Impact of Pelvic and Para-aortic Lymphadenectomy in Advanced Ovarian Cancer After Neoadjuvant Chemotherapy

AIM

The aim of our study was to evaluate the impact of systemic pelvic and para-aortic lymphadenectomy on survival in patients with advanced ovarian cancer after neoadjuvant chemotherapy.

PATIENTS AND METHODS

This multi-centric descriptive study included patients with initially inoperable advanced ovarian cancer, undergoing neoadjuvant chemotherapy followed by cytoreductive surgery with no residual tumor between 1998 and 2012. They were distributed into two groups depending on if they underwent lymphadenectomy or not during the interval surgery.

RESULTS

Among the 101 included patients, 54 underwent lymphadenectomy and 47 did not. The multivariate analysis for overall survival showed no significant difference between the two groups [hazard ratio (HR)=1.88, confidence interval (CI)=0.89-3.94; p=0.08]. The multivariate analysis for progression-free survival showed no significant difference (HR=1.43, 95% CI=0.86-2.39; p=0.17).

CONCLUSION

In patients with advanced ovarian cancer, treated by neoadjuvant chemotherapy and interval surgery with no residual tumor, lymphadenectomy does not seem to improve the survival rate.

Relevance of pelvic and para-aortic node metastases in early-stage ovarian cancer

AIM

To delineate the relevance of pelvic and para-aortic node involvement in early-stage ovarian cancer.

PATIENTS AND METHODS

Data on 75 consecutive patients with primary stage T1 and 2 ovarian cancer treated at the Department of Gynecology, University Tuebingen, Germany were retrospectively analyzed. All patients underwent stage-related surgery with pelvic and para-aortic lymphadenectomy and adjuvant platinum-based chemotherapy (except pT1aG1). Median follow up was 53.5 months. Clinico-pathological parameters and the distribution pattern of node metastases were evaluated. Statistical analyses were performed using PASW.

RESULTS

Lymph node metastases were detectable in T1 and T2 in 6 (8%) of 75 patients. Three patients (4%) had lymph node metastases in the pelvic nodes only, 2 patients (2.7%) in the para-aortic nodes only; 1 patient (1.3%) both in the pelvic and para-aortic nodes. On multivariate analysis, histological grade 1/ 2 and 3 tumors, serous and endometrioid histology were independent predictors for node metastases, respectively. The risk of relapse was significantly higher with detection of node metastases (p=0.004).

CONCLUSION

A systematic lymphadenectomy in early-stage ovarian cancer leads to an upstaging in a few patients after detection of node metastases even in pelvic or para-aortic nodes, especially in patients with grade 3 tumours and serous cancers. Pelvic and para-aortic lymphadenectomy may detect node involvement in early-stage ovarian cancer and might be helpful in correct staging.

[Expression of SDHB, EPAS1 and MIB-1 in Zuckerkandl paragangliomas]

OBJECTIVE

To explore the significance of succinate dehydrogenase B (SDHB) mutation and EPAS1 overexpression in Zuckerkandl paragangliomas (PGL) and examine their correlations with malignant infiltration and metastasis.

METHODS

From March 2008 to July 2011, the clinical profiles of 16 Zuckerkandl PGL patients were analyzed retrospectively. For increased diagnostic specificity, a complex immunohistochemical panel of tissue microarray was performed for SDHB, EPAS1 and MIB-1. Positive expression identified as a granular cytoplasmic staining. Greater than or equal to 50% as strongly positive (+++), 1% to 10% as weakly positive (+).

RESULTS

Tissue microarray immunohistochemical staining showed SDHB immunoreactivity in the cytoplasm, whereas EPAS1 and MIB-1 in the nuclear of tumor cells. Positive expression of EPAS1 in which 13 cases of Zuckerkandl PGL. And high expression strongly associated with malignancy. SDHB mutation of 7 cases are all EPAS1 positive staining. Non-gene mutation 9 cases tumor specimens, 6 cases were EPAS1 positive expression (P < 0.05). CgA positive expression in 11 cases benign Zuckerkandl PGL, strongly positive in 4 malignant cases (4/4). MIB-1 below 1% in 12 cases of benign Zuckerkandl PGL. And in 4 malignant cases, MIB-1 was about 3%. Malignant neoplasms had significantly higher EPAS1, CgA and MIB-1 expression compared to benign counterparts (P < 0.05).

