# Surgical Approaches and Perioperative Outcomes in Mediastinal Paragangliomas: A 20-Year Comprehensive Systematic Review

## TL;DR

This paper reviews surgical approaches and outcomes for mediastinal paragangliomas, aiming to improve safety and reduce complications through a multidisciplinary approach.

## Contribution

A comprehensive systematic review of surgical management and outcomes for mediastinal paragangliomas over two decades, proposing standardized approaches.

## Key findings

- Sternotomy is the most common surgical approach, with cardiopulmonary bypass used in nearly 28% of cases.
- Postoperative complications occurred in 28% of patients, with left vocal cord palsy being the most frequent.
- A multidisciplinary approach is recommended to reduce risks and improve outcomes for these complex surgeries.

## Abstract

This study reviews the surgical management of a mediastinal paraganglioma, a rare type of tumor that is often located in the posterior mediastinum and can surround or involve the heart and major blood vessels. Often asymptomatic or with symptoms related to catecholamine secretion, the surgical approach is the treatment of choice, achieving local disease control and long-term outcomes. However, surgical removal poses a high risk of severe bleeding and perioperative complications. By analyzing literature from the last twenty years, we aim to establish a clearer and safer approach for diagnosis and surgery. The findings will help surgeons better plan these complex operations, potentially reducing complications and improving patient care for this uncommon but dangerous condition.

Background: Mediastinal paragangliomas (MPs) are rare, highly vascular neuroendocrine tumors whose surgical resection is the gold standard but carries a high risk of perioperative complications due to the MPs’ proximity to major cardiovascular structures with potential life-threatening hemorrhage. Due to their rarity, the literature consists primarily of case reports. Our systematic review aims to synthesize the evidence from the last two decades to propose a standardized, multidisciplinary approach to the diagnosis and surgical management of MPs. Methods: A systematic literature review was conducted from 2005 to 2025. Studies reporting on surgically resected adult mediastinal paragangliomas were included. Patient demographic data, diagnostic workup, surgical approaches, and outcomes were extracted and analyzed descriptively. Results: Analysis of 79 patients from 75 papers revealed a median age of 50 years (female predominance of 62%). Most tumors were in the middle mediastinum (51.9%). Sternotomy was the most common surgical approach (44.3%), with cardiopulmonary bypass utilized in 27.8% of cases. Postoperative complications occurred in 28% of patients, with left vocal cord palsy (12.7%) being most frequent. The median follow-up was 12 months. All percentages refer to the number of patients. Conclusions: Surgical removal is the standard of care for curative treatment of MPs. However, surgical treatment requires meticulous planning within a multidisciplinary team to reduce the risk of perioperative complications. The choice of surgical approach—open, minimally invasive, or with circulatory support—depends on tumor site, size, and vascular involvement. This review consolidates existing evidence of MPs’ surgical management, aiming to mitigate the significant risks associated with surgery. Lifelong follow-up is essential due to the potential for recurrence.