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Paraganglioma in the bladder: a case report
© The Author(s). 2017
Received: 20 July 2017
Accepted: 24 September 2017
Published: 31 October 2017
Paraganglioma is an extra site of pheochromocytoma. Paraganglioma in the bladder is a very rare disease accounting for 0.06% of all bladder tumors.
A 77-year-old Japanese man was referred to our department for the further examination of a bladder tumor detected on preoperative computed tomography of his gastric cancer. Cystoscopy revealed a submucosal tumor in the upper area of his bladder, so transurethral resection of the bladder tumor was performed. During transurethral resection of the bladder tumor, his blood pressure sharply increased, and a pathological examination showed paraganglioma in his bladder. Postoperative I-123-metaiodobenzylguanidine scintigraphy detected a higher intake of his bladder tumor. Laboratory examinations showed a slightly increased noradrenaline level of 530 pg/ml and reduced platelet count at 167,000/μL. Based on the progression of his gastric cancer, no additional therapy was performed on his bladder tumor. Eight months after surgery, he died from aspiration pneumonitis.
Here we report a rare case of paraganglioma in the bladder. We discuss paraganglioma based on previous studies.
Paraganglioma is an extra site of pheochromocytoma from the adrenal gland. Paraganglioma is reported to account for 18% of pheochromocytomas, and 10% of cases occur in the bladder. Paraganglioma in the bladder is a very rare disease and accounts for 0.06% of all bladder tumors [1–4].
We performed transurethral resection of bladder tumor (TUR-Bt) on a mass unexpectedly detected on preoperative computed tomography (CT) of a patient’s gastric cancer, and his arterial blood pressure was abnormally elevated during the procedure. Postoperatively, the tumor was diagnosed as paraganglioma. Here we report a rare case of paraganglioma in the bladder.
Based on these findings, TUR-Bt was performed for his bladder tumor. His usual blood pressure was around 120/80 mmHg with olmesartan medoxomil/azelnidipine intake. At the time of starting transurethral resection (TUR), his blood pressure was elevated as 240 mmHg in his systolic blood pressure. In the procedure of TUR, no active bleeding was observed.
Das et al. reported that the symptoms of paraganglioma in the bladder were macroscopic hematuria, hypertension, and hypertension seizure at urination . Yamamoto et al. examined 234 Japanese cases and found that 41.3% had macroscopic hematuria, 33.2% hypertension, and 23.0% hypertension seizure at urination. Only 1.4% showed all three symptoms, and 10.6% showed none of these symptoms . The present case showed only hypertension.
MRI and MIBG scintigraphy have been reported useful for a diagnosis. In a previous report, MRI T1-WI showed low intensity, while T2-WI showed high intensity, but not all cases show this pattern . In fact, the present case showed low intensity on both T1-WI and T2-WI.
Regarding laboratory findings, 88% of cases of paraganglioma show elevated levels of urine metanephrine and serum catecholamine [8, 9]. In bladder paraganglioma, more than 60% of cases show elevated levels of urine vanillylmandelic acid or serum catecholamine. Despite these high rates of elevation, a differential diagnosis is sometimes difficult because some cases do not show such elevation . In fact, in the present case, catecholamine was not elevated. As such, the preoperative diagnosis is thought to be difficult in cases of bladder paraganglioma. In a previous study, 28.9% of cases of bladder paraganglioma were diagnosed before surgery, and 61.6% were initially suspected to be bladder tumor or intramucosal bladder tumor . In the present case, the extremely elevated blood pressure during resection and the pathological findings helped us to arrive at the final diagnosis of bladder paraganglioma.
Paraganglioma in the bladder can be benign or malignant, but its histopathological diagnosis is difficult. The diagnosis of benign or malignant status depends on the degree of invasion, lymph node metastasis, and distant metastasis. Our patient had T1b(SM)N0M0 gastric cancer and no previous study showed a correlation between gastric cancer and paraganglioma. Partial cystectomy has been recommended, but TUR-Bt might be an option in cases in which the tumor has not invaded the surrounding fat [10, 11].
We describe the case of a patient whose blood pressure became extremely elevated during TUR-Bt, and a pathological examination showed paraganglioma of the bladder. Here we report a rare case of paraganglioma in the bladder.
Grants from KAKENHI grants (16K20152) from the Ministry of Education, Culture, Sports, Science and Technology of Japan and grant for 2016–2017 Research Development Fund (Nos. WJ2810) of Yokohama City University.
Availability of data and materials
Due to ethical restrictions, the raw data underlying this paper are available from the corresponding author upon request.
Conceived and designed the experiments: GI, TK, MT, and YH. Analyzed the data: GI, TK, and MT. Performed the experiments: MT, SN, DT, TM, SK, TT, KI, YH, JT, YY, YM, and HU. Wrote the paper: GI, TK, and MT. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The present study was approved by the Institutional Review Board (IRB) of Yokohama City University Medical Center.
Consent for publication
Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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