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Ultrastructure of malignant paraganglioma of organ of zuckerkandl
ULTRASTRUCTURE
OF MALIGNANT
PARAGANGLIOMA
OF ORGAN OF ZUCKERKANDL I. DAMJANOV, AH-ENG
M.D.
CHANG,
J. N. BLECHNER, J. FOSTER,
M.D. M.D.
M.D.
From the Departments of Pathology, Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut
and Surgery,
ABSTRACT - Electron microscopic study of a malignant paraganglioma of the organ of Zuckerkandl revealed similarities between the tumor and the normal paraganglia. The well-drfferentiated portion of the tumor recapitulated the structure of the basic functional units of the paraganglion. In addition there were signs of anaplasia both at the histologic and ultrastructural level. Large neurosecretory granules were noted in some of the tumor cells, but most of the cells were agranular. Cystaloids resembling those seen in alveolar soft part sarcoma were also noted. The study supports the theory on the common origin and histogenesis of paragangliomas and alveolar soft part sarcomas.
Tumors of the organ of Zuckerkandl are relatively rare and only about 50 cases have been reported.’ Most of those on record have been benign. Histologically, tumors of the organ of Zuckerkandl resemble paragangliomas in other functionally, biolocations, 2 or are both chemically, and structurally indistinguishable from adrenal pheochromocytomas.3 Our purpose is to describe the ultrastructure of a malignant paraganglioma originating from the organ of Zuckerkandl. In addition to being the first reported ultrastructural study of a malignant nonchromaffin abdominal paraganglioma, this article deals with some previously undescribed details, which may cast further light on the histogenesis of paragangliomas and their relationship to alveolar soft part sarcomas. Case Report A sixty-two-year-old white woman was hospitalized because of lower abdominal pain of six months’ duration, accompanied from time to time with diarrhea. On pelvic examination a tender, barely movable mass was palpated
414
above and behind the uterus. The existence of the mass was confirmed by ultrasound. There were no other notable physical findings, and the laboratory data were all within normal range except the elevated erythrocyte sedimentation rate of 77 per hour. At laparotomy a retroperitoneal mass measuring 8 by 6 by 5 cm. was found occupying the space between the broad ligament on the right side and the posterior abdominal wall, compressing the inferior vena cava and the bifurcation of the aorta. The tumor was firm, yellowish tan, and lobulated. It was adherent to the sigmoid colon and portion of the terminal ileum. Metastatic nodules were present on the serosa of the small intestine, mesenteric lymph nodes, and pelvic peritoneum. The main tumor mass was surgically removed together with the visible metastases, and the patient was discharged after an uneventful postoperative course. Material
and Methods
At the time of operation tissue was fixed for light microscopic examination in formalin and
UROLOGY
/ APRIL 1978 / VOLUME
XI, NUMBER 4
FIGURE 1. (A) Portion of paraganglioma fMnzing organoid nests; (B) trichromestained slide; (C) portion of paraganglioma composed of elongated cells. (Original magni$cations, X 220.)
,
also in cold 4 per cent glutaraldehyde, buffered to pH 7.2 with cacodylate buffer, for electron microscopy. The glutaraldehyde-fixed tissue was thereafter rinsed in cacodylate buffer (pH 7.2), postfixed in 1 per cent osmium tetroxide, dehydrated through graded alcohols, and embedded in epoxy resin. One-micron thick sections were cut with glass knives and stained with crystal violet to provide light microscopic orientation for subsequent electron microscopic examination of ultrathin sections obtained from the same block. Ultrathin sections from the selected blocks were stained with uranyl acetate and lead citrate, and examined with a Philips EM 300 electron microscope. Results On light microscopy the tumor was composed of areas exhibiting an organoid pattern and less differentiated portions consisting of bundles of elongated cells (Fig. 1). The cells had clear cytoplasms and round, bean-shaped or elongated nuclei. There was moderate nuclear atypia. Occasional mitotic figures and multinucleated cells were seen, especially in the portion of the tumor composed of compacted elongated cells. The organoid portion of the tumor was ultrastructurally composed of polygonal and elongated cells forming nests surrounded by loose connective tissue and capillaries (Fig. 2A). The polygonal cells were either light or dark with numerous transitional forms that displayed features of both the light and dark cells. The polygonal cells were in the center of the cell nests and were flanked on the periphery by spindle-shaped cells. The arrangement of the polygonal and spindle-shaped cells was reminiscent of the basic structural units
UROLOGY
/ APRIL1978 / VOLUMEXI,
NUMBER4
