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Tarling JA, Kumar R, Ward LJ, Boot C, Wassif WS. Phaeochromocytoma and paraganglioma. J Clin Pathol 2024:jcp-2023-209234. [PMID: 38453430 DOI: 10.1136/jcp-2023-209234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
Phaeochromocytomas and paragangliomas are rare catecholamine-producing neuroendocrine tumours which can potentially cause catastrophic crises with high morbidity and mortality. This best practice article considers the causes and presentation of such tumours, screening and diagnostic tests, management of these patients and consideration of family members at risk.
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Affiliation(s)
- Julie Ann Tarling
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Louise J Ward
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Christopher Boot
- Blood Sciences, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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Eisenhofer G, Pamporaki C, Lenders JWM. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev 2023; 44:862-909. [PMID: 36996131 DOI: 10.1210/endrev/bnad011] [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: 09/28/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
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Elhassan YS, Ronchi CL, Wijewickrama P, Baldeweg SE. Approach to the Patient With Adrenal Hemorrhage. J Clin Endocrinol Metab 2023; 108:995-1006. [PMID: 36404284 PMCID: PMC9999363 DOI: 10.1210/clinem/dgac672] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Adrenal hemorrhage is an uncommon, underrecognized condition that can be encountered in several clinical contexts. Diagnosing adrenal hemorrhage is challenging due to its nonspecific clinical features. Therefore, it remains a diagnosis that is made serendipitously on imaging of acutely unwell patients rather than with prospective clinical suspicion. Adrenal hemorrhage can follow abdominal trauma or appear on a background of predisposing conditions such as adrenal tumors, sepsis, or coagulopathy. Adrenal hemorrhage is also increasingly reported in patients with COVID-19 infection and in the context of vaccine-induced immune thrombocytopenia and thrombosis. Unexplained abdominal pain with hemodynamic instability in a patient with a predisposing condition should alert the physician to the possibility of adrenal hemorrhage. Bilateral adrenal hemorrhage can lead to adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and treatment. In this article, we highlight the clinical circumstances that are associated with higher risk of adrenal hemorrhage, encouraging clinicians to prospectively consider the diagnosis, and we share a diagnostic and management strategy.
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Affiliation(s)
- Yasir S Elhassan
- Correspondence: Yasir Elhassan, MBBS, MRCP, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
- Division of Endocrinology and Diabetes, University Hospital University Würzburg, Würzburg 97080, Germany
| | - Piyumi Wijewickrama
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
| | - Stephanie E Baldeweg
- Department of Diabetes and Endocrinology, University College London Hospital NHS Foundation Trust, London NW1 2BU, UK
- Centre for Obesity and Metabolism, Department of Experimental and Translational Medicine, Division of Medicine, University College London, London WC1E 6BT, UK
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Gubbi S, Mathias P, Palaiodimos L, Hulkower R, Schubart U. The clinical utility of plasma and urine metanephrines in hypertensive emergency. Hormones (Athens) 2023; 22:121-130. [PMID: 36596928 DOI: 10.1007/s42000-022-00422-6] [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: 07/20/2022] [Accepted: 11/17/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Metanephrines (MTNs) are metabolites of catecholamines and are constantly produced in high amounts by pheochromocytomas and paragangliomas (PPGLs). Marked MTN elevations (> 3 times the upper limit of normal [ULN]) are highly suggestive of PPGL. The frequency of marked MTN elevations in non-PPGL hypertensive emergencies (HTNEs) is unknown. METHODS We retrospectively analyzed plasma free metanephrine (PMTN) and 24-h urinary fractionated metanephrine (UMTN) levels in 48 consecutive patients (59.7 ± 15.6 years; 48% female; BMI: 31 ± 9.7 kg/m2) hospitalized for HTNE, defined as systolic blood pressure (SBP) > 180 mmHg or diastolic blood pressure (DBP) > 120 mmHg with end-organ damage. PMTNs were measured in 47 patients, UMTNs were measured in 16 patients, and both PMTNs and UMTNs were measured in 15 patients. RESULTS PMTN/UMTN levels were not associated with SBP/DBP, comorbidities, end-organ damage, or interfering medications, the exception being that plasma normetanephrines (PNMNs) were significantly associated with comorbidities (Adj. R2 = 0.16; p = 0.04) and interfering medications (Adj. R2 = 0.15; p = 0.03), although with weak correlation. Marked MTN (specifically PNMN) elevations (647, 521, and 453 pg/mL; normal ≤ 148 pg/mL) were noted in only three patients (6%). DISCUSSION Marked MTN elevations in HTNE are uncommon. Therefore, we recommend against measuring MTN in the setting of an apparent precipitating cause of HTNE to avoid unnecessary testing and imaging. Testing for MTN in HTNE should be pursued only when there is no clear precipitating cause and in cases where there is strong underlying clinical suspicion for PPGL. However, should testing be performed, marked MTN elevations should not be disregarded as being a commonly occurring result of HTNE.
