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Yang Y, Zhou T, Zhao X, Cai Y, Xu Y, Gang X, Wang G. Main mechanisms and clinical implications of alterations in energy expenditure state among patients with pheochromocytoma and paraganglioma: A review. Medicine (Baltimore) 2024; 103:e37916. [PMID: 38669419 PMCID: PMC11049756 DOI: 10.1097/md.0000000000037916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors with diverse clinical presentations. Alterations in energy expenditure state are commonly observed in patients with PPGL. However, the reported prevalence of hypermetabolism varies significantly and the underlying mechanisms and implications of this presentation have not been well elucidated. This review discusses and analyzes the factors that contribute to energy consumption. Elevated catecholamine levels in patients can significantly affect substance and energy metabolism. Additionally, changes in the activation of brown adipose tissue (BAT), inflammation, and the inherent energy demands of the tumor can contribute to increased resting energy expenditure (REE) and other energy metabolism indicators. The PPGL biomarker, chromogranin A (CgA), and its fragments also influence energy metabolism. Chronic hypermetabolic states may be detrimental to these patients, with surgical tumor removal remaining the primary therapeutic intervention. The high energy expenditure of PPGL has not received the attention it deserves, and an accurate assessment of energy metabolism is the cornerstone for an adequate understanding and treatment of the disease.
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Affiliation(s)
- Yuqi Yang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Tong Zhou
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Xue Zhao
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Yunjia Cai
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Yao Xu
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
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Richter S, Bechmann N. Patient Sex and Origin Influence Distribution of Driver Genes and Clinical Presentation of Paraganglioma. J Endocr Soc 2024; 8:bvae038. [PMID: 38481600 PMCID: PMC10928507 DOI: 10.1210/jendso/bvae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Indexed: 04/07/2024] Open
Abstract
Context Sexual and ancestral differences in driver gene prevalence have been described in many cancers but have not yet been investigated in pheochromocytoma and paraganglioma (PPGL). Objective This study aims to assess whether sex and ancestry influence prevalence of PPGL driver genes and clinical presentation. Methods We conducted a retrospective analysis of patients with PPGL considering studies from 2010 onwards that included minimal data of type of disease, sex, mutated gene, and country of origin. Additional features were recorded when available (age, tumor location, bilateral or multifocal, somatic or germline, and metastatic disease). Results We included 2162 patients: 877 in Europe and 757 in Asia. Males presented more often with germline pathogenic variants (PVs) in genes activating hypoxia pathways (P = .0006) and had more often sympathetic paragangliomas (P = .0005) and metastasis (P = .0039). On the other hand, females with PPGLs due to MAX PVs were diagnosed later than males (P = .0378) and more often developed metastasis (P = .0497). European but not Asian females presented more often with PPGLs due to PVs in genes related to kinase signaling (P = .0052), particularly RET and TMEM127. Contrary to experiences from Europe, Asian patients with PPGL due to PVs in kinase signaling genes NF1, HRAS, and FGFR1 showed a high proportion of sympathetic tumors, while European patients almost exclusively had adrenal tumors (P < .005). Conclusion Personalized management of patients with PPGL might benefit from considering sexual and ancestral differences. Further studies with better clinically aligned cohorts from various origins are required to better dissect ancestral influences on PPGL development.
