Pancreatic paraganglioma: An extremely rare entity and crucial role of immunohistochemistry for diagnosis

Primary non-functional pancreatic paraganglioma: A case report and review of the literature

Primary pancreatic paragangliomas are rare. They are mainly non-functional tumours that lack typical clinical manifestations. Definite diagnosis relies on histopathology and immunohistochemistry, and the main treatment is surgery. We report here a case of primary, non-functional, pancreatic paraganglioma in a 49-year-old woman. The tumour was approximately 5.0 × 3.2 ×4.7 cm in size and located in the pancreatic neck and body. We undertook 3D laparoscopic complete resection of the tumour. The patient developed a pancreatic fistula (biochemical leak) post-surgery, but she recovered and was discharged from hospital 11 days after surgery. We describe this case study and briefly summarize previous related reports.

Pancreatic paraganglioma diagnosed by endoscopic ultrasound-guided fine needle aspiration: A case report and review of literature

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.

Primary pancreatic paraganglioma harboring lymph node metastasis: A case report

BACKGROUND

Primary pancreatic paragangliomas are extremely rare tumors. Limited by the diagnostic efficacy of histopathological examination, their malignant behavior is thought to be associated with local invasion or metastasis, with only four malignant cases reported in the literature to date. As pancreatic paragangliomas share similar imaging features with other types of pancreatic neuroendocrine neoplasms, they are difficult to diagnose accurately without the support of pathological evidence. As primary pancreatic paragangliomas are rare, especially those accompanied by lymph node metastasis, there is currently no consensus on treatment. Herein, we report a case of primary pancreatic paraganglioma with lymph node metastasis.

CASE SUMMARY

A mass located in the pancreatic body was incidentally discovered on computed tomography in a 41-year-old Tibetan man. Distal pancreatectomy was subsequently performed and a 4.1 cm × 4.2 cm tumor was found embedded in the body of the pancreas during surgery. Histological examination confirmed the characteristics of paraganglioma in which the neoplastic chief cells were arranged in a classic Zellballen pattern under hematoxylin-eosin staining. Further, immunohistochemistry demonstrated that the sustentacular cells in the tumor tissue were positive for S-100 protein, and neoplastic cells and pancreatic draining lymph nodes were positive for chromogranin A and synaptophysin; thus, the presence of lymph node metastasis (two of the eight resected pancreatic draining lymph nodes) was also confirmed. A diagnosis of primary pancreatic paraganglioma with lymph node metastasis was finally established. The patient remained disease-free for 1 year after the surgery.

CONCLUSION

A definite diagnosis of pancreatic paraganglioma mainly depends on postoperative histopathological and immunohistochemical examinations. Surgical resection may be the first treatment of choice for patients with primary pancreatic paraganglioma that has metastasized to the lymph nodes.

A rare case of retroperitoneal paraganglioma located in the neck of the pancreas: a case report and literature review

Paraganglioma (PGL) is an uncommon tumor located in the head, neck and abdomen. The majority of the tumor is benign and the patient has no obvious clinical symptoms. However, PGL located in the pancreas is rather rare and tends to mimic Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Herein, we reported a patient with PGL that occurred in the neck of the pancreas. A 75-year-old Chinese female presented to our hospital with a complaint of upper abdomen pain for two weeks and she had good past health. The laboratory findings and physical examination were all normal. Preoperative computed tomography (CT) and magnetic resonance imaging revealed a tumor located in the neck of the pancreas and a tentative diagnosis of Castleman's disease or PGL was made. We resected the tumor by laparoscopic surgery. Postoperative pathology and immunohistochemistry confirmed that the tumor was a PGL. The patient was recovered well after a postoperative follow-up of 6 months. PGL located in the neck of the pancreas is difficult to be diagnosed accurately and clinicians have difficulties in distinguishing PGL from Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Fifteen cases were listed to show the characters of PGL located in the pancreas and we also presented the difference among PGL, Castleman's disease and pancreatic neuroendocrine tumor. We showed our experience of treating such a rare tumor hoping to help clinicians correctly diagnose and treat PGL.

