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Kishlyansky D, Ramesh R, Cook O, Luthra M. Inferior Laryngeal Nerve Paraganglioma With Norepinephrine Hypersecretion Diagnosed Shortly After Pregnancy. JCEM CASE REPORTS 2024; 2:luae107. [PMID: 38947415 PMCID: PMC11211820 DOI: 10.1210/jcemcr/luae107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Indexed: 07/02/2024]
Abstract
The diagnosis of pheochromocytoma or paraganglioma (PGL) during pregnancy is extremely rare, with 2 large case series suggesting that the prevalence is between 0.0002% and 0.007%. Here, we present a case of a 38-year-old woman who presented during pregnancy with clinical features suggestive of preeclampsia and was found to have a norepinephrine-secreting inferior laryngeal nerve PGL, which was diagnosed after pregnancy. She underwent uncomplicated surgical resection and genetic testing revealed a succinate dehydrogenase subunit B (SDHB) pathogenic variant. In conclusion, PGLs diagnosed during pregnancy and hypersecreting head and neck PGLs are both rare clinical entities. Hyperfunctioning PGLs may mimic pregnancy-induced hypertension or preeclampsia. Metanephrine testing should be considered in patients with atypical features and can be reliably assessed using nonpregnant reference ranges. Overall, maternal and fetal mortality has improved considerably with early diagnosis and treatment.
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Affiliation(s)
- David Kishlyansky
- McMaster University, Division of Endocrinology and Metabolism, Hamilton, ON L8S 4L8, Canada
| | - Rithvika Ramesh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8P 1H6, Canada
| | - Olivia Cook
- McMaster University, Division of Endocrinology and Metabolism, Hamilton, ON L8S 4L8, Canada
| | - Meera Luthra
- McMaster University, Division of Endocrinology and Metabolism, Hamilton, ON L8S 4L8, Canada
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2
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Tang M, Meng S. An Unusual Case of Pheochromocytoma Associated with von Hippel-Lindau Disease and Lynch Syndrome During Pregnancy. JCEM CASE REPORTS 2024; 2:luae097. [PMID: 38911362 PMCID: PMC11191648 DOI: 10.1210/jcemcr/luae097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Indexed: 06/25/2024]
Abstract
Pheochromocytomas (PCCs) and/or paragangliomas (PGLs) are a challenge to diagnose during pregnancy because of elusive signs and testing difficulties. We report a 25-year-old woman with no pertinent medical history who presented to the hospital with hypertension, vision loss, and weakness and was initially diagnosed with preeclampsia. Imaging showed hemangioblastomas in the medulla and thoracic spine, pancreatic cysts, and a renal cyst. The endocrinology service was consulted for possible PCCs associated with von Hippel-Lindau disease (VHL). Serum and urine normetanephrine levels were elevated despite the lack of overt PCCs/PGLs seen on magnetic resonance imaging and magnetic resonance angiography. The patient was medically managed with doxazosin and then labetalol. Despite successful resection of the hemangioblastoma in the medulla, the patient suffered respiratory distress requiring tracheostomy and venous-venous extracorporeal membrane oxygenation (V-V ECMO) and fetal demise. After 3 months, the patient was discharged to rehabilitation. Follow-up genetics were heterozygous for VHL and Lynch syndrome. DOTATATE positron emission tomography/computed tomography scan showed a small hepatic focus of a maximum standard uptake value of 12.1. Altogether, this case illustrates the importance of prompt diagnosis and proper management of PCCs/PGLs during pregnancy and incorporating genetic information during surveillance to lower morbidity and mortality.
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Affiliation(s)
- Michael Tang
- Department of Medicine, Texas A&M School of Medicine, Bryan, TX 77807, USA
| | - Shumei Meng
- Department of Medicine, Texas A&M School of Medicine, Bryan, TX 77807, USA
- Division of Endocrinology, Baylor University Medical Center, Dallas, TX 75246, USA
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3
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Ge T, Xie X, Liu J. A rare case of pheochromocytoma in a pregnant woman presenting with chest pain: extraordinary management. BMC Cardiovasc Disord 2024; 24:261. [PMID: 38769478 PMCID: PMC11103813 DOI: 10.1186/s12872-024-03943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/15/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Pheochromocytoma is rare in pregnant women. It presents as diverse symptoms, including hypertension and sweating. The symptoms of pregnant women with pheochromocytoma and comorbid hypertension often mimic the clinical manifestations of preeclampsia, and these women are often misdiagnosed with preeclampsia. CASE PRESENTATION In this case, a pregnant woman presented with chest pain as the primary symptom, and a diagnosis of pheochromocytoma was considered after ruling out myocardial ischemia and aortic dissection with the relevant diagnostic tools. This patient then underwent successful surgical resection using a nontraditional management approach, which resulted in a positive clinical outcome. CONCLUSIONS It is essential to consider pheochromocytoma as a potential cause of chest pain and myocardial infarction-like electrocardiographic changes in pregnant women, even if they do not have a history of hypertension.
