Rare extra-adrenal paraganglioma mimicking a painful Schwannoma: case report.

Picchetto, Andrea; Paganini, Alessandro M; Balla, Andrea; Quaresima, Silvia; Cantisani, Vito; D'Ambrosio, Giancarlo; Lezoche, Emanuele

INTRODUCTION Paragangliomas originate from chromaffin tissue primarily found in the Zuckerkandl body. A 53 years old man, was investigated with abdominal MRI for chronic backache, that had lasted for 2 years. CASE REPORT MRI revealed an incidental mass in para-aortic region, at the adrenal lodge, with characteristics of a solid nodular mass, which did not seem to arise from the adrenal gland. An abdominal CT showed a mass localized prior to left adrenal gland; the radiologist reported this mass as a malignant peripheral nerve sheath tumor (Schwannoma). During his stay in hospital, tumoral markers chromogranin and neuron-specific enolase were dosed, with a concentration of 187.00 ng/mL and 7.7 ng/mL. Patient's back pain was treated first with ketorolac, without any resolution of the problem, then with ketorolac plus tramadol in elastomeric pump, again with no relief, and finally with a continuous infusion of morphine. Since the exact nature of the neoplasm was not known and a CT guided biopsy was not technically feasible to do, a laparoscopic excision of the mass, with transperitoneal anterior submesocolic approach, as well as for the left adrenalectomy, was planned. After surgery, the patient no longer needed morphine. The postoperative course was uneventful. RESULTS Histopathological findings consisted of periadrenal paraganglioma. Extra-adrenal paragangliomas are rarely recognized during preoperative study. This is often due to its capacity of mimicking other type of tumors. CONCLUSIONS Paragangliomas could be successfully resected by laparoscopy, they are difficult to distinguish from other tumor and they should be investigated even if preoperative findings argue for something else.