Challenges in the surgical treatment of undiagnosed functional paragangliomas

Abstract

Introduction:Paragangliomas (PGs) or extra-adrenal pheochromocytomas are rare neuroendocrine neoplasms of ubiquitous distribution. Those that produce excess catecholamine are categorized as functional, and those that do not are categorized as nonfunctional. Although modern medical technology is becoming more widespread, there are still substantial risks of misdiagnosis or missed diagnosis of PGs.Case presentation:A 38-year-old woman who lived in an autonomous region of inner Mongolia presented complaining of having experienced coughing for approximately the past month. Chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion on the right side of thoracic vertebra 5–8 of approximately 66 mm × 54 mm, and it was deemed to be a mediastinal tumor that required surgical treatment. The patient exhibited severe hemodynamic instability during the operation, resulting in substantial challenges and risks with regard to anesthesia management.Conclusion:When a patient is suspected having PG, whether the surgery should be continued or not depends on their overall condition and whether hemodynamic fluctuation can be controlled to within the normal range. Both are factors that should be considered during intraoperative management. Communication between the surgeon and anesthesiologist is necessary, in order to accurately assess the risks associated with the operation. The combination of central venous pressure and the Flotrac/Vigileo system may provide precise guidance for complementary liquid therapy and reduce cardiopulmonary complications. After the operation, hemodynamic changes should be monitored continuously in the intensive care unit, and vasoactive drugs are required to avoid postoperative hypotension. Dramatic hemodynamic changes are certainly a challenge for patients and anesthesiologists, regardless of their origin, and sufficient attention should be paid to avoid serious consequences.

Anesthetic Management in Anterior Mediastinal Pheochromocytoma Case

“…In our case, well-circumscribed nodular lesions were observed in the anterior mediastinum on PA chest radiography, thorax CT and scintigraphy. Radioactive iodine labeled methiodobenzylguanidene scintigraphy is a very reliable approach in the diagnosis of paraganglioma [1,6] . In the biochemical study conducted 1 month ago, high urinary metanephrine and normetanephrine levels were observed.…”

“…In our case, no other clinical finding was found except hypertension. The com- monly used treatments in combination for paraganglioma are α-adrenergic receptor blockers,-adrenergic receptor antagonists, angiotensin receptor blockers (ACE inhibitors) and calcium channel blockers [1,3,7] . ACE inhibitor (enalapril) and calcium channel blocker (amlodipine) were used in our case.…”

“…Pheochromocytoma and paraganglioma are rare variations of neuroendocrine tumors arising from the sympathetic chain focus of the adreneal medulla and non-adrenal medulla [1,2] . Paraganglioma can be seen in a wide variety of locations including abdomen (80-85%), pelvis, neck and head (5%) and chest cavity (5%).…”