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Weber F, Belker J, Unger N, Lahner H, Theurer S, Schmid KW, Führer D, Dralle H. [Pheochromocytomatosis after adrenalectomy: metastasis or cell seeding?]. Chirurg 2019; 91:345-353. [PMID: 31781805 DOI: 10.1007/s00104-019-01070-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pheochromocytomatosis is defined as a multifocal cell dissemination limited to the operatively opened space with no signs of distant metastasis. After primary adrenalectomy due to a pheochromocytoma this is a rare and underrecognized manifestation of a tumor recurrence. Between 2010 and 2019 a total of 5 patients with the presentation of pheochromocytomatosis were treated in this center. Clinical and survival data were compared to 12 patients with a metastasized pheochromocytoma. Patients presenting with pheochromocytomatosis showed a better but not significant overall survival (136.8 vs. 107 months). Furthermore, patients with pheochromocytomatosis presented more often with a noradrenaline secretion type. Tumor recurrence in the pheochromocytomatosis group occurred on average 69.2 months after the initial diagnosis and was therefore much later than in patients with distant metastases from a pheochromocytoma (39 months, p = 0.13). This article outlines this special manifestation of recurrence of a pheochromocytoma based on this patient collective. Besides technical operative aspects there appears to be evidence for tumor-specific factors that promote the development of pheochromocytomatosis. Importantly, it seems that all patients with a pheochromocytoma should receive lifelong aftercare and that patients should be closely monitored during the first 5 years after surgery.
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Affiliation(s)
- F Weber
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland.
| | - J Belker
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland
| | - N Unger
- Klinik für Endokrinologie und Stoffwechselerkrankungen, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland
| | - H Lahner
- Klinik für Endokrinologie und Stoffwechselerkrankungen, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland
| | - S Theurer
- Institut für Pathologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland
| | - K W Schmid
- Institut für Pathologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland
| | - D Führer
- Klinik für Endokrinologie und Stoffwechselerkrankungen, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland
| | - H Dralle
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Sektion Endokrine Chirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstraße 55, 45124, Essen, Deutschland
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Andrade MDO, Cunha VSD, Oliveira DCD, Moraes OLD, Lofrano-Porto A. What determines mortality in malignant pheochromocytoma? – Report of a case with eighteen-year survival and review of the literature. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:264-269. [PMID: 29768630 PMCID: PMC10118982 DOI: 10.20945/2359-3997000000033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/19/2018] [Indexed: 11/23/2022]
Abstract
Pheochromocytoma (PCC) is a tumor derived from adrenomedullary chromaffin cells. Prognosis of malignant PCC is generally poor due to local recurrence or metastasis. We aim to report a case of malignant PCC with 18-year survival and discuss which factors may be related to mortality and long-term survival in malignant pheochromocytoma. The patient, a 45-year-old man, reported sustained arterial hypertension with paroxysmal episodes of tachycardia, associated with head and neck burning sensation, and hand and foot tremors. Diagnosis of PCC was established biochemically and a tumor with infiltration of renal parenchyma was resected. No genetic mutation or copy number variations were identified in SDHB, SDHD, SDHC, MAX and VHL. Over 18 years, tumor progression was managed with 131I-MIBG (iodine-metaiodobenzylguanidine) and 177Lutetium-octreotate therapy. Currently, the patient is asymptomatic and presents sustained stable disease, despite the presence of lung, para-aortic lymph nodes and femoral metastases. Adequate response to treatment with control of tumor progression, absence of significant cardiovascular events and other neoplasms, and lack of mutations in the main predisposing genes reported so far may be factors possibly associated with the prolonged survival in this case. Early diagnosis and life-long follow-up in patients with malignant pheochromocytoma are known to be crucial in improving survival.
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Farrugia FA, Martikos G, Tzanetis P, Charalampopoulos A, Misiakos E, Zavras N, Sotiropoulos D. Pheochromocytoma, diagnosis and treatment: Review of the literature. Endocr Regul 2017; 51:168-181. [DOI: 10.1515/enr-2017-0018] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Abstract
Objective. We conducted an extensive review of the literature and tried to cite the most recent recommendations concerning the pheochromocytoma (PHEO).
Methods. Pub Med and Google Scholar databases were searched systematically for studies concerning pheochromocytomas (intra-adrenal paragangliomas) from 1980 until 2016. Bibliographies were searched to find additional articles.
