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J Thorac Cardiovasc Surg 2006;132:705-706
© 2006 The American Association for Thoracic Surgery

Brief Communication

Successful perioperative management of a middle mediastinal paraganglioma

Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan.

Received for publication January 23, 2006; accepted for publication February 22, 2006.

^_* Address for reprints: Jun Matsumoto, MD, Division of Surgery, Asahi General Hospital, I-1326 Asahi, Chiba, Japan (Email: matsumoto{at}hospital.asahi.chiba.jp).

Dr Matsumoto

Middle mediastinal paragangliomas are very rare, slow-growing tumors, but almost all of them are very hypervascular tumors. Complete surgical resection is difficult to achieve because of their proximity to the heart, great vessels, and trachea. We report successful complete resection incorporating preoperative embolization and a clamshell bilateral thoracotomy.

Clinical Summary

A 52-year-old woman was found to have an abnormal shadow on a chest radiograph for a medical checkup. Chest computed tomography at another hospital revealed a large well-enhanced mass with a cystic lesion located between the superior vena cava, aortic arch, right pulmonary artery, left atrium, and trachea (Figures 1 and 2). A video-assisted thoracoscopic biopsy was performed at another hospital to make the diagnosis, but massive bleeding occurred during the procedure, and the biopsy was abandoned. The patient was then referred to our department. We strongly suspected a paraganglioma of the middle mediastinum. The serum noradrenaline level was slightly increased, and an iodine 123–meta-iodobenzylguanidine scan showed uptake in the tumor. An angiographic study showed many feeding arteries, and the main feeders were 3 thick bronchial arteries. Preoperative embolization with Gelfoam (Pfizer, Ann Arbor, Mich) and several microcoils was performed the day before the operation. At operation, we were ready to perform cardiopulmonary bypass; however, complete resection of the tumor without cardiopulmonary bypass was performed via the clamshell approach. Finally, intraoperative blood loss was reduced to 1070 mL. Histologic diagnosis was reported as a typical paraganglioma, 7 cm in size. There was no sign of recurrence on a computed tomography scan 1 year after surgery.

View larger version (67K): [in this window] [in a new window]   Figure 1. Computed tomography scan showing a large tumor with a cystic region located around the aortic arch and compressing the left main bronchus posteriorly.

View larger version (141K): [in this window] [in a new window]   Figure 2. Three-dimensional computed tomography showing 2 thick feeding vessels (right bronchial arteries) on the back side of the tumor.

Aorticopulmonary paragangliomas are rare neoplasms; 79 anterior and middle mediastinal paragangliomas, which represent a surgical challenge, were reviewed.¹ Because of their location close to the great vessels and trachea, complete resection is very difficult. Paragangliomas are locally invasive and have a high local recurrence rate (55.7%) and metastatic potential (26.6%). Radiation and chemotherapy seem to be ineffective. Complete resection is an important prognostic factor.¹

Preoperative embolization for posterior mediastinal paraganglioma was first described in 1987² and minimizes perioperative vascular complications.³ In our case, preoperative embolization of the three main feeders (bronchial arteries) was performed the day before surgery, and it reduced intraoperative blood loss and permitted dilated bronchial arteries behind the tumor to be ligated and divided more safely.

The surgical approach we selected was the clamshell approach, which was described by Bains and coworkers.⁴ It provides a better view of lateral and posterior aspects of the tumor than median sternotomy, but it causes longer-lasting pain and more impaired postoperative respiratory function than median sternotomy. In our case, the intraoperative view was excellent, and complete resection was achieved more safely than it would have been by median sternotomy.

In a few of the cases that have been reported, surgery was performed with the help of cardiopulmonary bypass.^1,5 Cardiopulmonary bypass should be available and used if necessary for complete resection in cases in which there is local invasion to vital structures.

Almost all aorticopulmonary paragangliomas are aggressive and locally invade vital structures. A careful perioperative strategy (eg, preoperative embolization, an appropriate surgical approach, and cardiopulmonary bypass) is required to resect them completely.

References

1. Lamy AL, Fradet GJ, Luoma A, Nelems B. Anterior and middle mediastinum paraganglioma. complete resection is the treatment of choice. Ann Thorac Surg 1994;57:249-252.[Abstract/Free Full Text]
   
2. Drucker EA, McLoud TC, Dedrick CG, Hilgenberg AD, Geller SC, Shepard JO. Mediastinal paraganglioma. radiologic evaluation of an unusual vascular tumor. AJR Am J Roentgenol 1987;148:521-522.[Medline]
   
3. Rakovich G, Ferraro P, Therasse E, Duranceau A. Preoperative embolization in the management of a mediastinal paraganglioma. Ann Thorac Surg 2001;72:601-603.[Abstract/Free Full Text]
   
4. Bains MS, Ginsberg RJ, Jones II WG, McCormack PM, Rusch VW, Burt ME, et al. The clamshell incision. an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994;58:30-33.[Abstract/Free Full Text]
   
5. Kern JA, Milbrandt TA, Rolf S, Tribble CG. Resection of multiple mediastinal paragangliomas with cardiopulmonary bypass. Ann Thorac Surg 1997;64:1824-1826.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jun Nakajima Kan Nawata Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Matsumoto, J. Articles by Takamoto, S.-i. Search for Related Content PubMed PubMed Citation Articles by Matsumoto, J. Articles by Takamoto, S.-i. Related Collections Mediastinum