of the normal paraganglia and was not dissimilar from the ultrastructure of “Zellballen” in other paragangliomas. 2*4 These cells corresponded basically to type I and II, or chief and sustentacular cells of the normal paraganglion.2 In addition to these well-structured areas the tumor contained portions composed of only polygonal cells (Fig. 2B) or polygonal cells intermixed irregularly with occasional spindleshaped cells. The histologically more solid and “undifferentiated” portions of the tumor were composed of cells reminiscent of the polygonal chief cells. These cells had in general large elongated nuclei, matched with a similarly elongated cytoplasm (Fig. 2C). In contrast to the relative abundance of cytoplasmic organelles in the polygonal cells, the cytoplasm of the latter cells was relatively sparsely populated with mitochondria, endoplasmic reticulum, and granules. Tight junctions were seldom seen between these large cells, in contrast to chief cells within the organoid nests, which were often interconnected one with another. The polygonal cells did occasionally contain large round osmiophilic granules surrounded by a limiting membrane. Although they varied in size, most of them were 100 to 120 nm. in diameter (Fig. 3A). Occasionally similar granules were seen in the spindle-shaped sustentacular cells. Other noteworthy cytoplasmic structures seen both in the chief polygonal and the large elongated tumor cells were the crystaloids located in the perinuclear cytoplasm (Fig. 2B and C). They were oval shaped or rhomboid and consisted of parallel arrays of regularly layered filaments without any cross striation or periodicity (Fig. 3B). The smaller crystaloids were membrane bound and the larger ones were not.
415
FIGURE 2. (A) Organoid, Zellballen-like group of cells; note polygonal, chief cells surrounded in part by elongated sustentacular cells. (B) Group of dark and light polygonal cells; centrally located light cell contains crystaloid (arrow). (C) Large elongated cells not interconnected with tight junctions; long trinucleated cell contains cytoplasmic crystaloids (arrow). (Original magni$cation (A and C) x 7,000; (B) x 6,200.)
Comment Organ of Zuckerkandl and the periaortic paraganglia are relatively rare sites of origin of malignant tumors. It was therefore of interest to study the ultrastructure of the present malignant paraganglioma and compare it with the appearance of normal paraganglia and prebenign paragangliomas from v&usly described the same or other locations.
FIGURE
3.
The only other previous tumor of the organ of Zuckerkandl studied ultrastructurally was the case reported by Cornog et aZe3 In contrast to our case, that one was a chromaffin pheochromocytoma, that caused profound functional disturbances despite its relatively small size and benign clinical behavior. Ultrastructurally the two lesions differed one from another as well. The present case was composed in its welldifferentiated portion of Zellballen that resembled remarkably the functional basic units of normal paraganglia’ while the pheochromocythe toma of Cornog et al. 3 did not recapitulate paraganglionic structures. The functional activity of the pheochromocytoma was reflected in the abundance of secretory, neuroendocrine granules in the tumor cell cytoplasm. The
(A)
chief cell; note relatively large size of granules. (B) Cytoplasmic crystaloids formed of parallel lamellae without periodicity or cross striation. (Original magni$cation {A) x 11,200; (B) x 32,000.)
416
UROLOGY
/ APRIL 1978 / VOLUMEXI.
NUMBER4
number of granules and the number of granular cells in the present tumor were relatively modest. In addition these granules were large in comparison with the typical epinephrine and norepinephrine containing granules of pheoresponsible for the chromaffin chromocytoma, reaction. The negative chromaffin reaction in the present tumor could be accounted for by the scarcity of the granules, but could also reflect the fact that these granules are morphologically and possibly biochemically different from those seen in pheochromocytomas. Unfortunately the present tumor was not analyzed biochemically, and we do not know whether or not it contained biogenic amines. The organoid portion of the present tumor resembled ultrastructurally the carotid body tumors.2,4 The less differentiated part had, however, a sarcomatous appearance and was composed of densely packed cells without interlying stroma. Ultrastructurally the cells forming this part had fewer cytoplasmic organelles than the cells forming the Zellballen and were rarely interconnected with intercellular junctions. This was interpreted as being a sign of dedifferentiation or anaplasia related to the malignancy of the neoplasm. In the polygonal chief cells, as well as in the dedifferentiated elongated cells there were crystaloids of a peculiar structure. Similar structures, although admittedly much more numerous and larger, were previously described in alveolar soft part sarcomas5-’ Crystaloids of this type were not previously reported in The finding of crystaloids, paragangliomas. considered to be nathoenomonic of alveolar
UROLOGY
/
APRIL
1978
/
VOLUME
Xl, NUMBER
4
soft part sarcoma, in a malignant paraganglioma could be explained on the basis of common origin of both neoplasms. Indeed it has been postulated on the basis of both light microscopic* and electron microscopic studie@,’ that alveolar soft part sarcomas are closely related to nonchromaf6n paragangliomas. The basic architectural similarity of the two tumors, coupled with the presence of cytoplasmic granules and crystaloids, as seen in this study, lends further support to this contention. Hahnemann Medical College and Hospital of Philadelphia 230 North Broad Street Philadelphia, Pennsylvania 19102 (DR. DAM JANOV) ACKNOWLEDGMENT. Eastwood for technical
To Mrs. assistance.