CONCLUSIONS

The SDHB mutation causes the EPAS1 over expression in PGL and correlation with higher positive expression of CgA and MIB-1. It may be one of the mechanisms of malignant invasiveness and metastasis in PGL.

Paraganglioma of the Organ of Zuckerkandl

Paragangliomas are tumors of the sympathetic and parasympathetic paraganglia. While most paraganglioma are of parasympathetic origin and present as benign palpable masses of the neck, sympathetic paraganglioma are often secretory, presenting with symptoms related to excess catecholamines. Such symptoms include hypertension, headache, palpitations, and diaphoresis. Most sympathetic paraganglioma form within the adrenal medulla, the largest sympathetic paraganglia, and are commonly known as pheochromocytomas. However, sympathetic paragangliomas may present extra-adrenally, carrying a significantly higher risk of malignancy. In this manuscript, we examine a case of a young man with an extra-adrenal sympathetic paraganglioma of the Organ of Zuckerkandl. Furthermore, we discuss appropriate diagnostic workup and treatment of pheochromocytomas and sympathetic paragangliomas.

Succinate dehydrogenase gene mutations are strongly associated with paraganglioma of the organ of Zuckerkandl

Organ of Zuckerkandl paragangliomas (PGLs) are rare neuroendocrine tumors that are derived from chromaffin cells located around the origin of the inferior mesenteric artery extending to the level of the aortic bifurcation. Mutations in the genes encoding succinate dehydrogenase subunits (SDH) B, C, and D (SDHx) have been associated with PGLs, but their contribution to PGLs of the organ of Zuckerkandl PGLs is not known. We aimed to describe the clinical presentation of patients with PGLs of the organ of Zuckerkandl and investigate the prevalence of SDHx mutations and other genetic defects among them. The clinical characteristics of 14 patients with PGL of the organ of Zuckerkandl were analyzed retrospectively; their DNA was tested for SDHx mutations and deletions. Eleven out of 14 (79%) patients with PGLs of the organ of Zuckerkandl were found to have mutations in the SDHB (9) or SDHD (2) genes; one patient was found to have the Carney-Stratakis syndrome (CSS), and his PGL was discovered during surgery for gastrointestinal stromal tumor. Our results show that SDHx mutations are prevalent in pediatric and adult PGLs of the organ of Zuckerkandl. Patients with PGLs of the organ of Zuckerkandl should be screened for SDHx mutations and the CSS; in addition, asymptomatic carriers of an SDHx mutation among the relatives of affected patients may benefit from tumor screening for early PGL detection.

An extra-adrenal pheochromocytoma of the organ of Zuckerkandl: report of a case

The authors report a case of extra-adrenal pheochromocytoma of the organ of Zuckerkandl presenting with hypertension and an abdominal mass in a young adult. Preoperative diagnosis was made by biochemical and imaging studies. The operation to remove the tumor was successfully performed. The patient remains normotensive and symptom free at 15-month follow-up. The authors also discuss the diagnostic modalities and surgical technique used in the presented patient.

The Zuckerkandl's tubercle: a useful anatomical landmark for detecting both the recurrent laryngeal nerve and the superior parathyroid during thyroid surgery

Zuckerkandl's tubercle (ZT) is a well-documented anatomical structure. This study evaluated ZT anatomical characteristics in terms of the recurrent laryngeal nerve (RLN) and the superior parathyroid (SP). The study involved 325 (10 with benign tumors and 315 with malignancies) patients who underwent thyroidectomy between February and June 2007. ZTs were classified according to size: Grade 0 (unrecognizable), Grade I (</=5 mm), Grade II (6~10 mm) and Grade III (>10 mm). The incidence and size of the ZT and its positional relationship to the RLN and SP were investigated during thyroid surgery. ZTs were identified in most patients (right 89.3%, left 85.6%). The distribution of ZTs according to grade was as follows: Grade 0, right 10.7% and left 14.4%; Grade I, right 7.9% and left 11.1%; Grade II, right 43.5% and left 38.5%; and Grade III, right 37.9% and left 35.9%. The most common RLN course was in a groove between the ZT and the main body of the thyroid. The majority of SPs were cranial to the ZT which was located at the 1 or 2 o'clock position (96.1%) in the left, and at 10 or 11 o'clock (95.2%) in the right. The smaller the size of the ZT, the greater the distance between the ZT and the SP. There was a constant relationship between the ZT and RLN and SP. Therefore, an identification of ZT and an understanding of the relationship between the ZT and RLN and SP are essential for performing safe thyroid surgery.