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Affiliation(s)
- Tao Ge
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China
| | - Xiangrong Xie
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China
| | - Jichun Liu
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China.
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Gunnesson L, Ragnarsson O, Nilsson M, Sengpiel V, Elfvin A, Elias E, Muth A. Maternal pheochromocytoma and childbirth in Sweden 1973-2015: a population-based study on short and long-term outcome. Endocrine 2024; 84:720-726. [PMID: 38421555 PMCID: PMC11076314 DOI: 10.1007/s12020-024-03749-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Data guiding management of pheochromocytoma and paraganglioma (PPGL) in pregnant women is limited, and long-term effects on the child are unknown. The aim of this retrospective registry-based case-cohort study was to assess how maternal PPGL and treatment impacts maternal and fetal outcome, including long-term outcome for the child. The main outcomes were maternal and fetal mortality and morbidity at delivery and relative healthcare consumption in children born by mothers with PPGL during pregnancy. METHODS The National Birth Register identified 4,390,869 pregnancies between 1973-2015. Data was crosslinked with three Swedish national registers to identify women diagnosed with pheochromocytoma or paraganglioma within one year before or after childbirth. Hospital records were reviewed and register data was collected for five age-matched controls for each child until age 18. RESULTS 21 women and 23 children were identified (incidence 4.8/1.000.000 births/year), all women with adrenal pheochromocytomas (Pc). The majority (71%) were diagnosed post-partum. Nine women (43%) were hypertensive during pregnancy. Preterm delivery was more common in Pc patients compared to controls (30% vs 6%, p < 0.001). There was no maternal or fetal mortality. Timing of tumor removal did not affect gestational weight or APGAR scores. There was no observed difference in hospital admissions between children affected by maternal Pc and controls. CONCLUSION Pc was commonly diagnosed after delivery and raised the risk of pre-term delivery, suggesting a need for an increased awareness of this diagnosis. However, reassuringly, there was no fetal or maternal mortality or any observed long-term impact on the children.
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Affiliation(s)
- Lisa Gunnesson
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Oskar Ragnarsson
- Department of Endocrinology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, Gothenburg, Sweden
| | - Maria Nilsson
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Verena Sengpiel
- Department of Obstetrics and Gynecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Elfvin
- The Queen Silvia Children's hospital, Department of Pediatrics, Gothenburg, Sweden
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Elias
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Muth
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Inkollu S, Faizi N, Kohlenberg J. Pheochromocytoma Discovery During Pregnancy Leads to Neurofibromatosis Diagnosis. JCEM CASE REPORTS 2024; 2:luae032. [PMID: 38562988 PMCID: PMC10983068 DOI: 10.1210/jcemcr/luae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Sindhura Inkollu
- Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, MN 55455, USA
| | - Nauroze Faizi
- Department of Radiology, Thoracoabdominal Imaging Division, University of Minnesota, Minneapolis, MN 55455, USA
| | - Jacob Kohlenberg
- Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, MN 55455, USA
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Giorgi RB, Aroucha PT, Favreto TM, Montero MF, Velloni JMF, Korkes I, Ferreira EN, Olivati C, Lima JV, Kater CE, Costa-Barbosa FA. Pheochromocytoma/Paraganglioma (PPGL): A Misdiagnosed Cause of Hypertension during Pregnancy. Case Rep Obstet Gynecol 2024; 2024:6655229. [PMID: 38572182 PMCID: PMC10990643 DOI: 10.1155/2024/6655229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/12/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
Hypertension (HT) during pregnancy is not an infrequent obstetric problem, reaching a prevalence of 5-10%. This condition is highly associated with both maternal and fetal complications if not precisely diagnosed and managed. Even though primary HT, obesity, and preeclampsia are the main causes of HT in this period, other less familiar conditions must be considered during the investigation. Pheochromocytoma and paraganglioma (PPGL) are chromaffin cell tumors that produce, store, and secrete catecholamines, leading to HT and other adrenergic manifestations. Recognition of PPGL is crucial since misdiagnosis and improper management can lead to high morbidity and mortality, particularly during pregnancy. We report on two cases of PPGL diagnosed during pregnancy with different managements. Case 1 is a 25-year-old female at 31 weeks of first pregnancy, whose severe HT and life-threatening symptoms prompted an emergency