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Li Q, Lan Z, Jiang Y, Wang R, Li Z, Jiang X. Validation and Evaluation of 5 Scoring Systems for Predicting Metastatic Risk in Pheochromocytoma and Paraganglioma. Am J Surg Pathol 2024; 48:855-865. [PMID: 38712603 DOI: 10.1097/pas.0000000000002238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Currently, 5 scoring systems have been proposed in the literature for predicting metastatic risk in pheochromocytoma and paraganglioma (PPGL): Pheochromocytoma of the Adrenal Gland Scaled Score (PASS), Grading System for Adrenal Pheochromocytoma and Paraganglioma (GAPP), Composite Pheochromocytoma/paraganglioma Prognostic Score (COPPS), Age, Size, Extra-adrenal location, Secretion type (ASES) score, and Size, Genetic, Age, and PASS (SGAP) model. To validate and evaluate these 5 scoring systems, we conducted a retrospective review of cases diagnosed as PPGL at the Department of Pathology, West China Hospital of Sichuan University, between January 2012 and December 2019. A total of 185 PPGL cases were included, comprising 35 cases with metastasis and 150 cases remained metastasis-free for over 8 years after surgery. The criteria of the 5 scoring systems were used for scoring and risk classification. The predictive performance of the 5 scoring systems was validated, compared, and evaluated using concordance index (C-index) and decision curve analysis (DCA). The C-indices for PASS, GAPP, and SGAP were 0.600, 0.547, and 0.547, respectively, indicating low discriminative ability. In contrast, COPPS and ASES had C-indices of 0.740 and 0.706, respectively, indicating better discriminative performance. DCA also showed that the predictive capability of COPPS was superior to that of ASES, with both outperformed PASS, while PASS had better predictive ability than GAPP and SGAP. Our analysis indicated that pathology-based scoring systems cannot accurately predict metastatic risk of PPGL. Establishing a precise prediction system requires integrating clinical, pathologic, and molecular information, using a scientific methodology for predictive factor selection and weight assessment.
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Affiliation(s)
- Qin Li
- Departments of Pathology
- Neurosurgery, West China Hospital of Sichuan University
| | - Zhigang Lan
- Department of Pathology, Chengdu Fifth People's Hospital, The Fifth People's Hospital Affiliated to Chengdu University of Traditional Chinese Medicine
| | | | | | | | - Xiaolin Jiang
- Department of Pathology, Guangyuan Central Hospital, Chengdu, Sichuan Province, China
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Kim SJ, Park CY, Kwon H, Kim YH. Evaluation of adrenal masses using 18 F-FDOPA PET/CT in patients suspected with pheochromocytoma. Nucl Med Commun 2024; 45:86-92. [PMID: 37901929 DOI: 10.1097/mnm.0000000000001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
OBJECTIVE Pheochromocytomas (PHEOs) are chromaffin cell-derived adrenal tumors. 6-[ 18 F]-L-fluoro-L-3, 4-dihydroxyphenylalanine ( 18 F-FDOPA) is a radiotracer taken up in neuroendocrine chromaffin cells via the L-type amino-acid transporter. 18 F-FDOPA is useful in patients with PHEO. However, more information about the use of 18 F-FDOPA PET/CT scan is needed. Thus, the current study investigated various PET parameters on preoperative 18 F-FDOPA PET/CT scan. METHODS The 18 F-FDOPA PET/CT scan findings of 29 patients who underwent adrenalectomy after PET/CT scans were evaluated according to their pathologic diagnosis. Thereafter, the patients were classified under different risk groups which were compared based on the Grading System for Adrenal Pheochromocytoma and Paraganglioma (GAPP). RESULTS In terms of histopathologic results after surgery, 24 patients presented with PHEO. The remaining 5 patients were diagnosed with adrenal cortical adenomas or adrenal medullary hyperplasia. The maximum standardized uptake value, mean standardized uptake value, tumor-to-liver ratio, and tumor-to-contralateral adrenal gland ratio of PHEOs on preoperative 18 F-FDOPA PET/CT scan were higher than those of other tumors. The metabolic tumor volume (MTV) and total lesion uptake of PHEOs in the intermediate-risk group (n = 19) were higher than those in the low-risk group (n = 5). The MTV and total lesion uptake were significantly correlated with the GAPP score. CONCLUSION Preoperative 18 F-FDOPA PET/CT is helpful to identifying PHEOs. In addition, imaging interpretation using the standardized uptake value of the suspected tumor or the tumor-to-liver/contralateral adrenal gland ratio can be effective. The metabolic parameters of PHEOs are positively correlated with the GAPP score.
