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Combined surgical and radiosurgical treatment for a symptomatic cervical metastasis in a case of malignant paraganglioma: a case report.

Sasaki K, Inose H, Kawabata S, Yoshii T, Kato T, Saito M, Okawa A - BMC Res Notes (2013)

Bottom Line: Magnetic resonance imaging of the cervical spine revealed a metastasis at C4 with severe vertebral body destruction.The patient regained strength in all extremities in the postoperative field, and his pain was dramatically reduced.A magnetic resonance imaging study performed three months after the surgery showed a reduced tumor size and spinal cord decompression.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopedics, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 108-0075, Japan. inoorth@tmd.ac.jp.

ABSTRACT

Background: Paragangliomas of the head and neck are rare tumors. Moreover, malignant paragangliomas of the cervical spine are extremely rare. Currently, the combination of curative surgical resection and secondary adjuvant radiotherapy is the gold standard for treating symptomatic malignant paragangliomas. However, traditional treatments for malignant paraganglioma remain unsuccessful. The purpose of this study is to report an exceedingly rare case involving cervical metastasis of a malignant paraganglioma.

Case presentation: In this case report, we present a case involving a 72-year-old male with a history of paraganglioma of the neck. He had been experiencing bilateral shoulder pain, neck pain and weakness in the upper extremities for more than six months. Magnetic resonance imaging of the cervical spine revealed a metastasis at C4 with severe vertebral body destruction. To avoid serious complications associated with surgical resection, CyberKnife® radiosurgery (Accuray, Inc., Sunnyvale, CA, USA) was performed on the parapharyngeal and cervical lesions. A secondary surgery, which involved a posterior laminectomy at C3-6 and posterior fusion at C1-T1, was performed two weeks after the radiosurgery. A histological examination of the surgical specimen demonstrated a malignant paraganglioma. The patient regained strength in all extremities in the postoperative field, and his pain was dramatically reduced. A magnetic resonance imaging study performed three months after the surgery showed a reduced tumor size and spinal cord decompression.

Conclusion: This case study is the first report of a patient with symptomatic cervical metastasis of a malignant paraganglioma treated with a combination of radiosurgery and posterior spinal surgery. Although the optimal treatment for these conditions remains unclear, concomitant treatment with radiosurgery and reconstructive surgery appeared to be both safe and effective in this challenging case.

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Postoperative sagittal (a) and axial (b) T2-weighted magnetic resonance image showing a reduced tumor size and spinal cord decompression.
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Figure 4: Postoperative sagittal (a) and axial (b) T2-weighted magnetic resonance image showing a reduced tumor size and spinal cord decompression.

Mentions: As the tumor was extremely large and close to the artery and nervous tissue, the head and neck surgeons avoided this treatment route. The conventional anterior approach to the vertebral body was also rendered impossible because of the obstruction of the primary neck tumor. Therefore, CyberKnife® radiosurgery (Accuray, Inc.) was employed as the primary treatment for the cervical and parapharyngeal lesions. Even after the radiosurgery, the pain and weakness in the upper limbs persisted. We concluded that it would take some time for the effect of radiosurgery to appear, as his severe neck pain was caused by the destruction of vertebrae. Consequently, a C3-6 laminectomy and C1-T1 fusion using pedicle screw fixation was also performed. The highly vascularized tumor on the C4 lamina was removed and sent to the pathology department. A histological examination (Figure 3) revealed a malignant paraganglioma. Immediately after the second operation, the patient displayed significant improvement in pain and upper-extremity weakness without any complications. As for the metastasis in the lumbar lesion, the patient had yet to show symptoms, a regular course of radiation was administered. Three months after the second operation, an MRI (Figure 4) confirmed that the tumor had shrunk, and the spinal cord compression had disappeared. The last follow-up (six months after the second operation) demonstrated complete recovery of the upper-extremity strength.


Combined surgical and radiosurgical treatment for a symptomatic cervical metastasis in a case of malignant paraganglioma: a case report.

Sasaki K, Inose H, Kawabata S, Yoshii T, Kato T, Saito M, Okawa A - BMC Res Notes (2013)

Postoperative sagittal (a) and axial (b) T2-weighted magnetic resonance image showing a reduced tumor size and spinal cord decompression.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4222095&req=5

Figure 4: Postoperative sagittal (a) and axial (b) T2-weighted magnetic resonance image showing a reduced tumor size and spinal cord decompression.
Mentions: As the tumor was extremely large and close to the artery and nervous tissue, the head and neck surgeons avoided this treatment route. The conventional anterior approach to the vertebral body was also rendered impossible because of the obstruction of the primary neck tumor. Therefore, CyberKnife® radiosurgery (Accuray, Inc.) was employed as the primary treatment for the cervical and parapharyngeal lesions. Even after the radiosurgery, the pain and weakness in the upper limbs persisted. We concluded that it would take some time for the effect of radiosurgery to appear, as his severe neck pain was caused by the destruction of vertebrae. Consequently, a C3-6 laminectomy and C1-T1 fusion using pedicle screw fixation was also performed. The highly vascularized tumor on the C4 lamina was removed and sent to the pathology department. A histological examination (Figure 3) revealed a malignant paraganglioma. Immediately after the second operation, the patient displayed significant improvement in pain and upper-extremity weakness without any complications. As for the metastasis in the lumbar lesion, the patient had yet to show symptoms, a regular course of radiation was administered. Three months after the second operation, an MRI (Figure 4) confirmed that the tumor had shrunk, and the spinal cord compression had disappeared. The last follow-up (six months after the second operation) demonstrated complete recovery of the upper-extremity strength.

Bottom Line: Magnetic resonance imaging of the cervical spine revealed a metastasis at C4 with severe vertebral body destruction.The patient regained strength in all extremities in the postoperative field, and his pain was dramatically reduced.A magnetic resonance imaging study performed three months after the surgery showed a reduced tumor size and spinal cord decompression.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopedics, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 108-0075, Japan. inoorth@tmd.ac.jp.

ABSTRACT

Background: Paragangliomas of the head and neck are rare tumors. Moreover, malignant paragangliomas of the cervical spine are extremely rare. Currently, the combination of curative surgical resection and secondary adjuvant radiotherapy is the gold standard for treating symptomatic malignant paragangliomas. However, traditional treatments for malignant paraganglioma remain unsuccessful. The purpose of this study is to report an exceedingly rare case involving cervical metastasis of a malignant paraganglioma.

Case presentation: In this case report, we present a case involving a 72-year-old male with a history of paraganglioma of the neck. He had been experiencing bilateral shoulder pain, neck pain and weakness in the upper extremities for more than six months. Magnetic resonance imaging of the cervical spine revealed a metastasis at C4 with severe vertebral body destruction. To avoid serious complications associated with surgical resection, CyberKnife® radiosurgery (Accuray, Inc., Sunnyvale, CA, USA) was performed on the parapharyngeal and cervical lesions. A secondary surgery, which involved a posterior laminectomy at C3-6 and posterior fusion at C1-T1, was performed two weeks after the radiosurgery. A histological examination of the surgical specimen demonstrated a malignant paraganglioma. The patient regained strength in all extremities in the postoperative field, and his pain was dramatically reduced. A magnetic resonance imaging study performed three months after the surgery showed a reduced tumor size and spinal cord decompression.

Conclusion: This case study is the first report of a patient with symptomatic cervical metastasis of a malignant paraganglioma treated with a combination of radiosurgery and posterior spinal surgery. Although the optimal treatment for these conditions remains unclear, concomitant treatment with radiosurgery and reconstructive surgery appeared to be both safe and effective in this challenging case.

Show MeSH
Related in: MedlinePlus