A case of perioperative and intraoperative management of a rare vaginal paraganglioma

Background: We present the case of a 24-year-old woman with a vaginal paraganglioma and review management considerations, noting that only eleven cases have been previously reported in the literature. Case presentation: Our patient was initially evaluated during a pregnancy complicated by severe pre-eclampsia and later presented with persistent catecholamine-related symptoms, including headaches, diaphoresis, and tachycardia. Laboratory testing demonstrated markedly elevated normetanephrines, and imaging subsequently revealed a paravaginal mass. Given the clinical presentation, a paraganglioma was suspected. Notably, the mass was not avid on the^68 Ga-DOTATATE scan. To obtain a definitive diagnosis, an excisional procedure was planned. Because of the hypervascular nature of these tumors, preoperative embolization was performed to reduce intraoperative blood loss. The patient experienced a hypertensive crisis episode at the time of embolization that was successfully managed with antihypertensive medications in the ICU setting. Final pathology confirmed a 3.6-cm paraganglioma with extensive necrosis and negative surgical margins. Conclusion: This case is the first reported case of arterial embolization with delayed surgical resection of a vaginal paraganglioma. While arterial embolization has been reported previously, in our case, resection was delayed due to a hypertensive crisis. Multidisciplinary management strategies are discussed.