delivery without previous confirmation or medical treatment of a suspected PPGL. After confirmation, a right adrenal PPGL was surgically resected 4 months later, following 15 days of medical therapy. Case 2 is a 22-year-old female at 18 weeks of pregnancy whose symptomatic PPGL was resected in the second trimester. A next-generation sequencing panel, including 23 PPGL-related genes, found no germline pathogenic variants (GPVs) in case 1 and an exon 1-4 germinative heterozygous deletion of the MAX gene in case 2. Despite the different medical approaches, both cases had satisfactory outcomes. Although uncommon, PPGL should be considered in the differential diagnosis of HT in pregnancy since missing the diagnosis and failing to introduce appropriate and timely treatment may lead to dramatic consequences for the mother and fetus. PPGL diagnosed during reproductive age is likely to result from GPV, prompting genetic investigation and counseling.
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Affiliation(s)
- Rafael Buck Giorgi
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
- Division of Endocrinology, Faculty of Medical Sciences and Health, Pontific Catholic University of São Paulo, Sorocaba, Brazil
| | - Priscila Teixeira Aroucha
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Thalissa M. Favreto
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Micaela F. Montero
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Julia M. F. Velloni
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Ilana Korkes
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | | | - Caroline Olivati
- Research and Development Division, Fleury Group, São Paulo, Brazil
| | - Jose Viana Lima
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
- Research and Development Division, Fleury Group, São Paulo, Brazil
- Division of Endocrinology and Metabolism, Department of Medicine, Santa Casa de São Paulo, São Paulo, Brazil
| | - Claudio E. Kater
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
| | - Flavia A. Costa-Barbosa
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Federal University of Sao Paulo Medical School-EPM/Unifesp, São Paulo, Brazil
- Research and Development Division, Fleury Group, São Paulo, Brazil
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7
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Beard V, Ghawji M, Salman F, Oktaei H. Pheochromocytoma Diagnosed During First Trimester of Pregnancy. JCEM CASE REPORTS 2024; 2:luae027. [PMID: 38495398 PMCID: PMC10941258 DOI: 10.1210/jcemcr/luae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Indexed: 03/19/2024]
Abstract
Pheochromocytomas are rare catecholamine-secreting tumors that occur in 0.002% of pregnancies. These tumors result in high maternal and fetal morbidity and mortality unless diagnosed in early stages of development, because excess levels of catecholamines cause vasoconstriction of both maternal and uteroplacental vasculature. Paroxysmal hypertension is the most common manifestation, but its variability in presentation and similarity to other pregnancy-related conditions often make diagnosis of pheochromocytoma difficult. Thus, it is essential to consider underlying pathological causes of hypertension during gestation. Diagnosis and treatment of pheochromocytoma must be approached uniquely given the physiologic changes during pregnancy. The standard of care for diagnostic imaging during pregnancy is with magnetic resonance imaging. For these reasons, knowledge of therapy for pheochromocytomas in the pregnant patient is essential for clinical endocrinology practice.
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Affiliation(s)
- Victoria Beard
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Maher Ghawji
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Fariha Salman
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Hooman Oktaei
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
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8
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Ballard S, Le Roux JJ, Wakabayashi K, Labuschagne HC, Jooma Z. The Silent Killer Seeks Young Blood: A Case Report on the Perioperative Anesthetic Management of a Paraganglionoma in Pregnancy. Cureus 2023; 15:e44025. [PMID: 37746444 PMCID: PMC10517734 DOI: 10.7759/cureus.44025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Pheochromocytomas and paraganglionomas are rare neuroendocrine tumors. The multisystem effects of these tumors on the pregnant woman and fetus, the timing of surgery in relation to the pregnancy, and the pharmacological treatment have several anesthetic implications. Case reports on elective cesarean section followed by postpartum resection of the tumor are scarce. A case is presented of a 31-year-old nulliparous female where an antenatal diagnosis of a paraganglionoma was made at 19 weeks gestation for whom an elective cesarean section was performed at 31 weeks gestation under graded lumbar epidural anesthesia, followed by an elective open surgical removal of the tumor six weeks postpartum.