Results. More than four times elevation of plasma fractionated metanephrines or elevated 24-h urinary fractionated metanephrines are keys to diagnosing pheochromocytoma. If the results are equivocal then we perform the clonidine test. If we have not done it already, we preferably do a CT scan and/or an MRI scan. The patient needs pre-treatment with α1-blockers at least 10–14 days before operation. Alternatives or sometimes adjuncts are Calcium Channels Blockers and/or β-Blockers. Several familial syndromes are associated with PHEO and genetic testing should be considered.
Conclusions. The biggest problem for pheochromocytoma is to suspect it in the first place. Elevated metanephrines establish the diagnosis. With the proper preoperative preparation the risks during operation and the postoperative period are minimal. If there is a risk of the hereditable mutation, it is strongly suggested that all the patients with pheochromocytoma need clinical genetic testing.
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Affiliation(s)
- FA Farrugia
- 3 University Department of Surgery, Attikon University Hospital , University of Athens, School of Medicine , Athens , Greece
| | - G Martikos
- 3 University Department of Surgery, Attikon University Hospital , University of Athens, School of Medicine , Athens , Greece
| | - P Tzanetis
- 3 University Department of Surgery, Attikon University Hospital , University of Athens, School of Medicine , Athens , Greece
| | - A Charalampopoulos
- 3 University Department of Surgery, Attikon University Hospital , University of Athens, School of Medicine , Athens , Greece
| | - E Misiakos
- 3 University Department of Surgery, Attikon University Hospital , University of Athens, School of Medicine , Athens , Greece
| | - N Zavras
- 3 University Department of Surgery, Attikon University Hospital , University of Athens, School of Medicine , Athens , Greece
| | - D Sotiropoulos
- 3 University Department of Surgery, Attikon University Hospital , University of Athens, School of Medicine , Athens , Greece
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Yu R, Sharaga D, Donner C, Palma Diaz MF, Livhits MJ, Yeh MW. Pheochromocytomatosis associated with a novel TMEM127 mutation. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170026. [PMID: 28567294 PMCID: PMC5445434 DOI: 10.1530/edm-17-0026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 04/10/2017] [Indexed: 11/20/2022] Open
Abstract
Pheochromocytomatosis, a very rare form of pheochromocytoma recurrence, refers to new, multiple, and often small pheochromocytomas growing in and around the surgical resection bed of a previous adrenalectomy for a solitary pheochromocytoma. We here report a case of pheochromocytomatosis in a 70-year-old female. At age 64 years, she was diagnosed with a 6-cm right pheochromocytoma. She underwent laparoscopic right adrenalectomy, during which the tumor capsule was ruptured. At age 67 years, CT of abdomen did not detect recurrence. At age 69 years, she began experiencing episodes of headache and diaphoresis. At age 70 years, biochemical markers of pheochromocytoma became elevated with normal calcitonin level. CT revealed multiple nodules of various sizes in the right adrenal fossa, some of which were positive on metaiodobenzylguanidine (MIBG) scan. She underwent open resection of pheochromocytomatosis. Histological examination confirmed numerous pheochromocytomas ranging 0.1–1.2 cm in size. Next-generation sequencing of a panel of genes found a novel heterozygous germline c.570delC mutation in TMEM127, one of the genes that, if mutated, confers susceptibility to syndromic pheochromocytoma. Molecular analysis showed that the c.570delC mutation is likely pathogenic. Our case highlights the typical presentation of pheochromocytomatosis, a rare complication of adrenalectomy for pheochromocytoma. Previous cases and ours collectively demonstrate that tumor capsule rupture during adrenalectomy is a risk factor for pheochromocytomatosis. We also report a novel TMEM127 mutation in this case.
