Synchronous carotid body and anterior mediastinal paraganglioma revealed by 18F-fluorodeoxyglucose and 68Ga-DOTA(0)-Tyr(3)-octreotate positron emission tomography-computed tomography
Letter to the Editor

Synchronous carotid body and anterior mediastinal paraganglioma revealed by 18F-fluorodeoxyglucose and 68Ga-DOTA(0)-Tyr(3)-octreotate positron emission tomography-computed tomography

Hangyu Xie#, Hua Lin#, Lin Li*, Wenjie Zhang*

Department of Nuclear Medicine, West China Hospital of Sichuan University, Chengdu, China

#These authors contributed equally to this work and should be considered as co-first authors.

*These authors contributed equally to this work and should be considered as co-corresponding authors.

Correspondence to: Lin Li, MD; Wenjie Zhang, MD. Department of Nuclear Medicine, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, China. Email:;

Submitted Sep 23, 2022. Accepted for publication Mar 15, 2023. Published online Apr 04, 2023.

doi: 10.21037/qims-22-1018


Paragangliomas (PGLs) are rare nonepithelial neuroendocrine neoplasms (NENs) (1,2). Synchronous PGLs in the neck and anterior mediastinum are highly rare. The present study describes how a synchronous carotid body and anterior mediastinal PGL was revealed with 18F-fluorodeoxyglucose (18F-FDG) and 68Ga-DOTA(0)-Tyr(3)-octreotate (68Ga-DOTATATE) positron emission tomography-computed tomography (PET-CT), which included using 2 types of quantitative imaging tracers. Different degrees of tracer accumulation were observed in 2 synchronous PGLs. Surgical resection of both lesions was performed. Histopathologic examination and immunohistochemistry of the neck and thoracic lesions confirmed the diagnosis of 2 primary synchronous PGLs.

Case presentation

A 41-year-old man had a mass on the right side of the neck for 5 years. He reported a month of gradual expansion of the mass. There was a palpable, movable, tender mass with a diameter of approximately 4 cm. Deep pressure caused the patient to cough. The patient’s 24-hour urinary dopamine level was 438.12 µg/24 hours (65–400 µg/24 hours), his homovanillic acid level was 13.64 µg/24 hours (0–8 µg/24 hours), and his vanillic acid level was 10.38 µg/24 hours (0–8 µg/24 hours). The patient’s 24-hour urinary methoxynoradrenaline level was 30.14 µg/24 hours (103–560 µg/24 hours). His biochemical investigations, including blood catecholamine and metabolites, were within the normal range. Three-dimensional reconstruction of the neck vessels (Figure 1A) showed that this mass enclosed the right distal common carotid artery (CCA), the carotid bifurcation, the proximal internal carotid artery (ICA), and the external carotid artery (ECA). Contrast-enhanced computed tomography (CT; Figure 1B) showed a highly vascularized lesion measuring 4.7×4.1 cm in size on the right side of the upper neck, which was mainly located in the CCA region. The possibility of PGL was considered.

Figure 1 A 3D reconstruction of vessels and the contrast-enhanced CT finding. (A) A 3D reconstruction of the cervical vessels showed a mass enclosing the right distal CCA, the carotid bifurcation, ICA, and ECA. (B) Contrast-enhanced CT showed a highly vascularized lesion on the right side of the upper neck. 3D, 3-dimensional; CT, computed tomography; CCA, common carotid artery; ICA, the proximal internal carotid artery; ECA, the external carotid artery.

