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McKissic DA, Meisner JK, Chen M, Lim HM. Abdominal Pain, Fatigue, and Headaches in a 9-year-old Boy. Pediatr Rev 2022; 43:714-716. [PMID: 36450633 DOI: 10.1542/pir.2020-003756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | | | - Ming Chen
- Division of Pediatric Endocrinology, University of Michigan, Ann Arbor, MI
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Abstract
Pediatric adrenal tumors are uncommon entities that are frequently occult and identified incidentally or by recognizing symptoms related to hormone overproduction. They often have a genetic underpinning, arise from the medulla or cortex, can be malignant or benign, and require precise diagnostic algorithms. However, pseudotumors must also be a diagnostic consideration. Therapeutic interventions and plans are tumor dependent, but surgery is a cornerstone of treatment. Ongoing surveillance after treatment, regardless of malignant determination, is of utmost importance as well.
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Pamporaki C, Hamplova B, Peitzsch M, Prejbisz A, Beuschlein F, Timmers HJ, Fassnacht M, Klink B, Lodish M, Stratakis CA, Huebner A, Fliedner S, Robledo M, Sinnott RO, Januszewicz A, Pacak K, Eisenhofer G. Characteristics of Pediatric vs Adult Pheochromocytomas and Paragangliomas. J Clin Endocrinol Metab 2017; 102:1122-1132. [PMID: 28324046 PMCID: PMC5460722 DOI: 10.1210/jc.2016-3829] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/26/2017] [Indexed: 12/22/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGLs) in children are often hereditary and may present with different characteristics compared with adults. Hereditary PPGLs can be separated into cluster 1 and cluster 2 tumors due to mutations impacting hypoxia and kinase receptor signaling pathways, respectively. OBJECTIVE To identify differences in presentation of PPGLs between children and adults. DESIGN A retrospective cross-sectional clinical study. SETTING Seven tertiary medical centers. PATIENTS The study included 748 patients with PPGLs, including 95 with a first presentation during childhood. Genetic testing was available in 611 patients. Other data included locations of primary tumors, presence of recurrent or metastatic disease, and plasma concentrations of metanephrines and 3-methoxytyramine. RESULTS Children showed higher (P < 0.0001) prevalence than adults of hereditary (80.4% vs 52.6%), extra-adrenal (66.3% vs 35.1%), multifocal (32.6% vs 13.5%), metastatic (49.5% vs 29.1%), and recurrent (29.5% vs 14.2%) PPGLs. Tumors due to cluster 1 mutations were more prevalent among children than adults (76.1% vs 39.3%; P < 0.0001), and this paralleled a higher prevalence of noradrenergic tumors, characterized by relative lack of increased plasma metanephrine, in children than in adults (93.2% vs 57.3%; P < 0.0001). CONCLUSIONS The higher prevalence of hereditary, extra-adrenal, multifocal, and metastatic PPGLs in children than adults represents interrelated features that, in part, reflect the lower age of disease presentation of noradrenergic cluster 1 than adrenergic cluster 2 tumors. The differences in disease presentation are important to consider in children at risk for PPGLs due to a known mutation or previous history of tumor.
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Affiliation(s)
| | - Barbora Hamplova
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, D-01307 Dresden, Germany
| | | | - Felix Beuschlein
- Department of Medicine IV, University Hospital of Munich, 80539 Munich, Germany
| | - Henri J.L.M. Timmers
- Department of Internal Medicine, Radboud University Medical Centre, 6525 HP Nijmegen, The Netherlands
| | - Martin Fassnacht
- Department of Internal Medicine, Division of Endocrinology, University Hospital, University of Wuerzburg, 97070 Wuerzburg, Germany
| | - Barbara Klink
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus at the TU Dresden, D-01307 Dresden, Germany
- German Cancer Consortium, D-01307 Dresden, Germany
- German Cancer Research Center, 69120 Heidelberg, Germany
- National Center for Tumor Diseases, D-01307 Dresden, Germany
| | - Maya Lodish
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | - Constantine A. Stratakis
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | | | - Stephanie Fliedner
- Department of Medicine, University Medical Center Schleswig-Holstein, 23562 Luebeck, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Human Cancer Genetics Programme, Spanish National Cancer Research Centre, 28029 Madrid, Spain
| | - Richard O. Sinnott
- Department of Computing and Information, University of Melbourne, 3010 Melbourne, Australia
| | | | - Karel Pacak
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | - Graeme Eisenhofer
- Medicine ΙΙI and
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, D-01307 Dresden, Germany
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Abstract
Acute hypertension (HTN) in hospitalized children and adolescents occurs relatively frequently, and in some cases, if not recognized and treated promptly, it can lead to hypertensive crisis with potentially significant morbidity and mortality. In contrast to adults, where acute HTN is most likely due to uncontrolled primary HTN, children and adolescents with acute HTN are more likely to have secondary HTN. This review will briefly cover evaluation of acute HTN and various age-specific etiologies of secondary HTN and provide more in-depth discussion on treatment targets, potential risks of acute HTN therapy, and available pediatric data on intravenous and oral antihypertensive agents, and it proposes treatment schema including unique therapy of specific secondary HTN scenarios.