A rare case of retroperitoneal paraganglioma located in the neck of the pancreas: a case report and literature review

Paraganglioma (PGL) is an uncommon tumor located in the head, neck and abdomen. The majority of the tumor is benign and the patient has no obvious clinical symptoms. However, PGL located in the pancreas is rather rare and tends to mimic Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Herein, we reported a patient with PGL that occurred in the neck of the pancreas. A 75-year-old Chinese female presented to our hospital with a complaint of upper abdomen pain for two weeks and she had good past health. The laboratory findings and physical examination were all normal. Preoperative computed tomography (CT) and magnetic resonance imaging revealed a tumor located in the neck of the pancreas and a tentative diagnosis of Castleman's disease or PGL was made. We resected the tumor by laparoscopic surgery. Postoperative pathology and immunohistochemistry confirmed that the tumor was a PGL. The patient was recovered well after a postoperative follow-up of 6 months. PGL located in the neck of the pancreas is difficult to be diagnosed accurately and clinicians have difficulties in distinguishing PGL from Castleman's disease, pancreatic neuroendocrine tumors and pancreatic primary tumor. Fifteen cases were listed to show the characters of PGL located in the pancreas and we also presented the difference among PGL, Castleman's disease and pancreatic neuroendocrine tumor. We showed our experience of treating such a rare tumor hoping to help clinicians correctly diagnose and treat PGL.

Pancreatic neuroendocrine tumors with somatostatin expression and paraganglioma-like features

A small fraction of pancreatic neuroendocrine tumors (PanNETs) shows a solid, paraganglioma-like (PG-like) histology. We wanted to know whether these PanNETs have a special hormone expression and are related to paragangliomas (PGs)/pheochromocytomas (PCs). We screened a series of 48 surgically resected PanNETs for their histological growth patterns and their association with expression of islet hormones. The PanNETs were divided into PG-like and non-PG-like tumors and immunohistochemically monitored for the expression of islet hormones, cytokeratins, and S100. The results were correlated to histological pattern, lymph node status, and data in 28 PGs/PCs, including 2 PGs attached to the pancreas. All PanNETs, in contrast to PGs/PCs, were cytokeratin positive. A PG-like growth pattern was identified in 9 of 48 PanNETs and correlated with somatostatin expression. Only half of the non-PG-like PanNETs also contained somatostatin-positive cells. Eight of 28 PGs/PCs expressed somatostatin, mostly in individual cells. PG-like PanNETs and non-PG-like PanNETs infiltrated the adjacent pancreatic tissue, whereas 2 to the pancreas-associated PGs were well demarcated. Lymph node metastases were detected in 58%, 39%, 57%, and 53% of the somatostatin-producing, somatostatin-negative, PG-like, and non-PG-like PanNETs, respectively. PG-like PanNETs, in contrast to PG/PCs, are characterized by the expression of cytokeratin and somatostatin, the development of lymph node metastasis, and the infiltration into pancreatic parenchyma. Non-PG-like PanNETs may also express somatostatin and show lymph node metastases to the same extent. A literature review of cases reported as PG of the pancreas reveals that only a small fraction of these tumors probably represents true pancreatic PGs.

