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Ng Hung Shin PB, Lombardo A, Black K. Retroperitoneal venous malformation mimics paraganglioma on triple imaging modalities. BMJ Case Rep 2024; 17:e258708. [PMID: 38538100 PMCID: PMC10982780 DOI: 10.1136/bcr-2023-258708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Here, we report a case of a woman in her 50s who was referred for an incidentally discovered lesion anterior to the origin of inferior vena cava suspicious for a paraganglioma following a CT scan for vaginal bleeding. A follow-up 68Ga-DOTATATE PET-CT and MRI of the abdomen reinforced the radiological impression of an extra-adrenal paraganglioma (EAP). The EAP was deemed non-functional given normal urine biogenic amine, supine plasma fractionated metanephrines and chromogranin A levels. The mass was resected laparoscopically without perioperative blockade. Histological examination revealed a venous malformation. Extrahepatic abdominal venous malformations are rare and can be indistinguishable from an EAP on imaging preoperatively. Although benign, the lesion nevertheless warrants excision as it is associated with a risk of haemorrhage.
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Affiliation(s)
| | | | - Katherine Black
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
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2
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Bernal Torres W, Vinasco LAG, Gómez JE, de León JDLP. Cardiac paraganglioma: implications and impacts of a rare disease-a case report †. Eur Heart J Case Rep 2024; 8:ytae032. [PMID: 38496798 PMCID: PMC10941256 DOI: 10.1093/ehjcr/ytae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 03/19/2024]
Abstract
Background Tumour-producing catecholamines arise in the adrenal medulla (pheochromocytomas), as well as in extra-adrenal chromaffin cells (paragangliomas). The origin can be from any location; however, it is very rare in the heart. Case summary A 43-year-old woman with a history of arterial hypertension presented with dyspnoea on moderate exertion, New York Class Association (NYHA) functional classes III and IV, and oedema in the lower extremities. Medical and laboratory evaluation revealed an NT-proBNP of 6046 pg/mL, a left ventricular ejection fraction (LVEF) of 15%, longitudinal strain of -7%, and a mass located on the inner surface of the left atrioventricular groove. Surgical intervention was performed, and the tumour was resected. Pathological report showed an extra-adrenal paraganglioma without neoplastic involvement in the margins of the vena cava. After surgery, the patient showed clinical improvement with NYHA functional class I, LVEF of 56%, and longitudinal strain of -20% on transthoracic echocardiography 4 months after treatment. Discussion Paragangliomas are tumours that are rarely found in the heart, and their diagnosis is difficult. However, early detection and treatment can improve the quality of life of affected patients.
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Affiliation(s)
- Wikler Bernal Torres
- Departamento de Cardiología, Fundación Valle del Lili, Cra. 98 # 18-49, 760026 Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad ICESI, Cl. 18 # 122-135, 760031 Cali, Colombia
| | - Leidy A Giraldo Vinasco
- Facultad de Ciencias de la Salud, Universidad ICESI, Cl. 18 # 122-135, 760031 Cali, Colombia
- Departamento de Medicina Interna, Fundación Valle del Lili, Cali, Colombia
| | - Juan Esteban Gómez
- Departamento de Cardiología, Fundación Valle del Lili, Cra. 98 # 18-49, 760026 Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad ICESI, Cl. 18 # 122-135, 760031 Cali, Colombia
| | - Juan D López Ponce de León
- Departamento de Cardiología, Fundación Valle del Lili, Cra. 98 # 18-49, 760026 Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad ICESI, Cl. 18 # 122-135, 760031 Cali, Colombia
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3
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Samba S, Bensghier A, Margoum S, Berhili S, Moukhlissi M, Mezouar L. Exploring Head and Neck Paraganglioma: A Case Report. Cureus 2024; 16:e55720. [PMID: 38586626 PMCID: PMC10998543 DOI: 10.7759/cureus.55720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Paragangliomas (PGLs) are tumors that are rarely malignant; the majority of them are benign. Similar to pheochromocytoma, they develop from the autonomic nerve system. This system originates from neural crest cells and can undergo neoplastic transformation. PGLs can arise either inside or outside the adrenal glands. Head and neck PGLs are very scarce. The primary locations where this tumor commonly originates within this region are the carotid body, jugular bulb, and vagal body. Hence, in our case report, we attempt to highlight the uncommon presentation of this disease in a 46-year-old female, who initially presented with hypertension and persistent dysphonia. The patient underwent successful external radiotherapy. This case report aims to raise awareness of the characteristics of these rare malignancies.
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Affiliation(s)
- Soumiya Samba
- Department of Radiation Oncology, Mohammed VI University Hospital, Oujda, MAR
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
| | - Ahmed Bensghier
- Department of Radiation Oncology, Mohammed VI University Hospital, Oujda, MAR
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
| | - Souad Margoum
- Department of Radiation Oncology, Mohammed VI University Hospital, Oujda, MAR
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
| | - Soufiane Berhili
- Department of Radiation Oncology, Mohammed VI University Hospital, Oujda, MAR
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
| | - Mohamed Moukhlissi
- Department of Radiation Oncology, Mohammed VI University Hospital, Oujda, MAR
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
| | - Loubna Mezouar
- Department of Radiation Oncology, Mohammed VI University Hospital, Oujda, MAR
- Faculty of Medicine and Pharmacy, Mohammed First University, Oujda, MAR
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Ma L, Li X, Zhang M, Li G. Mesenteric paraganglioma: A case report. Asian J Surg 2024; 47:1159-1160. [PMID: 37996376 DOI: 10.1016/j.asjsur.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/03/2023] [Indexed: 11/25/2023] Open
Affiliation(s)
- Le Ma
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiya Li
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Mengmeng Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China.
| | - Guangsen Li
- Department of Ultrasound, The Second Affiliated Hospital of Dalian Medical University, Dalian, China.
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Karamitopoulou-Diamantis E. [Exocrine meets neuroendocrine: mimickers of pancreatic neuroendocrine neoplasms]. PATHOLOGIE (HEIDELBERG, GERMANY) 2024; 45:42-49. [PMID: 38091082 DOI: 10.1007/s00292-023-01286-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 01/31/2024]
Abstract
Neuroendocrine neoplasms (NENs) originate from various epithelial or neuroectodermal tissues, can occur in any organ, including the pancreas, and are characterized by the expression of the neuroendocrine markers synaptophysin and chromogranin A. Pancreatic neuroendocrine tumors (PanNETs) are well-differentiated epithelial neoplasms with morphological and immunohistochemical features of neuroendocrine differentiation of low, intermediate, or high grade. Pancreatic neuroendocrine carcinomas (PanNECs) are clinically aggressive, high-grade (poorly differentiated) carcinomas with morphologic features suggesting neuroendocrine differentiation, a high proliferative rate (> 20 mitoses per 2 mm2 and Ki67 index > 20%), and immunohistochemical labeling for neuroendocrine markers. They include the small cell neuroendocrine carcinoma and the large cell neuroendocrine carcinoma categories.Neuroendocrine-like morphology coupled with immunohistochemical markers of neuroendocrine differentiation are highly specific. However, neuroendocrine markers may also be expressed in non-neuroendocrine neoplasms, which can therefore be confused with NENs. Mimickers of pancreatic NENs comprise a number of important pitfall tumors, including epithelial and non-epithelial neoplasms, such as acinar cell carcinomas, solid pseudopapillary neoplasms (SPNs), or even non-neoplastic lesions. All of these lesions have the expression of neuroendocrine markers in common, such as synaptophysin and chromogranin A, and although they are comparatively rare, they can cause considerable diagnostic problems. This review article deals with some of the most important mimickers of pancreatic neuroendocrine neoplasms and even non-neoplastic lesions, such as islet aggregation. The similarities and differences between these entities and pancreatic neuroendocrine neoplasms are highlighted, and key findings that facilitate the correct diagnosis are discussed.
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Affiliation(s)
- Eva Karamitopoulou-Diamantis
- Institut für Gewebemedizin und Pathologie, Universität Bern, Bern, Schweiz.
- PATHOLOGIE INSTITUT ENGE, Hardturmstr. 133, 8005, Zürich, Schweiz.
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Usmani S, Al Riyami K, Jain A, Selvakumar RJ, Jayakrishan VV. The Great Imitator: Pulmonary Paraganglioma Mimicking Pulmonary Metastasis of Breast Cancer on 18 F-FDG PET/CT. Clin Nucl Med 2024; 49:e82-e84. [PMID: 38170907 DOI: 10.1097/rlu.0000000000005029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
ABSTRACT Primary pulmonary paragangliomas are rare neuroendocrine tumors and are often discovered incidentally as nonfunctioning masses. We report a case of 58-year-old woman recently diagnosed with multifocal right breast cancer and suspicious right axillary lymph nodes. 18 F-FDG PET/CT showed a well-defined marginated lesion in the lower lobe of the right lung with intense FDG uptake. Findings were suspicious for pulmonary metastases. CT-guided biopsy results were consistent with a paraganglioma. Paragangliomas can mimic metastases, especially if they are large or have a high degree of FDG uptake, and careful evaluation of imaging features and clinical findings can help differentiate these entities. Most of the time biopsy is necessary to confirm the diagnosis.
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Affiliation(s)
| | | | - Anjali Jain
- From the Departments of Radiology and Nuclear Medicine
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Ajluni SC, Feroze R, Asa SL, Sundaram V. Paraganglioma-induced reverse takotsubo syndrome treated with extracorporeal membrane oxygenation in a young patient with a history of malignancy: a case report. Eur Heart J Case Rep 2023; 7:ytad591. [PMID: 38130863 PMCID: PMC10733169 DOI: 10.1093/ehjcr/ytad591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 12/23/2023]
Abstract
Background Reverse takotsubo-like cardiomyopathy (rTCC) is a rare type of stress-induced cardiomyopathy associated with catecholamine surges. Reverse takotsubo-like cardiomyopathy is characterized by basal and mid-ventricular hypokinesis with apical sparing. Paragangliomas are catecholamine-secreting neuroendocrine tumours outside the adrenal gland that can cause palpitations, hypertension, and rarely cardiomyopathy. In cases of occult paraganglioma, catecholamine-induced rTCC can be rapidly reversed with adequate haemodynamic support. Case summary A 28-year-old woman with a history of cervical cancer, ovarian insufficiency, and preeclampsia presented to the emergency department with nausea, vomiting, and chest pain. The patient was initially tachycardic, tachypnoeic, and hypotensive. On exam, she was in distress with diffuse rales and cool extremities. Electrocardiogram showed sinus tachycardia to 147 b.p.m. and lateral ST depression in V4 and V5. Troponin was elevated to 13 563 ng/L. An echocardiogram showed severely reduced left ventricular ejection fraction (LVEF) with hypokinesis of the basal segments and apical sparing, identified as rTCC. Computed tomography of the abdomen showed a 3.6 × 2.7 cm right adrenal mass. The patient rapidly developed respiratory failure and was subsequently intubated, sedated, and initiated on vasopressors. In the setting of cardiogenic shock refractory to vasopressor support, the decision was made to cannulate for venoarterial extracorporeal membrane oxygenation (VA-ECMO). Plasma and urine metanephrines were elevated. After 5 days, the patient's LVEF recovered to her baseline, and the rTCC had resolved. The patient's hypertension was managed with gradual alpha-blockade, and she subsequently underwent successful adrenalectomy on Day 44. Discussion An occult paraganglioma should be considered when rTCC pattern is identified. The pathophysiology of paraganglioma-mediated catecholamine surges predisposing to rTCC is unclear. Potential mechanisms for rTCC include oestrogen deficiency, catecholamine cardiotoxicity, and coronary artery spasm. The VA-ECMO is an increasingly used modality to provide haemodynamic support to patients with refractory cardiogenic shock.
