• Users Online:1225
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 108-109

Endoscopic ultrasound-guided fine needle aspiration for the diagnosis of nonfunctional paragangliomas: A case report and review of the literature


Santa Casa Medical School, Sao Paulo, Brazil

Date of Web Publication6-Sep-2013

Correspondence Address:
Ana Carolina F Castro
Santa Casa Medical School, Sao Paulo
Brazil
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.7178/eus.02.009

Rights and Permissions
  Abstract 

Paraganglioma is a rare tumor that should be included in the differential diagnosis of retroperitoneal tumors. Endoscopic ultra­sound-guided fine needle aspiration (EUS-FNA) has emerged as an effective tool in the diagnosis of these lesions. A 37-year-old female patient with a history of microcytic anemia underwent EUS-FNA and was diagnosed with a neuroendocrine tumor by histo­pathological and immunohistochemical analysis. The tumor was surgically removed, and the final diagnosis was paraganglioma. This case report emphasizes the importance of EUS in the evaluation of this type of lesion.

Keywords: paraganglioma; neuroendocrine tumor; pancreas; endoscopic ultrasound; fine needle aspiration; immunohistochemstry


How to cite this article:
Ganc RL, Castro AF, Colaiacovo R, Vigil R, Rossini LG, Altenfelder R. Endoscopic ultrasound-guided fine needle aspiration for the diagnosis of nonfunctional paragangliomas: A case report and review of the literature. Endosc Ultrasound 2012;1:108-9

How to cite this URL:
Ganc RL, Castro AF, Colaiacovo R, Vigil R, Rossini LG, Altenfelder R. Endoscopic ultrasound-guided fine needle aspiration for the diagnosis of nonfunctional paragangliomas: A case report and review of the literature. Endosc Ultrasound [serial online] 2012 [cited 2019 Sep 18];1:108-9. Available from: http://www.eusjournal.com/text.asp?2012/1/2/108/117750


  Introduction Top


Paraganglioma is a rare tumor derived from the chromaffin cells of a sympathetic ganglia. It should always be included in the differential diagnosis of retroperitoneal tumors.[1] The diagnosis is made by histopathology and confirmed by immunohistochemistry.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has emerged as an effective tool in the diagnosis of lesions located into the retroperitonium.[2] Even though EUS-FNA should not be done in functional paragangliomas, it is uncertain if FNA can trigger the secretion of catecholamines in non-funcional tumors. The authors present a rare case of an uneventful EUS-FNA diagnosis of such a tumor.


  Case Report Top


A 37-years-old female with a history of microcytic anemia presented at the Santa Casa University General Hospital. She was asymptomatic and there were no alterations in laboratorial tests and physical examination, except for a lesion in the palate, which was later diagnosed as a adenocarcinoma. During the staging of this lesion, the abdomen computed tomography (CT) showed a tumor measuring 4.8 cm × 3.2 cm × 4.3 cm localized in the retroperitoneal region between the vena cava, pancreas head and duodenum. EUS revealed a hipoechogenic, heterogeneous lesion, measuring 3.5 cm × 3.5 cm localized in the pancreatic region, between the vena cava and aorta and next to the superior mesenteric vein. Its invasion could not be rulled out [Figure 1]. The suspected diagnosis was of a retroperitoneum metastasis. EUS-FNA was then performed with a 22-G needle. The histopathological analysis demonstrated malignant cells and immunohistochemical analysis was positive for chromogranin and sinaptophisin, diagnosing neuroendocrine tumor [Figure 2]. After further team discussion, a decision was made to surgically remove the tumor [Figure 3]. The patient was advised for a duodenum pancreatectomy and the final diagnosis was a paraganglioma.
Figure 1. Endoscopic ultrasound: hipoechogenic lesion in the pancreatic region.

Click here to view
Figure 2. Immunohistochemical compatible with neuroendocrine tumor.

Click here to view
Figure 3. Ressected lesion.

Click here to view



  Discussion Top


Paragangliomas are rare neuroendocrine tumors most commonly found in the abdomen (84%). About 30% to 50% are malignant.[3] The functional ones represent 36% to 60% of all paragangliomas and secrete norepinephrine and normetanephrine. Such patients may be present with severe hypertension, although there are reports of patients with normal blood pressure.[3]

The preoperative diagnosis is difficult to obtain, especially in non-functional cases, as demonstrated in this case. Functional cases are easier to diagnose because urinary catecholamines are elevated.[4],[5]

Even though imaging studies are helpful, diagnosis of paragangliomas can be safely done only with careful histologic and immunohistochemical evaluation of stains of chromogranin A and S100 protein.[4] Recent studies have showed that the diagnosis may be unanticipated by EUS, with anedoctal reports regarding such cases.[6]

The present case was not different and the diagnosis of paraganglioma was not expected, since the patient had an adenocarcinoma under investigation, had no symptoms related to the first and the EUS appearance was unusual for a neuroendocrine tumour.

The EUS-FNA allows preoperative diagnosis with material for histological analysis. If the patient has symptoms consistent with a pheochromocytoma or a cystic mass of uncertain etiology, it is advisable to assay a 24-hour urine collection for catecholamines, metanephrines, and vanillylmandelic acid before needle puncturing of the lesion.[7]

Clinical signs should raise a suspicion of paraganglioma, in which case, needle puncture is contraindicated and appropriate imaging and biochemical studies should be obtained. Although EUS-FNA is contraindicated, assessment of anatomically adjacent structures by EUS may provide useful information before surgical resection.[2] In the present case, the main diferential diagnosis was a metastatic lesion. Nonetheless, EUS-FNA was performed uneventfully and this most unusual diagnosis was possible.

 
  References Top

1.Rha SE, Byun JY, Jung SE, et al . Neurogenic tumors in the abdomen: tumor types and imaging characteristics. Radiographics 2003; 23: 29-43.  Back to cited text no. 1
[PUBMED]    
2.Kubota K, Kato S, Mawatari H, et al . Risk endoscopic ultrasonography-guided fne-needle aspiration for asymptomatic retroperitoneal tumors. Digest Endosc 2010; 22: 144-6.  Back to cited text no. 2
    
3.Yang JH, Bae SJ, Park S, et al . Bilateral pheochromocytoma associated with paraganglioma and papillary thyroid carcinoma: report of an unusual case. Endocr J 2007; 54: 227-31.  Back to cited text no. 3
[PUBMED]    
4.Ohkawara T, Naruse H, Takeda H, et al . Primary paraganglioma of the head of pancreas: contribution of combinatorial image analyses to the diagnosis of disease. Intern Med 2005; 44: 1195-6.  Back to cited text no. 4
[PUBMED]    
5.Sahdev A, Sohaib A, Monson JP, et al . CT and MR imaging of unusual locations of extra-adrenal paragangliomas (pheochromcytomas). Eur Radiol 2005; 15: 85-92.  Back to cited text no. 5
[PUBMED]    
6.Akdamar MK, Eltoum I, Eloubeidi MA. Retroperitoneal paraganglioma: EUS appearance and risk associated with EUS-guided FNA. Gastrointstinal. Endosc 2004; 60: 1018-21.  Back to cited text no. 6
    
7.Baguet JP, Hammer L, Tremel F, et al . Metastatic phaeochro-mocytoma: risks of diagnostic needle puncture and treatment by arterial embolisation. J Hum Hypertens 2001; 15: 209-11.  Back to cited text no. 7
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
   References
   Article Figures

 Article Access Statistics
    Viewed821    
    Printed29    
    Emailed0    
    PDF Downloaded169    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]