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      Thoracotomy of an asymptomatic, functional, posterior mediastinal paraganglioma: A case report

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          Abstract

          BACKGROUND

          Paragangliomas in the mediastinum are rare, accounting for only 1%-2% of all paragangliomas and < 0.3% of all mediastinal tumors. Most paragangliomas are nonfunctional, therefore, asymptomatic functional paragangliomas in the left posterior mediastinum are extremely rare. Perioperative management including preoperative preparation, careful intraoperative procedures, and strict postoperative care is important, and one-stage surgical resection should be performed only after appropriate perioperative measures are undertaken. Because those tumors are rare, it is necessary to report known cases to raise awareness regarding them.

          CASE SUMMARY

          We report the case of a 47-year-old male who was admitted to our hospital with the chief complaints of intermittent tearing pain on the left side of the chest and back for more than 10 mo. A chest contrast-enhanced computed tomography scan revealed a round, solid mass in the left posterior mediastinum, with low-density cystic lesions in the middle, and no enlarged lymph nodes in the hilum or mediastinum (Figure 1). After the diagnosis of paraganglioma, the patient was preoperatively given an oral adrenoceptor blocking drug (phenoxybenzamine), and intravenous fluid resuscitation for two weeks, subsequently the patient underwent a one-stage resection of lesions via left thoracotomy. The patient’s blood pressure increased to 220/120 mmHg when the tumor was touched, which could be relieved by symptomatic treatment such as accelerating liquid transfusion or other intervention to lower blood pressure. The patient recovered uneventfully after surgery, with no abnormal blood pressure or recurrence during one year of follow-up visits.

          CONCLUSION

          Surgical resection is the preferred treatment for asymptomatic functional paragangliomas.

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          Most cited references14

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          Limited value of adrenal biopsy in the evaluation of adrenal neoplasm: a decade of experience.

          To determine the value of percutaneous adrenal biopsy in the evaluation of adrenal neoplasm. Retrospective review. Tertiary referral center. All adult patients undergoing image-guided adrenal biopsy from 1997 to 2007. Main Outcome Measure Biopsy sensitivity for malignancy. There were 163 biopsies performed on 154 patients. Mean (SD) age was 66 (12.5) years. Eighty-eight biopsies (53.4%) were performed in patients with a prior diagnosis of cancer. Forty-five (26.4%) were performed when imaging study results suggested previously undiagnosed cancer with a simultaneous adrenal metastasis. Thirty (20.2%) were performed for isolated adrenal incidentalomas. Rates of positive biopsy results in these 3 groups were 70.6%, 69.0%, and 16.7%, respectively. Prebiopsy evaluation for pheochromocytoma was performed in less than 5% of patients with established or suspected nonadrenal malignancies and 32% of patients with incidentalomas. In patients with isolated adrenal incidentaloma, a radiology report recommended biopsy 33% of the time for characteristics inconsistent with benign adenoma. Benign incidentalomas measured mean (SD) 4.2 (2.1) cm (range, 1.4-10.7 cm), and malignancies measured mean (SD) 9.3 (3.3) cm (range, 5.3-14 cm) (P < .05). All incidentalomas 5 cm or less (n = 18) were benign. There were 4 false-negative biopsy results: 3 adrenocortical carcinomas and 1 pheochromocytoma. Biopsy is unhelpful in patients with isolated adrenal incidentaloma. Despite atypical radiographic findings, all nonfunctioning nodules 5 cm or less were benign. The negative predictive value is unacceptably low and cannot be relied on to rule out malignancy. The value of biopsy remains the diagnosis of metastatic carcinoma in patients with a nonadrenal primary malignancy, proven by the more than 70% positive rate in this group.
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            Successful outcomes in pheochromocytoma surgery in the modern era.

            We describe our experience with surgical management, complications and treatment outcome of histologically confirmed pheochromocytoma. The records of 113 patients who underwent surgical excision of pheochromocytoma were reviewed and assessed for preoperative medical treatment, intraoperative findings, postoperative hospitalization and complications. There were no surgical mortalities. Average length of stay in the intensive care unit was 1.2 days. There were only 6 major cardiovascular complications all of which occurred in patients who received preoperative medications, including 5 with alpha blockade. Patients receiving no preoperative alpha blockade required an average of 956 cc less in total intraoperative fluids, which approached statistical significance, and 479 cc less fluids on postoperative day 1, which was statistically significant. Preoperative alpha-adrenergic blockade is not essential in pheochromocytoma patients. Calcium channel blockers are just as effective and safer when used as the primary mode of antihypertensive therapy. Surgery for pheochromocytoma is safe in the modern era.
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              Paragangliomas of the head and neck region. A pathologic study of tumors from 71 patients.

              The histopathology of 72 paragangliomas originating in the head and neck region of 71 patients is presented. There were 45 carotid body, 13 vagal body, eight jugulotympanic, and three nasal paragangliomas. In addition, two arose in the larynx and one in the area of the aortic arch. Tumors occurred in four unrelated families. The two most important histologic features leading to a diagnosis of paraganglioma were zellballen and the presence of cytoplasmic argyrophil granules in all cases in which staining with the Grimelius technique was carried out. Ultrastructural study of three carotid body and two vagal body paragangliomas revealed both light and dark chief cells. Tumor cells contained membrane bound, electron dense neurosecretory types of granules, which usually ranged in diameter from 120 to 200 nm. Follow-up information was available for 67 patients (94 per cent). Two of the three nasal paragangliomas, 50 per cent of the jugulotympanic paragangliomas, 17 per cent of the vagal body paragangliomas, and 10 per cent of those of the carotid body recurred locally following attempted surgical resection. All patients treated with radiation had persistent tumor. Four (9 per cent) of the carotid body paragangliomas were malignant, all four patients dying with widespread metastases. One vagal body paragangliomas metastasized to regional lymph nodes (the patient was alive and well at five years), and another caused death by direct intracranial extension. In contrast to the benign tumors, malignant paragangliomas tended to show foci of necrosis and vascular invasion. Mitotic figures, which usually were not identified in the benign cases, were seen in all malignant tumors.
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                Author and article information

                Contributors
                Journal
                World J Clin Cases
                WJCC
                World Journal of Clinical Cases
                Baishideng Publishing Group Inc
                2307-8960
                26 June 2019
                26 June 2019
                : 7
                : 12
                : 1529-1534
                Affiliations
                Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, Changchun 130000, Jilin Province, China
                Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, Changchun 130000, Jilin Province, China
                National Institutes on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD 20892, United States
                Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, Changchun 130000, Jilin Province, China. yinjie17@ 123456mails.jlu.edu.cn
                Author notes

                Author contributions: Yin YY contributed to study design and manuscript preparation and revision; Yang B contributed to literature research and clinical studies; Ahmed YA contributed to manuscript editing and language polishing; Xin H contributed to manuscript final version approval.

                Corresponding author: Hua Xin, MD, PhD, Chief Doctor, Professor, Chief, Department of Thoracic Surgery, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun 130000, Jinlin Province, China. yinjie17@ 123456mails.jlu.edu.cn

                Telephone: +86-431-84995999 Fax: +86-431-84995999

                Article
                jWJCC.v7.i12.pg1529
                10.12998/wjcc.v7.i12.1529
                6656679
                31363483
                bcaaedcd-eab8-47dd-a869-2a239ceb78dc
                ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.

                This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

                History
                : 11 January 2019
                : 21 March 2019
                : 18 April 2019
                Categories
                Case Report

                mediastinal tumor,paraganglioma,pheochromocytoma,hypertension,case report

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