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Affiliation(s)
- Steven C Ajluni
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Rafey Feroze
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sylvia L Asa
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Varun Sundaram
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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8
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Ezzat S, de Herder WW, Volante M, Grossman A. The Driver Role of Pathologists in Endocrine Oncology: What Clinicians Seek in Pathology Reports. Endocr Pathol 2023; 34:437-454. [PMID: 37166678 PMCID: PMC10733199 DOI: 10.1007/s12022-023-09768-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Abstract
Endocrine neoplasia represents an increasingly broad spectrum of disorders. Endocrine neoplasms range from incidental findings to potentially lethal malignancies. In this paper, we cover the impact of pathology in the interpretation of the clinic-pathological, genetic, and radiographic features underpinning these neoplasms. We highlight the critical role of multidisciplinary interactions in structuring a rational diagnostic and efficient therapeutic plan and emphasize the role of histopathological input in decision-making. In this context, standardized pathology reporting and second opinion endocrine pathology review represent relevant tools to improve the overall diagnostic workup of patients affected by endocrine tumors in every specific scenario. In fact, although a relevant proportion of cases may be correctly identified based on clinical presentation and biochemical/imaging investigations, a subset of cases presents with atypical findings that may lead to an inappropriate diagnosis and treatment plan based on a wrong pathological diagnosis if all pieces of the puzzle are not correctly considered. Pathologists have a responsibility to actively guide clinicians before and during surgical procedures to prevent unnecessary interventions. In all areas of endocrine pathology, pathologists must understand the complexity of tissue preservation and assay sensitivities and specificities to ensure the optimal quality and interpretation of diagnostic material. Finally, pathologists are central actors in tumor tissue biobanking, which is an expanding field in oncology that should be promoted while adhering to strict ethical and methodological standards.
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Affiliation(s)
- Shereen Ezzat
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Wouter W de Herder
- Department of Internal Medicine, Sector of Endocrinology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco Volante
- Department of Oncology, University of Turin, San Luigi Hospital, Regione Gonzole 10, 10043, Orbassano, Turin, Italy.
| | - Ashley Grossman
- Barts and the London School of Medicine, University of London, London, UK
- Green Templeton College, University of Oxford, Oxford, UK
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Kiriakopoulos A, Giannakis P, Menenakos E. Pheochromocytoma: a changing perspective and current concepts. Ther Adv Endocrinol Metab 2023; 14:20420188231207544. [PMID: 37916027 PMCID: PMC10617285 DOI: 10.1177/20420188231207544] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Abstract
This article aims to review current concepts in diagnosing and managing pheochromocytoma and paraganglioma (PPGL). Personalized genetic testing is vital, as 40-60% of tumors are linked to a known mutation. Tumor DNA should be sampled first. Next-generation sequencing is the best and most cost-effective choice and also helps with the expansion of current knowledge. Recent advancements have also led to the increased incorporation of regulatory RNA, metabolome markers, and the NETest in PPGL workup. PPGL presentation is highly volatile and nonspecific due to its multifactorial etiology. Symptoms mainly derive from catecholamine (CMN) excess or mass effect, primarily affecting the cardiovascular system. However, paroxysmal nature, hypertension, and the classic triad are no longer perceived as telltale signs. Identifying high-risk subjects and diagnosing patients at the correct time by using appropriate personalized methods are essential. Free plasma/urine catecholamine metabolites must be first-line examinations using liquid chromatography with tandem mass spectrometry as the gold standard analytical method. Reference intervals should be personalized according to demographics and comorbidity. The same applies to result interpretation. Threefold increase from the upper limit is highly suggestive of PPGL. Computed tomography (CT) is preferred for pheochromocytoma due to better cost-effectiveness and spatial resolution. Unenhanced attenuation of >10HU in non-contrast CT is indicative. The choice of extra-adrenal tumor imaging is based on location. Functional imaging with positron emission tomography/computed tomography and radionuclide administration improves diagnostic accuracy, especially in extra-adrenal/malignant or familial cases. Surgery is the mainstay treatment when feasible. Preoperative α-adrenergic blockade reduces surgical morbidity. Aggressive metastatic PPGL benefits from systemic chemotherapy, while milder cases can be managed with radionuclides. Short-term postoperative follow-up evaluates the adequacy of resection. Long-term follow-up assesses the risk of recurrence or metastasis. Asymptomatic carriers and their families can benefit from surveillance, with intervals depending on the specific gene mutation. Trials primarily focusing on targeted therapy and radionuclides are currently active. A multidisciplinary approach, correct timing, and personalization are key for successful PPGL management.
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Affiliation(s)
- Andreas Kiriakopoulos
- Department of Surgery, ‘Evgenidion Hospital’, National and Kapodistrian University of Athens School of Medicine, 5th Surgical Clinic, Papadiamantopoulou 20 Str, PO: 11528, Athens 11528, Greece
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Đapić K, Stepan J, Pavlović M, Vidjak V, Poljak M, Gašparov S, Mikulić D. Retroperitoneal Paraganglioma Treated With Tumor Resection and Replacement of the Inferior Vena Cava. Cureus 2023; 15:e47160. [PMID: 38021902 PMCID: PMC10651940 DOI: 10.7759/cureus.47160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 12/01/2023] Open
Abstract
Retroperitoneal paragangliomas are tumors of neuroectodermal origin rarely appearing in the pediatric population. We report a case of a large paraganglioma infiltrating the right kidney and inferior vena cava in a 16-year-old boy who initially presented with a right-sided varicocele. Right retroperitoneal paraganglioma was embolized preoperatively, followed by total tumor excision, right nephrectomy, inferior vena cava resection, and reconstruction using a prosthetic vascular graft. Retroperitoneal tumors requiring surgery can successfully be treated by radical resection and replacement of the inferior vena cava in experienced centers.
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Affiliation(s)
- Krešimir Đapić
- Department of Urology, Clinical Hospital Dubrava, Zagreb, HRV
| | - Jasminka Stepan
- Department of Oncology and Hematology, Children's Hospital Zagreb, Zagreb, HRV
| | - Maja Pavlović
- Department of Oncology and Hematology, Children's Hospital Zagreb, Zagreb, HRV
| | - Vinko Vidjak
- Department of Diagnostic and Interventional Radiology, University Hospital Merkur, Zagreb, HRV
| | - Mirko Poljak
- Department of Surgery, University Hospital Merkur, Zagreb, HRV
| | - Slavko Gašparov
- Department of Pathology and Cytology, University Hospital Merkur, Zagreb, HRV
| | - Danko Mikulić
- Department of Surgery, University Hospital Merkur, Zagreb, HRV
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11
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Enguita JM, Díaz I, García D, Cubiella T, Chiara MD, Valdés N. Visual analytics identifies key miRNAs for differentiating peripancreatic paraganglioma and pancreatic neuroendocrine tumors. Front Endocrinol (Lausanne) 2023; 14:1162725. [PMID: 37383401 PMCID: PMC10299733 DOI: 10.3389/fendo.2023.1162725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/18/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Paragangliomas (PGL), a type of neuroendocrine tumor, pose a significant diagnostic challenge due to their potential for unpredictable locations and asymptomatic presentation. Misdiagnosis of peripancreatic PGLs, particularly as pancreatic neuroendocrine tumors (PANNETs), is a pressing issue as it can negatively impact both pre- and post-treatment decision-making. The aim of our study was to identify microRNA markers for the reliable differential diagnosis of peripancreatic PGLs and PANNETs, addressing a crucial unmet need in the field and advancing the standard of care for these patients. Methods Morphing projections tool was used to analyze miRNA data from PGL and PANNET tumors present in the TCGA database. The findings were validated using two additional databases: GSE29742 and GSE73367. Results Our research uncovered substantial differences in the miRNA expression profiles of PGL and PANNET, leading to the identification of 6 key miRNAs (miR-10b-3p, miR-10b-5p, and the miRNA families miR-200c/141 and miR-194/192) that can effectively differentiate between the two types of tumors. Discussion These miRNA levels hold potential as biomarkers for improved diagnosis, offering a solution to the diagnostic challenge posed by these tumors and potentially improving the standard of care for patients.
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Affiliation(s)
- Jose María Enguita
- Department of Electrical Engineering, University of Oviedo, Gijón, Spain
| | - Ignacio Díaz
- Department of Electrical Engineering, University of Oviedo, Gijón, Spain
| | - Diego García
- Department of Electrical Engineering, University of Oviedo, Gijón, Spain
| | - Tamara Cubiella
- Department of Cancer, Health Research Institute of the Principality of Asturias, Oviedo, Spain
- Respiratory Tract Tumors, CIBERONC (Network of Biomedical Research in Cancer), Madrid, Spain
- Institute of Oncology of the Principality of Asturias, University of Oviedo, Oviedo, Spain
| | - María-Dolores Chiara
- Department of Cancer, Health Research Institute of the Principality of Asturias, Oviedo, Spain
- Respiratory Tract Tumors, CIBERONC (Network of Biomedical Research in Cancer), Madrid, Spain
- Institute of Oncology of the Principality of Asturias, University of Oviedo, Oviedo, Spain
| | - Nuria Valdés
- Department of Cancer, Health Research Institute of the Principality of Asturias, Oviedo, Spain
- Department of Internal Medicine, Section of Endocrinology and Nutrition, Cabueñes University Hospital, Gijón, Spain
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Gaisendrees C, Luehr M, Siemanowski J, Siebolts U, Kuhn-Régnier F, Wahlers T. Aortic Paraganglioma Masking as Intramural Hematoma: When You Hear Hoofbeats Think Zebras, Not Horses. JACC Case Rep 2023; 15:101852. [PMID: 37283833 PMCID: PMC10240262 DOI: 10.1016/j.jaccas.2023.101852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 06/08/2023]
Abstract
A 52-year-old woman presented dyspnea and angina. The computed tomography scan indicated an intramural hematoma, and the patient underwent surgery, during which a structure was excised that was identified as aortic paraganglioma. This case report underlines the importance of a multiprofessional interdisciplinary team to diagnose and treat cardiac masses. (Level of Difficulty: Advanced.).
