AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Fahmy Abu Shawish, Department of Urology, Dr Suleiman al habib Hospital, Dubai, United Arab Emirates.
Citation: Fahmy A Shawish., Walid A Shawish. (2020) Urinary bladder Paraganglioma Unusual case with a rare presentation a plea for multidisciplinary approach. International Journal of Clinical Case Reports and Reviews. 2(1); DOI:10.31579/2690-4861/002
Copyright: © 2020 Fahmy Abu Shawish, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 16 November 2019 | Accepted: 30 January 2020 | Published: 03 February 2020
Keywords: paraganglioma; catecholamines; urinary bladder; metastasis, bladder tumor resection(turbt); partial and radical cystectomy
Para ganglia is a rare bladder tumor may occur in all of the age groups. It accounts for less than 0.06% of all of the bladder tumors. It is more common in females.Typically they are extra adrenal pheochromocytoma and arise from the ganglion (Chromaffin) cells of the bladder wall. Some of them are functioning and secrets chatecholamines, others are not. Some of them are malignant and can metastasis. However approximately 10% of them possess the capacity to invade despite their lack of mitosis and cellular dissociation which usually associated with malignant tumors. We present this case because its rarity, difficult preoperative diagnosis and the lack of related proper guidelines. Currently their treatment generally is not unified. Hence it is advisable to manage such cases with a multidisciplinary approach.
Chromaffin cells are neuroendocrine cells mediate the response of stress and release catecholamines regulating the circulation and respiration. Essentially they localized in the adrenal medulla and alongside the sympathetic chain [1].Tumors which arise from the adrenal medulla called pheochromcytoma. The similar extra adrenal tumor alongside the sympathetic chain called paraganglioma. The genitourinary system is rarely involved with such tumors. The urinary bladder is affected in the majority of the urinary system cases[2].Painless gross hematuria is the most common symptom. Other symptom includes persistent hypertension, headache, sweating, anxiety and micturition syncope [3,4]. Calcification within the tumor mimicking bladder calculi is another possible presentation [2]. A silent para ganglia is very unusual but quite dangerous as per-operative attention is not provided [5]. Commonly on CT scan it shows homogeneous or heterogeneous hyper enhancing soft tissue lesion. MRI in such cases reveal multiple areas of signal voids interspersed with hyper tense foci described as salt-pepper appearance[6].With high index of suspicion laboratory tests for catecholamines and its inactive metabolites in serum and urine as well as immunehistochemical studies particularly succinate dehydrogenase B, can help in establishing the preoperative diagnosis and hence saving the patient’s life[7]. Recent advances in genetics increases our understanding of genotype-phenotype correlations which is important for both pathological diagnosis and clinical management [8]. Trans urethral bladder tumor resection may not be sufficient particularly in a lesion extended deeply into muscularis propria and even it may recur. For that reason partial or radical cystectomy with pelvic node dissection can offer a better urological outcome [9]. In metastatic (malignant) cases aggressive therapies like radical cystectomy may be essential. Nevertheless still patient may require long life follow up. However prospective studies which could assess risk and optimize management of bladder para ganglioma do not exist, thus currently pathological staging dictates the treatment [8]. Herein we present a case of nonfunctioning bladder paragangalioma and describe the clinical presentation, surgical intervention, pathological reports and clinical outcomes. We also review the literature to provide more information and understanding of this unusual disease.
Case presentation
A 56 years old male patient retired athlete, not diabetic, not alcoholic and not smoker.The main symptom makes him to seek medical advice that he lost up to 10 Kg in the last year in spite of his regular life style. His wife noticed that he had nocturia (2-3T/N) and frequency of micturition which himself thought that is the normal of athlete consuming daily adequate fluids.To elicit the cause of his weight loss initially he had gastroscopy and colonscopy. Both were reported as normal. Subsequent whole body CT scan with contrast revealed a large (5.6cm) well circumscribed heterogeneous and enhancing bladder base lesion (Figure 1,2).
Figure 1
Figure 2
In addition a bilateral thyroid small nodules, 8mm nodule at the lateral limb of the right adrenal gland and a small pancreatic cyst were all reported (Figure 3,4,5).
Figure 3
Figure 4
Figure 5
Urine analysis was normal (No RBCs). Blood works including CBC,kidney profile,blood sugar and liver profile were all normal.Trans urethral resection was done with almost complete clearance of the lesion(Figure 6,7).
Figure 6
Figure 7
His blood pressure maintained on (110-130/70-90) during the surgery and even after. Post-operative follow up was uneventful. The pathologist concluded that the submitted tumor tissue which invaded the deep muscle was neither urothelial nor a prostatic carcinoma and confirmed that the morphological features although unusual are indicative of PT2 paraganglioma(Figure 8,9,10,11).
