Robotic approach to a subcarinal functional paraganglioma

Abstract

Intro: Functional mediastinal paragangliomas arise from extra-adrenal tissues and are rare. These cases create challenges related to diagnosis, peri-operative management, and surgical management. We present a case that demonstrates a planned robot-assisted thoracoscopic resection of a mediastinal paraganglioma that ultimately required a trans-sternal resection of the tumor off the left atrium.

Case report: Our patient is a 42-year-old male with a prolonged history of refractory hypertension, palpitations, headaches, and diaphoresis, which led to the discovery of a subcarinal functional mediastinal paraganglioma. The patient was brought to the operating room for a right robotic-assisted thoracoscopic subcarinal dissection with attempted resection of the mass. Subsequently, the patient's paraganglioma was successfully resected off the left atrium using a trans-sternal approach, cardiopulmonary bypass, and cardioplegic arrest. He was successfully transitioned to minimal anti-hypertensive medication post-operatively.

Discussion: Pheochromocytomas are neural-crest derived tumors that typically arise from the adrenal medulla. Rarely, paragangliomas arise in the thoracic cavity, at an approximate incidence of 2%. Our sequential approach offered the potential for a minimally invasive resection, and though initially unsuccessful, safely elucidated the feasibility of resection using cardiopulmonary bypass after confirming no invasion of the airway, esophagus, or other mediastinal structures.

Fig. 1

10-18-18 MIBG/CT combined scan demonstrating the subcarinal paraganglioma.

Fig. 2

10/12/18 preoperative CT with contrast.

Fig. 3

1/9/19 Intraoperative Trans-Esophageal Echocardiography (TEE): (long axis, showing pulmonary vein compressed by mass and mitral valve in near vicinity).

Fig. 4

Intraoperative TEE cont'd: now showing the aortic valve (and right coronary) with mass abutting the area immediately adjacent.