Subsequently, 18F-FDG and 68Ga-DOTATATE PET-CT scans were conducted to evaluate the presence of multifocal lesions or distant metastases. The whole-body maximum intensity projection (MIP) image revealed that the neck (Figure 2A,2B, short black arrow) and thoracic region (Figure 2A,2B, long black arrow) had a focal and increased FDG and DOTATATE uptake lesion, respectively. Axial CT of the neck showed a soft tissue lesion in the right upper neck region (Figure 2C,2D, short blue arrow) with moderate FDG accumulation [maximum standardized uptake value (SUVmax) of 3.92] and significantly intense DOTATATE accumulation (SUVmax of 51.0) on PET-CT fusion images (Figure 2E,2F, long blue arrow) and PET images (Figure 2G,2H, orange arrow), respectively. Interestingly, axial CT of the anterior mediastinum showed an irregular soft tissue mass close to the ascending aorta (Figure 2I,2J, short white arrow) with intense FDG uptake (SUVmax 7.56) and relatively intense DOTATATE uptake (SUVmax 20.79) on PET-CT fusion images (Figure 2K,2L, long white arrow) and PET images (Figure 2M,2N, red arrow), respectively. Based on the above findings, it was suggested that the right neck mass was a PGL and that the anterior mediastinal mass was possibly another primary tumor. Right carotid body aneurysm resection and autologous saphenous vein bypass of the right common carotid-ICA were performed on August 20, 2021. Postoperatively, the patient presented with a slight tongue deviation to the right and experienced hoarseness, choking, or coughing while drinking water. Considering the patient’s inability to tolerate joint cervical and thoracic surgery, subxiphoid video-assisted thoracic surgery thymectomy and anterior mediastinal mass resection were performed 4 months later on December 21, 2021. Serum and urine catecholamine metabolite levels were not rechecked postoperatively. No new complications occurred. Histopathologic examination of the neck and thoracic lesions confirmed the diagnosis of 2 primary synchronous PGLs (Figure 3; Figure 4), and immunohistochemical analysis of thoracic lesions showed that chromogranin A (CgA), S-100, and synaptophysin (Syn) were all positive (Figure 4). All procedures performed in this study were conducted in accordance with the ethical standards of the institutional and/or national research committee(s) and the Declaration of Helsinki (as revised in 2013). Written informed consent was provided by the patient to publish this case report and accompanying images. A copy of the written consent is available for review from the editorial office of this journal.

Figure 2 18F-FDG and 68Ga-DOTATATE PET-CT imaging of the right upper neck and the anterior mediastinum lesions. (A,B) MIP. The short black arrow indicates the neck region, and the long black arrow indicates the thoracic region). (C,D: short blue arrow) Axial CT of the neck and chest. (E,F: long blue arrow) FDG PET-CT fusion images. (G,H: orange arrow) PET imaging. (I,J: short white arrow) Axial CT of the chest. (K,L: long white arrow) DOTATATE PET-CT fusion imaging. (M,N: red arrow) PET imaging revealed a soft tissue mass in the right neck and anterior mediastinum with increased 18F-FDG and 68Ga-DOTATATE uptake. 18F-FDG, 18F-fluorodeoxyglucose; 68Ga-DOTATATE, 68Ga-DOTA(0)-Tyr(3)-octreotate; PET-CT, positron emission tomography-computed tomography; MIP, maximum intensity projection.
Figure 3 The pathology of the tumor showed carotid body paraganglioma. HE staining showed that the tumor was composed of nests of cells arranged in a classic Zellballen pattern with abundant blood sinuses between cell nests (magnification ×200). No immunohistochemical staining was performed for this lesion. HE, hematoxylin and eosin.
Figure 4 The pathology of the tumor showing anterior mediastinal paraganglioma. (A) HE staining showed that the tumor was composed of nests of cells arranged in a classic Zellballen pattern with abundant blood sinuses between cell nests (magnification ×200). (B-D) Immunohistochemical staining showed CgA, S-100, and Syn positivity (+) in tumor cells (magnification ×100). HE, hematoxylin and eosin; CgA, chromogranin A; Syn, synaptophysin.