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Affiliation(s)
- Soo Jeong Kim
- Department of Nuclear Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine and
| | - Cheol-Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyemi Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Hwan Kim
- Department of Nuclear Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine and
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Juhlin CC, Bal M. Top 10 Histological Mimics of Neuroendocrine Carcinoma You Should Not Miss in the Head and Neck. Head Neck Pathol 2023; 17:66-84. [PMID: 36941503 PMCID: PMC10063750 DOI: 10.1007/s12105-022-01521-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/10/2022] [Indexed: 03/23/2023]
Abstract
BACKGROUND The spectrum of neuroendocrine neoplasia (NEN) of the head and neck region is wide-ranging and diverse, including a variety of diagnoses stretching from benign and low-malignant tumor forms to highly proliferative, poor prognosis neuroendocrine carcinoma (NEC). Moreover, there are several non-neuroendocrine differential diagnoses to keep in mind as well, displaying various degree of morphological and/or immunohistochemical overlap with bona fide neuroendocrine lesions. METHODS Review. RESULTS While the growth patterns may vary, well-differentiated NEN usually display a stippled "salt and pepper" chromatin, a granular cytoplasm, and unequivocal expression of neuroendocrine markers such as chromogranin A and synaptophysin. However, these features are often less pronounced in NEC, which may cause diagnostic confusion-not the least since several non-NEC head and neck tumors may exhibit morphological similarities and focal neuroendocrine differentiation. CONCLUSION As patients with NEC may require specific adjuvant treatment and follow-up, knowledge regarding differential diagnoses and potential pitfalls is therefore clinically relevant. In this review, the top ten morphological and/or immunohistochemical mimics of NEC are detailed in terms of histology, immunohistochemistry, and molecular genetics.
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Affiliation(s)
- C Christofer Juhlin
- Department of Oncology-Pathology, BioClinicum J6:20, Karolinska Institutet, Solna, 171 64, Stockholm, Sweden.
- Department of Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden.
| | - Munita Bal
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, 400012, India.
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Miyauchi M, Akashi T, Furukawa A, Uchida K, Tamura T, Ando N, Kirimura S, Shintaku H, Yamamoto K, Ito T, Miura K, Kayamori K, Ariizumi Y, Asakage T, Kudo A, Tanabe M, Fujii Y, Ishibashi H, Okubo K, Murakami M, Yamada T, Takemoto A, Bae Y, Eishi Y, Ohashi K. PHOX2B is a Sensitive and Specific Marker for the Histopathological Diagnosis of Pheochromocytoma and Paraganglioma. Endocr Pathol 2022; 33:506-518. [PMID: 36029394 DOI: 10.1007/s12022-022-09730-4] [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] [Accepted: 08/19/2022] [Indexed: 11/28/2022]
Abstract
Pheochromocytomas (PCCs) and paragangliomas (PGLs) are non-epithelial neuroendocrine neoplasms originating from the adrenal medulla and paraganglion of the sympathetic and parasympathetic nervous system, respectively. PCCs and PGLs show histological similarities with other epithelial neuroendocrine neoplasms and olfactory neuroblastomas (ONBs), and the differential diagnosis of PGLs is particularly difficult. Therefore, we compared the sensitivity of PHOX2A, PHOX2B, and tyrosine hydroxylase (TH) in the histopathological diagnosis of PCCs and PGLs immunohistochemically using the tissue microarrays of 297 neoplasms including PCCs, PGLs, neuroblastomas, ganglioneuromas, epithelial neuroendocrine neoplasms, and ONBs. Using cutoff values of 25%, 5%, and 5% of tumor cells expressing PHOX2A, PHOX2B, and TH, respectively, as positive, 40 of 51 PCCs, 32 of 33 parasympathetic/head and neck PGLs (HNPGLs), 17 of 19 sympathetic/thoracoabdominal PGLs (TAPGLs), and 12 of 152 epithelial neuroendocrine neoplasms, including 123 well-differentiated and 29 poorly differentiated neuroendocrine neoplasms, were PHOX2A-positive. All 51 PCCs, 33 HNPGLs, and 19 TAPGLs were PHOX2B-positive, while all 152 epithelial neuroendocrine neoplasms were PHOX2B-negative. Moreover, 50 of 51 PCCs, 13 of 33 HNPGLs, all TAPGLs, and 12 of 152 epithelial neuroendocrine neoplasms were TH-positive. All ONBs were negative for PHOX2A, PHOX2B, and TH. PHOX2B was the most sensitive and specific diagnostic marker for PCCs and PGLs among PHOX2A, PHOX2B, and TH. PHOX2B can facilitate identification of PCCs and PGLs from epithelial neuroendocrine neoplasms and ONBs, especially in the case of HNPGLs, in which TH is often negative.
