Pheochromocytoma and paraganglioma-an update on diagnosis, evaluation, and management

Cardiovascular Risk Factors in Children with Obesity, Preventive Diagnostics and Possible Interventions

The increasing burden of obesity plays an essential role in increased cardiovascular morbidity and mortality. The effects of obesity on the cardiovascular system have also been demonstrated in childhood, where prevention is even more important. Obesity is associated with hormonal changes and vascular dysfunction, which eventually lead to hypertension, hyperinsulinemia, chronic kidney disease, dyslipidemia and cardiac dysfunction—all associated with increased cardiovascular risk, leading to potential cardiovascular events in early adulthood. Several preventive strategies are being implemented to reduce the cardiovascular burden in children. This paper presents a comprehensive review of obesity-associated cardiovascular morbidity with the preventive diagnostic workup at our hospital and possible interventions in children.

Metastatic urinary bladder paraganglioma on Ga-68 DOTATATE PET/CT

Paragangliomas are extra-adrenal catecholamine-secreting neuroendocrine tumors that can present with adrenergic signs and symptoms. The urinary bladder is a rare location for a paraganglioma, and these tumors must be distinguished from other more common bladder neoplasms. In this case report, we discuss a 59 year-old woman who initially presented with tachycardia, palpitations, chest tightness, shortness of breath, and weight loss. Laboratory evaluation showed significantly elevated catecholamines in the plasma and urine. A CT (Computed Tomography) scan of the abdomen and pelvis revealed an enhancing mass arising from the urinary bladder and an enlarged right pelvic lymph node. A follow up Ga-68 DOTATATE PET/CT (Positron Emission Tomography and/or Computed Tomography) showed increased uptake in the primary bladder mass, right pelvic lymph node, numerous skeletal lesions, and pulmonary nodules, consistent with metastatic paraganglioma of the urinary bladder. This case report demonstrates the radiological findings of metastatic urinary bladder paraganglioma and highlights the importance of skull base to mid-thigh PET/CT using Ga-68 DOTATATE. It is crucial for the radiologist to be familiar with the characteristics of urinary bladder paragangliomas and identify these tumors on imaging to allow prompt initiation of surgical resection and/or systemic therapy.

Operative management and outcome in children with pheochromocytoma

OBJECTIVE

This study aimed to evaluate management and prognosis in children with pheochromocytoma who were treated at an Egyptian tertiary center.

METHODS

The authors conducted an 8-year retrospective analysis for 17 patients who were presented from January 2013 to January 2021. Clinical criteria, operative details, and follow-up data were assessed. Overall (OS) and event-free survival (EFS) were estimated by the Kaplan-Meier method. An event was assigned with the occurrence of recurrence or metachronous disease, or death.

RESULTS

Median age at diagnosis was 14 years (range: 6-17.5 years). Ten patients (58.8%) were males and seven (41.2%) were females. Hypertension-related symptoms were the main presentations in 15 patients (88%). None of the included children underwent genetic testing. Sixteen patients (94%) had unilateral tumors (right side: 12), whereas only one was presented with bilateral masses. The median tumor size was 7 cm (range: 4-9 cm). Metastatic workup did not reveal any metastatic lesions. All patients underwent open adrenalectomy, and clinical manifestations were completely resolved after surgery. Adjuvant therapy was not administered to any patient. There were no deaths or relapses at a median follow-up time of 40 months, whilst two children had metachronous disease after primary resection. Both were managed by adrenal-sparing surgery, and they achieved a second complete remission thereafter. Five-year OS and EFS were 100% and 88%, respectively.

CONCLUSIONS

Complete surgical resection achieves excellent clinical and survival outcomes for pheochromocytoma in children. Meticulous, long-term follow-up is imperative for early detection of metachronous disease to facilitate adrenal-sparing surgery. Genetic assessment for patients and their families is essential; however, it was not available at our institution.