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Affiliation(s)
- Samantha Ballard
- Department of Anesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Johannes J Le Roux
- Department of Anesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Koji Wakabayashi
- Department of Anesthesia, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Hendrik C Labuschagne
- Department of Radiology, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
| | - Zainub Jooma
- Anesthesia and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, ZAF
- Department of Anesthesia, University of the Witwatersrand, Johannesburg, Johannesburg, ZAF
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9
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Grigoryan S, Nhan W, Zhang L, Urban C, Zhao L, Turcu AF. Rates of Pheochromocytoma/Paraganglioma Screening in At-Risk Populations. J Clin Endocrinol Metab 2023; 108:e343-e349. [PMID: 36469797 PMCID: PMC10188311 DOI: 10.1210/clinem/dgac701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/11/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGL) are rare causes of secondary hypertension, but when unrecognized, they can lead to serious complications. Data regarding PPGL screening are lacking. OBJECTIVE This study aimed to assess the rates and patterns of PPGL screening among eligible patients. METHODS We conducted a retrospective review of adults with hypertension seen in outpatient clinics of a large academic center between January 1, 2017, and June 30, 2020. We included patients with treatment-resistant hypertension, hypertension at age < 35 years, and/or adrenal mass(es). RESULTS Of 203 535 patients with hypertension identified, 71 088 (35%) met ≥ 1 inclusion criteria, and 2013 (2.83%) were screened for PPGL. Patients screened were younger (56.2 ± 17.4 vs 64.0 ± 17.1 years), more often women (54.1% vs 44.2%), and never-smokers (54.6% vs 47.5%, P < 0.001 for all). The rate of screening was highest in patients with hypertension and adrenal mass(es) (51.7%, vs 3.9% in patients with early-onset hypertension, and 2.4% in those with treatment-resistant hypertension). Multivariable logistic regression showed higher odds ratio (OR) of PPGL screening in women (OR [95% CI]: 1.48 [1.34-1.63]); Black vs White patients (1.35 [1.19-1.53]); patients with adrenal mass(es) (55.1 [44.53-68.15]), stroke (1.34 [1.16-1.54]), dyslipidemia (1.41 [1.26-1.58]), chronic kidney disease (1.40 [1.26-1.56]), and obstructive sleep apnea (1.96 [1.76-2.19]). CONCLUSION PPGL screening is pursued in roughly half of patients with adrenal nodules and hypertension, but rarely in patients with treatment-resistant or early-onset hypertension. Similar to screening for other forms of secondary hypertension, PPGL screening occurs more often after serious complications develop.
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Affiliation(s)
- Seda Grigoryan
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Winnie Nhan
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lei Zhang
- School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Caitlin Urban
- Michigan State University College of Human Medicine, Grand Rapids, MI 49503, USA
| | - Lili Zhao
- School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
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10
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Clifton-Bligh RJ. The diagnosis and management of pheochromocytoma and paraganglioma during pregnancy. Rev Endocr Metab Disord 2023; 24:49-56. [PMID: 36637675 PMCID: PMC9884650 DOI: 10.1007/s11154-022-09773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 01/14/2023]
Abstract
Diagnosis of pheochromocytoma or paraganglioma (PPGL) in pregnancy has been associated historically with high rates of materno-fetal morbidity and mortality. Recent evidence suggests outcomes are improved by recognition of PPGL before or during pregnancy and appropriate medical management with alpha-blockade. Whether antepartum surgery (before the third trimester) is required remains controversial and open to case-based merits. Women with PPGL in pregnancy are more commonly delivered by Caesarean section, although vaginal delivery appears to be safe in selected cases. At least some PPGLs express the luteinizing hormone/chorionic gonadotropin receptor (LHCGR) which may explain their dramatic manifestation in pregnancy. PPGLs in pregnancy are often associated with heritable syndromes, and genetic counselling and testing should be offered routinely in this setting. Since optimal outcomes are only achieved by early recognition of PPGL in (or ideally before) pregnancy, it is incumbent for clinicians to be aware of this diagnosis in a pregnant woman with hypertension occurring before 20 weeks' gestation, and acute and/or refractory hypertension particularly if paroxysmal and accompanied by sweating, palpitations and/or headaches. All women with a past history of PPGL and/or heritable PPGL syndrome should be carefully assessed for the presence of residual or recurrent disease before considering pregnancy.