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Affiliation(s)
- Run Yu
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Danielle Sharaga
- Cancer Center of Santa Barbara with Sansum Clinic, Santa Barbara, California, USA
| | | | | | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, USA
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Javid M, Callender GG, Baregamian N, Carling T. Pheochromocytomatosis Treated By Radio-Guided Surgery. AACE Clin Case Rep 2017. [DOI: 10.4158/ep151053.cr] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Choi WS, Park JY, Roh MS, Choi PJ. Malignant pheochromocytoma with lung metastasis after right adrenalectomy for pheochromocytoma eleven years ago. J Thorac Dis 2015; 7:E37-42. [PMID: 25922747 DOI: 10.3978/j.issn.2072-1439.2015.01.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/05/2014] [Indexed: 11/14/2022]
Abstract
A 30-year-old woman had multiple masses on right adrenalectomy site, posterior mediastinum, and left lung on computed tomography (CT) and positron emission tomography. She had a right adrenalectomy for pheochromocytoma eleven years ago. She received proper alpha and beta blocker and completed surgical resection. Pheochromocytoma was confirmed by histopathology. Here we report the case of metastatic malignant pheochromocytoma with very poor prognosis.
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Affiliation(s)
- Won Suk Choi
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Pathology, Dong-A University College of Medicine, Busan 602-715, South Korea
| | - Jong Yoon Park
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Pathology, Dong-A University College of Medicine, Busan 602-715, South Korea
| | - Mee Sook Roh
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Pathology, Dong-A University College of Medicine, Busan 602-715, South Korea
| | - Pil Jo Choi
- 1 Department of Thoracic and Cardiovascular Surgery, 2 Department of Pathology, Dong-A University College of Medicine, Busan 602-715, South Korea
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Parghane RV, Basher RK, Vatsa R, Shukla J, Bhattacharya A, Mittal BR. Breast Metastasis Detected on Ga-68 DOTATATE Positron Emission Tomography/Computed Tomography Imaging in Malignant Pheochromocytoma. World J Nucl Med 2015; 14:69-70. [PMID: 25709553 PMCID: PMC4337016 DOI: 10.4103/1450-1147.150563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Rahul Vithalrao Parghane
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajinder Kumar Basher
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakhee Vatsa
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jaya Shukla
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anish Bhattacharya
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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8
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Press D, Akyuz M, Dural C, Aliyev S, Monteiro R, Mino J, Mitchell J, Hamrahian A, Siperstein A, Berber E. Predictors of recurrence in pheochromocytoma. Surgery 2014; 156:1523-7; discussion 1527-8. [DOI: 10.1016/j.surg.2014.08.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 08/19/2014] [Indexed: 02/03/2023]
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9
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Robledo AB, Marco JLP, Ibáñez TB, Anastasio MFM, Gavara CG. Pheochromocytomatosis: A Risk after Pheochromocytoma Surgery. Am Surg 2010. [DOI: 10.1177/000313481007600810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrea Boscà Robledo
- La Fe University Hospital General Surgery, Department of Endocrine Surgery Valencia, Spain
| | - Jose Luis Ponce Marco
- La Fe University Hospital General Surgery, Department of Endocrine Surgery Valencia, Spain
| | - Tatiana Belda Ibáñez
- La Fe University Hospital General Surgery, Department of Endocrine Surgery Valencia, Spain
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11
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Wan WH, Tan KY, Ng C, Tay KH, Mancer K, Tay MH, Chia WKJ, Soo KC, Ooi LL. Metastatic malignant phaeochromocytoma: A rare entity that underlies a therapeutic quandary. Asian J Surg 2006; 29:294-302. [PMID: 17098666 DOI: 10.1016/s1015-9584(09)60106-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Phaeochromocytoma is a rare condition that provides a diagnostic challenge as a result of its variable presentation. Treatment of metastatic malignant phaeochromocytoma is also not well defined owing to its rarity. We present four such cases and a review of the literature. The database of the Singapore Cancer Registry was used to trace all cases of metastatic malignant phaeochromocytoma from 1984 to 2004, and the case records were then reviewed retrospectively. There were four patients with metastatic malignant phaeochromocytoma seen in Singapore in the last 20 years. Their variable clinical courses were reviewed and compared with current knowledge and overseas experience in the literature. We further discuss the difficulties in diagnosis, and the dilemma in appropriate management of such cases. Phaeochromocytoma remains a commonly missed diagnosis unless a high index of suspicion is maintained. Malignant phaeochromocytoma has a variable clinical course. There is a place for radical surgery if this can render the patient free of gross disease, or when it can achieve symptom control for palliation and improvement in quality of life. In the metastatic context, debulking surgery does not appear to be of curative benefit, although it may be undertaken for good palliation.
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Affiliation(s)
- Wei-Hwang Wan
- Department of General Surgery, Changi General Hospital, Singapore.
