Neural crest cells give rise to the parenchymal cells of the paraganglia and other elements of the autonomic nervous system. These neural crest cells have the ability to migrate to various regions along the paravertebral and para-aortic axis, while remaining in close relation to the sympathetic nervous system. They extend to various places, anywhere from the neck to the base of the pelvis [
4]. In rare occasions, paragangliomas have been identified in areas where chromaffin tissue has not yet been characterized, such as the genitourinary tract, spermatic cord, sacro-coccygeal area, anus, renal capsule, broad ligament, ovary and vaginal wall and can only be explained by the migratory property of the neural crest cells [
5]. It has been hypothesized that tumors such as the one presented in this case report derive from the mesenteric paraganglionic tissue, which arises from vertebral migration from the root of the superior mesenteric artery [
4].
Diagnosing paragangliomas, and in particular those of the mesentery, can be achieved via biochemistry and/or imagery. Given the capacity of a paraganglioma to secrete catecholamines, plasma or urinary metanephrines have been described in the literature as a very sensitive technique. Unfortunately the secreting property is only found in 25% of mesenteric paragangliomas [
1]. Anatomical imagery with US/CT/MRI are equally as effective in identifying these abdominal masses. In addition, specific functional imaging with metaiodo-benzylguanidine scintigraphy or PET imaging with 6 [
18F] fluoro-DOPA help identify and characterize the extent of the mass as well as the staging [
6]. These techniques are then followed up with seemingly essential laparoscopic exploration and biopsy [
7]. Finally, tumor resection is the form of treatment that has achieved the best results. Throughout all the cases described in the literature, none described any recurrence post-excision of the mass, but median follow-up was relatively short [Table
1]. Chemotherapy and radiotherapy have not demonstrated convincing results for patients with unresectable or metastatic disease. Its involvement remains palliative, as there is no current evidence of increased survival using these modalities [
6]. Treatment with radiolabelled MIBG is gaining popularity given its avidity for the chromaffin cell tumors and in particular their metastases [
8]. The literature stipulates that while
131I-MIBG is not a curative therapy, its involvement as an adjuvant to surgical resection as well as the possibility of a synergistic effect with chemotherapy seem promising and are venues to be explored in the near future [
9]. Radioactive somatostatin analogues is yet another radiopharmaceutical to be considered [
6]. Focus has now shifted to specific molecular targets involved in the malignant transformation of chromaffin cell tumors, and its development has shown signs of promise, yet development in these areas is still necessary [
10].
With the exception of a single case documenting liver metastases, and to the best of our knowledge, this is the first case documenting regional lymph node metastases. As a result, this case can further be classified as one of malignant paraganglioma. This comes to no surprise given malignant chromaffin cell tumor have been documented to metastasize to local lymph nodes, bone liver and lung [
6].