Sequential occurrence of paraganglioma in abdomen, neck and head demonstrated by serial Ga68-DOTANOC PET-CT

Objectives: We here by demonstrate a rare case of mullticentric serial occurrence of paragangliomas with the help of Ga68 DOTANOC PET-CT Case report: A 44 year old male patient developed palpitation, elevated urinary metanephrine and diagnostic Contrast enhanced CT scan revealed a retroperitoneal mass(2x1.4cm) abutting the infra hepatic IVC. He under went surgical removal of the tumor in 2014 and histopathogy/IHC revealed it to be a paraganglioma. After one year, he had repeated headache, palpitation, for which he was evaluated again and Ga68 DOTANOC PET-CT was done, which revealed bilateral carotid body tumors(1x1cm each, SUVmax-13.8). Both the carotid body tumors were operated in 2015 and histopathogy turned out to be chemodectoma. Patient for asymptomatic for 3 years, again he developed palpitation and elevated urinary metanephrin/normetanephrine in 2018. He underwent repeated Ga68 DOTANOC PET-CT in May 2018, which revealed a soft tissue density mass lesion(1.8x2.3cm, SUVmax-51) in the left parapharyngeal space closely abutting & indenting the carotid artery and another small tracer(0.6x0.8cm, SUVmax-10.8) avid lesion in the left styloid mastoid foreman(likely to be associated with left facial nerve). Patient was not operated and was kept on antihypertensive medication and followed up. Ga68 DOTANOC PET-CT was again repeated in July 2019, which revealed similar status as before with no significant changes in the avidity, hence stable disease status was considered and subsequently monitored.

Conclusions: Paragaliomas have to be assessed for multi centricity and syndromic association in the initial assessment of the disease. Lesions are slow to grow but can ofter cause serious complication if not looked upon. This case is a rare example of sequential occurrence of paraganglioma from the retroperitoneum, then in the neck and finally in the head region. Ga68 DOTANOC PET-CT is a strong asset in evaluating the small lesion with high SSTR expression and plays a crucial role in disease monitoring.