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Affiliation(s)
- Susan Richter
- Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Nicole Bechmann
- Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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Parisien-La Salle S, Bourdeau I. Sex-Related Differences in Self-Reported Symptoms at Diagnosis in Pheochromocytomas and Paragangliomas. J Endocr Soc 2024; 8:bvae005. [PMID: 38313160 PMCID: PMC10836828 DOI: 10.1210/jendso/bvae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Indexed: 02/06/2024] Open
Abstract
Context Biological sex can play a role in the severity of certain diseases. Objective Our objective was to evaluate whether sex-related differences affect the signs and symptoms of pheochromocytomas and paragangliomas (PPGLs) at presentation. Methods We reviewed the records of patients with PPGLs at our center from 1995 to 2022. Results Our study included 385 patients with PPGLs: 118 (30.6%) head and neck paragangliomas (HNPGLs), 58 (15.1%) thoracoabdominal paragangliomas (TAPGLs) and 209 (54.3%) pheochromocytomas (PHEOs). The cohort consisted of 234 (60.8%) women and 151 (39.2%) men. At diagnosis, more women than men presented with headaches (47.5% vs 32.4%; P = .007); however, more men presented with diabetes (21.1% vs 12.5%; P = .039). When subdivided by tumor location, headaches occurred more often in women with HNPGLs and TAPGLs (31.0% vs 11.4%; P = .0499 and 60.0% vs 21.7%; P = .0167). More men presented with diabetes among patients with PHEOs (28.2% vs 11.2%; P = .0038). In regard to nonsecretory PPGLs, women presented with a higher prevalence of headaches (46.9% vs 3.6%; P = .0002), diaphoresis (16.3% vs 0.0%; P = .0454), and palpitations (22.4% vs 0.0%; P = .0057). In patients with secretory tumors, women presented with more headaches (58.9% vs 42.7%; P = .0282) and men with more diabetes (29.3% vs 12.5%; P = .0035). Conclusion In our cohort, more women presented with headaches across all tumor types and secretory statuses. More men presented with diabetes among patients with PHEOs and secretory tumors. In nonsecretory PPGLs, women had more adrenergic symptoms. These findings can be explained by differences in adrenergic receptor sensitivity, self-reported symptoms, and possibly other vasoactive peptides and sex-hormone status.
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Affiliation(s)
- Stefanie Parisien-La Salle
- Division of Endocrinology, Department of Medicine, Research Center, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec H2X 0A9, Canada
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine, Research Center, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec H2X 0A9, Canada
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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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Patel SP, Jarbath M, Saravis L, Senada P, Lindner DH, Grossman RA, Francosadud RA. Pheochromocytoma manifesting as cortical blindness secondary to PRES with associated TMA: a case report and literature review. BMC Endocr Disord 2022; 22:205. [PMID: 35971105 PMCID: PMC9380330 DOI: 10.1186/s12902-022-01109-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 07/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pheochromocytomas are neoplasms originating from neuroectodermal chromaffin cells leading to excess catecholamine production. They are notorious for causing a triad of headaches, palpitations, and sweats. Though the Menard triad is one to be vigilant of, symptomatic presentation can vary immensely, hence the tumor earning the label "the great masquerader." CASE PRESENTATION We report a case of pheochromocytoma initially presenting with cortical blindness secondary to posterior reversible encephalopathy syndrome and thrombotic microangiopathy from malignant hypertension. Our patient was seen in our facility less than a week prior to this manifestation and discharged after an unremarkable coronary ischemia work-up. In the outpatient setting, she had been prescribed multiple anti-hypertensives with remarkably elevated blood pressure throughout her hospitalization history. CONCLUSION Pheochromocytoma presenting with malignant hypertension and hypertensive encephalopathy should be expected if left untreated; nonetheless, the precipitation of cortical blindness is rare in the literature. This case contributes an additional vignette to the growing literature revolving adrenal tumors and their symptomatic presentation along with complex management. It also serves to promote increased diagnostic suspicion among clinicians upon evaluating patients with refractory hypertension.
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Affiliation(s)
- Sankalp P Patel
- Department of Graduate Medical Education, Internal Medicine Residency, NCH Healthcare System, Naples, FL, 311 9th St. N34102, USA.
