult case of endocrinologically active adrenal GN incidentally diagnosed in a 64-year-old male patient with history of uncontrolled hypertension. On physical examination, he had a blood pressure (BP) of 160/100 mmHg. Abdominal computed tomography and magnetic resonance imaging showed a large solid tumor (8.5 × 7.5 × 7 cm) in the right adrenal gland. Urinary levels of norepinephrine, normetanephrine, vanillylmandelic acid and dopamin were elevated, although urinary level of epinephrine was suppressed. Right adrenalectomy was performed for treatment purposes. The histological diagnosis of the resected tumor was adrenal GN. CONCLUSIONS. Hormone-secreting pure adrenal GN occurs very rarely in adults and preoperative diagnosis is difficult. Adrenal GN may present with hormonal activity such as increased secretion of catecholamines and their metabolites. There are no specific diagnostic signs and symptoms discriminating GN and pheochromocytoma. Therefore, histopathological examination need for a definitive diagnosis of adrenal GN. The prognosis after completed surgical resection without further therapy seems to be excellent. To our knowledge, the present case is the second report that describes hormone-secreting pure adrenal GN in an adult from Turkey in the English literature. We discuss this case and review the literature on this unusual entity.

Laparoscopic excision of a retroperitoneal ganglioneuroma

This study suggests that excision of retroperitoneal tumors can be reliably performed with minimally invasive surgical techniques.

Objective:

Ganglioneuromas are rare benign tumors originating from ganglion cells. Ganglioneuromas are detected incidentally because they are asymptomatic. We report a case of laparoscopic excision of a retroperitoneal ganglioneuroma.

Case Description:

A 49-y-old female was admitted to our medical center with the complaint of abdominal pain. Abdominal ultrasound showed a hypoechoic solid lesion at the level of the liver hilum, adjacent to the pancreas. Computerized tomography scan confirmed the presence of a thin walled mass 44 mm in diameter, adjacent to the pancreas and liver. Laparoscopic excision of the retroperitoneal mass was planned. The tumor was removed en bloc, and the pathologic diagnosis was ganglioneuroma. The patient was discharged from the hospital on the third postoperative day without any complications.

Conclusion:

Minimally invasive surgery has been shown to be safe and reliable in patients with retroperitoneal tumors.

Retropharyngeal ganglioneuroma: a case report

Ganglioneuromas are uncommon, benign, and highly differentiated tumors arising from sympathetic ganglia. Common sites for these tumors include the paraspinal region of the retroperitoneum and posterior mediastinum. We report a case of a retropharyngeal ganglioneuroma, a rare occurrence, emphasizing its key imaging characteristics.

Multiple cervical ganglioneuroma: A case report and review of the literature

Ganglioneuromas (GNs) arising from neural crest sympathogonia are rare benign neurogenic tumors. The most commonly affected sites are the posterior mediastinum, the retroperitoneum and the adrenal gland. GNs often present as a solitary, painless and slow-growing mass, and multiple occurrences in the cervical region are extremely rare. Here, we report a case of massive multiple cervical GN in a 4-year-old girl, and review cases of cervical GN that have been reported in the past 10 years. The results demonstrated that cervical GN, compared to other sites, is seldom secretory. The signs and symptoms of cervical GN are unspecific; the ultimate diagnosis of GN depends on pathological examination. Fine-needle aspiration biopsy has limited value in diagnosis. Surgical excision is the treatment of choice and the prognosis is excellent even in cases where complete excision cannot be achieved. Furthermore, GNs should be considered in patients with multiple masses in the neck.