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Affiliation(s)
- Roderick J Clifton-Bligh
- University of Sydney, Sydney, NSW, Australia.
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
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11
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Pheochromocytomas and Abdominal Paragangliomas: A Practical Guidance. Cancers (Basel) 2022; 14:cancers14040917. [PMID: 35205664 PMCID: PMC8869962 DOI: 10.3390/cancers14040917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare. They can be discovered incidentally by imaging with computed tomography or magnetic resonance imaging and during hormonal surveillance in patients with known genetic variants that are associated with PPGLs. As most PPGLs are functioning, a hormonal work-up evaluating for catecholamine excess is recommended. Classical symptoms, such as tachycardia, hypertension and headache, can be present, but when the PPGL is discovered as an incidentaloma, symptoms may be lacking or be more discrete. PPGLs carry malignant potential, and patients should undergo close surveillance, as recurrence of disease or metastasis may develop. Genetic susceptibility for multifocal disease has gained more attention, and germline variants are commonly detected, thus facilitating detection of hereditary cases and afflicted family members. Any patient with a PPGL should be managed by an expert multidisciplinary team consisting of endocrinologists, radiologists, surgeons, pathologists and clinical geneticists. Abstract Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare tumors arising from the adrenal medulla or the sympathetic nervous system. This review presents a practical guidance for clinicians dealing with PPGLs. The incidence of PPGLs has risen. Most cases are detected via imaging and less present with symptoms of catecholamine excess. Most PPGLs secrete catecholamines, with diffuse symptoms. Diagnosis is made by imaging and tests of catecholamines. Localized disease can be cured by surgery. PPGLs are the most heritable of all human tumors, and germline variants are found in approximately 30–50% of cases. Such variants can give information regarding the risk of developing recurrence or metastases as well as the risk of developing other tumors and may identify relatives at risk for disease. All PPGLs harbor malignant potential, and current histological and immunohistochemical algorithms can aid in the identification of indolent vs. aggressive tumors. While most patients with metastatic PPGL have slowly progressive disease, a proportion of patients present with an aggressive course, highlighting the need for more effective therapies in these cases. We conclude that PPGLs are rare but increasing in incidence and management should be guided by a multidisciplinary team.
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12
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Aftiss F, El Mezzeoui S, El Aidouni G, Merbouh M, Nasri S, Jabi R, Bkiyar H, Skikar I, Bouziane M, Housni B. Surgical and anesthetic management of paraganglioma diagnosed in a 2nd trimester parturient: Case report. Ann Med Surg (Lond) 2021; 72:103094. [PMID: 34934482 PMCID: PMC8654780 DOI: 10.1016/j.amsu.2021.103094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Neuroendocrine tumors represent a rare entity whose diagnosis is based on clinical, biological and radiological arguments. When they are secreting, they expose the patient to serious complications that can be much more severe during pregnancy and engage the vital prognosis of both the mother and the fetus, which requires multidisciplinary management: anesthesiologist resuscitator - obstetrician – endocrinologist. Case presentation In our article, we report the case of a patient with an estimated pregnancy at 25 weeks of amenorrhea (WA) with a history of 3 miscarriages related to atypical gravid hypertension. The treatment consisted of preoperative medical preparation followed by removal of the paraganglioma and postoperative monitoring. The maternal-fetal evolution was favorable. Conclusion The non-negligible morbi-mortality of this type of tumors require a multidisciplinary management. Neuroendocrine tumors represent a rare entity whose diagnosis is based on clinical, biological and radiological arguments. The treatment consisted of preoperative medical preparation, removal of the paraganglioma and postoperative monitoring. The anesthetic and surgical management of pheochromocytomas and paragangliomas in pregnant women presents a real challenge.