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Affiliation(s)
| | - Maximilian Luehr
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Jana Siemanowski
- Department of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Udo Siebolts
- Department of Pathology, University Hospital of Cologne, Cologne, Germany
| | | | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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13
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Kanj AN, Young WF, Ryu JH. Mediastinal Paraganglioma: A retrospective analysis of 51 cases. Respir Med 2023:107296. [PMID: 37257785 DOI: 10.1016/j.rmed.2023.107296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Paragangliomas are rarely found in the mediastinum, where they account for a small proportion of mediastinal masses. This study aimed to better characterize the presenting features and relevant aspects in optimizing the diagnosis and treatment of mediastinal paragangliomas. METHODS A computer-assisted search of electronic health records was performed to identify adult patients (≥18 years) who underwent evaluation for a primary mediastinal paraganglioma at Mayo Clinic between January 2000 and April 2022. Medical charts, laboratory tests and radiology images were reviewed to collect data. RESULTS The study included 51 patients, each with a single mediastinal paraganglioma. The median age was 47 years (IQR: 39-67), 67% females. Symptoms of catecholamine excess were manifest in 39% of patients, and 14% presented with mass effect, while the remaining 47% had no paraganglioma-related symptoms. Genetic testing was performed in 35 patients; 66% harbored a pathogenic variant in the succinate dehydrogenase enzyme complex. Most paragangliomas (71%) were in the middle mediastinum and showed uptake of intravenous contrast on chest imaging. Biopsies were performed in 30 (59%) patients; 27% were inconclusive and 10% resulted in major complications. Surgical resection occurred in 75%, primarily for relief of symptoms (50%) followed by proximity to critical structures (45%). Perioperative complications were common (66%), but there were no cases of local tumor recurrence during the follow-up period (median 8 years; IQR: 4-13). CONCLUSION Mediastinal paragangliomas are most located in the middle mediastinum and can often be diagnosed noninvasively using a combination of clinical, biochemical, and radiological features.
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Affiliation(s)
- Amjad N Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA.
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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Zironda A, Grotz TE, Folpe AL, Thiels CA. Gastrointestinal Glomus Tumors: A Single Institution, 20-Year Retrospective Study. J Surg Res 2023; 283:982-991. [PMID: 36915027 DOI: 10.1016/j.jss.2022.10.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/06/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Glomus tumors are rare mesenchymal neoplasms composed of cells resembling those of the thermoregulatory glomus body, typically occurring in the skin and superficial soft tissues. Rarely do they occur in the gastrointestinal tract, in particular the stomach, where they have been the subject of case reports and small series. We present our institutional experience with gastrointestinal glomus tumors. METHODS A retrospective review of all gastrointestinal glomus tumors was conducted across all three Mayo Clinic sites in Minnesota, Arizona, and Florida from 2001 to 2021. Patient characteristics, pathologic findings, imaging features, operative reports, and clinical outcomes were abstracted. Descriptive statistics were utilized to report outcomes. RESULTS Nine patients with glomus tumors were identified (five men and four women). The median age was 53 [interquartile range (IQR), 44-69] y. Four patients presented with abdominal discomfort, three had anemia or bleeding, and two tumors were incidentally diagnosed. Computed tomography scans identified masses thought to represent gastrointestinal stromal tumors or neuroendocrine tumors in all patients. The tumors were localized to the stomach in all cases, specifically in the gastric antrum. Seven patients underwent preoperative endoscopy, including five with endoscopic ultrasonography. Endoscopic biopsies were interpreted as glomus tumors (n = 3), neuroendocrine tumors (n = 2), and nondiagnostic (n = 2). All patients underwent open (n = 3) or minimally invasive (n = 6) margin-negative resection by wedge resection (n = 5) or distal gastrectomy (n = 4). No nodal metastases were identified radiographically or on pathologic examination. The median tumor size was 2.5 [IQR 1.3-3.4] cm. All tumors showed at least in part typical glomus tumor morphology and smooth muscle actin expression. Aberrant synaptophysin expression was present in the two tumors initially classified as NET. Using the current WHO criteria, tumors were classified as histologically malignant (n = 1) and of "uncertain malignant potential" (n = 8). At a median follow-up of 15 [IQR 1-56] mo, all patients were asymptomatic and without recurrence. Two patients died of unrelated causes. No patients received adjuvant therapies. CONCLUSIONS Our 20-year, single institution, 3-site experience with resected gastrointestinal glomus tumors suggests the rarity, predisposition to involve the gastric antrum, and potentially an indolent clinical behavior of many of these tumors. Long-term follow-up is warranted as some previously reported gastric glomus tumors have metastasized, including cases lacking morphologic evidence of malignancy. Surgical resection, with minimally invasive wedge resection alone, is likely sufficient for the management of most gastric glomus tumors.
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Affiliation(s)
- Andrea Zironda
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Travis E Grotz
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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15
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Yu W, Zhang C. Imaging appearances of paraganglioma of the urinary bladder. Quant Imaging Med Surg 2023; 13:2008-2012. [PMID: 36915331 PMCID: PMC10006104 DOI: 10.21037/qims-22-747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 12/27/2022] [Indexed: 02/09/2023]
Affiliation(s)
- Wanjun Yu
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chunquan Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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16
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Stan-Ilie M, Şandru V, Plotogea OM, Rînja E, Pavel C, Constantinescu G, Negreanu L, Paduraru DN, Bolocan A, Andronic O, Davitoiu D, Bălan GG, Constantinescu A. Duodenal Gangliocytic Paragangliomas—Case Series and Literature Review. Life (Basel) 2023; 13:life13030597. [PMID: 36983753 PMCID: PMC10058500 DOI: 10.3390/life13030597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/12/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023] Open
Abstract
Duodenal gangliocytic paragangliomas are rare neuroendocrine tumors primarily localized in the periampullary area. Though mostly asymptomatic, they can present with various symptoms, most often jaundice, anemia and abdominal pain. The present paper is a case series report, describing our personal experience with patients presenting to the Emergency Unit with different symptoms due to duodenal gangliocytic paraganglioma. Endoscopic resection is safe and indicated in most of the cases, being also associated with lower medical costs. EUS plays a central role in the pre-resection management and in surveillance, and immunostaining is decisive to ascertain the tumor histologic origin. In addition to reporting our experience, we researched the literature regarding these rare tumors and performed a comprehensive review.
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Affiliation(s)
- Madalina Stan-Ilie
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Vasile Şandru
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Correspondence: (V.Ş.); (O.-M.P.)
| | - Oana-Mihaela Plotogea
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Correspondence: (V.Ş.); (O.-M.P.)
| | - Ecaterina Rînja
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Christopher Pavel
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Gabriel Constantinescu
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Lucian Negreanu
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Gastroenterology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Dan Nicolae Paduraru
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Alexandra Bolocan
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Octavian Andronic
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Dragos Davitoiu
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Gheorghe G. Bălan
- Department of Gastroenterology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Alexandru Constantinescu
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Gastroenterology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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17
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Gheorghișan-Gălățeanu AA, Ilieșiu A, Lambrescu IM, Țăpoi DA. The Complex Histopathological and Immunohistochemical Spectrum of Neuroendocrine Tumors-An Overview of the Latest Classifications. Int J Mol Sci 2023; 24:1418. [PMID: 36674939 PMCID: PMC9863618 DOI: 10.3390/ijms24021418] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/05/2023] [Accepted: 01/08/2023] [Indexed: 01/12/2023] Open
Abstract
Neuroendocrine neoplasms (NENs) originate from the neuroendocrine cell system, which may either take the shape of organoid cell aggregations or be composed of dispersed cells across various organs. Therefore, these tumors are heterogenous regarding the site of origin, functional status, degree of aggressiveness, and prognosis. When treating patients with neuroendocrine tumors, one of the most significant challenges for physicians is determining the correct tumor grade and thus classifying patients into risk categories. Over the years, the classification of these tumors has changed significantly, often causing confusion due to clinical, molecular, and immunohistochemical variability. This review aims to outline the latest NENs classifications regardless of their site of origin. Thus, an overview of the key histopathological and immunohistochemical characteristics of NENs could pave the way to validate possible predictive and prognostic markers and also guide the therapeutic conduct.
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Affiliation(s)
- Ancuța-Augustina Gheorghișan-Gălățeanu
- Department of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- C.I. Parhon National Institute of Endocrinology, 011863 Bucharest, Romania
| | - Andreea Ilieșiu
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Pathology, University Emergency Hospital, 050098 Bucharest, Romania
| | - Ioana Maria Lambrescu
- Department of Cellular and Molecular Biology and Histology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Victor Babes National Institute of Pathology, 050096 Bucharest, Romania
| | - Dana Antonia Țăpoi
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Pathology, University Emergency Hospital, 050098 Bucharest, Romania
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18
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Ojukwu DI, Galgano MA. En Bloc Resection of a Cauda Equina Paraganglioma and Associated Intradural Hematoma After Diagnosis of Renal Clear Cell Carcinoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e36-e37. [PMID: 36227185 DOI: 10.1227/ons.0000000000000423] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/16/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Disep I Ojukwu
- School of Medicine, St. George's University, Great River, New York, USA
| | - Michael A Galgano
- School of Medicine, St. George's University, Great River, New York, USA.,Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina, USA
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19
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Advances in Adrenal and Extra-adrenal Paraganglioma: Practical Synopsis for Pathologists. Adv Anat Pathol 2023; 30:47-57. [PMID: 36136370 DOI: 10.1097/pap.0000000000000365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adrenal paraganglioma (or "pheochromocytoma") and extra-adrenal paraganglioma, collectively abbreviated PPGL, are rare but spectacular nonepithelial neuroendocrine neoplasms. These are the most inheritable neoplasia of all, with a metastatic potential in a varying degree. As of such, these lesions demand careful histologic, immunohistochemical, and genetic characterization to provide the clinical team with a detailed report taking into account the anticipated prognosis and risk of syndromic/inherited disease. While no histologic algorithm, immunohistochemical biomarker, or molecular aberration single-handedly can identify potentially lethal cases upfront, the combined analysis of various risk parameters may stratify PPGL patients more stringently than previously. Moreover, the novel 2022 WHO Classification of Endocrine and Neuroendocrine Tumors also brings some new concepts into play, not least the reclassification of special neuroendocrine neoplasms (cauda equina neuroendocrine tumor and composite gangliocytoma/neuroma-neuroendocrine tumor) previously thought to belong to the spectrum of PPGL. This review focuses on updated key diagnostic and prognostic concepts that will aid when facing this rather enigmatic tumor entity in clinical practice.
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20
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Stefanova N, Enchev Y, Dzhenkov D, Hachmeryan A. Paraganglioma in the spinal cord histologically mimicking ependymoma - a case report. Folia Med (Plovdiv) 2022; 64:1007-1011. [PMID: 36876561 DOI: 10.3897/folmed.64.e71407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/20/2021] [Indexed: 01/01/2023] Open
Abstract
Paraganglioma is a tumour lesion of neuroectodermal origin that occurs at various places in the human body, but is rarely observed in the spinal cord. Usually, it presents in the lumbar region (cauda equine and filum terminal) as a slow-growing painless tumour mass that causes local compression.