Pat Bruinsma
and
Cathy
References 1. Glenn F, and Gray GF: Functional tumors of the organ of Zuckerkandl, Ann. Surg. 183: 578 (1976). 2. Glenner GG, and Grimley PM: Tumors of the extra-adrenal paraganglion system (including chemoreceptors). Washington, D.C., Armed Forces Institute of Pathology, 1974, p. 10. 3. Comog JL, et al.: Extra-adrenal pheochromocytoma. Some electron microscopic and biochemical studies, Am. J. Med. 48: 654 (1970). 4. Alpert LI, and Bochetto JF, Jr: Carotid body tumor: ultrastructural observations, Cancer 34: 564 (1974). 5. Shipkey FH, Lieberman PH, Foote FW, Jr, and Stewart FW: Ultrastructure of alveolar soft Dart sarcoma. ibid. 17: 821 (1964). 6. Welsh RA, Bray DM, III, Shipkey FH, Meyer, AT: Histoeenesis of alveolar soft Dart sarcoma. ibid. 29: 191 (1972). 7. finni KK, and Soule EH: Alveolar soft part sarcoma: An electron microscopic study, Mayo Clin. Proc. 59: 591 (1975). 8. Smetana HF, and Scott WF, Jr: Malignant tumors of nonchromai%n paraganglia, Milit. Surg. 109: 330 (1951).
417
OF MALIGNANT
PARAGANGLIOMA
OF ORGAN OF ZUCKERKANDL I. DAMJANOV, AH-ENG
M.D.
CHANG,
J. N. BLECHNER, J. FOSTER,
M.D. M.D.
M.D.
From the Departments of Pathology, Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut
and Surgery,
ABSTRACT - Electron microscopic study of a malignant paraganglioma of the organ of Zuckerkandl revealed similarities between the tumor and the normal paraganglia. The well-drfferentiated portion of the tumor recapitulated the structure of the basic functional units of the paraganglion. In addition there were signs of anaplasia both at the histologic and ultrastructural level. Large neurosecretory granules were noted in some of the tumor cells, but most of the cells were agranular. Cystaloids resembling those seen in alveolar soft part sarcoma were also noted. The study supports the theory on the common origin and histogenesis of paragangliomas and alveolar soft part sarcomas.
Tumors of the organ of Zuckerkandl are relatively rare and only about 50 cases have been reported.’ Most of those on record have been benign. Histologically, tumors of the organ of Zuckerkandl resemble paragangliomas in other functionally, biolocations, 2 or are both chemically, and structurally indistinguishable from adrenal pheochromocytomas.3 Our purpose is to describe the ultrastructure of a malignant paraganglioma originating from the organ of Zuckerkandl. In addition to being the first reported ultrastructural study of a malignant nonchromaffin abdominal paraganglioma, this article deals with some previously undescribed details, which may cast further light on the histogenesis of paragangliomas and their relationship to alveolar soft part sarcomas. Case Report A sixty-two-year-old white woman was hospitalized because of lower abdominal pain of six months’ duration, accompanied from time to time with diarrhea. On pelvic examination a tender, barely movable mass was palpated
414
above and behind the uterus. The existence of the mass was confirmed by ultrasound. There were no other notable physical findings, and the laboratory data were all within normal range except the elevated erythrocyte sedimentation rate of 77 per hour. At laparotomy a retroperitoneal mass measuring 8 by 6 by 5 cm. was found occupying the space between the broad ligament on the right side and the posterior abdominal wall, compressing the inferior vena cava and the bifurcation of the aorta. The tumor was firm, yellowish tan, and lobulated. It was adherent to the sigmoid colon and portion of the terminal ileum. Metastatic nodules were present on the serosa of the small intestine, mesenteric lymph nodes, and pelvic peritoneum. The main tumor mass was surgically removed together with the visible metastases, and the patient was discharged after an uneventful postoperative course. Material
and Methods
At the time of operation tissue was fixed for light microscopic examination in formalin and
UROLOGY
/ APRIL 1978 / VOLUME
XI, NUMBER 4
FIGURE 1. (A) Portion of paraganglioma fMnzing organoid nests; (B) trichromestained slide; (C) portion of paraganglioma composed of elongated cells. (Original magni$cations, X 220.)