Perioperative control of paroxysmal hypertension using esmolol with alpha-blockade in a child with a germline mutated paraganglioma

Summary

The use of antihypertensive medications in patients with pheochromocytomas and paragangliomas (PCC/PG) is usually a challenge. We report a case of familial paraganglioma that was successfully treated by esmolol and other antihypertensive medications without associated perioperative complications. Our patient was an 11-year-old girl who presented with classic symptoms and signs of PCC/PG and a CT scan of the abdomen that showed a right-sided paravertebral mass. Her father was diagnosed with paraganglioma a few years ago. Prazosin had been started but she continued to experience uncontrolled paroxysms of blood pressure (BP). She was known to have asthma; hence, she developed serious bronchospasm with atenolol. She was, therefore, switched to esmolol that successfully controlled her BP in addition to prazosin and intermittent doses of hydralazine prior to laparoscopic surgery with no side effects of medications or postoperative complications. Esmolol could be a good alternative to routinely used beta-blockers in children with PCC/PG with labile hypertension and related symptoms in the pre and intra-operative periods. It is titrable, effective, and can be weaned rapidly helping to avoid postoperative complications. Further larger studies on the use of esmolol in children with PCC/PG are needed to confirm our observation.

Learning points

In addition to alpha-blockers, esmolol could be a good alternative for routinely used beta-blockers to control paroxysmal hypertension and tachycardia in the pre- and intra-operative periods. Esmolol is titrable and an effective beta-blocker. It can be weaned rapidly helping to avoid postoperative complications in children with PCC/PG. Children with PCC/PG and other comorbidity like asthma may particularly benefit from the use of esmolol due to no or less side effects on airway resistance and the advantage of rapid titration of the medication compared to other beta-blockers.

Oncocytic Lipoadenoma: Report of 3 Rare Cases Involving the Parotid Gland, Including a Synchronous Presentation With Paraganglioma of the Right Carotid Bifurcation and Literature Review

Oncocytic lipoadenoma (OL) is a rare salivary gland tumor characterized by the presence of oncocytic cells and mature adipose tissue. To date, only 30 cases of OL have been reported in the English-language literature. We present 3 additional OL cases involving the parotid, including a synchronous presentation with paraganglioma of the right carotid bifurcation. Microscopically, both the OLs were composed of a mixed population of oncocytes and adipocytes in varying proportions surrounded by a thin, connective tissue fibrous capsule. Oncocytes were positive for pan-cytokeratins (CKs) AE1/AE3, epithelial membrane antigen, CK5, CK7, CK14, CK18, and CK19. Calponin, p63, alpha-smooth muscle actin, and carcinoembryonic antigen were negative. Vimentin and S-100 protein were positive only in adipose cells. Despite distinctive morphologic features, OL is often misdiagnosed, given its rarity. We hope to contribute to surgeons' and pathologists' awareness and knowledge regarding the existence of this tumor and provide adequate management through conservative surgical excision.

Hypertension in Pheochromocytoma and Paraganglioma: Evaluation and Management in Pediatric Patients

PURPOSE OF REVIEW

The rare catecholamine-secreting tumors, pheochromocytomas and paragangliomas (PPGL), account for a minority of cases of secondary hypertension in pediatrics. As such, perioperative blood pressure (BP) management in pediatric patients presents a distinct challenge. This review will expand the practitioner's knowledge of antihypertensive treatment options for the pediatric patient with PPGL with a focus on literature in the past several years.

RECENT FINDINGS

There continue to be only small case series and single-center experiences to provide guidelines regarding BP management. While phenoxybenzamine has been more routinely used, selective α₁-blockers, such as doxazosin, as well as calcium channel blockers, have also been utilized with success in pediatric patients. While the concept of obligatory α-adrenergic blockade for adult patients has been recently challenged, international guidelines and current practice patterns among pediatric clinicians continue to support preoperative α-adrenergic blockade to ensure the best possible patient outcomes. Selective α₁-blockers and calcium channel blockers are becoming more commonly used given the high cost, limited availability, and undesirable side effect profile of phenoxybenzamine.

Central Nervous System Hemangioblastoma in a Pediatric Patient Associated With Von Hippel-Lindau Disease: A Case Report and Literature Review

Background

Hemangioblastoma is a benign tumor of the central nervous system and may appear as a component of von Hippel-Lindau (VHL) disease. At present, approximately 40 cases of optic nerve HGBs have been reported in the literature. VHL disease is a rare autosomal-dominant inherited cancer syndrome with different phenotypes caused by variants in the VHL gene. Herein, the authors describe a case of a pediatric patient with VHL disease and with optic nerve HGB, a rare phenotypic expression. The purpose of this study was to explore the genotype-phenotype, clinical features, treatment and follow-up of VHL-associated hemangioblastomas in pediatric patients.