| | - Medjine Jarbath
- Department of Graduate Medical Education, Internal Medicine Residency, NCH Healthcare System, Naples, FL, 311 9th St. N34102, USA
| | - Lauren Saravis
- Department of Graduate Medical Education, Internal Medicine Residency, NCH Healthcare System, Naples, FL, 311 9th St. N34102, USA
| | - Peter Senada
- Department of Graduate Medical Education, Internal Medicine Residency, NCH Healthcare System, Naples, FL, 311 9th St. N34102, USA
| | - David H Lindner
- Department of Pulmonary/Critical Care Medicine, Associate Program Director of Pulmonary/Critical Care Fellowship, NCH Healthcare System, Naples, USA
| | - Robert A Grossman
- Department of General Surgery, General Surgeon, NCH Healthcare System, Naples, USA
| | - Ricardo A Francosadud
- Department of Graduate Medical Education, Associate Program Director of Internal Medicine Residency, NCH Healthcare System, Naples, USA
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Turner LM, Serraro-Brown H, McLaren M, Rachel L, Mosse C. The heart of the matter: secretory pheochromocytoma presenting as recurrent biventricular heart failure (Takotsubo cardiomyopathy). Oxf Med Case Reports 2022; 2022:omac066. [PMID: 35769190 PMCID: PMC9235020 DOI: 10.1093/omcr/omac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
Takotsubo’s syndrome (TS) is an acute, transient cardiomyopathy occurring secondary to physical or emotional stressors through catecholamine excess. Secretory pheochromocytomas have been previously implicated in cases of TS (PTS), however, often present atypically, are associated with reoccurrence, and have higher rates of complications. We describe the case of a 70-year-old female who presented central chest pain, hypotension and electrocardiogram changes on a background of a 6-month prior episode of resolved Takotsubo’s with unknown cause. After progressing to cardiogenic shock with biventricular failure, computerized tomography coronary aortogram revealed an incidental adrenal mass, later proven to be a secretory pheochromocytoma on biochemistry and subsequent histology. PTS has been associated with recurrence and rarely presents as cardiogenic shock. This case highlights the complexity of TS presentations and complications and the diagnostic delays that may occur in PTS.
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Affiliation(s)
- Lauren M Turner
- Department of Surgery , Division of Critical Care, Canberra Hospital, Garran, ACT, Australia
| | - Hazel Serraro-Brown
- Department of Surgery , Division of Critical Care, Canberra Hospital, Garran, ACT, Australia
| | - Mairi McLaren
- Department of Surgery , Division of Critical Care, Canberra Hospital, Garran, ACT, Australia
| | - Lau Rachel
- Department of Pathology , Canberra Hospital, Garran, ACT, Australia
| | - Charles Mosse
- Department of Surgery , Division of Critical Care, Canberra Hospital, Garran, ACT, Australia
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Li M, Pamporaki C, Fliedner SMJ, Timmers HJLM, Nölting S, Beuschlein F, Prejbisz A, Remde H, Robledo M, Bornstein SR, Lenders JWM, Eisenhofer G, Bechmann N. Metastatic pheochromocytoma and paraganglioma: signs and symptoms related to catecholamine secretion. Discov Oncol 2021; 12:9. [PMID: 35201450 PMCID: PMC8777503 DOI: 10.1007/s12672-021-00404-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The presence or future development of metastatic pheochromocytomas or paragangliomas (mPPGLs) can be difficult to diagnose or predict at initial presentation. Since production of catecholamines from mPPGLs is different from non-metastatic tumors (non-mPPGLs), this study aimed to clarify whether presenting catecholamine-related signs and symptoms (cSS) might also differ. METHODS The study included 249 patients, 43 with mPPGL and 206 with non-mPPGL. Clinical data at the time of biochemical diagnosis (i.e. at entry into the study) were used to generate a cumulative score of cSS for each patient. RESULTS Patients with mPPGL were significantly younger (43.3 ± 14 vs. 48.9 ± 16.1 years) and included a lower proportion of females (39.5% vs. 60.7%) than patients with non-mPPGLs. Frequencies of signs and symptoms did not differ between the two groups. Patients with mPPGLs had lower (P < 0.001) urinary excretion of epinephrine (3.5 (IQR, 1.9-6.5) µg/day) than those with non-mPPGLs (19.1 (IQR, 4.3-70.2) µg/day). There was no difference in urinary excretion of norepinephrine. In patients with mPPGLs a high cSS score was associated with high urinary excretion of norepinephrine and normetanephrine. In contrast, in patients with non-mPPGLs, a high cSS was associated with high urinary excretion of epinephrine and metanephrine. CONCLUSION Although presenting signs and symptoms were associated with production of norepinephrine in patients with mPPGLs and of epinephrine in patients with non-mPPGLs, there were no differences in signs and symptoms between the two groups. Therefore, consideration of signs and symptoms does not appear helpful for distinguishing patients with and without mPPGLs.