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Affiliation(s)
| | - Yavor Enchev
- Prof. Dr. Paraskev Stoyanov Medical University, Varna, Bulgaria
| | - Deyan Dzhenkov
- Prof. Dr. Paraskev Stoyanov Medical University, Varna, Bulgaria
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21
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Fan L, Ma L. A rare case report: vaginal paraganglioma. Am J Transl Res 2022; 14:8773-8781. [PMID: 36628227 PMCID: PMC9827333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 11/09/2022] [Indexed: 01/12/2023]
Abstract
Vaginal paraganglioma (VP), usually solitary and primary, is a rare adrenal type paraganglioma derived from the anterior neural crest, and can be classified as a functional or non-functional tumor. Only 10 cases of VP have been reported since 1955. Herein, we report an unusual case of a 39-year-old female VP patient with symptoms of hypercatecholaminism and a family history of hypertension. After preoperative control of blood pressure with an alpha-receptor blocker, laparoscopic surgery was performed. The blood pressure fluctuated after touching the tumor intraoperatively, and the tumor was successfully and completely removed under anesthesia by surgery. Postoperative pathology confirmed the diagnosis. The clinical characteristics, auxiliary examination, morphological and pathological immunohistochemical characteristics, and perioperative treatment of VP are analyzed, and the literature of the previous 10 cases is reviewed, so as to help further understand VP and provide clinical guidance.
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22
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Thodou E, Choreftaki T, Kounadi T, Papanastasiou L, Kontogeorgos G. Thyroid Paraganglioma With Medullary Carcinoma: A Unique Combination in a Patient in Association With Multiple Endocrine Neoplasia Type 2B Syndrome With Prolonged Survival. Cureus 2022; 14:e28423. [PMID: 36176816 PMCID: PMC9509527 DOI: 10.7759/cureus.28423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Head and neck paragangliomas (PGLs) most commonly derive from the carotid body, jugulotympanic, vagal, and laryngeal paraganglia. Thyroid PGLs originate in the inferior laryngeal paraganglion, which may lie inside the thyroid parenchyma. Intrathyroid PGLs are rare with approximately 75 cases reported to date, mostly as solitary lesions. The coexistence of thyroid PGL with medullary thyroid carcinoma (MTC) has not been reported. Here, we report a unique case of intrathyroid PGL concomitant with MTC in the context of multiple endocrine neoplasia type 2B syndrome. Interestingly, the patient showed a prolonged survival with good clinical response to tyrosine kinase inhibitors, despite her advanced metastatic MTC. We discuss the challenges in pathology, differential diagnosis, and genetic background for the development of these thyroid lesions.
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23
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Zhou FF, Ding JS, Zhang M, Tian X. Paraganglioma-induced inverted takotsubo-like cardiomyopathy leading to cardiogenic shock successfully treated with extracorporeal membrane oxygenation. Open Med (Wars) 2022; 17:1368-1375. [PMID: 36046634 PMCID: PMC9372704 DOI: 10.1515/med-2022-0535] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 06/26/2022] [Accepted: 07/12/2022] [Indexed: 11/21/2022] Open
Abstract
Paragangliomas are rare neuroendocrine tumors that originate in the chromaffin cells of the adrenal medulla or lymph nodes. Paragangliomas manifest in rare cases as catecholamine crisis, leading to heart failure, intracranial hemorrhage, renal failure, arrhythmias, pulmonary edema, or multisystem failure. Takotsubo cardiomyopathy is also called apical ballooning syndrome or stress cardiomyopathy. Left ventricular dysfunction with apical hyperkinesis and basilar and midventricular akinesis in the absence of coronary artery disease is highly suggestive of a variant of stress cardiomyopathy (inverted takotsubo cardiomyopathy). Herein, we report the case of a 69-year-old man with an unknown retroperitoneal paraganglioma who suffered from cardiogenic shock due to inverted takotsubo cardiomyopathy. He was treated with venoarterial extracorporeal membrane pulmonary oxygenation (ECMO) in combination with an intra-aortic balloon pump. After the restoration of cardiac function, a successful transition to curative retroperitoneal paraganglioma resection was performed. We conclude that ECMO is a valuable option for undiagnosed endocrine emergencies, helping to restore cardiac function and allowing sufficient time for further accurate diagnosis and specific treatment.
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Affiliation(s)
- Fang-Fang Zhou
- Department of Ultrasound, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University , Lishui 323000 , Zhejiang Province , China
| | - Jia-Sheng Ding
- Department of Intensive Care Unit, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University , Lishui 323000 , Zhejiang Province , China
| | - Min Zhang
- Department of Pathology, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University , Lishui 323000 , Zhejiang Province , China
| | - Xin Tian
- Department of Intensive Care Unit, Lishui Central Hospital, The Fifth Affiliated Hospital of Wenzhou Medical University , No. 289, Kuocang Road , Lishui 323000 , Zhejiang Province , China
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Preoperative Diagnosis of Abdominal Extra-Adrenal Paragangliomas with Fine-Needle Biopsy. Diagnostics (Basel) 2022; 12:diagnostics12081819. [PMID: 36010170 PMCID: PMC9406649 DOI: 10.3390/diagnostics12081819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
Paragangliomas are rare, non-epithelial neuroendocrine neoplasms originating in paraganglia, for instance the adrenal medulla, or at extra-adrenal locations. The aim of this study was to review the literature regarding abdominal extra-adrenal paragangliomas diagnosed pre-operatively with fine-needle biopsy (FNA and/or FNB). The PubMed database was searched to identify such cases, using a specific algorithm and inclusion/exclusion criteria. An unpublished case from our practice was also added to the rest of the data, resulting in a total of 36 cases for analysis. Overall, 24 (67%) lesions were found in females, whereas 12 (33%) in males. Most (21/36; 58.33%) were identified around and/or within the pancreatic parenchyma. FNA and/or FNB reached or suggested a paraganglioma diagnosis in 17/36 cases (47.22%). Of the preoperative misdiagnoses, the most common was an epithelial neuroendocrine tumor (NET). Regarding follow-up, most patients were alive with no reported recurrence; however, 5/36 patients exhibited a recurrence or a widespread disease, whereas one patient died 48 months following her diagnosis. In two patients, transient hypertension was reported during the EUS-FNA procedure. In conclusion, this study showed that the preoperative diagnosis of these lesions is feasible and, while diagnostic pitfalls exist, they could significantly be avoided with the application of immunochemistry.
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Santos MS, Teixeira MM, Alves A, Pereira BD, Henriques M. A Case of Paraganglioma-Induced Adrenergic Shock. Cureus 2022; 14:e26925. [PMID: 35983384 PMCID: PMC9377794 DOI: 10.7759/cureus.26925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2022] [Indexed: 11/22/2022] Open
Abstract
Paragangliomas (PGLs) are rare neuroendocrine tumors that, when functional, can release excessive catecholamines, causing health conditions ranging from asymptomatic arterial hypertension to life-threatening arrhythmias and cardiogenic shock. Early diagnosis of functional PGLs is extremely important as timely treatment can be curative and prevent vascular sequelae. We describe the clinical case of a 30-year-old woman with arterial hypertension under study, who was presented to the emergency department with a hypertensive crisis that progressed to adrenergic shock, in the context of a functional PGL.
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Rodríguez L, Girón F, Chaves CER, Venegas D, Núñez-Rocha RE, Nassar R. Aorto-iliac paraganglioma: Case report and literature review. Int J Surg Case Rep 2022; 95:107119. [PMID: 35580415 PMCID: PMC9117528 DOI: 10.1016/j.ijscr.2022.107119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/19/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Paraganglioma and pheochromocytoma are uncommon conditions that affect around 1.5–9 patients per million. The most frequent symptoms are headache, hypertension and diaphoresis; however, palpitations or tachycardia could be present. Malignancy is not frequent, and when is suspected, positron emission tomography (PET) should be performed. Surgery it's the gold standard treatment, with acceptable rates of morbidity and mortality. Presentation of the case A 33-year-old woman presented to private practice with long-standing symptoms consisting of asthenia, adynamia, and sensation of palpable masses in the neck. Due to her medical history and imaging findings, urine metanephrines were obtained, showing high values of adrenaline 6.69 (μg/24 h), noradrenaline 130.09 (μg/24 h), dopamine 262.59 (μg/24 h). PET was performed to identify hyperfunctioning masses in other locations, finding bilateral carotid hypermetabolic masses and a nodular lesion anterior to the aortoiliac bifurcation, probably malignant. Laparoscopic retroperitoneal tumor resection was performed by a laparoscopic and metabolic surgeon, with intraoperative findings of a vascularized mass (30 × 25 mm) closely related to the left aortoiliac bifurcation and peritoneal fluid. Discussion Paragangliomas are rare tumors that frequently produce catecholamines with varied symptoms. Diagnosis requires patient history, laboratory studies including 24-hour urine-metanephrines and plasma metanephrine levels. Imaging such as CT, MRI and PET scan are necessary. Perioperative management needs to be performed and surgery is the basis of the treatment in patients with localized disease. Metastatic disease has a 50% mortality at 5 years and requires a different approach. Conclusion Paraganglioma is a rare and complex entity that requires a multidisciplinary approach. Paragangliomas are rare tumors that produce catecholamines with varied symptoms. Diagnosis requires a detailed history, laboratory and imaging studies. Perioperative management needs to be performed by a multidisciplinary board. Surgery is the cornerstone treatment of this pathology.
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Tsuruta M, Goto T, Kono J, Kita Y, Masui K, Sano T, Fujimoto M, Sawada A, Akamatsu S, Kobayashi T. Paraurachal paraganglioma. IJU Case Rep 2022; 5:358-361. [PMID: 36090947 PMCID: PMC9436662 DOI: 10.1002/iju5.12488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/15/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Paragangliomas (PGLs) are frequently reported around the abdominal aorta; however, are extremely rare near the urachus. Case presentation A 78‐year‐old woman was referred to the urology department of our hospital for further examination and treatment of a 1.2‐cm tumor in the lower abdominal wall, a tumor excision was then performed. On immunohistochemical staining, the tumor and supporting cells were positive for chromogranin A and the S 100 protein, respectively, and were diagnosed as PGL. The PGL was thought to be derived from chromaffin cells that migrated to the wall of the urachus during embryonic life and remained even after the wall regressed. Conclusion We report a case of PGL near the urachus that can be explained by the distribution of the sympathetic network around the midline of the lower abdominal wall during embryonic development. Therefore, PGL should be considered in the differential diagnosis of periurachal tumors.
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Affiliation(s)
| | - Takayuki Goto
- Department of Urology Kyoto University Hospital Kyoto Japan
| | - Jin Kono
- Department of Urology Kyoto University Hospital Kyoto Japan
| | - Yuki Kita
- Department of Urology Kyoto University Hospital Kyoto Japan
| | - Kimihiko Masui
- Department of Urology Kyoto University Hospital Kyoto Japan
| | - Takeshi Sano
- Department of Urology Kyoto University Hospital Kyoto Japan
| | - Masakazu Fujimoto
- Department of Diagnostic Pathology Kyoto University Hospital Kyoto Japan
| | - Atsuro Sawada
- Department of Urology Kyoto University Hospital Kyoto Japan
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Metastatic Neuroendocrine Neoplasms of Unknown Primary: Clues from Pathology Workup. Cancers (Basel) 2022; 14:cancers14092210. [PMID: 35565339 PMCID: PMC9100271 DOI: 10.3390/cancers14092210] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary While most neuroendocrine neoplasms are indolent and slow-growing tumors, subsets of cases will spread beyond the tissue of origin. Given the rather slow progress, some lesions are incidentally discovered as metastatic deposits rather than primary masses. In these cases, a biopsy is often taken to allow the pathologist to identify the tumor type and possibly the primary tumor site via microscopic examination. In this review, the authors present a simplified guide on how to approach metastatic neuroendocrine tumors from a pathologist’s perspective. Abstract Neuroendocrine neoplasms (NENs) are diverse tumors arising in various anatomical locations and may therefore cause a variety of symptoms leading to their discovery. However, there are instances in which a NEN first presents clinically as a metastatic deposit, while the associated primary tumor is not easily identified using conventional imaging techniques because of small primary tumor sizes. In this setting (which is referred to as a “NEN of unknown primary”; NEN-UP), a tissue biopsy is often procured to allow the surgical pathologist to diagnose the metastatic lesion. If indeed a metastatic NEN-UP is found, several clues can be obtained from morphological assessment and immunohistochemical staining patterns that individually or in concert may help identify the primary tumor site. Herein, histological and auxiliary analyses of value in this context are discussed in order to aid the pathologist when encountering these lesions in clinical practice.