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Affiliation(s)
- Minami Miyauchi
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takumi Akashi
- Department of Diagnostic Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan.
| | - Asuka Furukawa
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keisuke Uchida
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Tomoki Tamura
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Noboru Ando
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Susumu Kirimura
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Hiroshi Shintaku
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kurara Yamamoto
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Ito
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiko Miura
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Kou Kayamori
- Department of Oral Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Ariizumi
- Department of Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahiro Asakage
- Department of Head and Neck Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Thoracic Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hironori Ishibashi
- Department of Urology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenichi Okubo
- Department of Urology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masanori Murakami
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akira Takemoto
- Division of Surgical Pathology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
- Bioresource Research Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuan Bae
- Department of Pathology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Yoshinobu Eishi
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenichi Ohashi
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Constantinescu G, Preda C, Constantinescu V, Siepmann T, Bornstein SR, Lenders JWM, Eisenhofer G, Pamporaki C. Silent pheochromocytoma and paraganglioma: Systematic review and proposed definitions for standardized terminology. Front Endocrinol (Lausanne) 2022; 13:1021420. [PMID: 36325453 PMCID: PMC9618947 DOI: 10.3389/fendo.2022.1021420] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors with heterogeneous clinical presentations and potential lethal outcomes. The diagnosis is based on clinical suspicion, biochemical testing, imaging and histopathological confirmation. Increasingly widespread use of imaging studies and surveillance of patients at risk of PPGL due to a hereditary background or a previous tumor is leading to the diagnosis of these tumors at an early stage. This has resulted in an increasing use of the term "silent" PPGL. This term and other variants are now commonly found in the literature without any clear or unified definition. Among the various terms, "clinically silent" is often used to describe the lack of signs and symptoms associated with catecholamine excess. Confusion arises when these and other terms are used to define the tumors according to their ability to synthesize and/or release catecholamines in relation to biochemical test results. In such cases the term "silent" and other variants are often inappropriately and misleadingly used. In the present analysis we provide an overview of the literature and propose standardized terminology in an attempt at harmonization to facilitate scientific communication.
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Affiliation(s)
- Georgiana Constantinescu
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
| | - Cristina Preda
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
| | - Victor Constantinescu
- Center of Clinical Neuroscience, University Clinic Carl-Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Timo Siepmann
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan R. Bornstein
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Jacques W. M. Lenders
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Graeme Eisenhofer
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University of Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
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Snezhkina A, Pavlov V, Dmitriev A, Melnikova N, Kudryavtseva A. Potential Biomarkers of Metastasizing Paragangliomas and Pheochromocytomas. Life (Basel) 2021; 11:1179. [PMID: 34833055 PMCID: PMC8619623 DOI: 10.3390/life11111179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 02/07/2023] Open
Abstract
Paragangliomas and pheochromocytomas (PPGLs) are rare neuroendocrine tumors originating from paraganglionic tissue in many sites of the body. Most PPGLs are characterized by nonaggressive behavior but all of them have the potential to metastasize. PPGLs represent a great diagnostic dilemma as it is difficult to recognize tumors that are likely to be metastasizing; criteria of malignancy can be found both in benign and metastatic forms. This review aims to analyze the current knowledge of the nature of metastasizing PPGLs paying particular attention to head and neck paragangliomas (HNPGLs). Potential predictors of the malignancy risk for PPGLs were summarized and discussed. These data may also help in the development of diagnostic and prognostic strategies, as well as in the identification of novel potential therapeutic targets for patients with PPGLs.