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Affiliation(s)
- Tennille N. Webb
- Pediatric Nephrology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15206, USA, Phone: 412-692-5182, Fax: 412-692-7443
| | - Ibrahim F. Shatat
- Division of Pediatric Nephrology and Hypertension, Medical University of South Carolina, Children's Hospital, 96 Jonathan Lucas Street, CSB-428, Charleston, SC 29425, USA, Phone: 843-792-8904, Fax: 843-792-2033
| | - Yosuke Miyashita
- Pediatric Nephrology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15206, USA, Phone: 412-692-5182, Fax: 412-692-7443
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Bettesworth JG, Martin DP, Tobias JD. Intraoperative Use of Clevidipine in a Patient With von Hippel-Lindau Disease With Associated Pheochromocytoma. J Cardiothorac Vasc Anesth 2013; 27:749-51. [DOI: 10.1053/j.jvca.2011.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Indexed: 11/11/2022]
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Patankar SB, Shah RB, Oza NN. Laparoscopic resection of extra-adrenal pheochromocytoma in paediatric age. J Minim Access Surg 2012; 8:13-5. [PMID: 22303083 PMCID: PMC3267329 DOI: 10.4103/0972-9941.91774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 06/09/2011] [Indexed: 11/14/2022] Open
Abstract
Today, in the era of minimally invasive surgery, paediatric laparoscopy has become widely popular. Extra-adrenal pheochromocytoma is a very rare entity, especially in the paediatric age group and utility of the laparoscopic approach is not established in this population. Early diagnosis and surgical excision are integral part of treatment of childhood pheochromocytoma. We present a case study of a child with hormonally active extra-adrenal pheochromocytoma that was resected laparoscopically. Laparoscopic approach provides excellent exposure with magnification and allows proper identification of the tumour and its relation to surrounding structures; complete resection of tumour was achieved with adequate vascular control. With our initial experience, we suggest laparoscopic resection is an appropriate and feasible tool in such cases.
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Affiliation(s)
- Suresh B Patankar
- Department of Urology, AMAI Trust's Ace Hospital, Pune, Maharashtra, India
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Georgetti FCD, Eugênio GDR. Feocromocitoma: uma causa rara de hipertensão arterial na infância. REVISTA PAULISTA DE PEDIATRIA 2007. [DOI: 10.1590/s0103-05822007000300015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Relatar o caso de um adolescente com feocromocitoma, uma causa rara de hipertensão arterial na infância. DESCRIÇÃO: Adolescente internado em unidade de terapia intensiva infantil em decorrência de emergência hipertensiva, conseqüente à presença de feocromocitoma em adrenal esquerda, diagnosticado por meio de tomografia computadorizada do abdome e pela dosagem de adrenalina e noradrenalina urinárias. O paciente foi submetido à adrenalectomia esquerda, após o uso de alfa-bloqueador para controle do quadro hipertensivo. O anatomopatológico confirmou o diagnóstico do tumor. No pós-operatório, o paciente permaneceu estável, possibilitando a suspensão dos anti-hipertensivos. COMENTÁRIOS: Os feocromocitomas são tumores capazes de produzir catecolaminas, especialmente adrenalina e/ou noradrenalina. Cerca de 85 a 95% dos tumores são únicos, benignos e encontrados na medula adrenal. O feocromocitoma é um tumor de incidência rara e apenas 10 a 20% ocorrem na infância, representando uma causa rara de hipertensão arterial. Esta última é um sinal freqüente na maioria das crianças (80%), podendo ser acompanhada por cefaléia e sudorese. A encefalopatia hipertensiva consiste em uma forma de apresentação excepcional da doença. O diagnóstico pode ser realizado, na maioria dos casos, pela tomografia de abdome e pela dosagem das catecolaminas e seus metabólitos produzidos pelo tumor. O tratamento de escolha consiste na ressecção completa do tumor após o preparo farmacológico do paciente com o uso de alfa-bloqueador. No pós-operatório, a maioria dos pacientes evolui com controle do quadro de hipertensão arterial.