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Mete O, Wenig BM. Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Overview of the 2022 WHO Classification of Head and Neck Neuroendocrine Neoplasms. Head Neck Pathol 2022; 16:123-142. [PMID: 35312985 PMCID: PMC9018952 DOI: 10.1007/s12105-022-01435-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/21/2022] [Indexed: 12/17/2022]
Abstract
This review article provides a brief overview of the new WHO classification by adopting a question-answer model to highlight the spectrum of head and neck neuroendocrine neoplasms which includes epithelial neuroendocrine neoplasms (neuroendocrine tumors and neuroendocrine carcinomas) arising from upper aerodigestive tract and salivary glands, and special neuroendocrine neoplasms including middle ear neuroendocrine tumors (MeNET), ectopic or invasive pituitary neuroendocrine tumors (PitNET; formerly known as pituitary adenoma) and Merkel cell carcinoma as well as non-epithelial neuroendocrine neoplasms (paragangliomas). The new WHO classification follows the IARC/WHO nomenclature framework and restricts the diagnostic term of neuroendocrine carcinoma to poorly differentiated epithelial neuroendocrine neoplasms. In this classification, well-differentiated epithelial neuroendocrine neoplasms are termed as neuroendocrine tumors (NET), and are graded as G1 NET (no necrosis and < 2 mitoses per 2 mm2; Ki67 < 20%), G2 NET (necrosis or 2-10 mitoses per 2 mm2, and Ki67 < 20%) and G3 NET (> 10 mitoses per 2 mm2 or Ki67 > 20%, and absence of poorly differentiated cytomorphology). Neuroendocrine carcinomas (> 10 mitoses per 2 mm2, Ki67 > 20%, and often associated with a Ki67 > 55%) are further subtyped based on cytomorphological characteristics as small cell and large cell neuroendocrine carcinomas. Unlike neuroendocrine carcinomas, head and neck NETs typically show no aberrant p53 expression or loss of RB reactivity. Ectopic or invasive PitNETs are subtyped using pituitary transcription factors (PIT1, TPIT, SF1, GATA3, ER-alpha), hormones and keratins (e.g., CAM5.2). The new classification emphasizes a strict correlation of morphology and immunohistochemical findings in the accurate diagnosis of neuroendocrine neoplasms. A particular emphasis on the role of biomarkers in the confirmation of the neuroendocrine nature of a neoplasm and in the distinction of various neuroendocrine neoplasms is provided by reviewing ancillary tools that are available to pathologists in the diagnostic workup of head and neck neuroendocrine neoplasms. Furthermore, the role of molecular immunohistochemistry in the diagnostic workup of head and neck paragangliomas is discussed. The unmet needs in the field of head and neck neuroendocrine neoplasms are also discussed in this article. The new WHO classification is an important step forward to ensure accurate diagnosis that will also form the basis of ongoing research in this field.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Endocrine Oncology Site, The Princess Margaret Cancer Center, Toronto, ON, Canada.
| | - Bruce M Wenig
- Department of Pathology Moffitt Cancer Center, Tampa, FL, USA
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Mete O, Asa SL, Gill AJ, Kimura N, de Krijger RR, Tischler A. Overview of the 2022 WHO Classification of Paragangliomas and Pheochromocytomas. Endocr Pathol 2022; 33:90-114. [PMID: 35285002 DOI: 10.1007/s12022-022-09704-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 12/12/2022]
Abstract
This review summarizes the classification of tumors of the adrenal medulla and extra-adrenal paraganglia as outlined in the 5th series of the WHO Classification of Endocrine and Neuroendocrine Tumors. The non-epithelial neuroendocrine neoplasms (NENs) known as paragangliomas produce predominantly catecholamines and secrete them into the bloodstream like hormones, and they represent a group of NENs that have exceptionally high genetic predisposition. This classification discusses the embryologic derivation of the cells that give rise to these lesions and the historical evolution of the terminology used to classify their tumors; paragangliomas can be sympathetic or parasympathetic and the term pheochromocytoma is used specifically for intra-adrenal paragangliomas that represent the classical sympathetic form. In addition to the general neuroendocrine cell biomarkers INSM1, synaptophysin, and chromogranins, these tumors are typically negative for keratins and instead have highly specific biomarkers, including the GATA3 transcription factor and enzymes involved in catecholamine biosynthesis: tyrosine hydroxylase that converts L-tyrosine to L-DOPA as the rate-limiting step in catecholamine biosynthesis, dopamine beta-hydroxylase that is present in cells expressing norepinephrine, and phenylethanolamine N-methyltransferase, which converts norepinephrine to epinephrine and therefore can be used to distinguish tumors that make epinephrine. In addition to these important tools that can be used to confirm the diagnosis of a paraganglioma, new tools are recommended to determine genetic predisposition syndromes; in addition to the identification of precursor lesions, molecular immunohistochemistry can serve to identify associations with SDHx, VHL, FH, MAX, and MEN1 mutations, as well as pseudohypoxia-related pathogenesis. Paragangliomas have a well-formed network of sustentacular cells that express SOX10 and S100, but this is not a distinctive feature, as other epithelial NENs also have sustentacular cells. Indeed, it is the presence of such cells and the association with ganglion cells that led to a misinterpretation of several unusual lesions as paragangliomas; in the 2022 WHO classification, the tumor formerly known as cauda equina paraganglioma is now classified as cauda equina neuroendocrine tumor and the lesion known as gangliocytic paraganglioma has been renamed composite gangliocytoma/neuroma and neuroendocrine tumor (CoGNET). Since the 4th edition of the WHO, paragangliomas have no longer been classified as benign and malignant, as any lesion can have metastatic potential and there are no clear-cut features that can predict metastatic behavior. Moreover, some tumors are lethal without metastatic spread, by nature of local invasion involving critical structures. Nevertheless, there are features that can be used to identify more aggressive lesions; the WHO does not endorse the various scoring systems that are reviewed but also does not discourage their use. The identification of metastases is also complex, particularly in patients with germline predisposition syndromes, since multiple lesions may represent multifocal primary tumors rather than metastatic spread; the identification of paragangliomas in unusual locations such as lung or liver is not diagnostic of metastasis, since these may be primary sites. The value of sustentacular cells and Ki67 labeling as prognostic features is also discussed in this new classification. A staging system for pheochromocytoma and extra-adrenal sympathetic PGLs, introduced in the 8th Edition AJCC Cancer Staging Manual, is now included. This paper also provides a summary of the criteria for the diagnosis of a composite paragangliomas and summarizes the classification of neuroblastic tumors. This review adopts a practical question-answer framework to provide members of the multidisciplinary endocrine oncology team with a most up-to-date approach to tumors of the adrenal medulla and extra-adrenal paraganglia.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON, Canada.
- Endocrine Oncology Site, Princess Margaret Cancer Centre, Toronto, ON, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Anthony J Gill
- Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Sydney, Australia
| | - Noriko Kimura
- Department of Clinical Research, Division of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
| | - Ronald R de Krijger
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arthur Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
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Rindi G, Mete O, Uccella S, Basturk O, La Rosa S, Brosens LAA, Ezzat S, de Herder WW, Klimstra DS, Papotti M, Asa SL. Overview of the 2022 WHO Classification of Neuroendocrine Neoplasms. Endocr Pathol 2022; 33:115-154. [PMID: 35294740 DOI: 10.1007/s12022-022-09708-2] [Citation(s) in RCA: 219] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2022] [Indexed: 02/07/2023]
Abstract
In this review, we detail the changes and the relevant features that are applied to neuroendocrine neoplasms (NENs) in the 2022 WHO Classification of Endocrine and Neuroendocrine Tumors. Using a question-and-answer approach, we discuss the consolidation of the nomenclature that distinguishes neuronal paragangliomas from epithelial neoplasms, which are divided into well-differentiated neuroendocrine tumors (NETs) and poorly differentiated neuroendocrine carcinomas (NECs). The criteria for these distinctions based on differentiation are outlined. NETs are generally (but not always) graded as G1, G2, and G3 based on proliferation, whereas NECs are by definition high grade; the importance of Ki67 as a tool for classification and grading is emphasized. The clinical relevance of proper classification is explained, and the importance of hormonal function is examined, including eutopic and ectopic hormone production. The tools available to pathologists for accurate classification include the conventional biomarkers of neuroendocrine lineage and differentiation, INSM1, synaptophysin, chromogranins, and somatostatin receptors (SSTRs), but also include transcription factors that can identify the site of origin of a metastatic lesion of unknown primary site, as well as hormones, enzymes, and keratins that play a role in functional and structural correlation. The recognition of highly proliferative, well-differentiated NETs has resulted in the need for biomarkers that can distinguish these G3 NETs from NECs, including stains to determine expression of SSTRs and those that can indicate the unique molecular pathogenetic alterations that underlie the distinction, for example, global loss of RB and aberrant p53 in pancreatic NECs compared with loss of ATRX, DAXX, and menin in pancreatic NETs. Other differential diagnoses are discussed with recommendations for biomarkers that can assist in correct classification, including the distinctions between epithelial and non-epithelial NENs that have allowed reclassification of epithelial NETs in the spine, in the duodenum, and in the middle ear; the first two may be composite tumors with neuronal and glial elements, and as this feature is integral to the duodenal lesion, it is now classified as composite gangliocytoma/neuroma and neuroendocrine tumor (CoGNET). The many other aspects of differential diagnosis are detailed with recommendations for biomarkers that can distinguish NENs from non-neuroendocrine lesions that can mimic their morphology. The concepts of mixed neuroendocrine and non-neuroendocrine (MiNEN) and amphicrine tumors are clarified with information about how to approach such lesions in routine practice. Theranostic biomarkers that assist patient management are reviewed. Given the significant proportion of NENs that are associated with germline mutations that predispose to this disease, we explain the role of the pathologist in identifying precursor lesions and applying molecular immunohistochemistry to guide genetic testing.
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Affiliation(s)
- Guido Rindi
- Department of Life Sciences and Public Health, Section of Anatomic Pathology, Università Cattolica del Sacro Cuore, Rome, Italy.