Malignant pheochromocytoma of the organ of Zuckerkandl requiring aortic and vena caval reconstruction

OBJECTIVE

To describe a case of a malignant pheochromocytoma located in the organ of Zuckerkandl that required aortic and vena caval resection and reconstruction.

METHODS

We present a case report that includes clinical, laboratory, and radiographic data as well as photographs, results from pathology, and a brief review of the literature.

RESULTS

A 46-year-old man was referred for evaluation of a 1.4-cm left adrenal mass incidentally discovered on an abdominopelvic computed tomography (CT) scan. Subsequent laboratory evaluation revealed the following values: urine norepinephrine, 252 microg/24 h; urine normetanephrine, 1122 microg/24 h; urine metanephrine, 162 microg/24 h; urine epinephrine, 7 microg/24 h; urine vanillylmandelic acid, 8 mg/24 h; and plasma metanephrine, 98 pg/ mL. Imaging characteristics of the left adrenal mass were consistent with a benign adenoma, but CT also demonstrated a hypervascular para-aortic mass. 123I-metaiodo-benzylguanidine scanning with fusion CT imaging demonstrated increased radiopharmaceutical uptake within the para-aortic mass consistent with a paraganglioma in the organ of Zuckerkandl. Findings from CT angiography of the abdomen and pelvis suggested aortic involvement and vena caval thrombus. The mass was excised en bloc, including portions of the aorta, inferior vena cava, and right ureter. The aorta and vena cava were reconstructed using Dacron grafts. The remaining right ureter and kidney were removed to avoid the possibility of a urine leak from an ureteroureterostomy. Final pathologic and operative findings confirmed a malignant pheochromocytoma of the organ of Zuckerkandl with invasion into the wall of the inferior vena cava and tumor thrombus extending into the lumen.

CONCLUSION

Malignant pheochromocytoma of the organ of Zuckerkandl involving the aorta and inferior vena cava is exceedingly rare, and although surgical resection and reconstruction can be radical and aggressive, this treatment offers the only chance for cure.

Laparoscopic resection of extra-adrenal pheochromocytoma--case report and review of the literature in pediatric patients

Surgery for pheochromocytoma differs from that of other tumors owing to the potential release of catecholamines, which may lead to severe intraoperative hemodynamic changes. The present standard of care for resection of adrenal pheochromocytoma has become a laparoscopic approach for surgical excision. Extra-adrenal pheochromocytoma is a very rare entity, especially in the pediatric age group; the utility of the laparoscopic approach is not established in this population. We present a case report of a child with hormonally active extra-adrenal pheochromocytoma originating in the organ of Zuckerkandl that was resected laparoscopically. We found the laparoscopic approach gave excellent exposure, allowing for proper identification of the tumor's origin and its relation to surrounding structures; a complete resection with excellent control of the feeding blood vessels was performed. Herein we present the details of this case and a review of the relevant literature. After our initial experience we can recommend laparoscopic exploration for similar cases of suspected extra-adrenal pheochromocytoma as an appropriate tool to identify extension of the disease and estimate resectability. Proper patient preparation and monitoring are critical for success.