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12
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Sisson JC, Shulkin BL, Esfandiari NH. Courses of Malignant Pheochromocytoma: Implications for Therapy. Ann N Y Acad Sci 2006; 1073:505-11. [PMID: 17102118 DOI: 10.1196/annals.1353.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Survival of patients with metastatic pheochromocytoma that have exceeded 30 years without therapy to reduce tumors have been reported. We reviewed the records of 38 patients with malignant pheochromocytoma who had received 131I-metaiodiobenzylguanidine (131I-MIBG) treatments between 1981 and 1996 to evaluate longevity. Survival from diagnosis to last follow-up exceeded 5 years in 21 of 38 (55%) and >or=10 years in 50%. In 17 of 21, the interval from diagnosis to 131I-MIBG therapy was greater than 5 years. Survival following 131I-MIBG was >or=5 years in 12 of 17 and >or=10 years in 7 of 17 patients despite continued evidence of excessive circulating catecholamines. Objective responses to 131I-MIBG therapy were seen in about 30% and were usually of a few years, duration, but one individual exhibited marked reductions in volume and function of tumors that have persisted for 21 years. No feature, including a remission of >5 years following surgical excision, was found to predict prolonged survival. In summary, many patients with malignant pheochromocytoma will follow a course extending over many years. The role of 131I-MIBG therapy in longevity is uncertain, but this radiopharmaceutical reduces evidence of tumors in some patients. Criteria for selecting patients who will benefit from treatment remain to be determined.
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Affiliation(s)
- James C Sisson
- Division of Nuclear Medicine, UH B1 G505D, Department of Radiology, University of Michigan Health System, Ann Arbor, MI 48109-0028, and Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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13
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Mercuri S, Gazzeri R, Galarza M, Esposito S, Giordano M. Primary meningeal pheochromocytoma: case report. J Neurooncol 2005; 73:169-72. [PMID: 15981108 DOI: 10.1007/s11060-004-4595-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE AND IMPORTANCE Intracranial pheochromocytomas are extremely rare tumors. Reported cases include metastatic tumors without known cases of primary pheochromocytomas. CLINICAL PRESENTATION A female patient with a history of a surgically treated adrenal pheochromocytoma presented 23 years later with headache, nausea and blood hypertension. A head CT scan demonstrated a right temporoparietal meningeal heterogeneous lesion with a surrounding hyperdense ring. No other lesions were disclosed. INTERVENTION The lesion developed in the inner and outer surface of the dura without brain infiltration and it was totally resected. The patient is free of disease 6 years after brain surgery. CONCLUSION To our knowledge this is the first reported case of a primary meningeal pheochromocytoma.
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Affiliation(s)
- Sandro Mercuri
- Dipartimento di scienze Neurologiche - Neurochirurgia, Rome, Italy
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Abstract
Repeat adrenalectomy may be required due to ipsilateral recurrence of benign or malignant adrenal tumors after previous total or subtotal adrenalectomy. Even for multivisceral resection in patients with adrenocortical carcinoma, complete resection of local recurrent tumor offers results similar to those of primary resection (5-year survival 40-60%). In contrast, since no benefit on long-term survival has been shown so far by tumor debulking, palliative tumor resection should only be performed individually for control of severe endocrine symptoms. The effect of endoscopic adrenalectomy in patients with large tumors (>5 cm) or suspected malignancy has still not been well examined. Further studies are required. In any case, during open or endoscopic approach, tumor spillage must be avoided to prevent local tumor cell implantation. Following subtotal adrenalectomy, the risk of ipsilateral recurrence correlates with disease, follow-up, localization, size of the adrenal remnant, and, in case of familial pheochromocytoma, probably with genotype.
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Affiliation(s)
- M Brauckhoff
- Klinik für Allgemein-, Viszeral- und Gefässchirurgie, Martin-Luther-Universität Halle-Wittenberg, Halle/Saale.
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15
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Walz MK. Extent of adrenalectomy for adrenal neoplasm: cortical sparing (subtotal) versus total adrenalectomy. Surg Clin North Am 2004; 84:743-53. [PMID: 15145232 DOI: 10.1016/j.suc.2004.01.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The standard operation on adrenal neoplasias is a complete adrenalectomy. Accepted exceptions are bilateral inherited pheochromocytomas. In these cases, clinical and biochemical cure, as well as preservation of cortical function, can be achieved by a noncomplete adrenalectomy. In that procedure, at least one third of one gland has to be preserved. In unilateral adrenal tumors, partial resection has been used, especially in Conns adenomas, with early results comparable to those of total adrenalectomy. Because longterm results are still limited in hyperaldosteronism, final conclusions are not possible today.