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Affiliation(s)
- Minghao Li
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stephanie M J Fliedner
- First Department of Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Svenja Nölting
- Medizinische Klinik Und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, Universitätsspital Zürich, Zurich, Switzerland
| | - Felix Beuschlein
- Medizinische Klinik Und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, Universitätsspital Zürich, Zurich, Switzerland
| | | | - Hanna Remde
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital of Würzburg, Würzburg, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Center and Centro de Investigación Biomédica en Red de Enfermedades Raras, Madrid, Spain
| | - Stefan R Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jacques W M Lenders
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Nicole Bechmann
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Alesina PF, Walz MK. Adrenal Tumors: Are Gender Aspects Relevant? Visc Med 2020; 36:15-19. [PMID: 32110652 DOI: 10.1159/000505788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 01/07/2020] [Indexed: 12/14/2022] Open
Abstract
The distribution of malignant tumors is strongly related to gender due to sex-related organ and tissue differentiation. Neoplasias of the adrenal glands are relatively common and typically benign. Mainly based on our recently published contributions, we analyzed the influence of gender on type of tumors, complexity of surgery, and long-term outcome. Cortisol-secreting adrenal tumors are more often diagnosed in female patients, while the incidence of Conn's syndrome and pheochromocytoma is similar between male and female patients. Adrenalectomy is more difficult in male patients because of longer operating time and higher blood loss. The probability of cure in male patients with Conn's syndrome is significantly lower. Gender does not influence long-term results in adrenal hypercortisolism and pheochromocytomas.
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Affiliation(s)
- Pier Francesco Alesina
- Department of Surgery and Center of Minimally Invasive Surgery, Evang. Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Martin K Walz
- Department of Surgery and Center of Minimally Invasive Surgery, Evang. Kliniken Essen-Mitte, Academic Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
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Pillai S, Lo CY, Liew V, Lalloz M, Smith RA, Gopalan V, Lam AKY. MicroRNA 183 family profiles in pheochromocytomas are related to clinical parameters and SDHB expression. Hum Pathol 2017; 64:91-97. [PMID: 28412207 DOI: 10.1016/j.humpath.2017.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/15/2017] [Accepted: 03/18/2017] [Indexed: 11/25/2022]
Abstract
This study aims to examine the expression profiles of the miR-183 cluster (miR-96/182/183) in pheochromocytoma. Pheochromocytoma tissues were prospectively collected from 50 patients with pheochromocytoma. Expression of miR-183 cluster members and SDHB protein expression were analyzed in these tissues by quantitative real-time polymerase chain reaction and immunohistochemistry, respectively. The expression of miR-183 cluster members in pheochromocytomas was correlated with the clinical and pathological parameters of these patients. The expression levels of miR-183 cluster members were predominantly downregulated or deleted in pheochromocytoma. Low expression or deletion of miR-96 was predominantly noted in younger patients with pheochromocytoma (<50 years, P=.01). Female patients in the study group showed marked deletion of miR-182 (P=.05). Deletion of the cluster was also associated with SDHB protein expression in pheochromocytoma. Moreover, patients with low miR-183 cluster expression had a slightly better survival rate when compared with patients with high expression. To conclude, the findings indicate a role for miR-183 cluster members in the pathogenesis and clinical progression of pheochromocytoma.
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Affiliation(s)
- Suja Pillai
- Cancer Molecular Pathology, School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast, Q4222, Australia
| | - Chung Y Lo
- Department of Surgery, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong
| | - Victor Liew
- Department of Surgery, Gold Coast Private Hospital, Gold Coast, Southport, Q4215, Australia
| | - Minella Lalloz
- Cancer Molecular Pathology, School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast, Q4222, Australia
| | - Robert A Smith
- Cancer Molecular Pathology, School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast, Q4222, Australia; Genomics Research Centre, Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Kelvin Grove, Q4059, Australia
| | - Vinod Gopalan
- Cancer Molecular Pathology, School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast, Q4222, Australia
| | - Alfred King-Yin Lam
- Cancer Molecular Pathology, School of Medicine and Menzies Health Institute Queensland, Griffith University, Gold Coast, Q4222, Australia.