An incidentally discovered small and asymptomatic para-aortic paraganglioma

Preoperative diagnosis of asymptomatic paraganglioma is difficult due to the lack of specific symptoms. In this report, we present a rare case of a small and asymptomatic para-aortic paraganglioma. A 34-year-old woman who complained of back pain was admitted for further examination. No abnormal findings were observed on physical or laboratory examinations. An abdominal CT scan and an abdominal MRI incidentally noted a mass about 3 cm in diameter adjacent to the right edge of the inferior vena cava. The following aortic angiography showed the tumor with a feeding artery diverting directly from the aorta. The tumor was completely resected by laparotomy. The resected tumor, 3 x 3 x 3 cm in size, was soft, dark-reddish and encapsulated. Immunohistochemical examinations showed that it was positive for neuron-specific enolase, chromogranin A and adrenocorticotropin. Under these findings, the diagnosis of para-aortic paraganglioma was determined. Seven years after the operation, she remains asymptomatic and free of disease.

Para-Aortic Involvement and Interest of Para-Aortic Lymphadenectomy after Chemoradiation Therapy in Patients with Stage IB2 and II Cervical Carcinoma Radiologically Confined to the Pelvic Cavity

BACKGROUND

Pelvic radiation therapy with concomitant chemotherapy (PCRT) is the standard treatment of stage IB2/II cervical carcinoma. The impact of concomitant chemotherapy on positive para-aortic nodes (PA+), however, remains unknown. The aim of this study was twofold: to evaluate the rate of histological PA+ after PCRT and to determine the survival of patients with PA+.

METHODS

Patients fulfilling the following inclusion criteria were studied: (1) stage IB2/II cervical carcinoma, (2) histological subtype: squamous cell, adenocarcinoma or an adenosquamous tumor, (3) exclusion of patients with radiological PA+ (CT scan/MRI), (4) pelvic external radiation therapy of 45 Gy with concomitant chemotherapy (cisplatin 40 mg/m2/week) + utero-vaginal brachytherapy, and (5) completion surgery after the end of PCRT including at least a para-aortic lymphadenectomy.

RESULTS

Seventy-three patients (16 stage IB2, 57 stage II) treated between 1998 and 2004 fulfilled all the inclusion criteria. PA+ after PCRT were observed in 13 patients (18%) with a median of five (range, 2-22) positive nodes. Overall and disease-free survival at 24 months in patients with PA+ was 40% and 17%. Only two patients with PA+ are currently alive and in remission.

CONCLUSIONS

The rate of PA+ remains high after PCRT in patients treated for stage IB2/II cervical carcinoma. Furthermore, the survival rate of patients with PA+ is very low. These important results suggest that detection of PA + at the time of completion surgery (after PCRT) is not beneficial for improving survival.

Extraperitoneal laparoscopic para-aortic lymphadenectomy as a diagnostic procedure for lymph node recurrence of gynaecological cancers

OBJECTIVE

The aim of this study was to evaluate the feasibility of extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of gynecological cancers.

METHODS

Seven patients underwent extraperitoneal laparoscopic para-aortic lymphadenectomies for suspected lymph node recurrence, detected by magnetic resonance image or CT scan. The suspicious nodes were removed through an extraperitoneal laparoscopic approach.

RESULTS

The median age of patients was 51 years (range: 39-67). The median operating time was 207 min (range 120-300). There were no intraoperative or postoperative complications. The median nodal yield was 7.3 (range: 1-15). The median hospital stay was 2.5 days (range: 2-3). Histological examination revealed metastasis in 6 of the 7 patients.

CONCLUSION

The extraperitoneal laparoscopic para-aortic lymphadenectomy for lymph node recurrence of gynecological cancers is a safe and feasible procedure which should be considered in the case of possible recurrence.

[Approach to diagnosing tuberculosis of intrathoracic lymph nodes of a paraaortic group in children]

A hundred and seventeen patients aged 3 to 14 years, with suspected tuberculosis of intrathoracic lymph nodes (ILN) of a paraaortic group in the phase of calcination, were examined at the Clinic of Childhood Pulmonary Tuberculosis, Saint Petersburg Research Institute of Phthisiology. The comprehensive examination made the diagnosis of tuberculosis be cancelled in 35% of cases and confirmed in 65%, by determining the phase and extent of a specific inflammation. In 8.5% the local manifestations of the disease were absent along with the significant symptoms of intoxication and with the activity of tuberculous infection, which gave grounds to establish the diagnosis of tuberculous intoxication. Despite the fact that computed tomography revealed aortic ligament calcification, enlarged mediastinal lymph nodes were detected in 35%. High tuberculous infection activity and mediastinal ILN lesion in different phases of the specific inflammation were found in 15.4%, which was indicative of the chronic course of inflammation. The first detected isolated calcification in the paraaortic group of lymph nodes was diagnosed in 5.9%. The use of the presented complex, the diagnostic efficiency of which was 98%, significantly enhanced the diagnosis and reduced the number of errors in making the diagnosis.