,
also in cold 4 per cent glutaraldehyde, buffered to pH 7.2 with cacodylate buffer, for electron microscopy. The glutaraldehyde-fixed tissue was thereafter rinsed in cacodylate buffer (pH 7.2), postfixed in 1 per cent osmium tetroxide, dehydrated through graded alcohols, and embedded in epoxy resin. One-micron thick sections were cut with glass knives and stained with crystal violet to provide light microscopic orientation for subsequent electron microscopic examination of ultrathin sections obtained from the same block. Ultrathin sections from the selected blocks were stained with uranyl acetate and lead citrate, and examined with a Philips EM 300 electron microscope. Results On light microscopy the tumor was composed of areas exhibiting an organoid pattern and less differentiated portions consisting of bundles of elongated cells (Fig. 1). The cells had clear cytoplasms and round, bean-shaped or elongated nuclei. There was moderate nuclear atypia. Occasional mitotic figures and multinucleated cells were seen, especially in the portion of the tumor composed of compacted elongated cells. The organoid portion of the tumor was ultrastructurally composed of polygonal and elongated cells forming nests surrounded by loose connective tissue and capillaries (Fig. 2A). The polygonal cells were either light or dark with numerous transitional forms that displayed features of both the light and dark cells. The polygonal cells were in the center of the cell nests and were flanked on the periphery by spindle-shaped cells. The arrangement of the polygonal and spindle-shaped cells was reminiscent of the basic structural units
UROLOGY
/ APRIL1978 / VOLUMEXI,
NUMBER4
of the normal paraganglia and was not dissimilar from the ultrastructure of “Zellballen” in other paragangliomas. 2*4 These cells corresponded basically to type I and II, or chief and sustentacular cells of the normal paraganglion.2 In addition to these well-structured areas the tumor contained portions composed of only polygonal cells (Fig. 2B) or polygonal cells intermixed irregularly with occasional spindleshaped cells. The histologically more solid and “undifferentiated” portions of the tumor were composed of cells reminiscent of the polygonal chief cells. These cells had in general large elongated nuclei, matched with a similarly elongated cytoplasm (Fig. 2C). In contrast to the relative abundance of cytoplasmic organelles in the polygonal cells, the cytoplasm of the latter cells was relatively sparsely populated with mitochondria, endoplasmic reticulum, and granules. Tight junctions were seldom seen between these large cells, in contrast to chief cells within the organoid nests, which were often interconnected one with another. The polygonal cells did occasionally contain large round osmiophilic granules surrounded by a limiting membrane. Although they varied in size, most of them were 100 to 120 nm. in diameter (Fig. 3A). Occasionally similar granules were seen in the spindle-shaped sustentacular cells. Other noteworthy cytoplasmic structures seen both in the chief polygonal and the large elongated tumor cells were the crystaloids located in the perinuclear cytoplasm (Fig. 2B and C). They were oval shaped or rhomboid and consisted of parallel arrays of regularly layered filaments without any cross striation or periodicity (Fig. 3B). The smaller crystaloids were membrane bound and the larger ones were not.
415
FIGURE 2. (A) Organoid, Zellballen-like group of cells; note polygonal, chief cells surrounded in part by elongated sustentacular cells. (B) Group of dark and light polygonal cells; centrally located light cell contains crystaloid (arrow). (C) Large elongated cells not interconnected with tight junctions; long trinucleated cell contains cytoplasmic crystaloids (arrow). (Original magni$cation (A and C) x 7,000; (B) x 6,200.)
Comment Organ of Zuckerkandl and the periaortic paraganglia are relatively rare sites of origin of malignant tumors. It was therefore of interest to study the ultrastructure of the present malignant paraganglioma and compare it with the appearance of normal paraganglia and prebenign paragangliomas from v&usly described the same or other locations.