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Affiliation(s)
- Anastasiya Snezhkina
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (V.P.); (A.D.); (N.M.)
| | | | | | | | - Anna Kudryavtseva
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (V.P.); (A.D.); (N.M.)
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Thompson LDR, Gill AJ, Asa SL, Clifton-Bligh RJ, de Krijger RR, Kimura N, Komminoth P, Lack EE, Lenders JWM, Lloyd RV, Papathomas TG, Sadow PM, Tischler AS. Data set for the reporting of pheochromocytoma and paraganglioma: explanations and recommendations of the guidelines from the International Collaboration on Cancer Reporting. Hum Pathol 2020; 110:83-97. [PMID: 32407815 DOI: 10.1016/j.humpath.2020.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The International Collaboration on Cancer Reporting (ICCR) is a not-for-profit to develop evidence-based, internationally agreed-upon standardized data sets for each anatomic site, to be used throughout the world. Providing global standardization of pathology tumor classification, staging, and other reporting elements will lead to improved patient management and enhanced epidemiological research. METHODS Pheochromocytoma and paraganglioma are uncommon and are frequently overlooked in registry data sets. Malignant criteria have previously been defined only when there was metastatic disease. RESULTS With recent recognition of a significant inheritance association and the development of risk stratification tools, this data set was created in order to obtain more meaningful outcomes and management data, using similar criteria across the global pathology community. Issues related to key core and non-core elements, especially clinical hormonal status, familial history, tumor focality, proliferative fraction, adverse or risk stratification features, and ancillary techniques, are discussed in the context of daily application to these types of specimens. CONCLUSIONS The ICCR data set, developed by an international panel of endocrine organ specialists, establishes a pathology-standardized reporting guide for pheochromocytoma and paraganglioma.
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Affiliation(s)
- Lester D R Thompson
- Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, CA, USA.
| | - Anthony J Gill
- University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Group Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Pathology, Case Western Reserve University, Cleveland, OH, USA; University Health Network, Toronto, Canada.
| | - Roderick J Clifton-Bligh
- University of Sydney, Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Ronald R de Krijger
- Department of Pathology, University Medical Centre and Princess Maxima Centre, Utrecht, the Netherlands.
| | - Noriko Kimura
- Department of Diagnostic Pathology, Department of Clinical Research, Pathology Division, National Hospital Organization Hakodate Hospital, Japan.
| | - Paul Komminoth
- University of Zürich, Institute of Pathology, City Hospital Triemli, Zürich, Switzerland.
| | - Ernest E Lack
- Department of Endocrine Pathology, The Joint Pathology Center, Silver Spring, MD, USA.
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Medicine III, University Hospital Carl Gustav Carus and Medical Faculty, Technical University Dresden, Dresden, Germany.
| | - Ricardo V Lloyd
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA.
| | - Thomas G Papathomas
- Institute of Metabolism and Systems Research, University of Birmingham, United Kingdom.
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Arthur S Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, USA.