Unusual association of adrenal pheochromocytoma and para-aortic neurofibroma in pregnancy

The association of pheochromocytoma (PHEO) and pregnancy is uncommon and life threatening for both the fetus and the mother. Early diagnosis and treatment is essential to decrease maternal and fetal mortality and to differentiate the disease from the more common pre-eclampsia. While medical treatment should be started immediately after diagnosis, the timing of surgical treatment is still debated. We describe the case of a 27-yr-old woman in the 18th week of pregnancy who showed a biochemical pattern typical of PHEO and, by imaging studies, 2 tumors with the same characteristics: the first localized on the right adrenal gland, the second at the right renal hilum. The patient underwent surgery because of suspicion of malignant PHEO with local metastasis, while histology revealed a rare association of a solitary PHEO and para-aortic neurofibroma, both tumors embryologically deriving from a common cell precursor.

Laparoscopic resection of a paraganglioma of the organ of Zuckerkandl in a patient with a carotid body tumor

Paragangliomas of the organ of Zuckerkandl are rare tumors with only several case reports noted in the literature. Synchronous paraganglioma occur sporadically, and on occasion, in association with several genetic syndromes. Paraganglioma of the organ of Zuckerkandl with synchronous carotid body paraganglioma is described herein. Traditionally, surgical resection of abdominal paraganglioma involved an exploratory laparotomy. In this manuscript, we describe one of the first reported laparoscopic resections of this tumor and review the literature on multiple paragangliomas and their associated genetic syndromes.

Surgical treatment of diaphragmatic eventration using video-assisted thoracic surgery: a prospective study

BACKGROUND

This study seeks to evaluate results regarding the repair of diaphragmatic eventration using video-assisted thoracic surgery (VATS).

METHODS

We performed a prospective observational study including patients referred to us for surgical treatment of diaphragmatic eventration during a 12-year period. Clinical, radiologic, and functional data were prospectively recorded. VATS was performed with two thoracoports and a 4-cm mini-thoracotomy. Diaphragmatic plication was performed using two nonresorbable running sutures from periphery to the cardio-phrenic angle. Follow-up data (clinical examination, chest roentgenogram, lung function tests at 3, 6, 12 months, and annually thereafter) were also prospectively recorded.

RESULTS

Twelve patients (4 male adults, mean age 57.7 +/- 14.8 years) were operated on between 1992 and 2003. The left side was involved in 8 patients and the mean height of diaphragm elevation was 7.5 +/- 1.8 cm. All patients experienced symptoms related to the disease; in 2 patients the operation was carried out to achieve weaning from mechanical ventilation. The etiologic mechanism could be identified in 11 out of 12 patients (trauma, n = 9; Charcot-Marie disease, n = 1; calcified para-aortic nodes, n = 1). Mean operative time, drainage output, and hospital stay were 77 +/- 15 minutes, 0.8 +/- 04 L, and 3.4 +/- 0.7 days, respectively. No mortality was observed; 1 patient experienced postoperative pneumonia, which was treated using antibiotics. All patients experienced amelioration of symptoms and long-term lung function tests revealed a marked improvement of both the forced volume capacity and the forced expiratory volume at 1 second. No relapses were observed at follow-up chest roentgenogram.

CONCLUSIONS

Treatment using VATS is a safe and effective alternative to conventional surgery. Functional improvement persists at long-term follow-up.

