Pancreatic Paraganglioma: A Case Report.

Background: Paraganglionic neoplasms that originate in the adrenal medullas are referred to as pheochromocytomas, but if they arise from other paraganglia scattered throughout the body, they are referred to as paragangliomas. Pancreatic paragangliomas are an extremely rare entity as only 20 cases have been reported in the literature. They tend to be nonfunctional and typically occur in the fourth to fifth decade of life without a gender predilection. We describe in this study a case of a pancreatic paraganglioma and its CT appearance. Case Presentation: A 62-year-old woman undergoing presurgical evaluation for an olfactory groove meningioma resection was incidentally found to have a pancreatic mass. Multiple fine needle aspirations of the mass through endoscopic ultrasound yielded only atypical epithelial cells. The mass demonstrated avid enhancement on serial CTs with mild interval growth over a period of 5 years. No lymphadenopathy was ever found. The patient's complete blood count, complete metabolic panel, and plasma carcinoembryonic antigen levels were all within normal limits. Urine catecholamine metabolite levels were never checked as the patient demonstrated no symptoms of catecholamine excess. The patient underwent a laparoscopic distal pancreatectomy and splenectomy, and the mass was eventually diagnosed as a pancreatic paraganglioma through pathology. While the patient tolerated the surgery well, she did require a biliary sphincterotomy and placement of a pancreatic duct stent postoperatively for treatment of a pancreatic duct leak, which completely resolved. She showed no evidence of disease recurrence on multiple subsequent CTs and continues to do well. Conclusion: Pancreatic paragangliomas are usually incidentally discovered and typically demonstrate avid homogenous enhancement on contrast-enhanced CT or MR. Aggressive surgical resection is necessary to maximize the chances of disease-free survival. Pancreatic paragangliomas are similar histologically, whether benign or malignant, to paragangliomas that occur anywhere else in the body, with ∼70% in the abdomen and 30% in the chest.

A patient safety approach to setting pass/fail standards for basic procedural skills checklists.

SUMMARY STATEMENT: Checklists for basic procedural skills require an approach to standard setting in which patient safety concerns are paramount. We suggest that faculty members identify dimensions such as patient or clinician safety, procedure outcome, and patient comfort that are essential for a given procedure and demand for essential checklist items a high level of mastery that is not compensated by performance of nonessential items. This approach differs from traditional standard setting methods developed for written examinations, which allow examinees to miss a given percentage of items regardless of the specific items missed. Application of cut scores based on this patient safety standard resulted in requiring a substantial number of students to retrain and retest; these students would have passed if the traditional Angoff method had been used. Only by demanding a high level of mastery in the simulation laboratory can we promote patient safety in the messy and unpredictable real world.