Pheochromocytomas with extension into central vascular structures

Anesthetic management of gigantic pheochromocytoma resection with inferior vena cava and right atrium tumor thrombosis: a case report

Background

This report describes one case of anesthetic management about surgical resection of a malignant phaeochromocytoma with tumor extension into vena cava and right atrium in a patient. Report for anesthetic management is limited in these patients under surgical resection until now.

Case presentation

In September 2015, a 24-year-old male presented to the department of cardiology with right flank pain and hypertensive urgency in our hospital. Contrast-enhanced CT abdomen and MRI abdomen revealed a mass phaeochromocytoma in right adrenal, which invaded the right inferior vena cava(IVC)wall along with IVC thrombus. Echocardiography shown no abnormal detection. Finally, this patient gave up the surgical resection of phaeochromocytoma and chose the expectant treatment. In April 2018, this patient once again presented to the emergence department in our hospital, he had experienced persistent cough and intermittent wheezing for 5 h. Contrast-enhanced CT and echocardiography shown existing IVC thrombus had extended into the right atrium. After the careful preoperative preparation, adrenalectomy with complete thrombus excision by inferior vena cava exploration and right atriotomy were performed successfully by a multidisciplinary team. After one month post-operation care, this patient healthily left our hospital.

Conclusion

To the best of our knowledge, the occurrence of pheochromocytoma with IVC and right atrium thrombosis has not been reported in mainland China so far. This clinical case may supply a rare reference experience for surgical treatment and anesthetic management in the group of phaeochromocytoma patient with distance vascular extension.

Update on the optimal management of patients with vascular extension of pheochromocytoma

AIM

Vascular extension of pheochromocytoma is extremely rare but highly resectable. The aim of this study was to review the available information in the literature for patients with this condition.

METHODS

A systematic literature search produced individual data for 29 treated patients with vascular extension of pheochromocytoma mainly to the inferior vena cava.

RESULTS

Out of 29 reported cases, 26 have been treated surgically. Nine of these patients required cardiopulmonary bypass. Two patients died untreated and one patient declined surgical treatment and discharged to follow-up. In 24 patients including nine with primarily missed diagnosis, surgery was documented as curative.

CONCLUSION

Surgeons need to be aware of this extremely rare characteristic feature of pheochromocytoma and indicated medical work-up in order to properly diagnose and manage this challenging group of patients.

Acute upper extremity arterial thrombosis and stroke in an unresected pheochromocytoma

Pheochromocytoma is a rare cause of hypertension in the general population. Only isolated reports show an association with acute obstructive arterial thrombosis. A 50-year-old chronically noncompliant woman with a known unresected pheochromocytoma presented to the emergency department with ataxia. Imaging confirmed a right-sided ischemic stroke. During her hospital stay, the patient developed signs consistent with acute right upper extremity ischemia resulting from occlusion in the distal right subclavian, axillary, and proximal brachial arteries. Emergent open thrombectomy was successfully performed. In patients with an unresected pheochromocytoma, one must consider acute arterial thrombosis as a rare but potentially limb-threatening and even life-threatening complication.

Surgical management of a neuroendocrine tumor of the inferior vena cava

Neuroendocrine tumors occurring outside of the gastrointestinal tract or lungs are very few, and to find a primary neuroendocrine tumor of the infrahepatic inferior vena cava (IVC) is extremely rare. We present a case of a patient with a large, 7 × 4 cm neuroendocrine tumor of the IVC, where the IVC and renal veins were completely extirpated and not reconstructed. As a result, the liver was anastomosed to the intrapericardial IVC, and the patient relied on collateral drainage. After an initial postoperative period of anasarca and weight gain, she ultimately recovered fully with no evidence of recurrence in the IVC.

Surgical excision with left atrial reconstruction of a primary functioning retrocardiac paraganglioma

About 2% of all paragangliomas are located in the chest, and a few have been described to be found in the heart. Primary cardiac paragangliomas are extremely uncommon tumors and surgical experience with this neoplasm is limited. Treatment strategies described in the literature have included simple excision, excision with reconstruction, autotransplantation after excision of the tumor and even orthotopic cardiac transplantation, depending on the extent of disease. A primary retrocardiac paraganglioma catecholamine-productive was identified in an asymptomatic 49–year old female associated to familial pheochromocytoma-paraganglioma syndrome caused by germline mutation of the gen which codifies for the subunit B of succinate dehydrogenase enzyme (SDHB). The neoplasm was surgically excised from the posterior surface of the left atrium via median sternotomy using cardiopulmonary bypass. Direct ligation of feeding vessels of the tumor along with left atrial reinforcement using a pericardial patch was performed. The post-operative course was uneventful, with normalization of catecholamine secretion and no recurrence at three-month follow-up. We review the current literature about this exceptional cardiac tumor, pathophysiological conditions and options for surgical management.