Figure 8
Figure 9
Figure 10
Figure 11
Two months later for taking a second opinion the patient visited a well-known universal oncology center where his 17 years old daughter used to be followed for pancreatic cancer treatment. Eventually he had another cystoscopy with a biopsy taken from the same site of the previously resected bladder lesion.The diagnosis of paraganglionoma pathologically was confirmed separately with this second biopsy. However the patient was recommended to have three monthly cystoscopy. A suggestion which he was not very welling to proceed with. In the other hand thyroid nodule aspirated with fine needle and the result revealed benign follicular nodule consistent with cystic degeneration (Figure 3).Subsequent yearly urinary bladder ultrasound for two successive years were reported as normal (Figure 12, 13).
Figure 12
Figure 13
Three years after the initial resection, real time ultrasound scan and contrast CT scan abdomen and pelvis revealed 1 cm intramural lesion encircling the lower portion of the right ureter, otherwise bladder was normal(Figure 14,15).
Figure 14
Figure 15
The right ureter and the right kidney both were normal. No regional recurrences and no local or distant lymph nodes metastasis were seen. Meanwhile Normetanephrine get raised (416ug/24hrs) and simultaneously Metanephrines, fraction, plasma free also get raised (99ug). Depending on these changes partial cystectomy with right ureter re implantation was strongly recommended. The patient was not very eager to proceed, at least, at this stage while he is still clinically free of any related symptom.
Dr Priti Joshi MD concluded: This tumor is neither a urothelial nor a prostatic carcinoma. The morphological features, although
Unusual are indicative of a paraganglioma (a type of neuroendocrine tumor). This is further supported by
Immunohistochemistry as the tumor cells shows diffuse and strong positive staining with neuroendocrine markers
–synaptophysin and chromogranin and S100 positive sustentacular cells are seen in the better preserved areas where the
tumour morphology is nested. The tumor stains negative with epithelial markers - AE1/AE3, CAM 5.2, CK 7, CK 20,
34BE12 and p63, thus excluding a carcinoma; negative for melanoma markers - HMB-45 and MelanA and negative for
Prostate carcinoma markers–PSA and PSAP. The large cells atypical cells described as having abundant eosinophilic
Cytoplasm stain positive with S100 in some areas and negative in others. In my opinion, these cells represent, both
Degenerative atypia and the S100 positive large cells are ganglion cells. As ganglion cells are also a component of the
tumour, the most appropriate designation for this entity is a composite paraganglioma.
Figure 16
Discussion
Bladder paraganglioma is a rare tumor, often originates in the bladder trigone and rarely in the anterior or lateral wall, which was exactly the same as in our presented case [9]. It should be taken in consideration that up to 50% of paraganglia are hereditary and can be associated with type 1 neurofibromatosis and familial paraganglia[10]. It can be metastatic, a nomination given recently by WHO to this type of the tumor previously was known as malignant paraganglioma[8,11]. However only when the primary tumor infiltrates locally into the non-nervous system or distant organs without embryo residual ganglia such as liver,lungs,spleen,brain ,bones and lymph nodes can the diagnosis of malignancy be made[12].Despite its potential lethality local invasion alone is a poor predictor of metastasis[8].The para ganglia tumor often metastasize late and their behavior is unpredictable.They have high recurrence rate regardless of the given treatment modal[4]. Nevertheless such tumor never be signed out as histologically benign. Equally they should not be signed out as malignant unless unequivocal documentation of distant metastasis with or without lymph node were confirmed [8]. Functional paraganglia are frequently malignant [13]. Transurethral resection of bladder tumor (TUR BT) might be an option in cases in which the tumor has not invaded the surrounding fat or in a periureteral orifice lesions [9,14]. In our presented case we have done TURBT on a mass unexpectedly detected preoperatively in a computer tomography (CT) with contrast scan. Subsequently the tumor was diagnosed pathologically as a nonfunctional paraganglioma. In our search in the English literature we found partial and even radical cystectomy frequently has been recommended. Radiotherapy attempted under special condition [15]. In one occasion the tumor initial resection was accomplished laparascopically[6,16]. Regardless the given treatment patient may require long term follow up, three monthly as suggested by V.Priyadarshi or annually as suggested by C.C.Tsai[5,17]. Obviously at present there is no definite guide lines to be considered in such cases.
Conclusion
Paraganglioma is a peculiar and rare endocrine bladder tumor presented with a different phenotype. Despite the accumulated pathological, radio logical and clinical knowledge about the tumor, its management is not optimized and the guidelines are not accomplished. At present mostly each case managed by its own merits. However when such cases are encountered we expect multidisciplinary approach may facilitate the treatment.
Acknowledgment
Said Al Shakh MD, Ahmad Albani MD,Ghaida Kaddaha MD, Wessam Bou-Assaly MD, Priti Joshi MD and Simon K Sfeir MD
For their input in diagnosis and management of the case.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
