Bilateral carotid paraganglioma: surgery and radiotherapy

BILATERAL CAROTID BODY PARAGANGLIOMAS - LITERATURE REVIEW AND COMMENTS IN A PATIENT WITH NO SIGNS OF MEN SYNDROME

Paragangliomas are rare neuroendocrine slow-growing tumors, often asymptomatic, that originate from embryonic neural crest cell. In the head and neck area, the most common location is the carotid body, followed, with decreasing frequency, in jugular, tympanic and vagal sites. Bilateral carotid body tumors are extremely rare.

Aim

To present the most important features of carotid body paragangliomas, illustrating the clinical characteristics, associated with a thorough analysis of the diagnostic imaging elements, but also the current therapeutic strategies, with respective anatomical, surgical considerations and potential complications that can occur. Surgical resection is the main line of treatment. The complex anatomy of the cervical region and the close relationships of carotid body paragangliomas with carotid vessels and cranial nerves, as well as its intense vascularization makes the surgical intervention a real challenge even for an experienced surgeon.

Discussion

Starts from a bilateral carotid paraganglioma in a 35-year-old male, with painless lateral neck swelling, accidentally discovered by his barber about two years ago. Diagnosis was suspected on the basis of history, clinical and radiological findings. "Wait and scan" strategy plus endocrinologic assessment for MEN syndromes were considered the optimal therapeutic approach in this case.

An Unusual Histology for a Lung Nodule: A Case Report of Primary Pulmonary Paraganglioma

Introduction: Primary pulmonary paraganglioma is a rare tumor with few cases reported in literature and unspecific clinical presentation.

Case Presentation: A 49-year-old woman presented to our department with an incidental finding of a pulmonary mass at chest X-ray and no associated clinical symptom. The CT scan and the FDG-PET showed mild uptake of contrast, but a definitive diagnosis was only possible after surgery through histopathological examination.

Conclusion: Paragangliomas originating in the pulmonary tissue are generally non-functioning masses discovered incidentally in otherwise asymptomatic patients. Surgery appears to be the best treatment option, with only radiologic follow-up necessary afterwards.

Immunohistochemistry and Mutation Analysis of SDHx Genes in Carotid Paragangliomas

Carotid paragangliomas (CPGLs) are rare neuroendocrine tumors often associated with mutations in SDHx genes. The immunohistochemistry of succinate dehydrogenase (SDH) subunits has been considered a useful instrument for the prediction of SDHx mutations in paragangliomas/pheochromocytomas. We compared the mutation status of SDHx genes with the immunohistochemical (IHC) staining of SDH subunits in CPGLs. To identify pathogenic/likely pathogenic variants in SDHx genes, exome sequencing data analysis among 42 CPGL patients was performed. IHC staining of SDH subunits was carried out for all CPGLs studied. We encountered SDHx variants in 38% (16/42) of the cases in SDHx genes. IHC showed negative (5/15) or weak diffuse (10/15) SDHB staining in most tumors with variants in any of SDHx (94%, 15/16). In SDHA-mutated CPGL, SDHA expression was completely absent and weak diffuse SDHB staining was detected. Positive immunoreactivity for all SDH subunits was found in one case with a variant in SDHD. Notably, CPGL samples without variants in SDHx also demonstrated negative (2/11) or weak diffuse (9/11) SDHB staining (42%, 11/26). Obtained results indicate that SDH immunohistochemistry does not fully reflect the presence of mutations in the genes; diagnostic effectiveness of this method was 71%. However, given the high sensitivity of SDHB immunohistochemistry, it could be used for initial identifications of patients potentially carrying SDHx mutations for recommendation of genetic testing.

Pathologic features and clinical course of a non-functioning primary pulmonary paraganglioma: A case report

Introduction

Paragangliomas (PGGL) are rare neuroendocrine tumors arising from non-epithelial extra-adrenal chromaffin cells. They have been described in different sites: abdomen, pelvis, head, neck and thorax. Incidence is very low, occurring in less than 2–8/million per year. PGGL's of the lung are extremely rare, they have a slow growth and present as painless lesions. Biopsy is the method of choice for diagnosis and prognosis.

Presentation of case

This is a 70-year-old woman with chronic cough, with a CT-scan showing a 3.3-cm mass in the left lower lobe. After video-assisted thoracic surgery, histologic findings confirmed a non-functioning pulmonary paraganglioma. We present the clinical, radiological, pathological findings and clinical course.

Discussion

Primary pulmonary PGGL's are extremely rare neuroendocrine tumors with low-grade malignancy, difficult to distinguish from other pulmonary tumors relying only on imaging techniques. In this case, PGGL presented as an incidentaloma during the evaluation of chronic cough. After histological diagnosis, genetic testing are ideally performed to identify somatic or germline mutations that may condition a higher risk of malignancy and metastasis.

Conclusion

PGGL's must be considered when other diagnoses are unlikely due to immunohistochemistry findings. Larger studies in this field are needed to determine the risk factors for its development and to determine which populations have the greatest potential for malignant transformation

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Paragangliomas are rare neuroendocrine tumors derived from non-epithelial extra-adrenal chromaffin cells.

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Paragangliomas from the lung are rare, they have a slow growth and present as non-painful lesions.

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Complete surgical resection is the diagnostic method of choice for solitary primary pulmonary paragangliomas.

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Genetic testing is important to identify somatic or germline mutations.