Case Description

A 12-year-old boy presented with vision loss, headache and dizziness at our hospital. Magnetic resonance imaging (MRI) revealed a large (19.8 mm*18.5 mm*23.5 mm) irregular mass located in the suprasellar region. The mass was successfully removed after craniotomy and microsurgical treatment. The pathological diagnosis was left optic nerve HGB. Genetic analyses showed p.Pro86Leu (c. 257C>T) heterozygous missense mutations in the VHL gene.

Conclusion

This is the first reported pediatric case of VHL-associated optic nerve HGB. The genotype-phenotype correlation of VHL disease may provide new evidences for predicting tumor penetrance and survival. Gross tumor resection combined with stereotactic radiosurgery might be the most beneficial treatment.

Diagnosis of a 09 cm pheochromocytoma mistaken to be an intramesenteric pancreatic tumor: Case report complying with the scare guidelines

INTRODUCTION

Pheochromocytoma is an adrenal medullary tumor of the chromaffin cells first described in 1886, remains an entity not fully discovered that case reports keep showing its diversity in clinical presentation, diagnosis methods treatment and follow up challenges.

CASE PRESENTATION

We report the case of a 47 year old woman with complaining from abdominal pain and major weightless with a 09 cm tumor of the body of the pancreas viewed in imaging with no hormonal secretion but high levels of chromogranine A open surgery conducted that revealed the tumor to be located between the adrenal medulla and the Aorta misleading the team between an adrenal tumor or a zuckerkandl body tumor. The hemodynamic changes after manipulation of the tumor and the histopathology confirming the diagnosis of pheochromocytoma. Our main surprise was the aspect of the tumor bombing in the peritoneal cavity firstly thought to be mesenteric tumor; and the stability of the patient with no premedication until the tumor had been manipulated, enlarging the hypothesis about catecholamine secretion of these tumor.

DISCUSSION

The diagnosis is basically simple when the tumor expresses its catecholamines by biomarkers testing, an imaging. Functional imaging should be used to locate the tumor or its metastasis, the sequence of testing or imaging can vary either it's a symptomatic tumor or an incidentaloma. Preoperative measures should be taken so no major preoperative complications and the main treatment is the tumor complete resection CONCLUSION: The malignancy of the pheochromocytoma is no near to be reliably identified which imposes a lifetime follow up of these patients as for metastasis were described even after 40 years after diagnosis.

Pheochromocytoma in a patient presenting with ventricular fibrillation and carotid dissection: a case report

BACKGROUND

Pheochromocytoma is an endocrine tumour secreting catecholamines, most often revealed by clinical symptoms (headache, palpitations, diaphoresis, or resistant hypertension). Some cases of ventricular arrhythmias were described in the literature, without any formal link between arrhythmia and pheochromocytoma.

CASE SUMMARY

We report a case of pheochromocytoma discovered after cardiac arrest due to ventricular fibrillation in a 46-year-old patient. The diagnosis was suggested by clinical symptoms (headache, palpitation, and diaphoresis) and suspected on the abdominal computed tomography scan. The diagnosis was corroborated by metaiodobenzylguanidine scintigraphy and finally confirmed by anatomopathological analysis of the operative specimen. The cerebral imaging showed a dissection of the left internal carotid artery and an intraparenchymal haematoma that might be secondary to a catecholaminergic discharge of phaeochromocytoma and severe hypertension.

DISCUSSION

Since pheochromocytoma is accessible to curative treatment, its detection in case of cardiac arrest is essential to decrease the risk of arrhythmic recurrence.

Perioperative management of pheocromocytoma/ paraganglioma: a comprehensive review

Pheochromocytomas are rare neuroendocrine neoplasms that require adequate preoperative evaluation in order to prevent and lessen the serious complications of catecholamine hypersecretion. Preoperative management contributes to reducing morbidity and mortality rates in patients who have not been diagnosed with this condition and undergo any surgery. However, current mortality seems to be lower, a fact attributed to preoperative management with alpha blockers.