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Barontini M, Levin G, Sanso G. Characteristics of pheochromocytoma in a 4- to 20-year-old population. Ann N Y Acad Sci 2006; 1073:30-7. [PMID: 17102069 DOI: 10.1196/annals.1353.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Hypertension in children and adolescents has become a major health problem recently recognized, and in a significant number of patients it is due to an endocrine tumor. The aim of this study was to establish the characteristics of pheochromocytoma in a population of 58 patients between 4 and 20 years of age studied at our Center. They represented a 23% of the total population of 255 pheochromocytoma patients studied. In the younger group (under 20 years of age), there was a marked predominance of severe sustained hypertension (93%), only 7% presented paroxysmal hypertension and none of them was normotensive. The youngsters studied showed a higher incidence of bilateral adrenal pheochromocytoma (34%) and extra-adrenal pheochromocytoma (22%). Malignancy was found in 12% of these patients. In addition, the incidence of familial pheochromocytoma was elevated in these patients (39%). Surprisingly, in contrast with the adult population where the most frequent familial pheochromocytomas were multiple endocrine neoplasia (MEN) type 2A (15%), the younger population showed a higher predominance of von Hippel-Lindau (VHL) (28%) and lower incidence of MEN 2A, MEN 2B, neurofibromatosis (NF), and succinate dehydrogenase subunit B (SDHB). In the VHL group, only two patients belonging to one family, showed the R167W mutation, while the others showed novel mutations in conserved amino acids. It may be speculated that the high incidence of VHL in youngsters may account for the biochemical and clinical features they usually present.
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Affiliation(s)
- Marta Barontini
- Centro de Investigaciones Endocrinológicas, Hospital de Niños Ricardo Gutiérrez, Gallo 1360, (1425) Buenos Aires, Argentina.
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Abstract
Adrenal tumors, apart from neuroblastoma, are relatively rare in infancy and childhood. Most adrenal lesions are benign, and both benign and malignant tumors may be hormonally active thus, making accurate preoperative diagnosis difficult. The two main malignant tumors are adrenocortical carcinoma and pheochromocytoma. In both tumors, it may be difficult to determine benign from malignant and the biologic behavior and degree of invasion may portend a more malignant course. Surgical excision is the primary therapy for both tumors, including excision of metastatic and recurrent tumor. An open procedure should be considered for invasive adrenocortical carcinoma and in pheochromocytomas in which preoperative imaging demonstrates metastatic nodal disease. A laparoscopic approach is preferred for lesions in which preoperative imaging demonstrates a localized lesion. Chemotherapy, although without proven efficacy, is utilized in some children with metastatic or unresectable disease.
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Affiliation(s)
- Frederick J Rescorla
- Section of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5200, USA.
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Sullivan J, Groshong T, Tobias JD. Presenting signs and symptoms of pheochromocytoma in pediatric-aged patients. Clin Pediatr (Phila) 2005; 44:715-9. [PMID: 16211197 DOI: 10.1177/000992280504400811] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To describe the varied presenting signs and symptoms in pediatric patients with pheochromocytoma, a retrospective chart review of the presenting signs and symptoms and subsequent clinical course of patients who presented to the Pediatric ICU following surgical excision of a pheochromocytoma was undertaken. The cohort of 7 patients (5 boys, 2 girls) ranged in age from 4 to 16 years. Two patients were hypertensive at initial presentation, and the other 5 developed hypertension after their initial presentation. The initial presenting signs and symptoms were related to the central nervous system (CNS) in 6 of the patients (5 with an acute alteration in mental status and 1 with visual disturbances). Two patients presented with congestive heart failure. Other signs and symptoms at the time of initial presentation included sweating, headache, weight loss, heat intolerance, increased thirst and urination, a decline in school activity, and red/puffy hands and feet. The time from the initial presentation until the diagnosis was confirmed was 5 months or more in 4 of the 7 patients. The diagnosis was confirmed by demonstration of elevated urinary catecholamines in all 7 patients, although 2 patients had initial negative urinary levels.