- Department of Woman and Child Health Sciences and Public Health, Anatomic Pathology Unit, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
- ENETS Center of Excellence, Rome, Italy.
| | - Ozgur Mete
- Department of Pathology, University Health Network, University of Toronto, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada.
| | - Silvia Uccella
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stefano La Rosa
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Shereen Ezzat
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Wouter W de Herder
- Department of Internal Medicine, Sector of Endocrinology, Erasmus MC Cancer Institute, ENETS Center of Excellence Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - David S Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Paige.AI, New York, NY, USA
| | - Mauro Papotti
- Department of Oncology, University of Turin, Turin, Italy
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Pingree GM, Fleming C, Reavey-Cantwell J, Coelho DH. Neurosurgical Causes of Pulsatile Tinnitus: Contemporary Update. Neurosurgery 2022; 90:161-169. [PMID: 34995248 DOI: 10.1227/neu.0000000000001778] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/31/2021] [Indexed: 12/15/2022] Open
Abstract
Traditionally in the domain of the otolaryngologist, pulsatile tinnitus (PT) has become increasingly relevant to neurosurgeons. PT may prove to be a harbinger of life-threatening pathology; however, often, it is a marker of a more benign process. Irrespectively, the neurosurgeon should be familiar with the many potential etiologies of this unique and challenging patient population. In this review, we discuss the myriad causes of PT, categorized by pulse-phase rhythmicity.
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Affiliation(s)
- Graham M Pingree
- Department of Otolaryngology - Head & Neck Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Charles Fleming
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Daniel H Coelho
- Department of Otolaryngology - Head & Neck Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Kuhlen M, Pamporaki C, Kunstreich M, Wudy SA, Hartmann MF, Peitzsch M, Vokuhl C, Seitz G, Kreissl MC, Simon T, Hero B, Frühwald MC, Vorwerk P, Redlich A. Adrenocortical Tumors and Pheochromocytoma/Paraganglioma Initially Mistaken as Neuroblastoma-Experiences From the GPOH-MET Registry. Front Endocrinol (Lausanne) 2022; 13:918435. [PMID: 35784570 PMCID: PMC9248437 DOI: 10.3389/fendo.2022.918435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/18/2022] [Indexed: 01/31/2023] Open
Abstract
In children and adolescents, neuroblastoma (NBL), pheochromocytoma (PCC), and adrenocortical tumors (ACT) can arise from the adrenal gland. It may be difficult to distinguish between these three entities including associated extra-adrenal tumors (paraganglioma, PGL). Precise discrimination, however, is of crucial importance for management. Biopsy in ACT or PCC is potentially harmful and should be avoided whenever possible. We herein report data on 10 children and adolescents with ACT and five with PCC/PGL, previously mistaken as NBL. Two patients with adrenocortical carcinoma died due to disease progression. Two (2/9, missing data in one patient) patients with a final diagnosis of ACT clearly presented with obvious clinical signs and symptoms of steroid hormone excess, while seven patients did not. Blood analyses indicated increased levels of steroid hormones in one additional patient; however, urinary steroid metabolome analysis was not performed in any patient. Two (2/10) patients underwent tumor biopsy, and in two others tumor rupture occurred intraoperatively. In 6/10 patients, ACT diagnosis was only established by a reference pediatric pathology laboratory. Four (4/5) patients with a final diagnosis of PCC/PGL presented with clinical signs and symptoms of catecholamine excess. Urine tests indicated possible catecholamine excess in two patients, while no testing was carried out in three patients. Measurements of plasma metanephrines were not performed in any patient. None of the five patients with PCC/PGL received adrenergic blockers before surgery. In four patients, PCC/PGL diagnosis was established by a local pathologist, and in one patient diagnosis was revised to PGL by a pediatric reference pathologist. Genetic testing, performed in three out of five patients with PCC/PGL, indicated pathogenic variants of PCC/PGL susceptibility genes. The differential diagnosis of adrenal neoplasias and associated extra-adrenal tumors in children and adolescents may be challenging, necessitating interdisciplinary and multidisciplinary efforts. In ambiguous and/or hormonally inactive cases through comprehensive biochemical testing, microscopical complete tumor resection by an experienced surgeon is vital to preventing poor outcome in children and adolescents with ACT and/or PCC/PGL. Finally, specimens need to be assessed by an experienced pediatric pathologist to establish diagnosis.
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Affiliation(s)
- Michaela Kuhlen
- Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- *Correspondence: Michaela Kuhlen,
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marina Kunstreich
- Pediatric Oncology Department, Otto von Guericke University Children’s Hospital, Magdeburg, Germany
| | - Stefan A. Wudy
- Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Division of Paediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F. Hartmann
- Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Division of Paediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Vokuhl
- Section of Pediatric Pathology, University of Bonn, Bonn, Germany
| | - Guido Seitz
- Department of Pediatric Surgery and Urology, University Children’s Hospital Marburg, Marburg, Germany
| | - Michael C. Kreissl
- Division of Nuclear Medicine, Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Otto-von Guericke University, Magdeburg, Germany
| | - Thorsten Simon
- Department of Pediatric Oncology and Hematology, University Hospital, University of Cologne, Cologne, Germany
| | - Barbara Hero
- Department of Pediatric Oncology and Hematology, University Hospital, University of Cologne, Cologne, Germany
| | - Michael C. Frühwald
- Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Peter Vorwerk
- Pediatric Oncology Department, Otto von Guericke University Children’s Hospital, Magdeburg, Germany
| | - Antje Redlich
- Pediatric Oncology Department, Otto von Guericke University Children’s Hospital, Magdeburg, Germany
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Robotic excision of interaortocaval paraganglioma: a case report with the literature review. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00264-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Paragangliomas are rare neuroendocrine tumors of extra adrenal origin. The symptomatic paragangliomas require multimodal treatment approach.
Case Presentation
We report a case of 34-year-old female who presented with complains of headache and blurring of vision. Examination revealed Hypertensive crisis with grade 3 retinopathy. The patient was diagnosed as a case of extra-adrenal paraganglioma during evaluation for secondary hypertension. Magnetic Resonance Imaging of the abdomen revealed 23*28*28 mm mass lesion in the inter-aortocaval region at the level of L3–L4. The patient was started on medical management for hypertension and was managed safely with robot-assisted surgery, owing to enhanced visualization of feeding vessels and avoidance of excessive manipulation of tumor.
Conclusions
Our case report emphasizes on the robot assisted surgical technique for the removal of tumor in a vulnerable anatomical position and presents a review of the literature.
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Asa SL, Arkun K, Tischler AS, Qamar A, Deng FM, Perez-Ordonez B, Weinreb I, Bishop JA, Wenig BM, Mete O. Middle Ear "Adenoma": a Neuroendocrine Tumor with Predominant L Cell Differentiation. Endocr Pathol 2021; 32:433-441. [PMID: 34041698 DOI: 10.1007/s12022-021-09684-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/24/2022]
Abstract
This morphological and immunohistochemical study demonstrates that tumors currently known as "middle ear adenomas" are truly well-differentiated epithelial neuroendocrine tumors (NETs) composed of cells comparable to normal intestinal L cells, and therefore, these tumors resemble hindgut NETs. These tumors show consistent expression of glucagon, pancreatic polypeptide, PYY, and the transcription factor SATB2, as well as generic neuroendocrine markers and keratins. The same L cell markers are expressed by cells within the normal middle ear epithelium. These markers define a valuable immunohistochemical profile that can be used for differential diagnosis of middle ear neoplasms, particularly in distinguishing epithelial NETs from paragangliomas. The discovery of neuroendocrine cells expressing the same markers in non-neoplastic middle ear mucosa opens new areas of investigation into the physiology of the normal middle ear and the pathophysiology of middle ear disorders.
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Affiliation(s)
- Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland Ohio, 44106, USA.
| | - Knarik Arkun
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, USA
| | - Arthur S Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, USA
| | - Adnan Qamar
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, USA
| | | | - Bayardo Perez-Ordonez
- Department of Pathology, University Health Network, University of Toronto, Ontario, M5G 2C4, Toronto, Canada
| | - Ilan Weinreb
- Department of Pathology, University Health Network, University of Toronto, Ontario, M5G 2C4, Toronto, Canada
| | - Justin A Bishop
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Bruce M Wenig
- Department of Pathology, Moffitt Cancer Center, Tampa, FL, 33616, USA
| | - Ozgur Mete
- Department of Pathology, University Health Network, University of Toronto, Ontario, M5G 2C4, Toronto, Canada
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Youssef O, Bushra A, Meryem R, Yassir H, Khadija EB, Sami R, Redallah A, Mohamed R, Mohamed M. An unusual combined glomus vagale and jugular tumor: A case report. Ann Med Surg (Lond) 2021; 70:102918. [PMID: 34691440 PMCID: PMC8519800 DOI: 10.1016/j.amsu.2021.102918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 10/03/2021] [Accepted: 10/03/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction and importance: Head and neck paragangliomas are slowly growing benign tumors and they originate from specialized neural crest cells. We report an unusual combined glomus vagal and jugular tumor that was rarely described in the literature to the best of our knowledge. Case presentation A 51 years old female with no pathological history was presented to our ENT department with 6 months’ history of a right latero cervical swelling gradually increasing in size associated with a swallowing difficulties and hoarseness. Preoperatively clinical examination had found vagal and hypoglossal nerve paralysis. Cervical CT scan and MRI had shown glomus jugular tumor. The patient underwent a surgical excision with severe swallowing difficulties and facial palsy in the immediate postoperative period with a mild recovery afterwards. Clinical discussion Paragangliomas of the mesotympanum and jugular foramen most commonly present as a vascular middle ear mass. The most common presenting symptom is pulsatile tinnitus occurring in 80% followed by hearing loss (60%). Dysfunction of cranial nerves traversing the jugular foramen may be commonly encountered with resultant abnormalities of speech, swallowing and airway function. Vagal paragangliomas are the least common of the three primary craniocervical paragangliomas. The most common presenting sign is the presence of a painless neck mass accompanied occasionally by dysphagia and hoarseness. The association of both glomus vagal and jugular tumor is rarely described in the literature to the best of our knowledge. Conclusion Head and neck paragangliomas are slowly growing benign tumors and they originate from specialized neural crest cells. Vagal paragangliomas are the least common of the three primary craniocervical paragangliomas. The association of both glomus vagal and jugular tumor is rarely described in the literature to the best of our knowledge. The choice of treatment depends on the location, size, and also biologic activity of the tumor as well as the physical condition of the patient. The combination of jugular tumor et glomus vagal is very rare in the literature to the best of our knowledge. The choice of treatment depends on the location, size, and also biologic activity of the tumor as well as the physical condition of the patient. Surgery can provide excellent control of the tumour while radiation therapy may be considered for patients with surgery contraindication. Facial nerve palsies and swallowing difficulty have been reported in the postoperative period in several cases.