Diagnosis and Management of Endocrine Hypertension in Children and Adolescents

Hypertension in childhood and adolescence has increased in prevalence. Interest in the disease was raised after the 2017 clinical practice guidelines of the American Academy of Paediatrics on the definition and classification of paediatric hypertension. Among the secondary causes of paediatric hypertension, endocrine causes are relatively rare but important due to their unique treatment options. Excess of catecholamine, glucocorticoids and mineralocorticoids, congenital adrenal hyperplasia, hyperaldosteronism, hyperthyroidism and other rare syndromes with specific genetic defects are endocrine disorders leading to paediatric and adolescent hypertension. Adipose tissue is currently considered the major endocrine gland. Obesity-related hypertension constitutes a distinct clinical entity leading to an endocrine disorder. The dramatic increase in the rates of obesity during childhood has resulted in a rise in obesity-related hypertension among children, leading to increased cardiovascular risk and associated increased morbidity and mortality. This review presents an overview of pathophysiology and diagnosis of hypertension resulting from hormonal excess, as well as obesity-related hypertension during childhood and adolescence, with a special focus on management.

Catecholamine-induced Myocarditis in a Child with Pheochromocytoma

Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors. The clinical presentation of pediatric PPGLs is highly variable. In cases with pheochromocytoma (PCC), excess catecholamine may stimulate myocytes and cause structural changes, leading to life-threatening complications ranging from stress cardiomyopathy (CM) to dilated CM. Herein, we report the case of catecholamine-induced myocarditis in a child with asymptomatic PCC. A 12-year-and-2-month-old male patient with a known diagnosis of type-1 neurofibromatosis was brought to the emergency department due to palpitations and vomiting. On physical examination, arterial blood pressure was 113/81 mmHg, pulse was 125/min, and body temperature was 36.5 °C. Laboratory tests showed a leucocyte count of 12.8x10³ μL/L and a serum C-reactive protein level of 1.1 mg/dL (Normal range: 0-0.5). Thyroid function tests were normal, while cardiac enzymes were elevated. Electrocardiogram revealed no pathological findings other than sinus tachycardia. The patient was diagnosed with and treated for myocarditis as echocardiography revealed a left ventricular ejection fraction of 48%. Viral and bacterial agents that may cause myocarditis were excluded via serological tests and blood cultures. Blood pressure, normal at the time of admission, was elevated (140/90 mmHg) on the 5^th day of hospitalization. Magnetic resonance imaging revealed a 41x46x45 mm solid adrenal mass. The diagnosis of PCC was confirmed by elevated urinary and plasma metanephrines. The patient underwent surgery. Histopathology of the excised mass was compatible with PCC. It should be kept in mind that, even if there are no signs and symptoms of catecholamine elevation, CM may be the first sign of PCC.

Imaging features of adrenal gland masses in the pediatric population

The spectrum of adrenal masses in the pediatric population markedly differs from that in the adult population. Imaging plays a crucial role in detecting adrenal masses, differentiating malignant from benign lesions, recognizing extra-adrenal lesions in the suprarenal fossa, and directing further management. Ultrasound is the primary imaging modality of choice for the evaluation of adrenal masses in the neonatal period, whereas MRI or CT is used as a problem-solving tool. In older children, computed tomography or magnetic resonance imaging is often required after initial sonographic evaluation for further characterization of a lesion. Herein, we discuss the salient imaging features along with pathophysiology and clinical features of pediatric adrenal masses.

The Identification of Differentially Expressed Genes Showing Aberrant Methylation Patterns in Pheochromocytoma by Integrated Bioinformatics Analysis

Malignant pheochromocytoma (PHEO) can only be fully diagnosed when metastatic foci develop. However, at this point in time, patients gain little benefit from traditional therapeutic methods. Methylation plays an important role in the pathogenesis of PHEO. The aim of this research was to use integrated bioinformatics analysis to identify differentially expressed genes (DEGs) showing aberrant methylation patterns in PHEO and therefore provide further understanding of the molecular mechanisms underlying this condition. Aberrantly methylated DEGs were first identified by using R software (version 3.6) to combine gene expression microarray data (GSE19422) with gene methylation microarray data (GSE43293). An online bioinformatics database (DAVID) was then used to identify all overlapping DEGs showing aberrant methylation; these were annotated and then functional enrichment was ascertained by gene ontology (GO) analysis. The online STRING tool was then used to analyze interactions between all overlapping DEGs showing aberrant methylation; these results were then visualized by Cytoscape (version 3.61). Next, using the cytoHubba plugin within Cytoscape, we identified the top 10 hub genes and found that these were predominantly enriched in pathways related to cancer. Reference to The Cancer Genome Atlas (TCGA) further confirmed our results and further identified an upregulated hypomethylated gene (SCN2A) and a downregulated hypermethylated gene (KCNQ1). Logistic regression analysis and receiver operating characteristic (ROC) curve analysis indicated that KCNQ1 and SCN2A represent promising differential diagnostic biomarkers between benign and malignant PHEO. Finally, clinical data showed that there were significant differences in the concentrations of potassium and sodium when compared between pre-surgery and post-surgery day 1. These suggest that KCNQ1 and SCN2A, genes that encode potassium and sodium channels, respectively, may serve as putative diagnostic targets for the diagnosis and prognosis of PHEO and therefore facilitate the clinical management of PHEO.