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Sarkadi B, Meszaros K, Krencz I, Canu L, Krokker L, Zakarias S, Barna G, Sebestyen A, Papay J, Hujber Z, Butz H, Darvasi O, Igaz P, Doczi J, Luconi M, Chinopoulos C, Patocs A. Glutaminases as a Novel Target for SDHB-Associated Pheochromocytomas/Paragangliomas. Cancers (Basel) 2020; 12:E599. [PMID: 32150977 PMCID: PMC7139890 DOI: 10.3390/cancers12030599] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 01/08/2023] Open
Abstract
Pheochromocytoma/paragangliomas (Pheo/PGL) are rare endocrine cancers with strong genetic background. Mutations in the SDHB subunit of succinate dehydrogenase (SDH) predispose patients to malignant disease with limited therapeutic options and poor prognosis. Using a host of cellular and molecular biology techniques in 2D and 3D cell culture formats we show that SDH inhibition had cell line specific biological and biochemical consequences. Based on our studies performed on PC12 (rat chromaffin cell line), Hela (human cervix epithelial cell line), and H295R (human adrenocortical cell line) cells, we demonstrated that chromaffin cells were not affected negatively by the inhibition of SDH either by siRNA directed against SDHB or treatment with SDH inhibitors (itaconate and atpenin A5). Cell viability and intracellular metabolite measurements pointed to the cell line specific consequences of SDH impairment and to the importance of glutamate metabolism in chromaffin cells. A significant increase in glutaminase-1 (GLS-1) expression after SDH impairment was observed in PC12 cells. GLS-1 inhibitor BPTES was capable of significantly decreasing proliferation of SDH impaired PC12 cells. Glutaminase-1 and SDHB expressions were tested in 35 Pheo/PGL tumor tissues. Expression of GLS1 was higher in the SDHB low expressed group compared to SDHB high expressed tumors. Our data suggest that the SDH-associated malignant potential of Pheo/PGL is strongly dependent on GLS-1 expression and glutaminases may be novel targets for therapy.
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Affiliation(s)
- Balazs Sarkadi
- 2nd Department of Internal Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.S.); (S.Z.); (P.I.)
- Hereditary Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, 1085 Budapest, Hungary; (K.M.); (L.K.); (H.B.); (O.D.)
| | - Katalin Meszaros
- Hereditary Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, 1085 Budapest, Hungary; (K.M.); (L.K.); (H.B.); (O.D.)
- Department of Laboratory Medicine, Semmelweis University, 1089 Budapest, Hungary
- Bionics Innovation Center, 1088 Budapest, Hungary;
| | - Ildiko Krencz
- 1st Department of Pathology and Experimental Cancer, Semmelweis University, 1085 Budapest, Hungary; (I.K.); (G.B.); (J.P.); (Z.H.)
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy; (L.C.); (M.L.)
| | - Lilla Krokker
- Hereditary Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, 1085 Budapest, Hungary; (K.M.); (L.K.); (H.B.); (O.D.)
- Bionics Innovation Center, 1088 Budapest, Hungary;
| | - Sara Zakarias
- 2nd Department of Internal Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.S.); (S.Z.); (P.I.)
| | - Gabor Barna
- 1st Department of Pathology and Experimental Cancer, Semmelweis University, 1085 Budapest, Hungary; (I.K.); (G.B.); (J.P.); (Z.H.)
| | - Anna Sebestyen
- Bionics Innovation Center, 1088 Budapest, Hungary;
- 1st Department of Pathology and Experimental Cancer, Semmelweis University, 1085 Budapest, Hungary; (I.K.); (G.B.); (J.P.); (Z.H.)
| | - Judit Papay
- 1st Department of Pathology and Experimental Cancer, Semmelweis University, 1085 Budapest, Hungary; (I.K.); (G.B.); (J.P.); (Z.H.)
| | - Zoltan Hujber
- 1st Department of Pathology and Experimental Cancer, Semmelweis University, 1085 Budapest, Hungary; (I.K.); (G.B.); (J.P.); (Z.H.)
| | - Henriett Butz
- Hereditary Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, 1085 Budapest, Hungary; (K.M.); (L.K.); (H.B.); (O.D.)
- Department of Laboratory Medicine, Semmelweis University, 1089 Budapest, Hungary
- Bionics Innovation Center, 1088 Budapest, Hungary;
- Department of Molecular Genetics, National Institute of Oncology, 1122 Budapest, Hungary
| | - Otto Darvasi
- Hereditary Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, 1085 Budapest, Hungary; (K.M.); (L.K.); (H.B.); (O.D.)
- Bionics Innovation Center, 1088 Budapest, Hungary;
| | - Peter Igaz
- 2nd Department of Internal Medicine, Semmelweis University, 1088 Budapest, Hungary; (B.S.); (S.Z.); (P.I.)
- Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, 1085 Budapest, Hungary
| | - Judit Doczi
- Department of Medical Biochemistry, Semmelweis University, 1094 Budapest, Hungary; (J.D.); (C.C.)
| | - Michaela Luconi
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy; (L.C.); (M.L.)
| | - Christos Chinopoulos
- Department of Medical Biochemistry, Semmelweis University, 1094 Budapest, Hungary; (J.D.); (C.C.)
| | - Attila Patocs
- Hereditary Tumours Research Group, Hungarian Academy of Sciences and Semmelweis University, 1085 Budapest, Hungary; (K.M.); (L.K.); (H.B.); (O.D.)
- Department of Laboratory Medicine, Semmelweis University, 1089 Budapest, Hungary
- Bionics Innovation Center, 1088 Budapest, Hungary;
- Department of Molecular Genetics, National Institute of Oncology, 1122 Budapest, Hungary
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Molecular Profiling of Pheochromocytoma and Abdominal Paraganglioma Stratified by the PASS Algorithm Reveals Chromogranin B as Associated With Histologic Prediction of Malignant Behavior. Am J Surg Pathol 2020; 43:409-421. [PMID: 30451732 DOI: 10.1097/pas.0000000000001190] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pheochromocytomas (PCCs) and abdominal paragangliomas (PGLs), collectively abbreviated PPGL, are believed to exhibit malignant potential-but only subsets of cases will display full-blown malignant properties. The Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) algorithm is a proposed histologic system to detect potential for aggressive behavior, but little is known regarding the coupling to underlying molecular genetics. In this study, a total of 92 PPGLs, previously characterized for susceptibility gene status and mRNA expressional profiles, were histologically assessed using the PASS criteria. A total of 32/92 PPGLs (35%) exhibited a PASS score ≥4, including all 8 cases with malignant behavior (7 with known metastases and 1 with extensively infiltrative local recurrence). Statistical analyzes between expressional data and clinical parameters as well as individual PASS criteria yielded significant associations to Chromogranin B (CHGB), BRCA2, HIST1H3B, BUB1B, and RET to name a few, and CHGB had the strongest correlation to both PASS and metastasis/local recurrence of all analyzed genes. Evident CHGB downregulation was observed in PPGLs with high PASS and overtly malignant behavior, and was also associated with shorter disease-related survival. This finding was validated using quantitative real-time polymerase chain reaction, in which CHGB expression correlated with both PASS and metastasis/local recurrence with consistent findings obtained in the TCGA cohort. Moreover, immunohistochemical analyses of subsets of tumors showed a correlation between high PASS scores and negative or weak CHGB protein expression. Patients with PPGLs obtaining high PASS scores postoperatively, also exhibited low preoperative plasma levels of CHGB. These data collectively point out CHGB as a possible preoperative and postoperative marker for PPGLs with potential for aggressive behavior.
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Yamazaki Y, Gao X, Pecori A, Nakamura Y, Tezuka Y, Omata K, Ono Y, Morimoto R, Satoh F, Sasano H. Recent Advances in Histopathological and Molecular Diagnosis in Pheochromocytoma and Paraganglioma: Challenges for Predicting Metastasis in Individual Patients. Front Endocrinol (Lausanne) 2020; 11:587769. [PMID: 33193100 PMCID: PMC7652733 DOI: 10.3389/fendo.2020.587769] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PHEO/PGL) are rare but occasionally life-threatening neoplasms, and are potentially malignant according to WHO classification in 2017. However, it is also well known that histopathological risk stratification to predict clinical outcome has not yet been established. The first histopathological diagnostic algorithm for PHEO, "PASS", was proposed in 2002 by Thompson et al. Another algorithm, GAPP, was then proposed by Kimura et al. in 2014. However, neither algorithm has necessarily been regarded a 'gold standard' for predicting post-operative clinical behavior of tumors. This is because the histopathological features of PHEO/PGL are rather diverse and independent of their hormonal activities, as well as the clinical course of patients. On the other hand, recent developments in wide-scale genetic analysis using next-generation sequencing have revealed the molecular characteristics of pheochromocytomas and paragangliomas. More than 30%-40% of PHEO/PGL are reported to be associated with hereditary genetic abnormalities involving > 20 genes, including SDHXs, RET, VHL, NF1, TMEM127, MAX, and others. Such genetic alterations are mainly involved in the pathogenesis of pseudohypoxia, Wnt, and kinase signaling, and other intracellular signaling cascades. In addition, recurrent somatic mutations are frequently detected and overlapped with the presence of genetic alterations associated with hereditary diseases. In addition, therapeutic strategies specifically targeting such genetic abnormalities have been proposed, but they are not clinically applicable at this time. Therefore, we herein review recent advances in relevant studies, including histopathological and molecular analyses, to summarize the current status of potential prognostic factors in patients with PHEO/PGL.