Wiederholungseingriffe an den Nebennieren

Repeat adrenalectomy may be required due to ipsilateral recurrence of benign or malignant adrenal tumors after previous total or subtotal adrenalectomy. Even for multivisceral resection in patients with adrenocortical carcinoma, complete resection of local recurrent tumor offers results similar to those of primary resection (5-year survival 40-60%). In contrast, since no benefit on long-term survival has been shown so far by tumor debulking, palliative tumor resection should only be performed individually for control of severe endocrine symptoms. The effect of endoscopic adrenalectomy in patients with large tumors (>5 cm) or suspected malignancy has still not been well examined. Further studies are required. In any case, during open or endoscopic approach, tumor spillage must be avoided to prevent local tumor cell implantation. Following subtotal adrenalectomy, the risk of ipsilateral recurrence correlates with disease, follow-up, localization, size of the adrenal remnant, and, in case of familial pheochromocytoma, probably with genotype.

Primary cardiac paraganglioma

We report a case of a 29-year-old male, who during workup of hypertension was found to have a malignant primary paraganglioma of the heart. The tumor arose from the site of the aortopulmonary window and right ventricular outflow tract (RVOT) and was removed with the aid of cardiopulmonary bypass. Reconstruction of the RVOT and pulmonary valve was necessary because of involvement by the tumor. The surgical course was uncomplicated, with normalization of catecholamine secretion and blood pressure.

[Right atrial pheochromocytoma]

Pheochromocytoma is a catecholamine-producing tumor and a rare cause of hypertension. Most cases are intra-adrenal and intrapericardial pheochromocytomas are extremely uncommon. We report the case of a 46-year-old woman with a 1-year history of hypertension, in which a right atrial pheochromocytoma was detected after a hypertensive crisis. 131I-metaiodobenzylguanidine scintigraphy and magnetic resonance imaging established the diagnosis. The tumor was successfully resected using cardiopulmonary bypass and the right atrium was reconstructed using bovine pericardium.

Cardiac phaeochromocytoma presenting with severe hypertension and chest pain

Cardiac phaeochromocytoma is a rare cause of endocrine hypertension. We report a case of a 25-year-old woman, who presented with severe hypertension and intermittent chest pain. The patient denied typical phaeochromocytoma spells of palpitation, headache, and diaphoresis. The 24-hr urinary excretion of norepinephrine was increased sevenfold above the upper limit of normal; however, the excretion of total metanephrines, epinephrine, and dopamine were normal. Computed tomography (CT) scan of the abdomen was normal. An 131I-labelled metaiodobenzylguanidine (MIBG) scan was falsely negative while the patient was taking labetalol. The cardiac phaeochromocytoma was localized with indium-111-pentetreotide scintigraphy and chest magnetic resonance imaging scan. Repeat 123I-MIBG scintigraphy was positive after discontinuing labetalol. The cardiac phaeochromocytoma was located in the right atrial groove, adjacent to the tricuspid valve, and contained multiple feeder arteries from the right coronary artery. After treatment with volume expansion, alpha-methyl-p-tyrosine, and alpha- and beta-adrenergic blockade, surgical resection was performed. While under cardiopulmonary bypass, coronary bypass grafting and tricuspid annuloplasty were performed to facilitate the complete surgical resection of the 4.5-cm tumour. The surgical course was uncomplicated, with complete cure of hypertension and normalization of catecholamine excretion. Post-operative cardiac function, as measured by echocardiogram, was normal. Although cardiac phaeochromocytoma may be highly vascular, invasive and difficult to resect, it can be cured.

Multicentric pheochromocytoma and involvement of the inferior vena cava

CONTEXT

Extension of pheochromocytomas to the inferior vena cava is rare. Multicentric tumors are rare as well, being present in up to 10% of cases. Surgery is the treatment of choice because of the long-term survival free of disease.

DESIGN

Case report.

CASE REPORT

We report on a case of right adrenal pheochromocytoma with extension to the supra-diaphragmatic vena cava, which underwent surgical excision through thoracophrenic laparotomy without the need for cardiopulmonary bypass. In a 6-year follow-up, another pheochromocytoma was found in the infra-renal Zuckerkandl's organ. Complete surgical excision of the tumor was performed by a median laparotomy and complete retroperitoneal dissection. In both cases, the total removal of the pheochromocytoma has been guaranteed by having margins free of tumor and a normal post-operative level of catecholamines. The pathological study revealed a malignant pheochromocytoma with margins free of neoplasia in both specimens.

Primary pheochromocytoma extending into the right atrium: report of a case and review of the literature

Pheochromocytoma rarely extends locally into the vena cava or the right atrium. We report a case of malignant pheochromocytoma with growth into the inferior vena cava, extending into the right atrium, address clinical aspects of this tumour and review the literature on this malignancy. Pre-operative work-up of this tumour should include measurements of urinary vanillyl mandelic acid and cathecholamine excretion, MRI and spiral CT of the abdomen and thorax. After the diagnosis is made the patient should be treated with catecholamine alpha-receptor blockade and if necessary with subsequent beta-receptor blockade. An aggressive surgical approach is always warranted, even in cases with very large localized tumours, because surgery has been shown to lead to relief of symptoms and to prolong survival in cases otherwise deemed irresectable. The optimal surgical exposure is obtained via a transsternal midline thoraco-laparotomy. If feasible, a combination of cardiopulmonary bypass, hypothermia, cardiac arrest and exsanguination procedures should be used. In case of local of tumour remnants after surgery or distant metastases treatment options are secondary surgery, tumour embolization, or treatment with radioactive labelled drugs, including(131)I-MIBG.