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Affiliation(s)
- F Aftiss
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - S El Mezzeoui
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - G El Aidouni
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - M Merbouh
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco
| | - S Nasri
- Department of Radiology, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - R Jabi
- Department of General Surgery, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - H Bkiyar
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco.,Oujda Medical Simulation Training Center, Morocco
| | - I Skikar
- Department of Radiology, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - M Bouziane
- Department of General Surgery, Mohamed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - B Housni
- Intensive Care Unit, Mohammed VI University Hospital Center, Oujda, Morocco.,Faculty of Medicine and Pharmacy, Oujda, Morocco.,Oujda Medical Simulation Training Center, Morocco
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Special situations in pheochromocytomas and paragangliomas: pregnancy, metastatic disease, and cyanotic congenital heart diseases. Clin Exp Med 2021; 22:359-370. [PMID: 34591219 DOI: 10.1007/s10238-021-00763-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/18/2021] [Indexed: 01/08/2023]
Abstract
The aim of our study was to describe the epidemiology, diagnosis, and treatment of the most complex pheochromocytoma and paraganglioma (PGL) cases, including pheochromocytoma/PGL during pregnancy, in cyanotic congenital heart diseases (CCHDs), and metastatic pheochromocytoma. The English and Spanish literature was thoroughly evaluated searching for articles reporting clinical studies, case reports, or reviews of pheochromocytoma/PGL in pregnancy and in CCHD and metastatic pheochromocytoma/PGL. Particular settings in the diagnosis and management of pheochromocytoma and PGLs remain challenging. Those special situations include the diagnosis during pregnancy or in the context of CCHD since the typical clinical features of pheochromocytoma may be confounded with preeclampsia during pregnancy and with the complications commonly observed in CCHD. In addition, although some clinical and genetic features have been associated with higher risk of metastatic pheochromocytoma, the detection and prediction of the development of metastatic disease involve another complex situation that may require special hormonal determinations as plasmatic 3-methoxytyramine and nuclear medicine studies including 18FDG PET-CT or 18F-FDOPA PET-CT, among others. Furthermore, the selection of the most appropriate treatment in these situations, as well as the moment to carry it out, requires special care as limited evidence is available. This article reviews the epidemiology, diagnosis, and treatment of the pheochromocytoma/PGL during pregnancy, metastatic pheochromocytoma/PGL, and pheochromocytoma/PGL in CCHD. The diagnosis, and especially the treatment, of metastatic pheochromocytomas and pheochromocytoma/PGL during pregnancy and in CCHD is challenging. Thus, these cases should be management in reference centres by multidisciplinary teams specialized in the pheochromocytoma/PGL treatment.
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Pheochromocytoma in Pregnancy: A Syndromic Association. J Obstet Gynaecol India 2021; 72:48-54. [PMID: 35928058 PMCID: PMC9343562 DOI: 10.1007/s13224-021-01532-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022] Open
Abstract
Introduction Pheochromocytoma during pregnancy is a rare cause of secondary hypertension with lethal consequences to both mother and fetus. As patients are young, the possibility of syndromic associations like MEN-2, VHL, NF-1, etc., needs to be considered. Methodology Three primigravida were diagnosed before the 20th week of gestation when they presented with classical triad of pheochromocytoma. Results Diagnosis of pheochromocytoma was confirmed by 24 h urinary metanephrine/normetanephrine or epinephrine/norepinephrine levels. Non-contrast MRI abdomen could localize the tumor. One patient had medullary thyroid carcinoma with hyperparathyroidism, indicative of MEN-2A. Another patient had brain stem hemangioblastoma, pancreatic cysts and family history of spinal hemangioblastoma, so diagnosed to have Von Hippel-Lindau (VHL) syndrome. Whereas, the third patient had sporadic pheochromocytoma. Preoperatively, they required antihypertensive medications including prazosin and metoprolol. They underwent laparoscopic/open adrenalectomy between 19th and 21st week of gestation without complication. Histopathology in all the three patients revealed low-grade pheochromocytoma by pheochromocytoma of the adrenal gland scaled score. None required antihypertensive medications after surgery. All the three newborns were small for gestational age, while one neonate expired due to intra-cardiac rhabdomyoma. So, the timely evaluation and surgical intervention for pheochromocytoma avoid lethal consequences. Conclusions Pregnancy leads to unmasking of pheochromocytoma as it is physiological stress. The syndromic association is more frequent as the population is younger. A poor fetal outcome like IUGR can be explained by endovascular changes in uterine vessel or due to the associated manifestations of MEN-2A, VHL syndromes. Family members should be screened for associated syndromic feature.
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