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Affiliation(s)
- Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Xin Gao
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Alessio Pecori
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Kei Omata
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yoshikiyo Ono
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- *Correspondence: Hironobu Sasano,
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Gao X, Yamazaki Y, Pecori A, Tezuka Y, Ono Y, Omata K, Morimoto R, Nakamura Y, Satoh F, Sasano H. Histopathological Analysis of Tumor Microenvironment and Angiogenesis in Pheochromocytoma. Front Endocrinol (Lausanne) 2020; 11:587779. [PMID: 33244312 PMCID: PMC7685215 DOI: 10.3389/fendo.2020.587779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/09/2020] [Indexed: 12/14/2022] Open
Abstract
Pheochromocytomas (PHEOs) are relatively rare catecholamine-producing tumors derived from adrenal medulla. Tumor microenvironment (TME) including neoangiogenesis has been explored in many human neoplasms but not necessarily in PHEOs. Therefore, in this study, we examined tumor infiltrating lymphocytes (CD4 and CD8), tumor associated macrophages (CD68 and CD163), sustentacular cells (S100p), and angiogenic markers (CD31 and areas of intratumoral hemorrhage) in 39 cases of PHEOs in the quantitative fashion. We then compared the results with pheochromocytoma of the adrenal gland scaled score (PASS), grading system for pheochromocytoma and paraganglioma (GAPP) and the status of intra-tumoral catecholamine-synthesizing enzymes (TH, DDC, and PNMT) as well as their clinicopathological factors. Intratumoral CD8 (p = 0.0256), CD31 (p = 0.0400), and PNMT (p = 0.0498) status was significantly higher in PHEOs with PASS <4 than PASS ≧4. In addition, intratumoral CD8+ lymphocytes were also significantly more abundant in well-than moderately differentiated PHEO according to GAPP score (p = 0.0108) and inversely correlated with tumor size (p = 0.0257). Intratumoral CD68+ cells were significantly higher in PHEOs with regular or normal histological patterns than those not (p = 0.0370) and inversely correlated with tumor size (p = 0.0457). The status of CD163 was significantly positively correlated with that of CD8 positive cells (p = 0.0032). The proportion of intratumoral hemorrhage areas was significantly higher in PHEOs with PASS ≧4 (p = 0.0172). DDC immunoreactivity in tumor cells was significantly positively correlated with PASS score (p = 0.0356) and TH status was significantly higher in PHEOs harboring normal histological patterns (p = 0.0236) and cellular monotony (p = 0.0219) than those not. Results of our present study did demonstrate that abundant CD8+ and CD68+ cells could represent a histologically low-scored tumor. In particular, PHEOs with increased intratumoral hemorrhage should be considered rather malignant. In addition, abnormal catecholamine-producing status of tumor cells such as deficient PNMT and TH and increased DDC could also represent more aggressive PHEOs.