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Pourian M, Mostafazadeh DB, Soltani A. Does this patient have pheochromocytoma? A systematic review of clinical signs and symptoms. J Diabetes Metab Disord 2016; 15:11. [PMID: 27034920 PMCID: PMC4815191 DOI: 10.1186/s40200-016-0230-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 03/02/2016] [Indexed: 11/27/2022]
Abstract
Context Pheochromocytoma is a rare disease but with high mortality if it is not being diagnosed early. Several biochemical tests with high accuracy have been obtained, but the clinical threshold for request of these tests is not determined clearly. Objectives To determine the Likelihood Ratios of clinical symptoms and signs in diagnosing pheochromocytoma. And also meta-analysis of their sensitivity in this disease. Data sources MEDLINE was searched for relevant English-language articles dated 1960 to February 2014. Bibliographies were searched to find additional articles. Study selection We included original studies describing the sensitivity and/or likelihood ratios of signs and symptoms in clinical suspicion of pheochromocytoma. Their method of diagnosis should have been based on pathology. We excluded specific subtypes or syndromes related to pheochromocytoma, or specific ages or gender. Also we excluded studies before 1993 (JNC5) which no definition of hypertension was presented. 37 articles were chosen finally. Data extraction Two authors reviewed data from articles independently and gave discrepancies to third author for decision. The aim was extraction of raw numbers of patients having defined signs or symptoms, and draw 2 × 2 tables if data available. We meta-analyzed sensitivities by Statsdirect and Likelihood Ratios by Meta-disc soft wares. Because our data was heterogeneous based on I2 > 50 % (except negative Likelihood ratio of hypertension), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test. Data synthesis The most prevalent signs and symptoms reported were hypertension (pooled sensitivity of 80.7 %), headache (pooled sensitivity of 60.4 %), palpitation (pooled sensitivity of 59.3 %) and diaphoresis (pooled sensitivity of 52.4 %). The definition of orthostatic hypotension was different among studies. The sensitivity was 23–50 %. Paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias based on Funnel plot and Egger test (P value < 0.05). Seven of the articles had control group, and could be used for calculating LR of signs/symptoms. Diaphoresis (LR+ 2.2, LR- 0.45), Palpitation (LR+ 1.9, LR- 0.52) and headache (LR+ 1.6, LR- 0.24) were significant symptoms in clinical diagnosis of pheochromocytoma. Other signs and symptoms had been reported in only one study and could not have been meta-analyzed. Classic triad of headache, palpitation and diaphoresis in hypertensive patients had the LR+ 6.312 (95 % CI 0.217–183.217) and LR- 0.139 (95 % CI 0.059–0.331). Surprisingly, hypertension was not important in clinical suspicion of pheochromocytoma, and even normotension increased the probability of the disease. Conclusions By available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, to specify the value of clinical findings. Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.
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Affiliation(s)
- M Pourian
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Davani B Mostafazadeh
- Evidence based Practice Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - A Soltani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Soltani A, Pourian M, Davani BM. Does this patient have Pheochromocytoma? a systematic review of clinical signs and symptoms. J Diabetes Metab Disord 2016; 15:6. [PMID: 26998444 PMCID: PMC4797176 DOI: 10.1186/s40200-016-0226-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 03/06/2016] [Indexed: 12/05/2022]
Abstract
Context Pheochromocytoma is a rare disease but with high mortality if it is not being diagnosed early. Several biochemical tests with high accuracy have been obtained, but the clinical threshold for request of these tests is not determined clearly. Objectives To determine the Likelihood Ratios of clinical symptoms and signs in diagnosing pheochromocytoma. And also meta-analysis of their sensitivity in this disease. Data sources MEDLINE was searched for relevant English-language articles dated 1960 to February 2014. Bibliographies were searched to find additional articles. Study selection We included original studies describing the sensitivity and/or likelihood ratios of signs and symptoms in clinical suspicion of pheochromocytoma. Their method of diagnosis should have been based on pathology. We excluded specific subtypes or syndromes related to pheochromocytoma, or specific ages or gender. Also we excluded studies before 1993 (JNC5) which no definition of hypertension was presented. 