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Affiliation(s)
- Sriram Gubbi
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA.
- Department of Internal Medicine, Division of Endocrinology, Montefiore Medical Center, Bronx, NY, USA.
| | - Priyanka Mathias
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
- Department of Internal Medicine, Division of Endocrinology, Montefiore Medical Center, Bronx, NY, USA
| | - Leonidas Palaiodimos
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
- Department of Internal Medicine, Montefiore Medical Center, Bronx, NY, USA
- Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Raphael Hulkower
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
- Department of Internal Medicine, Division of Endocrinology, Montefiore Medical Center, Bronx, NY, USA
| | - Ulrich Schubart
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA
- Department of Internal Medicine, Division of Endocrinology, Montefiore Medical Center, Bronx, NY, USA
- Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Pommer G, Pamporaki C, Peitzsch M, Remde H, Deutschbein T, Nölting S, Müller LM, Braun L, Gruber S, Pecori A, Hampson S, Davies E, Stell A, Rossi GP, Lenzini L, Ceccato F, Timmers HJLM, Deinum J, Amar L, Blanchard A, Baron S, Fassnacht M, Dobrowolski P, Januszewicz A, Zennaro MC, Prejbisz A, Eisenhofer G. Preanalytical Considerations and Outpatient Versus Inpatient Tests of Plasma Metanephrines to Diagnose Pheochromocytoma. J Clin Endocrinol Metab 2022; 107:e3689-e3698. [PMID: 35767279 DOI: 10.1210/clinem/dgac390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Sampling of blood in the supine position for diagnosis of pheochromocytoma and paraganglioma (PPGL) results in lower rates of false positives for plasma normetanephrine than seated sampling. It is unclear how inpatient vs outpatient testing and other preanalytical factors impact false positives. OBJECTIVE We aimed to identify preanalytical precautions to minimize false-positive results for plasma metanephrines. METHODS Impacts of different blood sampling conditions on plasma metanephrines were evaluated, including outpatient vs inpatient testing, sampling of blood in semi- vs fully recumbent positions, use of cannulae vs direct venipuncture, and differences in outside temperature. A total of 3147 patients at 10 tertiary referral centers were tested for PPGL, including 278 with and 2869 without tumors. Rates of false-positive results were analyzed. RESULTS Outpatient rather than inpatient sampling resulted in 44% higher plasma concentrations and a 3.4-fold increase in false-positive results for normetanephrine. Low temperature, a semi-recumbent position, and direct venipuncture also resulted in significantly higher plasma concentrations and rates of false-positive results for plasma normetanephrine than alternative sampling conditions, although with less impact than outpatient sampling. Higher concentrations and rates of false-positive results for plasma normetanephrine with low compared with warm temperatures were only apparent for outpatient sampling. Preanalytical factors were without impact on plasma metanephrines in patients with PPGL. CONCLUSION Although inpatient blood sampling is largely impractical for screening patients with suspected PPGL, other preanalytical precautions (eg, cannulae, warm testing conditions) may be useful. Inpatient sampling may be reserved for follow-up of patients with difficult to distinguish true- from false-positive results.