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Affiliation(s)
- Janet Sullivan
- University of Missouri School of Medicine, Columbia, Missouri 65212, USA
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Abstract
BACKGROUND/PURPOSE Etiopathogenesis, management, and outcome of pediatric pheochromocytoma (PHEO) still is obscure because of limited number of cases. Therefore, a retrospective clinical study was performed to present an updated picture of the entire spectrum of pediatric PHEO based on the authors' 30 years' experience consisting of one of the largest noncollected series treated in a single medical center. METHODS Records of patients treated for PHEO in the authors' unit from 1970 to 1999, inclusive, were reviewed retrospectively. Information recorded for each patient included age, sex, past medical and family history, clinical characteristics, diagnostic methods, treatment, pathologic findings, and outcome. RESULTS Sixteen children with a mean age of 10.7 +/- 2.9 years consisting of 12 boys and 4 girls were treated for PHEO. Most of the tumors were right sided (n = 6) and bilateral (n = 6). Sporadic cases of PHEO accounted for 14 patients (88%), whereas 2 children had von Hippel-Lindau (VHL) disease and multiple endocrine neoplasia type 2b (MEN2b). Hypertension was the most common symptom followed by headache and sweating. The diagnosis of PHEO was made by laboratory and radiologic studies. Preoperative medical therapy was done in all patients. Laparotomy confirmed that 11 patients had localized, 4 patients had regional, and 1 patient had metastatic disease. The localized tumors were excised totally by bilateral (n = 4) and unilateral (n = 6) adrenalectomy. Surgical procedures performed for regional disease were total excision (n = 2), incisional biopsy (n = 1) and partial excision (n = 1). Incisional biopsy could be taken only from a patient with metastatic disease at presentation. Two patients with localized disease and 2 patients with regional disease had benign recurrences in right (n = 2) and left (n = 2) adrenal glands within 3 to 7 years after operation. Total excision of the recurrent tumors was done in all patients. Pathologic examination found apparently malignant features in 3 patients who presented with regional (n = 2) or metastatic (n = 1) disease and underwent incisional biopsy (n = 2) or partial excision (n = 1). Pathologic features suggestive of malignancy were noted in 4 patients presenting with regional (n = 2) and localized disease (n = 2). Apparently benign pathologic features were noted in the remaining 9 patients. There was not any operative mortality in our series. Adjuvant chemotherapy was commenced postoperatively in all patients with malignant and suggestive of malignant pathologic features. During the long-term follow-up for 16 years, 3 patients died (19%). One patient with VHL disease died of astrositoma 5 years after her recurrent PHEO was excised. Of the 3 patients with malignant disease, 2 patients in whom only incisional biopsies were done had distant metastases and died of disease within 2 years. Another patient with malignancy who had MEN2b was lost to follow-up. CONCLUSIONS Early diagnosis and total excision are the most important aspects of accurate treatment for childhood PHEO. Pre- intra- and postoperative medical management is as important as the surgical procedure. Our surgical treatment policy is mainly minimizing the risk of recurrence while preserving adequately functioning adrenal medullar tissue. Incomplete excision and advanced-stage disease are the major determinants of poor outcome. None of the clinical, laboratory, or pathologic features are reliable predictors for recurrence and discrimination of malignancy. Because of the steadily increasing incidence of precancerous genetic syndromes related to adrenal glands and poor prognosis of advanced-stage PHEO, childhood cases of hypertensive disorders should receive a detailed and vigorous diagnostic evaluation and appropriate treatment as given to adults.
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Affiliation(s)
- A O Ciftci
- Department of Pediatric Surgery, Hacettepe University Medical Faculty, Ankara, Turkey
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Abstract
Hypertension in children is not a common problem. When it is found, however, a pathologic cause can often be identified. The endocrine causes of hypertension in children are generally rare. We have reviewed the diverse and rare endocrine causes of hypertension in the pediatric population. Table 3 lists features of these conditions that assist in their diagnosis. In all patients with hypertension, a thorough history and physical examination may point to the diagnosis of endocrine or other causes of secondary hypertension. For a more detailed approach to these diagnoses, other reviews may be helpful. A phased laboratory evaluation similar to that suggested by Ogborn and Crocker facilitates in the evaluation of secondary hypertension. The critical screening tests from an endocrine point of view are plasma sodium, potassium, calcium, renin activity, and thyroid function tests, including T4, T3, and thyroid stimulating hormone. Measurement of a 24-hour urine collection for aldosterone, metanephrine, and catecholamines may be warranted if the previously mentioned studies are unrevealing. More specific studies also may be suggested by these preliminary evaluations and the history and physical examination. Further investigations should be done with the additional guidance of a pediatric endocrinologist.
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Affiliation(s)
- C J Rodd
- Division of Endocrinology and Metabolism, University of Minnesota, Minneapolis
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