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Affiliation(s)
- Martin K Walz
- Clinic of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Akademisches Lehrkrankenhaus der Universität Duisburg-Essen, Henricistrasse 92, D-45136, Essen, Germany.
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16
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Gupta NP, Goel A, Dodamani D, Ansari MS, Dureja GP. Recurrent adrenal pheochromocytoma: a case report. Int Urol Nephrol 2003; 34:9-11. [PMID: 12549630 DOI: 10.1023/a:1021309023695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We report an unusual case of benign recurrent pheochromocytoma that developed at the same site 8 years following initial treatment. This tumor was managed successfully through the 11th rib bed using the transperitoneal extrapleural approach.
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Affiliation(s)
- N P Gupta
- Department of Urology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
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17
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Li ML, Fitzgerald PA, Price DC, Norton JA. Iatrogenic pheochromocytomatosis: a previously unreported result of laparoscopic adrenalectomy. Surgery 2001; 130:1072-7. [PMID: 11742341 DOI: 10.1067/msy.2001.118373] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy is now regarded as the procedure of choice for treatment of small or benign adrenal tumors, including pheochromocytoma. However, long-term outcomes have not been critically assessed. We report here 3 cases of pheochromocytomatosis recurring 3 to 4 years after laparoscopic adrenalectomy. We postulate laparoscopic-induced seeding of tumor as the mechanism of recurrence. METHODS We retrospectively reviewed the cases of 3 patients with documented biochemical and radiolabeled metaiodobenzylguanidine evidence of recurrent pheochromocytoma after prior presumed curative laparoscopic adrenalectomy. RESULTS Original pheochromocytomas were 5.5 to 6.5 cm in diameter. At the time of laparoscopic adrenalectomy, tumors were not believed to be malignant, based on clinical or histopathologic data. However, on 3- to 4-year follow-up, each patient developed symptoms, elevated urinary catecholamine levels, and metaiodobenzylguanidine imaging consistent with recurrence. At reoperation, multiple small tumor nodules were found in the adrenal bed near the site of the initial laparoscopic resection. The original operative notes suggested some possible method of local seeding: tumor fragmentation and spillage or excessive tumor manipulation. CONCLUSIONS Pheochromocytoma recurrence may occur as a result of local spillage of tumor during laparoscopic adrenalectomy. The relative risk of recurrence between open and laparoscopic resection needs to be assessed. Long-term follow-up will continue to be important, regardless of operative approach.
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Affiliation(s)
- M L Li
- University of California, San Francisco, Calif., USA
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18
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Kanomata F, Mello ELRD, Correa JHS. Tratamento cirúrgico da metástase de feocromocitoma. Rev Col Bras Cir 2001. [DOI: 10.1590/s0100-69912001000500015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
We report the case of a malignant primary cardiac pheochromocytoma treated by adjuvant cytotoxic chemotherapy after surgical resection, with a 5-year survival. There is no specific chemotherapy for malignant pheochromocytoma, but because it has the same embryologic origin as neuroblastoma, we used similar chemotherapy. Because of unexpected malignancy potential, we think that total and meticulous resection of the tumor must be done.
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Affiliation(s)
- A Jirari
- Department of Cardiovascular Surgery, Hospital Civil de Strasbourg, France.
