Cardiovascular magnetic resonance and PET-CT of left atrial paraganglioma
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CASE REPORT
Open Access
Cardiovascular magnetic resonance and PET-CT of left atrial paraganglioma Anderanik Tomasian1, Chi Lai2, Stefan Ruehm1, Mayil S Krishnam1*
Abstract Cardiac paragangliomas are among the rarest primary cardiac tumors. We present a case of left atrial paraganglioma in a patient who presented with symptoms and signs of catecholamine excess in which cardiovascular magnetic resonance in multiple orientations and PET-CT played an important role in the diagnosis and tissue characterization. Introduction Pheochromocytomas or functioning paragangliomas are catecholamine-producing tumors arising from secretory chromograffin cells of neuroectodermal origin. These lesions commonly originate from the adrenal medulla. Approximately 18% of pheochromocytomas are extraadrenal [1].Primary cardiac paragangliomas are extremely rare with less than 50 cases reported in the literature [2]. Recent advances in cross sectional imaging have provided the potential for non-invasive and accurate diagnosis of these lesions [3-5]. In this report, we describe a left atrial paraganglioma, characterized in a multi-modality setting and confirmed on histopathology. Case report A 25-year-old female in her third trimester of pregnancy, presented with paroxysmal headache, palpitations, sweating, and hypertension of up to 230/130 for three weeks. Her medical history was negative for previous hypertension, and physical examination was unremarkable. Initial work-up for hypertension excluded pre-eclampsia. Further biochemistry evaluation revealed markedly elevated urine catecholamines; Dopamine 607 μg/24 hours (range 65 - 400), Norepinephrine 978 μg/24 hours (range 15 - 80), Metanephrine 108 μg/24 hours (range 24 - 96), Normetanephrine 4067 μg/24 hours (range 75 - 375), and Vanillyl mandelic acid 13.6 mg/24 hours (range 2 - 7). Epinephrine level was 0.8 μg/24 hours (range 0.0-20.0). A diagnosis of pheochromocytoma was considered and the patient underwent * Correspondence: [email protected] 1 Department of Radiological Sciences, University of California at Los Angeles, USA
abdominal magnetic resonance imaging (MRI) which demonstrated a 28 × 19 mm left juxta-adrenal mass. Treatment with phenoxybenzamine (10 mg, twice a day) was initiated. Six weeks following uneventful delivery by Cesarean Section, the patient underwent left laparoscopic adrenalectomy for suspected pheochromocytoma. Histopathology showed normal adrenal gland and brown fat in the juxta-adrenal mass. The patient’s symptoms continued, and with the suspicion of extra-adrenal pheochromocytoma, F18 Levo-DOPA positron emission tomographycomputed tomography or PET-CT scan of the whole body was performed to localize the lesion (Siemens Medical Solutions, Erlangen, Germany). The intravenous F18 LevoDOPA dose was 6.9 mCi, and the patient was pre-medicated with 200 mg of carbidopa 45 minutes before the scan to enhance the uptake of F18 Levo-DOPA. On PETCT, a large hyper-metabolic soft tissue mass measuring 4.5 × 2.7 × 3.9 cm in the region of posterior mediastinum near th
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