FIGURE
3.
The only other previous tumor of the organ of Zuckerkandl studied ultrastructurally was the case reported by Cornog et aZe3 In contrast to our case, that one was a chromaffin pheochromocytoma, that caused profound functional disturbances despite its relatively small size and benign clinical behavior. Ultrastructurally the two lesions differed one from another as well. The present case was composed in its welldifferentiated portion of Zellballen that resembled remarkably the functional basic units of normal paraganglia’ while the pheochromocythe toma of Cornog et al. 3 did not recapitulate paraganglionic structures. The functional activity of the pheochromocytoma was reflected in the abundance of secretory, neuroendocrine granules in the tumor cell cytoplasm. The
(A)
chief cell; note relatively large size of granules. (B) Cytoplasmic crystaloids formed of parallel lamellae without periodicity or cross striation. (Original magni$cation {A) x 11,200; (B) x 32,000.)
416
UROLOGY
/ APRIL 1978 / VOLUMEXI.
NUMBER4
number of granules and the number of granular cells in the present tumor were relatively modest. In addition these granules were large in comparison with the typical epinephrine and norepinephrine containing granules of pheoresponsible for the chromaffin chromocytoma, reaction. The negative chromaffin reaction in the present tumor could be accounted for by the scarcity of the granules, but could also reflect the fact that these granules are morphologically and possibly biochemically different from those seen in pheochromocytomas. Unfortunately the present tumor was not analyzed biochemically, and we do not know whether or not it contained biogenic amines. The organoid portion of the present tumor resembled ultrastructurally the carotid body tumors.2,4 The less differentiated part had, however, a sarcomatous appearance and was composed of densely packed cells without interlying stroma. Ultrastructurally the cells forming this part had fewer cytoplasmic organelles than the cells forming the Zellballen and were rarely interconnected with intercellular junctions. This was interpreted as being a sign of dedifferentiation or anaplasia related to the malignancy of the neoplasm. In the polygonal chief cells, as well as in the dedifferentiated elongated cells there were crystaloids of a peculiar structure. Similar structures, although admittedly much more numerous and larger, were previously described in alveolar soft part sarcomas5-’ Crystaloids of this type were not previously reported in The finding of crystaloids, paragangliomas. considered to be nathoenomonic of alveolar
UROLOGY
/
APRIL
1978
/
VOLUME
Xl, NUMBER
4
soft part sarcoma, in a malignant paraganglioma could be explained on the basis of common origin of both neoplasms. Indeed it has been postulated on the basis of both light microscopic* and electron microscopic studie@,’ that alveolar soft part sarcomas are closely related to nonchromaf6n paragangliomas. The basic architectural similarity of the two tumors, coupled with the presence of cytoplasmic granules and crystaloids, as seen in this study, lends further support to this contention. Hahnemann Medical College and Hospital of Philadelphia 230 North Broad Street Philadelphia, Pennsylvania 19102 (DR. DAM JANOV) ACKNOWLEDGMENT. Eastwood for technical
To Mrs. assistance.
Pat Bruinsma
and
Cathy
References 1. Glenn F, and Gray GF: Functional tumors of the organ of Zuckerkandl, Ann. Surg. 183: 578 (1976). 2. Glenner GG, and Grimley PM: Tumors of the extra-adrenal paraganglion system (including chemoreceptors). Washington, D.C., Armed Forces Institute of Pathology, 1974, p. 10. 3. Comog JL, et al.: Extra-adrenal pheochromocytoma. Some electron microscopic and biochemical studies, Am. J. Med. 48: 654 (1970). 4. Alpert LI, and Bochetto JF, Jr: Carotid body tumor: ultrastructural observations, Cancer 34: 564 (1974). 5. Shipkey FH, Lieberman PH, Foote FW, Jr, and Stewart FW: Ultrastructure of alveolar soft Dart sarcoma. ibid. 17: 821 (1964). 6. Welsh RA, Bray DM, III, Shipkey FH, Meyer, AT: Histoeenesis of alveolar soft Dart sarcoma. ibid. 29: 191 (1972). 7. finni KK, and Soule EH: Alveolar soft part sarcoma: An electron microscopic study, Mayo Clin. Proc. 59: 591 (1975). 8. Smetana HF, and Scott WF, Jr: Malignant tumors of nonchromai%n paraganglia, Milit. Surg. 109: 330 (1951).
417