An Uncommon Cause of Vague Abdominal Pain and Nausea.

Abstract

A 78-year-old woman with history of papillary thyroid cancer presented with 1-year history of abdominal pain and unintentional weight loss. A 3.3 × 2.9 cm mass was found on abdominal computed tomography (Figure A) and was metabolically active on positron emission tomography scan. On endoscopic ultrasound, it was well defined, hyperechoic, and solid (Figure B). During fine-needle biopsy (FNB), the patient became transiently hypertensive. Histologic sections demonstrated eosinophilic epithelioid cells arranged in a distinct “Zellballen” nested architecture consistent with a paraganglioma (Figure C). The patient was started on an α-receptor blocker, followed by surgical resection, confirming paraganglioma (Figure D). Paragangliomas are rare neuroendocrine tumors that arise from the extra-adrenal autonomic paraganglia. Most are benign, but 15%–35% are malignant. A presumptive diagnosis can be made using biochemical and radiographic testing, but a definitive diagnosis requires histopathology. Incisional biopsy or FNB is contraindicated if a paraganglioma is suspected unless biochemical screening is negative or the patient is prepared with α-adrenergic blockade; otherwise, a catecholamine crisis can occur. Undiagnosed catecholamine hypersecretion in asymptomatic patients is not uncommon. In our case, imaging was suggestive of a lymphoma or metastatic disease; thus, we proceeded with FNB, with immediate hypertension raising suspicion for a paraganglioma.