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Affiliation(s)
- Oukessou Youssef
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
| | - Abdulhakeem Bushra
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
- Corresponding author
| | - Regragui Meryem
- Pathology Department, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
| | - Hammouda Yassir
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
| | - El Bouhmadi Khadija
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
| | - Rouadi Sami
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
| | - Abada Redallah
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
| | - Roubal Mohamed
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
| | - Mahtar Mohamed
- Department of Otolaryngology Head Neck Surgery, University Hospital Ibn Rochd, Faculty of Medecine and Pharmacy, Hassan II University, Casablanca, Morocco
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Differences in clinical presentation and management between pre- and postsurgical diagnoses of urinary bladder paraganglioma: is there clinical relevance? A systematic review. World J Urol 2021; 40:385-390. [PMID: 34655306 PMCID: PMC8921018 DOI: 10.1007/s00345-021-03851-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/28/2021] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Paraganglioma of the urinary bladder (UBPGL) is a rare neuroendocrine tumor diagnosed in many patients only after surgery. We, therefore, assessed clinical clues relevant to presurgical diagnosis and clinical consequences in patients with a missed presurgical diagnosis of UBPGL. MATERIALS AND METHODS Case reports describing a UBPGL (published from 1-1-2001 and 31-12-2020) were identified in Pubmed. Two authors independently performed data extraction and assessed data quality according to the PRISMA guideline. Patients were divided into two groups: UBPGL diagnosis before and after surgery. RESULTS We included 177 articles reporting 194 cases. In 90 (46.4%) patients, the UBPGL was diagnosed before and in 104 (53.6%) after surgery. In presurgically diagnosed UBPGL, hypertension and catecholamine-associated symptoms were 2- to 3-fold (p < 0.001) more frequent than in postsurgically diagnosed patients whereas hematuria was twofold (p = 0.003) more prevalent in those with postsurgical diagnosis. Hypertension was an independent factor for presurgical biochemical testing (OR 4.45, 95% CI 1.66-11.94) while hematuria (OR 0.23, 95% CI 0.09-0.60) was an independent factor for not performing presurgical biochemical testing. Most patients diagnosed after surgery were not pretreated with alpha-adrenoceptor blockade (95.2%), underwent more frequently transurethral resection instead of cystectomy (70.2% vs. 23.1%) and had more frequent peroperative complications and residual tumor mass. CONCLUSIONS In nearly half of all patients with a UBPGL, the diagnosis was not established before surgery. Hypertension and hematuria contributed independently to a presurgical diagnosis. Postsurgical diagnosis, which was associated with suboptimal presurgical and surgical management, resulted in more peroperative complications and incomplete tumor resections.
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Konukiewitz B, Jesinghaus M, Kasajima A, Klöppel G. Neuroendocrine neoplasms of the pancreas: diagnosis and pitfalls. Virchows Arch 2021; 480:247-257. [PMID: 34647171 PMCID: PMC8986719 DOI: 10.1007/s00428-021-03211-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/06/2021] [Accepted: 09/21/2021] [Indexed: 12/29/2022]
Abstract
Common to neuroendocrine neoplasms of the pancreas is their expression of synaptophysin, chromogranin A, and/or INSM1. They differ, however, in their histological differentiation and molecular profile. Three groups can be distinguished: well-differentiated neuroendocrine neoplasms (neuroendocrine tumors), poorly differentiated neuroendocrine neoplasms (neuroendocrine carcinomas), and mixed neuroendocrine-non-neuroendocrine neoplasms. However, the expression of synaptophysin and, to a lesser extent, also chromogranin A is not restricted to the neuroendocrine neoplasms, but may also be in a subset of non-neuroendocrine epithelial and non-epithelial neoplasms. This review provides the essential criteria for the diagnosis of pancreatic neuroendocrine neoplasms including diagnostic clues for the distinction of high-grade neuroendocrine tumors from neuroendocrine carcinomas and an algorithm avoiding diagnostic pitfalls in the delineation of non-neuroendocrine neoplasms with neuroendocrine features from pancreatic neuroendocrine neoplasms.
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Affiliation(s)
- Björn Konukiewitz
- Institute of Pathology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Christian-Albrechts-Universität zu Kiel, Arnold-Heller-Straße 3/14, 24105, Kiel, Germany.
| | - Moritz Jesinghaus
- Institute of Pathology, Universitätsklinikum Marburg, Baldingerstraße, 35043, Marburg, Germany
| | - Atsuko Kasajima
- Institute of Pathology, Technische Universität München, Trogerstraße 18, 81675, Munich, Germany
| | - Günter Klöppel
- Institute of Pathology, Technische Universität München, Trogerstraße 18, 81675, Munich, Germany
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Lanke G, Stewart JM, Lee JH. Pancreatic paraganglioma diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report and review of literature. World J Gastroenterol 2021; 27:6322-6331. [PMID: 34712035 PMCID: PMC8515802 DOI: 10.3748/wjg.v27.i37.6322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/28/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic paragangliomas (PPGL) are rare benign neuroendocrine neoplasms but malignancy can occur. PPGL are often misdiagnosed as pancreatic neuroendocrine tumor or pancreatic adenocarcinoma.
CASE SUMMARY We reviewed 47 case reports of PPGL published in PubMed to date. Fifteen patients (15/47) with PPGL underwent endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Only six (6/15) were correctly diagnosed as PPGL. All patients with PPGL underwent surgical resection except three (one patient surgery was aborted because of hypertensive crisis, two patients had metastasis or involvement of major vessels). Our patient remained on close surveillance as she was asymptomatic.
CONCLUSION Accurate preoperative diagnosis of PPGL can be safely achieved by EUS-FNA with immunohistochemistry. Multidisciplinary team approach should be considered to bring the optimal results in the management of PPGL.
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Affiliation(s)
- Gandhi Lanke
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Lubbock, TX 79407, United States
| | - John M Stewart
- Pathology-lab Medicine Division, MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX 77030, United States
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Role of GATA3 in tumor diagnosis: A review. Pathol Res Pract 2021; 226:153611. [PMID: 34547599 DOI: 10.1016/j.prp.2021.153611] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022]
Abstract
GATA binding protein 3 (GATA3) belongs to a family of transcription factors comprising six members. These proteins identify G-A-T-A containing sequences in the target gene and bind to DNA target via two zinc-finger domains. The aim of this study was to evaluate the role of GATA3 in the diagnosis of tumors and its value as a prognostic marker. To perform this review, a comprehensive search was conducted through PubMed, Embase, Scopus, Cochrane and Google Scholar databases from 1985 to 2020. Articles were considered thoroughly by independent reviewers and data were extracted in predefined forms. Final synthesis was conducted by using appropriate data from included articles in each topic. Studies have shown that GATA3 has a critical role in the development of epithelial structures in both embryonic and adult tissues. The majority of studies regarding GATA3 expression in tumor evaluation focused on breast and urothelial neoplasms, whether primary or metastatic. Its sensitivity in these neoplasms has been reported to be high and made this marker more valuable than other available immunohistochemistry markers. However, GATA3 expression was not restricted to these tumors. Studies have shown that GATA3 immunostaining could be a useful tool in various tumors in kidney, salivary gland, endocrine system, hematopoietic system, and skin. GATA3 can also be used as a useful prognostic tool. Although GATA3 is a multi-specific immunohistochemical stain, it is a valuable marker in the panel for confirming many epithelial or mesenchymal neoplasms as both a diagnostic and prognostic tool.
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41
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Thakur A, Choudhary NS, Sarin H, Srivastava S, Puri R. Peripancreatic paraganglioma: A diagnostic dilemma resolved on endoscopic ultrasound guided fine needle aspiration cytology. Diagn Cytopathol 2021; 49:1213-1216. [PMID: 34491633 DOI: 10.1002/dc.24870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/13/2021] [Accepted: 08/30/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Abha Thakur
- Department of Pathology and Laboratory Medicine, Medanta-The Medicity, Gurgaon, India
| | - Narendra S Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon, India
| | - Haimanti Sarin
- Department of Pathology and Laboratory Medicine, Medanta-The Medicity, Gurgaon, India
| | | | - Rajesh Puri
- Institute of Digestive and Hepatobiliary Sciences, Medanta-The Medicity, Gurgaon, India
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Asa SL, Mete O, Cusimano MD, McCutcheon IE, Perry A, Yamada S, Nishioka H, Casar-Borota O, Uccella S, La Rosa S, Grossman AB, Ezzat S. Pituitary neuroendocrine tumors: a model for neuroendocrine tumor classification. Mod Pathol 2021; 34:1634-1650. [PMID: 34017065 DOI: 10.1038/s41379-021-00820-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023]
Abstract
The classification of adenohypophysial neoplasms as "pituitary neuroendocrine tumors" (PitNETs) was proposed in 2017 to reflect their characteristics as epithelial neuroendocrine neoplasms with a spectrum of clinical behaviors ranging from small indolent lesions to large, locally invasive, unresectable tumors. Tumor growth and hormone hypersecretion cause significant morbidity and mortality in a subset of patients. The proposal was endorsed by a WHO working group that sought to provide a unified approach to neuroendocrine neoplasia in all body sites. We review the features that are characteristic of neuroendocrine cells, the epidemiology and prognosis of these tumors, as well as further refinements in terms used for other pituitary tumors to ensure consistency with the WHO framework. The intense study of PitNETs has provided information about the importance of cellular differentiation in tumor prognosis as a model for neuroendocrine tumors in different locations.