[Pheochromocytoma of the organ of Zuckerkandl. Apropos of a case]

INTRODUCTION

Extraadrenal pheochromocytomae represent 17-18% of pheochromocytomae, 85% of which are located infradiaphragmaticaly and generally wherever there is cromaffin tissue, as in this case, located at the organ of Zuckerkand. They can also appear in the context of family syndromes, i.e. phacomatosis and MEN (IIA and IIB).

CLINICAL CASE

The authors present a case of pheochromocytoma located in the organ of Zuckerkand, diagnosed in the course of uncontroled HBP. Diagnosis was achieved by metanephrine determinations and radiological tests (ultrasound, CAT and MIBG). This patient was surgically treated by exeresis of the lession previous alpha and beta adrenergic blockade with phenoxybenzamine and propanolol. Currently this patient is asymptomatic with normal blood pressor and metanephrines blood levels.

DISCUSSION

Extraadrenal pheochromocytomae are usually located in superior paraaortic infradiaphragmatic region. The grade of malignancy must be established by histopathological findings, local recidives and metastasis. After clinical suspicion and the finding of a retroperitoneal mass with ultrasound, CAT and/or MRI, MIBG must be performed to confirm the diagnosis as well as to leave out possible tumours at distance. Treatment is surgery previous blockade of cathecolamines secretion by the preoperative administration of alpha blockers, with or without beta blockers.

Growth factors and cytokines in paragangliomas and pheochromocytomas, with special reference to sustentacular cells

The aim of this study was to localize various growth factors and cytokines in paragangliomas and pheochromocytomas in order to understand their possible autocrine or paracrine functions, and to compare sustentacular cells of the adrenal medulla with pituitary stellate cells. Thirteen resected tumors, 11 paragangliomas and 2 pheochromocytomas of the adrenal medulla, were studied. In addition, five surgically removed nontumorous adrenals and five nontumorous pituitaries were studied. Varying numbers of sustentacular cells were immunopositive for S-100 protein and in most instances for glial fibrillary acidic protein. Insulin-like growth factor-1 (IGF-1), tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 were localized to both cell types in all cases, whereas epidermal growth factor (EGF) immunopositivity was noted in only three. In all tumors, leukemia inhibitory factor (LIF) was restricted to chief cells and EGF receptor to sustentacular cells. Nontumorous chief cells and sustentacular cells of adrenal medulla exhibited immunoreactivities similar to those of paragangliomas and pheochromocytomas. Secretory adenohypophysial cells displayed various immunoreactivities for all growth factors, receptors, and cytokines studied. Pituitary stellate cells were immunopositive for EGF, EGF receptor, IGF-1, LIF, and TNF-alpha. In conclusion, paragangliomas and pheochromocytomas are immunoreactive for a wide spectrum of growth factors and cytokines. Immunocytochemistry demonstrated similarities between sustentacular cells and stellate cells of the pituitary in addition to their similar morphology. The significance of these observations regarding paracrine activities of chief and sustentacular cells remains to be determined.

Prediction of malignant behavior of pheochromocytomas and paragangliomas using immunohistochemical techniques

Pheochromocytomas and paragangliomas arise from the adrenal glands and extraadrenal paraganglia, respectively. Malignant behavior of these tumors is uncommon and is, in part, dependent on their sites of origin, such as extraadrenal location. Morphologic criteria for malignancy of pheochromocytoma and paragangliomas have not been clearly defined. In this study, to clarify the histologic features that distinguish the benign from malignant pheochromocytomas and paragangliomas, we examined metastatic and nonmetastatic tumors using immunohistochemical techniques. A total of eight cases, five pheochromocytomas from the adrenal glands (four benign and one malignant tumor) and three paragangliomas with invasion or metastasis, were studied. The markers used in this study were chromogranin A, synaptophysin, NCAM (CD56), SNAP25, neuron-specific enolase, S-100 protein, and MIB-1. Our results suggest that MIB-1 immunostaining is a useful adjunct marker to predict malignant behavior in these tumors.

Multifocal malignant extra-adrenal paragangliomas of the Organ of Zuckerkandl and urinary bladder

A case of multifocal malignant extra-adrenal paragangliomas involving the Organ of Zuckerkandl and urinary bladder is presented. The role and order of imaging investigations of functioning extra-adrenal paraganglioma is discussed.

