Video-Assisted Thoracoscopic Removal of a Paraspinal Neuroblastoma Presenting as a Parotid Mass

Abstract

Introduction: Neuroblastoma is the most common extracranial cancer in childhood. Paravertebral neuroblastomas arise from the paravertebral sympathetic ganglia. The cancer metastasizes through both lymphatic and hematogenous routes to bone, skin, and liver. The video demonstrates an atypical presentation of a paraspinal neuroblastoma with surgical resection of the primary paraspinal lesion. Materials and Methods: The patient presented with increased swelling over the right mandible for 2 weeks despite antibiotic treatment for presumed parotitis. Preoperative computed tomography (CT) imaging of the mass revealed a lytic lesion. CT-guided fine needle aspiration revealed neuroblastoma. CT of head/chest/abdomen/pelvis was performed for staging that revealed a left paraspinal mass measuring 2.5 × 3.0 × 1.3 cm adjacent to T10–T11. A bone scan and metaiodobenzylguanidine (MIBG) scan showed metastatic disease consistent with Stage IV neuroblastoma. After four cycles of chemotherapy, the patient had a >50% reduction in the primary paraspinal lesion. Video-assisted thoracoscopic surgery (VATS) was performed. The mass and accompanying lymph node were excised without complication. Results and Conclusion: Final pathology demonstrated a 1.5 × 1.2 × 0.8 cm neuroblastic tumor with treatment effect with involvement of the margin. The accompanying lymph node was negative for tumor involvement. The patient underwent subsequent chemotherapy under the guidance of pediatric oncology. Repeat CT, bone scan, and MIBG scan at 1-year follow-up were negative for disease recurrence. Parotid metastases of neuroblastoma are rare with fewer than five case reports have been published in the past several decades.1 Common causes of parotid masses include salivary gland tumors and parotitis. Typically, metastatic disease in the parotid gland arises from nearby head and neck neoplasms. For a practicing clinician, it is important to keep in mind this rare entity when apparent parotitis does not respond to conventional antibiotic treatment. For Stage IV neuroblastoma, chemotherapy and immunomodulatory therapy are critical. Surgical resection is attempted with the goal of removal of the entire tumor and histologic staging; however, negative microscopic tumor margins are not necessary.2 Currently, open thoracotomy has been the standard procedure for thoracic disease in children, whereas VATS has remained controversial.3 However, recently, VATS for neurogenic tumors has shown to give good results with minimal postoperative complications. Major advantages include avoidance of open thoracotomy complications and enhanced surgical visualization.4 Several other advantages include decreased morbidity and duration of hospital stay. The case presented demonstrates an atypical presentation of paraspinal neuroblastoma with metastasis to the parotid gland. VATS procedure was used for removal of the primary paraspinal mass. This case shows that the VATS procedure is a safe and effective method of surgery for thoracic masses in children. No competing financial interests exist. Runtime of video: 5 mins 29 secs