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20
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Obara T, Kanbe M, Okamoto T, Ito Y, Yamashita T, Ito K, Hirose K, Yamazaki K, Hagihara J, Kusakabe K. Surgical strategy for pheochromocytoma: emphasis on the pledge of flank extraperitoneal approach in selected patients. Surgery 1995; 118:1083-9. [PMID: 7491527 DOI: 10.1016/s0039-6060(05)80118-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Anterior transabdominal exploration has traditionally been advocated as the standard procedure for pheochromocytoma. However, some authors claim that a flank extraperitoneal approach with accurate unilateral localization is justifiable. METHODS Retrospective analysis was performed on 87 patients with pheochromocytoma to determine the appropriateness of extraperitoneal exploration. RESULTS There were 45 men and 42 women with a mean age of 44.7 years (range, 16 to 83 years). Fifteen patients (17.5%) had pheochromocytoma as a part of multiple endocrine neoplasia (MEN) type 2A, and four had familial pheochromocytoma, von Hippel-Lindau disease, or von Recklinghausen's disease. All tumors detected by preoperative localization studies were correctly identified and were resected through flank extraperitoneal (45 patients), transabdominal (28), thoracoabdominal (13), and posterior (1) approaches. Tumors were extraadrenal in 14, multiple in 22, bilateral in 12, and unequivocally malignant in 2 patients at the initial operation. Two patients died during the immediate postoperative period, giving an operative mortality of 2.3%. Two patients had persistent disease. During follow-up within a mean period of 5 years (range, 1 month to 13.7 years) 8 patients (9.1%) experienced recurrence or metastasis. Other than the patients with MEN 2, recurrence was not attributable to the operative approach. CONCLUSIONS If a preoperative localization study is accurate, an extraperitoneal approach is justifiable for many patients with pheochromocytomas.
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Affiliation(s)
- T Obara
- Department of Endocrine Surgery, Tokyo Women's Medical College, Japan
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21
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Zogakis TG, Norton JA. Palliative operations for patients with unresectable endocrine neoplasia. Surg Clin North Am 1995; 75:525-38. [PMID: 7538230 DOI: 10.1016/s0039-6109(16)46638-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
No good randomized studies exist for many types of endocrine tumors to prove that surgery increases the survival of patients with these tumors. However, many case reports and our own experience suggest that it does. Therefore, surgery may be performed to potentially increase the survival of patients with metastatic and localized malignant endocrine tumors. Subsequently, these tumors may still recur locally or distantly. Therefore, surgery is usually a palliative procedure but is occasionally curative. Because endocrine tumors secrete hormonal substances resulting in particular syndromes, debulking surgery may be necessary to control hormonal syndromes. The location of a tumor may cause mass symptoms that can also be relieved by surgery. Thus, many patients with malignant endocrine neoplasia benefit from aggressive surgery. The surgeon must determine the resectability of the tumor as well as the operative morbidity and benefit to the patient before proceeding.
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Affiliation(s)
- T G Zogakis
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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22
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Brückner M, Padberg BC, Dürig M, Schröder S. [Malignant adrenal pheochromocytoma--problems in evaluating clinical diagnosis and morphologic extent]. LANGENBECKS ARCHIV FUR CHIRURGIE 1993; 378:37-40. [PMID: 8437501 DOI: 10.1007/bf00207993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Reports on three patients with malignant adrenal phaeochromocytoma are used as a basis for discussion of involved in diagnosing functionally inactive paragangliomas and in discriminating between benign and malignant adrenomedullary tumours. Malignancy can so far only be ascertained in such neoplasms by evidence of metastatic growth. Our findings, however, show that increased tumour weight (more than 200 g), high mitotic activity (more than 5 mitoses per HPF) and loss of S-100 protein-positive subtentacular cells make it possible to distinguish high-risk cases (with increased risk of recurrence and metastasis).
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Affiliation(s)
- M Brückner
- Abteilung für Allgemeinchirurgie, Universitätsklinik Hamburg Eppendorf
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23
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Proye C, Vix M, Goropoulos A, Kerlo P, Lecomte-Houcke M. High incidence of malignant pheochromocytoma in a surgical unit. 26 cases out of 100 patients operated from 1971 to 1991. J Endocrinol Invest 1992; 15:651-63. [PMID: 1479148 DOI: 10.1007/bf03345810] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In this surgical series of 100 pheochromocytomas (PH), where 91 cases were studied and followed up, the frequency of malignancy appears high (29%) on macroscopic criteria observed at the first operation (25 out 26 cases of malignant PH) or thanks to the occurrence of metastases (1 case out of 26 malignant PH). While some clinical signs are suggestive, there is no excretory profile predictive of malignancy. Isolated or predominant secretion of dopamine is not specific of malignancy event if it occurs more frequently and severely in malignant PH. Bilateral involvement, occurring in the setting of phacomatosis or of multiple endocrine neoplasia (MEN II), or in a sporadic case, is not a predictor for malignancy. Contrarily, extraadrenal involvement is a major feature indicative of malignancy. A CT scan which demonstrates possible locoregional invasion, and a MIGB scan revealing distant localizations raise the suspicion of malignancy. The preferred surgical approach is via a laparotomy, thus allowing the exploration of all possible abdominal chromaffin site and the search for intraabdominal metastases. Intraoperative MIBG scanning checks the completeness of the excision. Flow cytometric DNA ploidy studies have been performed in 25 of our patients. The follow up of benign or malignant PH, after excision "for cure" must be life-long: clinically, biologically and by MIGB scan. Persistence of the disease after surgery or recurrence with unresectable metastases can benefit from MIGB and chemotherapy.