Paraaortic lymph node biopsy: a twenty-year study

OBJECTIVES

Paraaortic lymph node biopsy is a controversial but proved technique to determine the extent of spread of cancers from the uterine cervix or endometrium. This article explores the following questions. Does the presence of positive paraaortic lymph nodes result in modification of the patient's therapy? Does the evidence gained from a paraaortic lymph note biopsy improve patient survival?

STUDY DESIGN

Five hundred sixty-eight patients had paraaortic lymph node sampling in conjunction with another operative procedure between 1976 and 1995. Five hundred seven (89.3%) of these patients had either endometrial or cervical cancer.

RESULTS

Paraaortic lymph node biopsies led to a survival rate of 9.1% for cervical carcinoma and 46.6% for endometrial carcinoma and were associated with acceptable morbidity.

CONCLUSIONS

We believe that paraaortic lymph node biopsies should be part of the routine evaluation of patients with gynecologic cancers. The knowledge gained by this procedure along with appropriately administered radiation therapy can save lives.

Giant extra-adrenal pheochromocytoma: magnetic resonance imaging with gadolinium-DTPA enhancement

A case report of a 35-yr-old male presenting with moderate hypertension and a giant extra-adrenal pheochromocytoma is discussed. The patient was treated by chemotherapy and surgery with regression of the lesion and clinical relief of symptoms. Initial magnetic resonance imaging (MRI) with gadolinium-DTPA enhancement revealed a large complex pelvic mass. Follow-up examination following chemotherapy three months later demonstrated partial regression. The MRI findings and the pattern of gadolinium-DTPA enhancement are discussed.

[Late recurrence in pheochromocytoma: need for a long term follow up]

Pheochromocytoma is a catecholamine secreting tumor which has been traditionally considered as a potentially curable cause of hypertension. However, the existence of malignant pheochromocytomas as well as the problem which the recurrence of benign pheochromocytomas present, make the eradication of this tumor more complicated. It is note worthy the difficulty in localizing recurrent pheochromocytomas as well as the prognostic interest that presents the possibility of differentiating between recurrence and metastasis. We refer the case of a female patient suffering benign adrenal pheochromocytoma, who, 10 years it was surgically removed, presented a relapse of symptoms, and was diagnosed of extra-adrenal pheochromocytoma, in Zuckerkandl organ. The importance of performing a long term post-surgical follow-up in these patients is stressed.

Inguinal and iliac lymph node involvement in germ cell tumours of the testis: implications for radiological investigation and for therapy

The clinical details of 1191 patients with primary germ cell tumours of the testis seen at the Royal Marsden Hospital between 1977 and 1989 were reviewed in order to determine the incidence of inguinal or iliac node metastases. This was detected in 22 patients, 11 with inguinal and 11 with iliac lymphadenopathy. Seven of these patients had a history of maldescent and orchidopexy, and one patient had congenitally fused testes. Of the remaining 14 patients, eight had bulky para-aortic lymphadenopathy (5 cm or greater in diameter), one had histological evidence of breach of the tunica vaginalis by tumour, and in five patients no predisposing factors were identified. Eight patients had a seminoma, 11 a non-seminoma, and two a combined tumour. Inguinal or iliac nodes were significantly more common in the group of patients defined by bulky para-aortic disease or a history of maldescent and orchidopexy (15/267) than those without either factor (7/924, P less than 0.0004). Patients with a history of maldescent, congenital anomalies of the genitourinary system, or with bulky para-aortic disease, should routinely have the pelvis and inguinal regions included in a staging or follow-up CT scan. These factors should also influence the extent of the radiation field or of surgical dissection when these modalities are employed.