CT and MR Imaging Findings of Pancreatic Paragangliomas: A Case Report

Previous studies on pancreatic paraganglioma, a rare neoplasm, have primarily reported its ultrasound and routine and contrast-enhanced computed tomography (CT) findings. To our knowledge, we are the first to report the contrast-enhanced magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) sequence findings of pancreatic paraganglioma. A male patient, ages 41 years, was admitted to our hospital due to a pancreatic space-occupying lesion that had been present for more than 10 days. The patient had no obvious discomfort. He had a history of hypertension and hyperthyroidism. Physical examination revealed upper abdominal tenderness without a palpable mass. Routine and contrast-enhanced abdominal CT showed a soft tissue mass at the pancreatic head/uncinate process, with patchy calcification within the lesion. On a contrast-enhanced CT scan, severe enhancement of the mass in the arterial phase was noted, as was slightly reduced but still marked enhancement in the venous phase. The celiac trunk and superior mesenteric artery segment were wrapped by the tumor. Thickened, tortuous vessels were observed at the lesion edges, around which there were multiple enlarged lymph nodes. The main pancreatic duct was markedly dilated. Routine and contrast-enhanced pancreatic MRI demonstrated an abnormal nodular signal in the pancreatic head/uncinate process that was approximately 4.3 × 6.4 cm² in size. T1-weighted imaging (T1WI) revealed hypointensity, whereas T2-weighted imaging (T2WI) revealed nonhomogeneous, slight hyperintensity. Patchy hypointensity on both T1WI and T2WI was observed within the lesion. DWI showed slight hyperintensity. Grossly heterogeneous enhancement of the mass was observed on a contrast-enhanced MRI scan, with the tumor wrapped around the adjacent vasculature, and multiple enlarged lymph nodes were observed peripherally. After preoperative preparation, the patient underwent pancreatoduodenectomy. Histopathology and immunohistochemistry of the resected tumor indicated pancreatic paraganglioma. After surgery, the patient recovered well, without presenting any recurrence or metastasis during short-term follow-up. For hypervascular pancreatic tumors on contrast-enhanced CT or MRI, and particularly those occurring in the pancreatic head, with a clear display of draining veins, the possibility of pancreatic paraganglioma should be considered. These tumors usually exhibit necrosis or cystic changes and are occasionally accompanied by calcification.

Primary pancreatic paraganglioma: a case report and literature review

Backgroud

Primary pancreatic paraganglioma is an extremely rare extra-adrenal paraganglioma.

Case presentation

We report a case of primary pancreatic paraganglioma undergoing middle segment pancreatectomy in a 42-year-old woman. Histological examination showed that the tumor was composed of well-defined nests of cuboidal cells separated by vascular fibrous septa, forming the classic Zellballen pattern. The chief cells showed positive staining to neuron-specific enolase, chromogranin A, synaptophysin, and the chief cells were surrounded by S-100 protein-positive sustentacular cells. The patient has remained tumor free for 12 months after surgery. A brief discussion about the histopathological features, clinical behavior, and treatment of primary pancreatic paraganglioma, and review of the relevant literature is presented.

Conclusions

Primary pancreatic paraganglioma is a rare clinical entity, its diagnosis mainly depends on histopathological and immunohistochemical examinations. Complete surgical resection is the first choice of treatment and close postoperative follow-up is necessnary.

Pancreatic paraganglioma with draining vessels

A pancreatic paraganglioma is a rare neoplasm that is difficult to distinguish from a pancreatic neuroendocrine tumour. Here we present a case of pancreatic paraganglioma that was surgically resected following preoperative diagnosis of a pancreatic neuroendocrine tumour. Careful evaluation of the endoscopic ultrasonography findings revealed abundant draining vessels, which could have led to a correct preoperative diagnosis of pancreatic paraganglioma.

Primary pancreatic paraganglioma: A report of two cases and literature review

Paraganglioma is a rare tumor of paraganglia, derived from neural crest cells in sympathetic or parasympathetic ganglions. Primary paraganglioma originating from the pancreas is rare. We report two patients with paraganglioma in the head of the pancreas, in whom computed tomography showed a sharply marginated, hypervascular tumor with cystic areas. Significant intratumoral vessels and early contrast filling of the draining veins from the mass were not found. Although the pancreatic paraganglioma was located at the pancreatic head, the bile ducts often revealed no dilation, and sometimes the main pancreatic duct was mildly dilated. These findings are helpful in differentiating pancreatic paraganglioma from other pancreatic neoplasms. It is often difficult to distinguish between nonfunctional pancreatic paragangliomas and pancreatic endocrine tumors. In many reports,pancreatic paragangliomas show the retroperitoneal extension of a paraganglioma into the pancreas rather than a true pancreatic neoplasm. In surgical treatment, we could select simple excision of the tumor rather than radical surgery.