Spinal paragangliomas: Surgical treatment and follow-up outcomes in eight cases

Paragangliomas are neuro-endocrine tumors originating from the adrenal gland. They are usually benign and nonfunctioning, rarely seen in central nervous system. More than 90% of central nervous system paragangliomas are manifested as carotid and glomus jugulare tumors. Spinal paragangliomas are quite rare.The study was conducted through retrospective analysis of the files of the patients who had undergone surgery with pre-diagnosis of spinal intradural tumor between 2011 and 2017 and diagnosed with paraganglioma.A total of 8 patients (4 females and 4 males) were included in the study. Mean age of the patients was 51.1 years (28-64). Time to admission was mean 6.5 months (3 weeks-24 months). Recurrence was not observed in 7 patients, 1 patient is being followed up due to residual tumor.Treatment may be achieved through recognizing malignant transformation in patients who were not diagnosed histopathologically. We consider that quality of life of the patients may be improved through this way.

Clinical characteristics and surgical treatment of spinal paraganglioma: A case series of 18 patients

BACKGROUND AND OBJECTIVES

Paraganglioma rarely develops in the spine. With few cases reported, little knowledge about this disease was known. The objective of this study is to illustrate the clinical features, imaging manifestations, pathological appearances and long-term outcomes of the consecutive surgeries by literature review.

METHODS

The clinical and follow-up data of 18 patients who were diagnosed of spinal paraganglioma and treated with surgeries in our hospitals from 2003 to 2014 were retrospectively analyzed.

RESULT

A total of fourteen patients radiographed of intra-spinal tumor underwent extra-capsular tumor resection. Of five patients with obvious vertebral bone damage, four cases underwent piecemeal resection, and the left one with sacral tumor underwent en bloc tumor excision. Spinal reconstruction was performed in all cases. Follow-up lasted for 16-96 months (44.1 months on average). There was no local recurrence or distant metastasis in cases without obvious bone invasion. Of those five cases with vertebral bone damage, one case suffered and survived from the repeat relapse of T1 vertebral body tumor. Local recurrence was not observed in one case with T10 vertebral tumor after tumor resection, but the tumor metastasized to T2 attachment during the follow-up and was finally eradicated by re-operation. No tumor recurrence was observed in the left three cases.

CONCLUSION

Paraganglioma, usually benign, rarely occurs. Surgical resection, especially complete surgical resection, is preferred to treat spinal paraganglioma. Chemotherapy, radiotherapy, use of octreotide and other somatostatin are selected as adjuvant therapies, but their effects remain unknown.

Paraganglioma of the Filum Terminale: Case Report, Pathology and Review of the Literature

Spinal paragangliomas are very rare neuroendocrine tumors often presenting with low back pain and radicular symptoms; once resected, they often show benign clinical outcomes. Radiographically spinal paragangliomas mimic more commonly described tumors, such as ependymomas, schwannomas, meningiomas, and even hemangiomas, but a “salt and pepper” appearance related to a serpiginous vascular structure is instructive. Indeed, the rarity of this tumor makes the diagnosis rather challenging radiographically. Graded as a WHO Grade I tumor, they are slow-growing with low proliferation indices. Gross total resection is the mainstay of operative treatment but is often limited by tumor adherence to functional nerves. Here, we present a case of this rare tumor and its management, including a review of the pathology and literature related to this tumor.

Primary Pulmonary Paraganglioma: A Case Report and Review of Literature

Primary pulmonary paraganglioma is a rare disease. We report a case of a 37-year old female patient with space-occupying lesions in the right lower pulmonary lobe during a routine examination without any symptoms. The patient underwent video-assisted thoracoscopic surgery (VATS) resection of the right middle lobe and dissection of hilar and mediastinal lymph nodes under general anesthesia. She recovered without recrudescence. Preoperative diagnosis is difficult. Accurate diagnosis requires pathological examination, and immunohistochemical test is particularly important. Complete resection is the first treatment option for solitary primary pulmonary paraganglioma; however, VATS is a better technique. Given the high local control rates and few complications of radiotherapy, it is considered as a standard treatment.

Clinical characteristics and surgical outcomes of primary spinal paragangliomas

Spinal paragangliomas are extremely rare tumors, most frequently involving the cauda equina and the filum terminale. We aimed to investigate the clinical manifestations, radiological features, management, and follow-up data of primary spinal paraganglioma. We present the clinical data and long-term outcomes from a consecutive surgical series of 19 patients with pathologically diagnosed spinal paragangliomas. All of the patients had undergone surgical resection. Pre- and postoperative magnetic resonance imaging was performed and follow-up data and neurological functional assessment are presented and discussed. The mean age at diagnosis was 47.7 years, with a significant male predominance. The primary clinical symptoms were low back pain and sciatica. Magnetic resonance images (MRI) showed characteristic signs that help differentiate paragangliomas from other spinal tumors, including a "salt & pepper" sign, serpiginous flow void, and a peripheral hypointense rim. Also, a well-encapsulated appearance can be found intraoperatively. During a mean follow-up period of 62.1 months, remnant tumor progression was noted on MRI in three patients with incomplete resection. Pain symptoms were relieved immediately after surgical intervention, while motor and sphincter dysfunction were much slower to improve. Differential diagnosis of paraganglioma based on MR images alone is challenging, but the presence of specific characteristic features provides suggestive clues; however, accurate diagnosis depends on pathological criteria. Despite the benign course, gross total resection is ideal, given an increased risk of recurrence in situ. Timely recognition and surgical treatment should be emphasized to avoid progressive neurological deficits.