Clinical-pathologic study of stage IIB, III, and IVA carcinoma of the cervix: extended diagnostic evaluation for paraaortic node metastasis--a Gynecologic Oncology Group study

Three hundred twenty patients were entered into GOG Protocol 63, a clinical-pathologic study of stage IIB, III, and IVA cervical carcinoma. Following the completion of FIGO staging prerequisites, patients had computerized tomography (CT), a lymph-angiogram (LAG), and an ultrasound (US) of the aortic area. If any study was positive, a cytologic or histologic evaluation by fine-needle aspiration or selective paraaortic lymphadenectomy was performed. Paraaortic node dissection was mandated for patients with negative extended staging studies. Results of extended staging evaluations were compared with histologic or cytologic results. Two hundred sixty-four patients were eligible and evaluable. One hundred sixty-seven patients (63%) were stage IIB, 89 (34%) were stage III, and 8 (3%) were stage IVA. Positive paraaortic nodes occurred in 21% of stage IIB, 31% of stage III, and 13% of stage IVA. LAG sensitivity was 79% with a specificity of 73%. Sensitivity of CT and US was 34 and 19%, respectively, with specificities of 96 and 99%, respectively. The frequency of false-negative results with LAG for patients with stage IIB disease was 6%. This decrease is consistent with a stable sensitivity and specificity. These findings suggest that a negative LAG may be adequate to eliminate surgical staging in subgroups with low risk of metastasis to the aortic nodes. Until new noninvasive testing methods are developed, LAG appears to be the most reliable noninvasive examination to evaluate spread of cervical cancer to aortic nodes.

Fine-needle aspiration cytology of pheochromocytoma-ganglioneuroma of the organ of Zuckerkandl

Fine-needle aspiration (FNA) cytologic and immunocytochemical findings of a rare combined pheochromocytoma-ganglioneuroma developing in a 48-yr-old Japanese man in the organ of Zuckerkandl are described. This is the first report of a combined pheochromocytoma-ganglioneuroma of the organ of Zuckerkandl. FNA cytology showed typical cytologic findings of these two components similar to those described individually in fine-needle aspirates of these neoplasms. The neoplastic cells showed positive reactions for vasoactive intestinal polypeptide, neuron-specific enolase, and S-100.

Malignant pheochromocytoma arising in the organ of Zuckerkandl--a clinicopathological study

An autopsy case of malignant pheochromocytoma arising in the organ of Zuckerkandl is reported, of which distant metastases were found in the liver and lymph nodes. The biochemical and electron microscopic findings from the tumor tissue showed noradrenaline-secreting type. It was revealed that sex ratio in malignant pheochromocytoma was more prominent in the female, and the frequency of extra-adrenal origin was higher in malignant pheochromocytoma than in benign one from comparative study of reported cases of malignant pheochromocytoma.

Ultrastructure of malignant paraganglioma of organ of Zuckerkandl

Electron microscopic study of a malignant paraganglioma of the organ of Zuckerkandl revealed similarities between the tumor and the normal paraganglia. The well-differentiated portion of the tumor recapitulated the structure of the basic functional units of the paraganglion. In addition there signs of anaplasia both at the histologic and ultrastructural level. Large neurosecretory granules were noted in some of the tumor cells, but most of the cells were agranular. Crystaloids resembling those seen in alveolar soft part sarcoma were also noted. The study supports the theory on the common origin and histogenesis of paragangliomas and alveolar soft part sarcomas.

Phaeochromocytoma and pregnancy: a case report

A case of maternal death associated with phaeochromocytoma is reported. Diagnostic difficulty and the poor maternal and fetal prognosis are discussed. A note of caution about inadvertent use of sympathomimetic agents in such patients is included in the discussion.

Functional tumors of the organ of Zuckerkandl

Chromaffin-reacting pheochromocytomas of the adrenal medulla are the most frequently encountered functional paraganglionic neoplasms. However, extra-adrenal pheochromocytomas as well as non-chromaffin paragangliomas, including those of the carotid body and glomus jugulare, may produce symptoms from catecholamine secretion. One of the extra-adrenal sites from which these tumors arise is from a collection of para-aortic, paraganglion cells around the origin of the inferior mesenteric artery. This collection of paraganglia was described in fetuses by Zuckerkandl in 1901 and has subsequently been referred to as the organ of Zuckerkandl. The diagnosis and management of these neoplasms differ somewhat from that of adrenal pheochromocytomas, but excellent results are often obtained by excision of these lesions. Four patients with functional tumors of the organ of Zuckerkandl are reviewed together with the other reported cases in the literature.