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Affiliation(s)
- C Proye
- Surgical Professorial Unit, Department of General and Endocrine Surgery, Lille, France
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24
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Nativ O, Grant CS, Sheps SG, O'Fallon JR, Farrow GM, van Heerden JA, Lieber MM. Prognostic profile for patients with pheochromocytoma derived from clinical and pathological factors and DNA ploidy pattern. J Surg Oncol 1992; 50:258-62. [PMID: 1640712 DOI: 10.1002/jso.2930500413] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Eighty-eight patients with pheochromocytoma and paraganglioma treated over a 28 year period (1960-1987) were studied. Based on clinical course, they were divided into three prognostic groups: benign (n = 57); multiple (n = 12); and metastatic (n = 19). Using clinical data, histopathologic findings, and tumor nuclear DNA content a prognostic profile for each group was constructed. The following variables were studied: age, familial pheochromocytoma, associated endocrine or neoplastic disorders, number and location of the lesion at diagnosis, size of the tumor, and the nuclear DNA ploidy pattern. Of these prognostic factors the most significant to predict a future malignant clinical course were large size and local tumor extension at time of surgery. Family history of pheochromocytoma, associated endocrine disorders, and young age at presentation predicted multiplicity. Old age, absence of familial pheochromocytoma or related endocrine disorders and DNA diploid tumors seem to be favorable findings. Using these variables in combination may be helpful for early identification of patients with malignant, multiple, or benign pheochromocytoma and paraganglioma.
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Affiliation(s)
- O Nativ
- Department of Urology, Mayo Clinic, Rochester, Minnesota
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25
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van Heerden JA, Roland CF, Carney JA, Sheps SG, Grant CS. Long-term evaluation following resection of apparently benign pheochromocytoma(s)/paraganglioma(s). World J Surg 1990; 14:325-9. [PMID: 1973322 DOI: 10.1007/bf01658516] [Citation(s) in RCA: 123] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In the absence of distant disease, the pathologic diagnosis of malignancy in pheochromocytoma or paraganglioma is impossible. In an effort to establish the true incidence of recurrence in this disease, we have analyzed long-term follow-up (average, 15.8 years) of 98 patients who underwent complete resection of localized, noninvasive, histologically-benign pheochromocytomas and paragangliomas at our institution between 1960 and 1976. Eighty-eight patients had nonfamilial, sporadic pheochromocytoma/paraganglioma. Nine had multiple endocrine neoplasia (MEN) type 2 (2A: 7, 2B: 2), and 1 had familial pheochromocytoma. Seventy-nine patients had single pheochromocytomas; 10 had single extraadrenal tumors (paragangliomas); and 9 had multicentric or bilateral adrenal tumors. Six patients (6.5%) developed recurrent pheochromocytoma after documentation of normal postoperative urinary catecholamine levels. One of these patients had MEN 2A. The recurrences developed at intervals from 5 to 13 years following initial resection. These were distant in 3 patients, local in 2, and both local and distant in a single patient. None of the recurrences occurred in the 13 patients who, on pathologic rereview, had either local or vascular invasion. No paraganglioma recurred. Life-long follow-up of all patients who have had pheochromocytomas or paragangliomas resected is mandatory.