PGLs are rare neuroendocrine tumors arising from the extra-adrenal sympathetic or parasympathetic autonomic paraganglia (3). PGLs are usually located in the thoracolumbar sympathetic ganglia and the craniosacral parasympathetic nervous system (4). Therefore, PGLs can appear in the abdomen, pelvis, head, neck, and thorax (5). Most PGLs are isolated, benign, and nonfunctional. PET-CT findings of solitary PGLs involving the carotid body, jugular, tympanic tumor, urinary bladder, mediastinum, pulmonary, spinal canal, atrial, and epicardial have been reported (6). Synchronous PGLs usually occur in the head and neck region, accounting for approximately 10–22% of sporadic or nonfamilial cases (7-11). Coexistence in the neck and anterior mediastinal PGLs is rare. To date, 8 cases (not including the present case) of synchronous neck and chest PGLs have been reported (12-19). The demographic, clinical, and tumor characteristics of these cases are summarized in Table 1. Among all these cases, most patients were middle-aged males with or without hypertension. The patients’ ages ranged from 30 to 58 years. The maximum diameter of the tumor was 8 cm. The clinical presentation of PGLs depends on the symptoms caused by excessive catecholamine secretion. Typical symptoms are headaches, palpitations, and profuse sweating. Synchronous cervical-thoracic PGLs reported in the literature are usually closely associated with the middle mediastinum. We here report the 18F-FDG and 68Ga-DOTATATE PET-CT findings for a case of synchronous carotid body and anterior mediastinum PGL.

Table 1

Demographic, clinical, and tumor characteristics of 8 reported cases of synchronous neck and chest PGLs

Publication [year] Age (years) Gender Signs and symptoms Previous history Tumor location (size) Imaging modality
Reinert [2000] (12) 47 Male Progressive swelling of the bilateral neck NA Jugular regions and anterior mediastinum Contrast-enhanced CT and angiography
Taïeb [2014] (13) NA NA NA NA Right carotid body and mediastinum Somatostatin receptor SPECT and 18F-FDG PET/CT
Witkowska [2014] (14) 37 Male NA Multiorgan sarcoidosis and hypertension Retroperitoneal (4 cm), mediastinum, neck (bilaterally), and right jugular foramen Contrast-enhanced CT, MRI, 68Ga DOTATATE PET-CT and 123I-MIBG SPECT
Stratakis [2014] (15) 37 Male Recurrent generalized headaches and visual difficulties Hypertension Bilateral carotid area, epicardial and paravertebral mass at the T6/T7 level 123I-MIBG, 111In-pentetreotide SPECT and 18F-FDG PET/CT
Massad [2017] (16) 30 Male Neck mass and palpitations NA Right carotid body bifurcation (3.0×8.0 cm) and left atrial Cardiac MRI, contrast-enhanced CT and 123I-MIBG SPECT
Inoue [2017] (17) 58 Female NA Resection of carotid body tumor and hypertension Left atrium (5.6×5.1 cm) Echocardiography, contrast-enhanced CT and MRI
Shu [2020] (18) 46 Male Recurrent chest pain Resection of bilateral carotid artery PGL Right atrioventricular groove (3.0×2.5×2.0 cm) Echocardiography, coronary angiography, and 18F-FDG PET-CT
Dhirawani [2021] (19) 42 Male Breathlessness, chest pain, and excessive perspiration Hypertension Left para-aortic region (4.1×2.8×2.9 cm) and left common carotid artery (1.7×1.5×1.1 cm) Contrast-enhanced CT, echocardiography, and 18F-FDG PET-CT

PGLs, paragangliomas; NA, not available; CT, computed tomography; SPECT, single-photon emission computed tomography; 18F-FDG, 18F-fluorodeoxyglucose; 68Ga-DOTATATE, 68Ga-DOTA(0)-Tyr(3)-octreotate; PET-CT, positron emission tomography-computed tomography; 123I-MIBG, 123I-metaiodobenzylguanidine; MRI, magnetic resonance imaging.