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Affiliation(s)
- Georg Pommer
- Institute of Clinical Genetics, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
- Medicover Oldenburg MVZ, 26122 Oldenburg, Germany
| | - Svenja Nölting
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80336 Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich and University of Zurich, CH-8091Zurich, Switzerland
| | - Lisa Marie Müller
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80336 Munich, Germany
| | - Leah Braun
- Department of Medicine IV, University Hospital, Ludwig Maximilian University of Munich, 80336 Munich, Germany
| | - Sven Gruber
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich and University of Zurich, CH-8091Zurich, Switzerland
| | - Alessio Pecori
- Department of Medical Sciences, University of Torino, 10126 Turin, Italy
| | - Stephanie Hampson
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, G12 8TA Glasgow, UK
| | - Eleanor Davies
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, G12 8TA Glasgow, UK
| | - Anthony Stell
- School of Computing and Information Systems, University of Melbourne, Melbourne, 3052 Victoria, Australia
| | - Gian Paolo Rossi
- Department of Medicine-DIMED, University of Padua, 35128 Padua, Italy
| | - Livia Lenzini
- Department of Medicine-DIMED, University of Padua, 35128 Padua, Italy
| | - Filippo Ceccato
- Department of Medicine-DIMED, University of Padua, 35128 Padua, Italy
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands
| | - Laurence Amar
- Université Paris Cité, PARCC, INSERM, F-75015 Paris, France
- Unité Hypertension artérielle - Centre de Reference en Maladies Rares des Surrénales, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Anne Blanchard
- Centre d'Investigations Cliniques, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Stephanie Baron
- Service de Physiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97082 Würzburg, Germany
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Maria-Christina Zennaro
- Université Paris Cité, PARCC, INSERM, F-75015 Paris, France
- Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, 75015 Paris, France
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
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Lyu T, Niu J, Liu Z, Li T. Case Report: Early Resection of Pheochromocytoma in a Patient With Cardiogenic Shock Due to Pheochromocytoma-Induced Cardiomyopathy With Extracorporeal Life Support. Front Cardiovasc Med 2022; 9:788644. [PMID: 35391844 PMCID: PMC8982527 DOI: 10.3389/fcvm.2022.788644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022] Open
Abstract
Background Pheochromocytoma-induced cardiomyopathy is a rare but potentially life-threatening complication of pheochromocytoma. It mimics the patterns of stress-induced cardiomyopathy. In severe cases, patients can develop refractory cardiogenic shock, which might require mechanical circulatory support. Case Presentation We presented a case of 54-year-old female who developed refractory cardiogenic shock, following an elective orthopaedic surgery complicated by cardiac arrest, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. After urgent coronary catheterisation revealed normal coronary arteries, further evaluation of the aetiology of cardiogenic shock revealed pheochromocytoma. With a diagnosis of pheochromocytoma-induced cardiomyopathy, the patient had accelerated preoperative alpha adrenergic blockade preparation for a total of 6 days and subsequently had the tumour removed under VA-ECMO support. Postoperatively, the patient recovered well and was off ECMO support and extubated a few days later. The optimal management of pheochromocytoma-induced cardiomyopathy, especially for severe cases, is still unclear. Indeed, some cases will require mechanical circulatory support to allow left ventricular function recovery. But our case also showed that it was possible to introduce alpha blockade safely whilst the patient is on VA-ECMO and has the pheochromocytoma removed with VA-ECMO support after accelerated preoperative preparation.
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Eisenhofer G, Peitzsch M, Bechmann N, Huebner A. Biochemical Diagnosis of Catecholamine-Producing Tumors of Childhood: Neuroblastoma, Pheochromocytoma and Paraganglioma. Front Endocrinol (Lausanne) 2022; 13:901760. [PMID: 35957826 PMCID: PMC9360409 DOI: 10.3389/fendo.2022.901760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Catecholamine-producing tumors of childhood include most notably neuroblastoma, but also pheochromocytoma and paraganglioma (PPGL). Diagnosis of the former depends largely on biopsy-dependent histopathology, but this is contraindicated in PPGL where diagnosis depends crucially on biochemical tests of catecholamine excess. Such tests retain some importance in neuroblastoma though continue to largely rely on measurements of homovanillic acid (HVA) and vanillylmandelic acid (VMA), which are no longer recommended for PPGL. For PPGL, urinary or plasma metanephrines are the recommended most accurate tests. Addition of methoxytyramine to the plasma panel is particularly useful to identify dopamine-producing tumors and combined with normetanephrine also shows superior diagnostic performance over HVA and VMA for neuroblastoma. While use of metanephrines and methoxytyramine for diagnosis of PPGL in adults is established, there are numerous pitfalls for use of these tests in children. The establishment of pediatric reference intervals is particularly difficult and complicated by dynamic changes in metabolites during childhood, especially in infants for both plasma and urinary measurements, and extending to adolescence for urinary measurements. Interpretation of test results is further complicated in children by difficulties in following recommended preanalytical precautions. Due to this, the slow growing nature of PPGL and neglected consideration of the tumors in childhood the true pediatric prevalence of PPGL is likely underappreciated. Earlier identification of disease, as facilitated by surveillance programs, may uncover the true prevalence and improve therapeutic outcomes of childhood PPGL. For neuroblastoma there remain considerable obstacles in moving from entrenched to more accurate tests of catecholamine excess.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine III, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Graeme Eisenhofer,
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Angela Huebner
- Department of Pediatrics, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
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