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Affiliation(s)
- Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Ozgur Mete
- Department of Pathology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Michael D Cusimano
- Department of Neurosurgery, Saint Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Ian E McCutcheon
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arie Perry
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, Tokyo, Japan
| | - Olivera Casar-Borota
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Silvia Uccella
- Department of Pathology, University of Insubria, Varese, Italy
| | - Stefano La Rosa
- Institute of Pathology, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ashley B Grossman
- Department of Endocrinology, University of Oxford, London, UK.,Royal Free London, London, UK.,Barts and the London School of Medicine, London, UK.,London Clinic Centre for Endocrinology, London, UK
| | - Shereen Ezzat
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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43
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Mete O, Pakbaz S, Lerario AM, Giordano TJ, Asa SL. Significance of Alpha-inhibin Expression in Pheochromocytomas and Paragangliomas. Am J Surg Pathol 2021; 45:1264-1273. [PMID: 33826547 DOI: 10.1097/pas.0000000000001715] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Alpha-inhibin expression has been reported in pheochromocytomas and paragangliomas (PPGLs). We analyzed alpha-inhibin immunohistochemistry in 77 PPGLs (37 pheochromocytomas [PCCs] and 40 paragangliomas) and correlated the results with catecholamine profile, tumor size, Ki-67 labeling index, succinate dehydrogenase B subunit and carbonic anhydrase IX (CAIX) staining, and genetic pathogenesis. PPGLs were classified as pseudohypoxic cluster 1 disease with documented VHL mutation or SDHx mutation or biochemical phenotype, whereas NF1-driven and RET-driven PPGLs and those with a mature secretory (adrenergic or mixed adrenergic and noradrenergic) phenotype were classified as cluster 2 disease. The Cancer Genome Atlas data on INHA expression in PPGLs was examined. Alpha-inhibin was positive in 43 PPGLs (56%). Ki-67 labeling indices were 8.07% and 4.43% in inhibin-positive and inhibin-negative PPGLs, respectively (P<0.05). Alpha-inhibin expression did not correlate with tumor size. Alpha-inhibin was expressed in 92% of SDHx-related and 86% of VHL-related PPGLs. CAIX membranous staining was found in 8 of 51 (16%) tumors, including 1 SDHx-related PCC and all 5 VHL-related PCCs. NF1-driven and RET-driven PPGLs were negative for alpha-inhibin and CAIX. Alpha-inhibin was expressed in 77% of PPGLs with a pseudohypoxia signature, and 20% of PPGLs without a pseudohypoxia signature (P<0.05). PPGLs with a mature secretory phenotype were negative for CAIX. The Cancer Genome Atlas data confirmed higher expression of INHA in cluster 1 than in cluster 2 PPGLs. This study identifies alpha-inhibin as a highly sensitive (90.3%) marker for SDHx/VHL-driven pseudohypoxic PPGLs. Although CAIX has low sensitivity, it is the most specific biomarker of VHL-related pathogenesis. While alpha-inhibin cannot replace succinate dehydrogenase B subunit immunohistochemistry for detection of SDHx-related disease, it adds value in prediction of cluster 1 disease. Importantly, these data emphasize that alpha-inhibin is not a specific marker of adrenal cortical differentiation, as it is also expressed in PCCs.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Endocrine Oncology Site, The Princess Margaret Cancer Centre
| | - Sara Pakbaz
- Department of Pathology, University Health Network
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Antonio M Lerario
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes
| | - Thomas J Giordano
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, OH
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Aaquist T, Dembic M, Thomassen M, de Stricker K, Bertelsen M, Christensen LG, Mortensen MB, Detlefsen S. Synchronous detection of pancreatic adenocarcinoma and paraganglioma in a Whipple resection specimen. Pathol Res Pract 2021; 226:153590. [PMID: 34454393 DOI: 10.1016/j.prp.2021.153590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/14/2021] [Indexed: 01/17/2023]
Abstract
We report a case of a pancreatic ductal adenocarcinoma (PDAC) presenting synchronously with a paraganglioma (PGL) in a Whipple reaction specimen. The patient was a 72-year-old female with a history of breast and vulvar cancer. The simultaneous occurrence of two synchronous tumours in the pancreas was striking. Due to the presence of PGL and multiple meta- and synchronous tumours, the patient was referred to genetic counselling. Tumour tissue from the vulvar carcinoma, the PDAC and the PGL was analysed by targeted next-generation sequencing (NGS) of 161 cancer-related genes and by whole exome sequencing (WES). Peripheral blood was also examined by NGS and WES. These genetic analyses revealed germline polymorphisms in AXIN2 (NM_004655.4:c 0.2272 G>A; p.Ala758Thr), BRCA2 (NM_000059.3:c.9976 A>T; p.Lys3326Ter), NCOR1 (NM_006311.4:c 0.6544 G>A; p.Ala2182Thr) and SPTA1 (NM_003126.3:c 0.373 G>A; p.Ala125Thr) and somatic mutations of KRAS (NM_033360.3;c 0.35 G>A; p.Gly12Asp) and TP53 (NM_000546.5; c.602delT; p.Leu201CysfsTer46) in the PDAC and of TP53 (NM_000546.5; c 0.733 G>A; p.Gly245Ser) and TERT (NM_198253.2; c.-124 C>T; promotor region) in the vulvar carcinoma. Breast carcinoma tissue was not available for genetic analysis. The results of the genetic analyses did not explain the presence of multiple tumours in this patient, despite a slightly increased risk of breast cancer associated with the identified BRCA2 polymorphism. To our knowledge, this is the first report of the synchronous occurrence of PDAC and PGL. This case emphasizes the importance of thorough macroscopic examination of pancreatic resection specimens, as coexisting neoplasms may otherwise be missed.
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Affiliation(s)
- Trine Aaquist
- Department of Pathology, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maja Dembic
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark; Department of Mathematics and Computer Science (IMADA), University of Southern Denmark, Odense, Denmark
| | - Mads Thomassen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Karin de Stricker
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Mette Bertelsen
- Department of Clinical Genetics, Rigshospitalet, Copenhagen, Denmark
| | | | - Michael Bau Mortensen
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
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45
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Abstract
Abdominal paragangliomas and pheochromocytomas (PPGLs) are rare neuroendocrine tumors of the infradiaphragmatic paraganglia and adrenal medulla, respectively. Although few pathologists outside of endocrine tertiary centers will ever diagnose such a lesion, the tumors are well known through the medical community-possible due to a combination of the sheer rarity, their often-spectacular presentation due to excess catecholamine secretion as well as their unrivaled coupling to constitutional susceptibility gene mutations and hereditary syndromes. All PPGLs are thought to harbor malignant potential, and therefore pose several challenges to the practicing pathologist. Specifically, a responsible diagnostician should recognize both the capacity and limitations of histological, immunohistochemical, and molecular algorithms to pinpoint high risk for future metastatic disease. This focused review aims to provide the surgical pathologist with a condensed update regarding the current strategies available in order to deliver an accurate prognostication of these enigmatic lesions.
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Affiliation(s)
- C Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden.
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden.
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46
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Abstract
Detailed analysis of cytodifferentiation and hormone production has classified pituitary neuroendocrine tumors (PitNETs) in a formal system that reflects the lineage differentiation of nontumorous adenohypophysial cells as well as subtypes of tumors that have predictive value. In addition, tumors composed of cells that lack terminal differentiation are well characterized. To comply with the proposal to create an overarching classification of neuroendocrine neoplasia, these tumors are now called PitNETs rather than adenomas. The next important step will be to relinquish the term "pituitary carcinoma" for metastatic PitNETs that remain well differentiated, and to alter the terminology used for tumors that are not terminally differentiated to reflect only their immature lineage. The existence of mixed neuroendocrine and non-neuroendocrine neoplasms (MiNENs) similar to those at other body sites is proven by mixed craniopharyngiomas with PitNETs. As with other NETs, these neoplasms should be reported with synoptic data that guide completeness of reporting. A formal system of grading should be created, but not only based on proliferation, as these tumors have shown the prognostic value of cytodifferentiation. A formal system of staging should also be devised to complement grade in the thorough and accurate diagnosis of tumors that arise from adenohypophysial cells.
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Affiliation(s)
- Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, 44106, USA.
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47
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Laparoscopic resection of a paraganglioma in the greater omentum mimicking a peripancreatic neoplasm: a case report. Clin J Gastroenterol 2021; 14:1364-1370. [PMID: 34053005 DOI: 10.1007/s12328-021-01452-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
A paraganglioma is a tumor originating in the sympathetic or parasympathetic nervous system. Its diagnosis may sometimes be confusing if it occurs in an atypical site. We described herein a case of a peripancreatic paraganglioma originating in the greater omentum. An asymptomatic, 61-year-old, female patient was referred to our hospital for detailed examination of a peripancreatic mass detected incidentally on computed tomography (CT). The differential diagnosis was a neuroendocrine neoplasm (NEN), and a biopsy using EUS-FNA was performed. Histologically, the tumor cells showed proliferation in solid cell nests and were positive for CD56, chromogranin A, and synaptophysin. These findings and the hypervascularity of the tumor on imaging studies were compatible with NEN. Since the imaging studies did not clearly demonstrate the continuity of the tumor with the pancreas, laparoscopic tumor resection without a pancreatectomy and sampling of the enlarged peripancreatic lymph nodes were planned as treatment. The absence of continuity with the pancreas was later confirmed by intraoperative observation, and the resection was carried out as planned. The resected tumor was pathologically considered as NEN at first in agreement with the preoperative diagnosis. However, several histological findings (such as a zelleballen-like growth pattern, pseudo-inclusion, and strong nuclear atypia compared with the cells' proliferative ability) were atypical for NEN, and paraganglioma was included in the differential diagnosis. Additional immunostainings of S-100 and AE1/AE3 were performed, leading to the final diagnosis of paraganglioma. Paragangliomas should be included in the differential diagnosis of an intraperitoneal mass of uncertain identity with hypervascularity.
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48
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Jia Y, Yan Y, Lu M, Kirkpatrick IDC. Paraganglioma with highly malignant potential involving the rib - Case report and review of the literature. Radiol Case Rep 2021; 16:1845-1850. [PMID: 34093930 PMCID: PMC8165291 DOI: 10.1016/j.radcr.2021.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
Paragangliomas are rare neuroendocrine tumors arising from paraganglion cells in sympathetic or parasympathetic chains, which may develop in the abdomen, chest, skull base, and neck. As paragangliomas have a wide range of imaging features, the diagnosis often requires tissue sampling. We present a unique case of a paraganglioma which originally presented as a rib tumor. A 64-year-old male with right flank pain for 2 months’ was referred for a noncontrast renal colic CT. He was found to have a 3.7 × 3.5 cm soft tissue mass invading the left posterior 9th rib and paraspinal muscle. This was fluorodeoxyglucose F 18, (18F-FDG) avid, with no other distant metabolic activity. He underwent ultrasound-guided core biopsy which revealed a diagnosis of paraganglioma. A right thoracotomy with chest wall resection of 8, 9, and 10 ribs were subsequently performed. The tumor was removed along with a small portion of adherent lung. The tumor was positive for CD56, synaptophysin and chromogranin. S-100 highlighted occasional sustentacular cells, consistent with a pathologic diagnosis of a paraganglioma. The patient remains symptom free for 6 months’ after the operation. Our case highlights that, when paragangliomas occur within the chest wall, they may present as a rib tumor and can mimic metastasis, myeloma or other primary neoplastic etiologies originating from ribs. Both imaging and pathologic diagnosis can be challenging.
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Affiliation(s)
- Yong Jia
- Department of Pathology, Max Rady College of Medicine Rady Faculty of Health Sciences, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9, Canada
| | - Yi Yan
- Department of Radiology, Max Rady College of Medicine Rady Faculty of Health Sciences, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9, Canada
| | - Miao Lu
- Department of Pathology, Max Rady College of Medicine Rady Faculty of Health Sciences, University of Manitoba, 820 Sherbrook Street, Winnipeg, MB R3A1R9, Canada
| | - Iain D C Kirkpatrick
- Department of Diagnostic Radiology, University of Manitoba, Room O2055, St Boniface General Hospital, 409 Tache Avenue, Winnipeg, MB R2H 2A6, Canada
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Campo-Rivera N, Abreu Lomba A, Ocampo-Chaparro J. Diaphragmatic Paraganglioma in an Adolescent Male. Cureus 2021; 13:e15027. [PMID: 34136320 PMCID: PMC8199847 DOI: 10.7759/cureus.15027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Paragangliomas are an infrequent type of neuroendocrine tumor that commonly produces catecholamines. We describe a case of a 14-year-old male with a history of uncontrolled hypertension who presented to the emergency department with a headache, palpitations, and profuse sweating. Symptoms were explained by the presence of a catecholamine-producing paraganglioma located at the right diaphragm. One year after radical surgical resection, the patient remains normotensive and does not require hypertensive medications.
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Affiliation(s)
- Natalia Campo-Rivera
- Internal Medicine Department, Grupo Interinstitucional de Medicina Interna (GIMI 1), Universidad Libre, Cali, COL
| | | | - Jose Ocampo-Chaparro
- Internal Medicine Department, Grupo Interinstitucional de Medicina Interna (GIMI 1), Universidad Libre, Cali, COL.,Departamento de Medicina Familiar, Universidad del Valle, Cali, COL
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50
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Feigin K, Fiocchi EH, Fleming MA, Looney AL. Anesthesia Case of the Month. J Am Vet Med Assoc 2021; 257:1125-1128. [PMID: 33226296 DOI: 10.2460/javma.2020.257.11.1125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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