Anatomical imaging, such as ultrasound, CT, and magnetic resonance imaging (MRI), has been used to evaluate PGLs. Contrast-enhanced CT or MRI provides lesion-enhancing details and can reveal the relationship between lesions and the surrounding blood vessels. Functional imaging, such as 18F-FDG PET, 68Ga-DOTA-somatostatin analog (SSA) PET, 3,4-dihydroxy-6-[18F]-fluoro-L-phenylalanine (18F-DOPA) PET, 123I-metaiodobenzylguanidine (123I-MIBG) single-photon emission computed tomography (SPECT), and 111In-pentetreotide/octreotide SPECT imaging, plays a crucial role in the detection, staging, therapeutic response assessment, and determination of suitability for peptide-based radioreceptor therapy in patients with PGLs (20-23). Generally, PET imaging is more sensitive than is SPECT imaging. 68Ga-DOTATATE has a high affinity for somatostatin receptor 2 (SSTR2), which is overexpressed in most PGLs. 68Ga-DOTA-SSA PET imaging has been recommended as a first-line imaging method for PGLs, especially metastatic PGLs. 18FDG PET-CT is recommended as a second-line imaging method (24-27). 68Ga-DOTA-SSA demonstrates superior lesion detectability for PGLs over other functional and anatomic imaging modalities. Tan et al. (28) showed that 68Ga-DOTATATE PET-CT (92.6%) was the most sensitive imaging modality in mapping PGLs and related lesions compared with 18F-FDG PET-CT (57.8%) and 131I-MIBG (26.0%) scintigraphy on a per-lesion basis, which was similar to the findings of other studies (29-31). Several studies that evaluated PGLs revealed significantly higher lesion detectability of 68Ga-DOTATATE PET-CT (98.6–100%) over CT and MRI (60.5–84.8%) (32-34).

The development of molecular imaging and tracers provides insights into intratumoral or intertumoral heterogeneity and shows the advantage of uncovering spatiotemporal heterogeneity (35). Understanding this remarkable biological heterogeneity helps us to gain insight into the clinical manifestations and disease course, which can guide clinical treatment decisions and assist in evaluating prognoses (36). Due to the differences in radiopharmaceutical avidity and imaging modalities in our case, the cervical lesions (Ki-67 5%) showed mild FDG uptake but significantly intense DOTATATE uptake. In contrast, the anterior mediastinal lesions (Ki-67 20%) showed increased FDG uptake and more intense DOTATATE uptake. The size of the 2 lesions on DOTATATE PET images was even larger than that of those on FDG PET images. The distinct imaging characteristics suggested tumor heterogeneity, which might have been related to the degree of cell proliferation index (Ki-67), tumor metabolic activity, and somatostatin receptor density.

PGL is a highly vascularized tumor in which the carotid body tumor is located at the carotid bifurcation and has classic radiographic features; that is, a homogeneously enhancing soft tissue mass can be seen at the carotid bifurcation on contrast-enhanced CT with splaying of the ICA and ECA, and the carotid bifurcation appears in a typical “goblet deformity”; meanwhile, MRI shows a hyperintense lesion in T2-weighted imaging and the typical “salt and pepper effect” appearance comprising low signal flow voids and high signal foci of hemorrhage (37). The differential diagnosis of an anterior mediastinal mass most often includes thymoma, teratoma, thyroid disease, and lymphoma (38). Anterior mediastinal PGLs show intense DOTATATE uptake, while other anterior mediastinal masses often have a background or mild to moderate DOTATATE uptake (6). PGLs should be considered when certain paraganglia sites have different degrees of FDG or DOTATATE uptake.


The present case report the use of 18F-FDG and 68Ga DOTATATE PET-CT for detecting synchronous PGLs. Moreover, our report shows that different degrees of FDG and DOTATATE uptake can occur at different sites of PGLs. These findings further our understanding the of metabolic differences in PGLs and provide quantitative information related to tumor biological aggressiveness and somatostatin expression levels.


Funding: The research was supported by the 1.3.5 Project for Disciplines of Excellence; the West China Hospital, Sichuan University (No. ZYGD18016); and the Sichuan Science and Technology Program (No. 2022YFH0047).


Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The authors report that this research was supported by the 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (No. ZYGD18016), and the Sichuan Science and Technology Program (No. 2022YFH0047). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were conducted in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient to publish this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See:


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Cite this article as: Xie H, Lin H, Li L, Zhang W. Synchronous carotid body and anterior mediastinal paraganglioma revealed by 18F-fluorodeoxyglucose and 68Ga-DOTA(0)-Tyr(3)-octreotate positron emission tomography-computed tomography. Quant Imaging Med Surg 2023;13(6):4007-4014. doi: 10.21037/qims-22-1018

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