Malignant phaeochromocytoma: report of a case and a critical review

Metastatic proclivities and patterns among APUD cell neoplasms

Neoplasms of APUD cell origin are quite variable in their metastatic behavior. Whereas pituitary and parathyroid tumors almost never metastasize, all oat cell lung cancers, malignant melanomas, trabecular carcinomas of the skin and medullary thyroid cancers are capable of dissemination. The metastatic proclivity of individual carcinoids, pancreatic and extrapancreatic islet cell tumors, and paragangliomas is much less predictable. In particular, there are no reliable histological markers of risk for lymphatic or hematogenous dissemination. The behavior of many carcinoids, islet cell carcinomas and paragangliomas is relatively indolent, even when metastatic disease is already present. However, unresectable distant metastases, especially liver involvement, connote a poor prognosis. Mortality is more often related to uncontrolled tumor growth and metastasis than to associated endocrinopathies. Curative or debulking surgical resection should be aggressively pursued as recent data show that worthwhile clinical disease-free survival can be realized in at least some patients.

Phaeochromocytoma: diagnosis and management

The incidence, symptoms, signs and differential diagnosis of phaeochromocytoma have been discussed in detail. Current methods of biochemical diagnosis and anatomical localization of the tumour have been reviewed, the appropriate pharmacotherapy and other aspects of medical management have been outlined. Also detailed herein are anaesthetic management and surgical approach, the pitfalls of drug administration in known or suspected phaeochromocytoma, and particular considerations when phaeochromocytoma is malignant or when it coexists with pregnancy. Three decades ago, the diagnosis and management of phaeochromocytoma was succinctly summarized as follows: 'think of it, confirm it, find it and remove it' (Manger and Gifford, 1977; Ross, 1962). Despite the availability of sophisticated diagnostic tests and the significant progress in management, where phaeochromocytoma is concerned, a high index of suspicion ('thinking of it') remains the physician's most valuable tool.

Malignant pheochromocytoma with ACTH production

An autopsy case of a 54-year-old woman with malignant pheochromocytoma and ectopic ACTH production was reported. Noradrenaline was increased in 24 hour urine and in the blood sample from the left adrenal vein. Hormone assay studies of the tumor tissue and plasma revealed abnormally high levels of ACTH. Formaldehyde fume induced fluorescence method demonstrated biogenic amine in the tumor cytoplasm. Electron microscopic examinations also disclosed numerous neurosecretory granules in the tumor cytoplasm. These findings confirmed that this pleomorphic carcinoma of the left adrenal gland was one of the APUDoma originating from the adrenal medulla, so-called pheochromocytoma.