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Affiliation(s)
- J A van Heerden
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905
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26
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Chevinsky AH, Minton JP. Ablation of recurrent and metastatic intraabdominal tumor with the CO2 laser. Lasers Surg Med 1990; 10:5-11. [PMID: 2308464 DOI: 10.1002/lsm.1900100104] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A retrospective study was carried out to determine the usefulness of the CO2 laser in the management of patients with recurrent and metastatic intraabdominal tumors. Twenty-six intraabdominal procedures utilizing the laser were carried out on 24 patients at The Ohio State University between 1984 and 1988. This included 11 patients with recurrent adenocarcinoma of colonic origin, 3 patients with malignant carcinoid tumors, 3 patients with ovarian carcinomas, and one patient each with metastatic pheochromocytoma, appendix, breast, stomach, and lung carcinoma. In addition, there was one patient with pseudomyxoma peritoneii and one patient with both colonic and ovarian carcinoma. Tumors were located in the retroperitoneum (3), pelvis (2), liver (11), bowel serosa (5), diaphragm (4), mesentery (3), and peritoneal implants (3). The laser was used as an adjunct to standard surgical techniques and in most instances was combined with other operative procedures. Its use was greatest in cases where en bloc resection was impossible, as with hepatic lesions located near the hepatic veins or vena cava. Additional benefit was derived in cases where cytoreductive or debulking surgery was useful as in ovarian carcinoma and metastatic neuroendocrine tumors. All four patients with neuroendocrine tumors are still alive 3, 7, 12, and 56 months after surgery. In addition, symptom relief was apparent in all after surgery. All patients with ovarian carcinoma are also alive 9-29 months after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A H Chevinsky
- Department of Surgery, Ohio State University College of Medicine, Columbus 43210
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27
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Cheung PS, Thompson NW, Dmuchowski CF, Sisson JC. Spectrum of pheochromocytoma in the 131I-MIBG era. World J Surg 1988; 12:546-51. [PMID: 2901801 DOI: 10.1007/bf01655447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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28
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Sparagana M. Late recurrence of benign pheochromocytomas: the necessity for long-term follow-up. J Surg Oncol 1988; 37:140-6. [PMID: 3343842 DOI: 10.1002/jso.2930370216] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Two patients who had removal of seemingly benign pheochromocytomas had recurrences 10 and 14 years later despite normal catecholamine excretion for 7 and 9 years postoperatively. The first patient returned with a myocardial infarction and an apparently solitary recurrence; the second patient with a stroke and metastatic disease. Both patients had recurrence of hypertension and increased catecholamine excretion. They were given phenoxybenzamine and are doing satisfactorily 7 and 9 years after their recurrences. Such patients should be followed after surgery for 15 or more years for early detection of recurrences. Prompt therapy should reduce the risk of undesirable complications.
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Affiliation(s)
- M Sparagana
- Medical Service, Veterans Administration Hospital, Hines, Illinois
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29
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Lewi HJ, Reid R, Mucci B, Davidson JK, Kyle KF, Macpherson SG, Semple P, Kaye S. Malignant phaeochromocytoma. BRITISH JOURNAL OF UROLOGY 1985; 57:394-8. [PMID: 4027507 DOI: 10.1111/j.1464-410x.1985.tb06295.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Malignant phaeochromocytoma is a rare tumour and experience in its management is therefore limited. Five patients are discussed in whom the development of metastases was associated with rapidly progressive disease.
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30
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Keiser HR, Goldstein DS, Wade JL, Douglas FL, Averbuch SD. Treatment of malignant pheochromocytoma with combination chemotherapy. Hypertension 1985; 7:I18-24. [PMID: 3997232 DOI: 10.1161/01.hyp.7.3_pt_2.i18] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Three patients with rapidly progressive, disseminated malignant pheochromocytoma were treated with a combination chemotherapeutic regimen consisting of cyclophosphamide, vincristine, and dacarbazine in repeated 21- to 28-day cycles. All three patients had a marked decrease in blood pressure and an improvement in performance status within the first few cycles of treatment. At a follow-up of 6 to 13 months all patients continue to receive chemotherapy with further regression of tumor in two and stable disease in one. Their blood pressure is normal with minimal or no antiadrenergic therapy. Therapy has been well tolerated; moderate reversible granulocytopenia, neurotoxicity, and one episode of pneumonitis have been the major toxicities encountered. Thus, combination chemotherapy appears to be effective for symptomatic malignant pheochromocytoma.
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31
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Welbourn RB, Manolas KJ, Khan O, Galland RB. Tumors of the neuroendocrine system (APUD cell tumors--Apudomas). Curr Probl Surg 1984; 21:1-73. [PMID: 6146496 DOI: 10.1016/0011-3840(84)90033-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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