Gastrointestinal bleeding from gangliocytic paraganglioma treated with palliative radiotherapy: a case report

Abstract

: Gangliocytic paraganglioma (GP) is a rare neuroendocrine tumor typically found in the second part of the duodenum. The rarity of this tumor has not allowed development of treatment guidelines. The mainstay of treatment involves endoscopic or surgical resection. Adjuvant chemotherapy or radiation have been utilized in a few cases. Gastrointestinal bleeding from GP treated with radiotherapy has not been described in the literature. The case described is of a patient presenting with a 6-month history of hematochezia and a one week history of fatigue. An esophagogastroduodenoscopy (EGD) was performed demonstrating a 3-cm periampullary, non-obstructing mass with areas of ulceration and oozing. Pathology from biopsy samples showed trabeculae and cords of epithelioid cells bordered by S-100 positive spindled cells consistent with paraganglioma as well as scattered “large cells” without typical ganglion cell morphology. GP was favored versus other neuroendocrine carcinomas given its classic location in the second part of duodenum, presentation with bleeding, and the morphological pattern of paraganglioma. This patient was a poor surgical candidate and at high risk of perioperative mortality due to multiple chronic comorbidities and poor functional capacity. It was decided to administer fourteen courses of 35 Gray (Gy) palliative radiotherapy to control the patient’s gastrointestinal (GI) bleeding. Surveillance EGD was performed after his tenth treatment which showed no further areas of oozing along the mass. From his first to his last radiotherapy session, his hemoglobin improved from 7.5 to 8.9 g/dL without further episodes of hematochezia. One week after his discharge, the patient died from cardiac arrest. Radiotherapy may be useful in controlling GI bleed secondary to GP in a palliative setting.