37 articles were chosen finally. Data extraction Two authors reviewed data from articles independently and gave discrepancies to third author for decision. The aim was extraction of raw numbers of patients having defined signs or symptoms, and draw 2 × 2 tables if data available. We meta-analyzed sensitivities by Statsdirect and Likelihood Ratios by Meta-disc soft wares. Because our data was heterogeneous based on I2 > 50 % (except negative Likelihood ratio of hypertension), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test. Data synthesis The most prevalent signs and symptoms reported were hypertension (pooled sensitivity of 80.7 %), headache (pooled sensitivity of 60.4 %), palpitation (pooled sensitivity of 59.3 %) and diaphoresis (pooled sensitivity of 52.4 %). The definition of orthostatic hypotension was different among studies. The sensitivity was 23–50 %. Paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias based on Funnel plot and Egger test (P value < 0.05). Seven of the articles had control group, and could be used for calculating LR of signs/symptoms. Diaphoresis (LR+ 2.2, LR-0.45), Palpitation (LR+ 1.9, LR-0.52) and headache (LR+ 1.6, LR-0.24) were significant symptoms in clinical diagnosis of pheochromocytoma. Other signs and symptoms had been reported in only one study and could not have been meta-analyzed. Classic triad of headache, palpitation and diaphoresis in hypertensive patients had the LR+ 6.312 (95 % CI 0.217–183.217) and LR-0.139 (95 % CI 0.059–0.331). Surprisingly, hypertension was not important in clinical suspicion of pheochromocytoma, and even normotension increased the probability of the disease. Conclusions By available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, to specify the value of clinical findings.Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.
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Affiliation(s)
- Akbar Soltani
- Evidence based Practice Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mandana Pourian
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Mostafazadeh Davani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Gender-based differences commonly encountered in pediatric nuclear medicine reflect both basic embryologic differences of the sexes, which are evident from infancy, and evolving physiological changes due to gender, which occur as the pediatric patient grows, undergoes puberty, and matures to adulthood. It is important for a nuclear medicine physician or radiologist to know both the gender and the age of a patient when interpreting her or his studies. It is also important that the reading physician be familiar with the normally evolving physiological changes that are specific for that patient's stage of development. It is particularly important that the reading physician consider such changes when comparing serial studies of the patient that are acquired during the patient's transitions through her or his different significant stages of development. Many pediatric nuclear medicine imaging protocols are modifications or adaptations of the protocols for adult imaging. Physicians reading pediatric studies must routinely incorporate knowledge on age and gender that is relevant to the patient for any given study. The age-defined gender-based subtleties of potential findings in pediatric nuclear medicine studies are often underrecognized. However, they are often of interest and at times important in the workup of both benign entities and pathologic processes of the pediatric patient.
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Affiliation(s)
- Adina L Alazraki
- Department of Radiology and Imaging Sciences, Children's Healthcare of Atlanta, Emory University, Atlanta, GA.
| | - Kiery A Braithwaite
- Department of Radiology and Imaging Sciences, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
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Lowery AJ, Walsh S, McDermott EW, Prichard RS. Molecular and therapeutic advances in the diagnosis and management of malignant pheochromocytomas and paragangliomas. Oncologist 2013; 18:391-407. [PMID: 23576482 DOI: 10.1634/theoncologist.2012-0410] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare catecholamine-secreting tumors derived from chromaffin cells originating in the neural crest. These tumors represent a significant diagnostic and therapeutic challenge because the diagnosis of malignancy is frequently made in retrospect by the development of metastatic or recurrent disease. Complete surgical resection offers the only potential for cure; however, recurrence can occur even after apparently successful resection of the primary tumor. The prognosis for malignant disease is poor because traditional treatment modalities have been limited. The last decade has witnessed exciting discoveries in the study of PCCs and PGLs; advances in molecular genetics have uncovered hereditary and germline mutations of at least 10 genes that contribute to the development of these tumors, and increasing knowledge of genotype-phenotype interactions has facilitated more accurate determination of malignant potential. Elucidating the molecular mechanisms responsible for malignant transformation in these tumors has opened avenues of investigation into targeted therapeutics that show promising results. There have also been significant advances in functional and radiological imaging and in the surgical approach to adrenalectomy, which remains the mainstay of treatment for PCC. In this review, we discuss the currently available diagnostic and therapeutic options for patients with malignant PCCs and PGLs and detail the molecular rationale and clinical evidence for novel and emerging diagnostic and therapeutic strategies.