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Affiliation(s)
- Xin Gao
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Alessio Pecori
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Kei Omata
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- *Correspondence: Hironobu Sasano,
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Intricacies of the Molecular Machinery of Catecholamine Biosynthesis and Secretion by Chromaffin Cells of the Normal Adrenal Medulla and in Pheochromocytoma and Paraganglioma. Cancers (Basel) 2019; 11:cancers11081121. [PMID: 31390824 PMCID: PMC6721535 DOI: 10.3390/cancers11081121] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/11/2022] Open
Abstract
The adrenal medulla is composed predominantly of chromaffin cells producing and secreting the catecholamines dopamine, norepinephrine, and epinephrine. Catecholamine biosynthesis and secretion is a complex and tightly controlled physiologic process. The pathways involved have been extensively studied, and various elements of the underlying molecular machinery have been identified. In this review, we provide a detailed description of the route from stimulus to secretion of catecholamines by the normal adrenal chromaffin cell compared to chromaffin tumor cells in pheochromocytomas. Pheochromocytomas are adrenomedullary tumors that are characterized by uncontrolled synthesis and secretion of catecholamines. This uncontrolled secretion can be partly explained by perturbations of the molecular catecholamine secretory machinery in pheochromocytoma cells. Chromaffin cell tumors also include sympathetic paragangliomas originating in sympathetic ganglia. Pheochromocytomas and paragangliomas are usually locally confined tumors, but about 15% do metastasize to distant locations. Histopathological examination currently poorly predicts future biologic behavior, thus long term postoperative follow-up is required. Therefore, there is an unmet need for prognostic biomarkers. Clearer understanding of the cellular mechanisms involved in the secretory characteristics of pheochromocytomas and sympathetic paragangliomas may offer one approach for the discovery of novel prognostic biomarkers for improved therapeutic targeting and monitoring of treatment or disease progression.
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Stenman A, Zedenius J, Juhlin CC. The Value of Histological Algorithms to Predict the Malignancy Potential of Pheochromocytomas and Abdominal Paragangliomas-A Meta-Analysis and Systematic Review of the Literature. Cancers (Basel) 2019; 11:cancers11020225. [PMID: 30769931 PMCID: PMC6406721 DOI: 10.3390/cancers11020225] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 12/26/2022] Open
Abstract
Pheochromocytomas (PCCs) and abdominal paragangliomas (PGLs), collectively abbreviated PPGLs, are neuroendocrine tumors of the adrenal medulla and paraganglia, respectively. These tumors exhibit malignant potential but seldom display evidence of metastatic spread, the latter being the only widely accepted evidence of malignancy. To counter this, pre-defined histological algorithms have been suggested to stratify the risk of malignancy: Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) and the Grading system for Adrenal Pheochromocytoma and Paraganglioma (GAPP). The PASS algorithm was originally intended for PCCs whereas the GAPP model is proposed for stratification of both PCCs and PGLs. In parallel, advances in terms of coupling overtly malignant PPGLs to the underlying molecular genetics have been made, but there is yet no combined risk stratification model based on histology and the overall mutational profile of the tumor. In this review, we systematically meta-analyzed previously reported cohorts using the PASS and GAPP algorithms and acknowledge a “rule-out” way of approaching these stratification models rather than a classical “rule-in” strategy. Moreover, the current genetic panorama regarding possible molecular adjunct markers for PPGL malignancy is reviewed. A combined histological and genetic approach will be needed to fully elucidate the malignant potential of these tumors.
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Affiliation(s)
- Adam Stenman
- Department of Oncology-Pathology, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, 171 76 Stockholm, Sweden.
| | - Jan Zedenius
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, 171 76 Stockholm, Sweden.
| | - Carl Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Pathology and Cytology, Karolinska University Hospital, 171 76 Stockholm, Sweden.
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Araki S, Kijima T, Waseda Y, Komai Y, Nakanishi Y, Uehara S, Yasuda Y, Yoshida S, Yokoyama M, Ishioka J, Matsuoka Y, Saito K, Kihara K, Nakano Y, Yoshimoto T, Uchida T, Fujii Y. Incidence and predictive factors of hypoglycemia after pheochromocytoma resection. Int J Urol 2018; 26:273-277. [DOI: 10.1111/iju.13864] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/23/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Saori Araki
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Toshiki Kijima
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Yuma Waseda
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Yoshinobu Komai
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Yasukazu Nakanishi
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Sho Uehara
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Yosuke Yasuda
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Soichiro Yoshida
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Minato Yokoyama
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Junichiro Ishioka
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Yoh Matsuoka
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Kazutaka Saito
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Kazunori Kihara
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Yujiro Nakano
- Department of Molecular Endocrinology and Metabolism Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Tokujiro Uchida
- Department of Anesthesiology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
| | - Yasuhisa Fujii
- Department of Urology Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
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