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Special Feature
January 2010

Image of the Month—Diagnosis

Author Affiliations

Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010

Arch Surg. 2010;145(1):100. doi:10.1001/archsurg.2009.242-b
Answer: Ganglioneuroma

Ganglioneuroma is a rare, benign tumor that is found most commonly in children and young adults and arises from the sympathetic ganglia. It is composed of mature Schwann cells, ganglion cells, and nerve fibers. The posterior mediastinum is the most frequent site of origin of ganglioneuroma. Less frequently it arises in the retroperitoneum and, quite rarely, in the adrenal glands.1,2

Characteristically, this tumor does not produce excess catecholamines or steroid hormones,3 and it usually presents as a clinically silent lesion incidentally detected in imaging studies for unrelated reasons. Surgery is not mandatory if a certain diagnosis of ganglioneuroma is made.

The rarity and the lack of understanding of ganglioneuroma biology often lead to inappropriate diagnosis and/or treatment.46 Unfortunately, there are no specific diagnostic signs or symptoms allowing preoperative discrimination between active ganglioneuroma and pheochromocytoma. In our case, the gradient between plasma catecholamine (normal) and urinary metanephrine levels (elevated) and, furthermore, the atypical appearance on computed tomographic scan (absence of irregular central areas representing necrosis or hemorrhage that, when present in large adrenal masses, are strongly suggestive for pheochromocytoma) most likely should have discouraged the hypothesis of pheochromocytoma. Nevertheless, the large diameter of the lesion was itself a strong indication for surgery because malignancy had to be excluded.

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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system ( Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery ( No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

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Article Information

Correspondence: Gabriele Materazzi, MD, Dipartimento di Chirurgia, Università de Pisa, Via Roma 67, 56100 Pisa, Italy (

Accepted for Publication: April 1, 2009.

Author Contributions:Study concept and design: Materazzi and Miccoli. Acquisition of data: Berti, Conte, and Faviana. Drafting of the manuscript: Materazzi and Conte. Critical revision of the manuscript for important intellectual content: Berti, Faviana, and Miccoli. Study supervision: Materazzi, Berti, Conte, Faviana, and Miccoli.

Financial Disclosure: None reported.

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