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Affiliation(s)
- Aoife J Lowery
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
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Audenet F, Méjean A, Chartier-Kastler E, Rouprêt M. Adrenal tumours are more predominant in females regardless of their histological subtype: a review. World J Urol 2013; 31:1037-43. [PMID: 23299088 DOI: 10.1007/s00345-012-1011-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 12/11/2012] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Adrenal tumours are a heterogeneous group of rare tumours. The aim of this article was to critically review gender-specific differences in the incidence, prognosis and symptoms of the different subtypes of adrenal tumours. METHODS Data acquisition regarding gender differences in adrenal tumours was performed using MEDLINE searches with combinations of the following keywords: adrenal tumours, gender, sex differences, adrenocortical carcinoma, pheochromocytoma, incidentaloma, risk factors and genetic aspects. RESULTS Data are scarce in the literature concerning the effects of gender on adrenal lesions. Although the incidence of most types of tumours (other than breast cancer and other gender-related tumours) is higher in men than in women, evidence suggests that adrenal tumours (i.e. incidentalomas, adrenal carcinomas, oncocytomas and adrenal cysts) are more frequent in women than in men. In addition, female patients have significantly increased numbers of self-reported signs and symptoms of pheochromocytoma than male patients, irrespective of biochemical phenotype and tumour presentation. Relatively little research has been performed examining the reasons for these disparities. However, hormonal interactions involving complex adrenal, endocrine and neurocrine functions together with variations in hormonal receptor sensitivity have been hypothesised to be involved. CONCLUSION Gender differences exist in the incidence and symptoms of several subtypes of adrenal tumours. The reasons for these disparities are not well established. In addition to epidemiological data, these results need to be further investigated to better understand the role of genetic and hormonal predispositions in the development, behaviour and aggressiveness of adrenal tumours.
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Affiliation(s)
- François Audenet
- Academic Department of Urology of Georges Pompidou European Hospital (HEGP), Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Descartes , University Paris V, Paris, France
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Korevaar TIM, Grossman AB. Pheochromocytomas and paragangliomas: assessment of malignant potential. Endocrine 2011; 40:354-65. [PMID: 22038451 DOI: 10.1007/s12020-011-9545-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 09/16/2011] [Indexed: 12/23/2022]
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting tumors which arise from the adrenal glands or sympathetic neuronal tissue. Malignant transformation of these tumors occurs in a significant proportion and may therefore lower overall survival rates. In patients with PPGLs it is impossible to identify malignant disease without the presence of metastatic disease, something which can occur as long as 20 years after initial surgery. Early identification of malignant disease would necessitate a more aggressive treatment approach, something which may result in better disease outcome. We have therefore reviewed possible predictors of malignancy and current developments in order to help clinicians to swiftly assess malignant potential in patients with PPGLs. Currently, there is no absolute marker which can objectively reflect malignant potential. Tumor size is the most reliable predictor and should therefore be used as the baseline characteristic. The combination of various clinical markers (extra-adrenal disease and post-operative hypertension), biochemical markers (high dopamine, high norepinephrine and epinephrine to total catecholamine ratio) and/or histological markers (SNAIL, microRNAs and/or microarray results) can raise or lower the suspicion of malignancy. Furthermore, we discuss how clinical markers may affect biochemical results linked to malignancy, how biochemical results may distinguish hereditary syndromes, the role of imaging in determining malignant potential and tumor detection, and recent results of proposed histological markers.
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Affiliation(s)
- Tim I M Korevaar
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Headington, Oxford, OX3 7LE, UK
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Somana S, Marilier S, Mazen E, de la Vega MF, Camus A, Popitean L, Pfitzenmeyer P, Pfitzenmeyer P, Manckoundia P. Psychobehavioral disorders, orthostatic hypotension, and falls related to a pheochromocytoma in a very elderly subject: a case report. J Am Geriatr Soc 2010; 58:1611-2. [PMID: 20942886 DOI: 10.1111/j.1532-5415.2010.02997.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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