Page 89 - Fluorescence-guided cancer surgery

INTRODUCTION
Paragangliomas are rare tumors arising from extra-adrenal chroma n cells within the sympathetic nervous system1-3. They can be found anywhere from the neck to the pelvis in the vicinity of sympathetic ganglions, and belong to the family of neuroendocrine tumors. An incidence rate of 2-8 cases per million is reported, and tumors can be either functional or non-functional. When functional there can be production of catecholamine, epinephrine, or norepinephrine.
The only curative treatment of paraganglioma is complete surgical resection. To help localize all sites of disease, preoperative identi cation can be performed using di erent anatomical and functional imaging modalities4. However, no speci c imaging modalities are available for the intraoperative identi cation of these tumors.
Near-infrared (NIR) uorescence imaging is a promising technique to assist in the intraoperative identi cation of sentinel lymph nodes, tumors, and vital structures5. Advantages of this optical imaging technique include real-time imaging, high sensitivity, and high resolution, with penetration depths several millimeters into tissue.
Methylene Blue (MB) is a clinically available tracer, which can be used at low dosage as a uorescent tracer during NIR uorescence imaging. Winer et al.6 described the successful identi cation of insulinomas, a pancreatic neuroendocrine tumor in transgenic mice, and clinically, the intraoperative identi cation of parathyroid adenomas was described7.
Based on these results, we explored the possibility to identify paragangliomas during surgery, using NIR uorescence imaging and MB.
PRESENTATION OF CASE
A 19-year-old female patient presented with complaints of fainting, nausea, vomiting, headaches, excessive sweating, ushing attacks, hand tremors, and heart palpitations. She had a negative family history for endocrine diseases or paragangliomas. While volunteering to donate blood, her systolic blood pressure was found to be 180 mm Hg. After referral, physical examination revealed a blood pressure of 180/110 mm Hg on the left arm, 190/115 mm Hg
Imaging of a paraganglioma 87