Pheochromocytomas and Paragangliomas

Pheochromocytomas are rare neuroendocrine tumors. Extra-adrenal lesions arising from the autonomic neural ganglia are termed paraganglioma. Clinical symptoms are common between the adrenal and extra-adrenal forms and are determined by excess secretion of catecholamines. Hypertension is a critical and often dramatic feature of pheochromocytoma/paraganglioma, and its most prevalent reported symptom. However, given the rare occurrence of this cancer, in patients undergoing screening for hypertension, the prevalence ranges from 0.1% to 0.6%. Still, patients frequently come to the attention of endocrinologist when pheochromocytoma/paraganglioma is suspected as a secondary cause of hypertension. This article summarizes current clinical approaches in patients with pheochromocytoma/paraganglioma.

Long-term blood pressure outcomes of patients with adrenal venous sampling-proven unilateral primary aldosteronism

Primary aldosteronism (PA) is mainly treated by mineralocorticoid receptor antagonists or laparoscopic adrenalectomy (LA), but the effectiveness of surgical versus medical treatment in patients with adrenal venous sampling (AVS)-proven unilateral PA is unclear. Fifty-one consecutive patients with AVS-proven PA were enrolled. We compared the therapeutic effects between the surgery group (n = 21) and medication group (n = 30) by evaluating the complete control rate (CCR) of hypertension, blood pressure (BP), and number of antihypertensive drugs after a long-term follow-up (>12 months). The CCR of hypertension was assessed using a multivariate adjusted Cox proportional hazards regression model. After a mean follow-up of 21.18 ± 5.35 months, the CCR was significantly higher in the surgery than medication group (85.7% vs. 13.3%, respectively; p < 0.001). Before adjustment for covariates, the CCR of hypertension in patients who underwent LA was 7.75 times higher than that in patients who underwent medical treatment (95% CI, 2.33-25.78; p = 0.001); significant results were also shown in the adjusted models. Systolic and diastolic BP were also lower in the surgery than medication group (120.3 ± 12.99 vs. 133.54 ± 16.60 and 79.00 ± 7.62 vs. 87.35 ± 12.36 mmHg, respectively; p = 0.01 for both), as was the number of antihypertensive drugs (0.19 ± 0.51 vs. 2.33 ± 0.78, respectively; p < 0.001). The rate of hypokalemia was not significantly different between the two groups (0.0% vs. 13.3%, respectively; p = 0.13). In conclusion, AVS plays an essential role in the subtype diagnosis of PA, and surgical candidates with AVS-proven unilateral PA should be highly suggested to undergo LA.

Effect of dietary status on plasma-fractionated metanephrines in healthy individuals measured by Elisa

Pheochromocytoma is a rare tumor that typically originates in the adrenal glands, often causing the over-production of catecholamines. The aim of this study was to determine whether dietary status could affect the concentration of plasma-fractionated metanephrines. This study was conducted at the Chemical Pathology Laboratory, Royal Hospital, Oman. Three plasma samples were collected from each participant (16 male and 16 female) over three consecutive days (day one: dietary restriction,day two: excess intake of restricted foods, day three: random sample following the typical diet for each participant). Samples were collected and centrifuged to obtain the plasma, which was then stored at -20°C prior to analysis. Metanephrine and normetanephrine concentrations were measured by comparative ELISA. Plasma metanephrine and normetanephrine measured under the three different dietary conditions for each individual were not significantly different and within normal range. Pearson correlation coefficient analysis of plasma concentration of metanephrines within individual patients under the three dietary conditions revealed positive correlation. We found no significant effect of dietary status on plasma metanephrine or normetanephrine concentration. Therefore, samples taken under any dietary condition may be used to determine plasma MN and NMN concentration. However, dietary restrictions in the diagnosis of Pheochromocytoma need further investigations.