Current concepts of pheochromocytoma

Management of Pheochromocytomas and Paragangliomas

Pheochromocytomas and paragangliomas are distinctive neuroendocrine tumors which frequently produce excess catecholamines with resultant cardiovascular morbidity. These tumors have a strong genetic component, with up to 40% linked to hereditary pathogenic variants; therefore, germline genetic testing is recommended for all patients. Surgical resection offers the only potential cure in the case of localized disease. Given the potential for catecholaminergic crises, appropriate perioperative management is crucial, and all patients should undergo alpha-adrenergic blockade before resection. Therapeutic options for metastatic disease are limited and include surgical debulking, radiopharmaceutical therapies, and conventional chemotherapy.

Cafe-au-lait spots with resistant hypertension are an indicator of pheochromocytoma: a rare case report

This case report is one of the rare cases of bilateral pheochromocytoma associated with neurofibromatosis type 1. The interest lies in the clinical form in which the diagnosis was revealed. We report the case of a 38-year-old woman admitted for severe hypertension resistant to triple therapy. Clinical examination revealed Cafe-au-lait spots, which are pigmented birthmarks that appear as patches on the skin with a light to dark brown colour. More than six spots are present in an estimated 95% of people diagnosed with neurofibromatosis type 1 (NF1). Abdominal computed tomography (CT) showed bilateral adrenal tumor involvement. The diagnosis of pheochromocytoma was made by measuring urinary Vanillylmandelic acid (VMA). The evolution was favorable after the excision of the tumor, with normalization of blood pressure. In conclusion: resistant hypertension with café au lait spots may indicate pheochromocytoma, especially bilateral, suggesting an underlying genetic condition like NF1, warranting systematic screening.

Composite pheochromocytoma associated with neurofibromatosis type 1

Introduction

Composite pheochromocytoma is a rare tumor, occurring in only 3% of pheochromocytomas. We report a case of composite pheochromocytoma with neurofibromatosis type 1.

Case presentation

A 42-year-old man was referred to our department for further evaluation of an incidentally detected right adrenal tumor. He was a patient at another hospital for neurofibromatosis type 1. The serum and urinary catecholamine levels exceeded the normal range. Abdominal computed tomography and magnetic resonance imaging showed a 2.8 cm diameter right adrenal tumor, and 123I-metaiodobenzyguanidine scintigraphy showed radioisotope uptake. He was diagnosed with pheochromocytoma and underwent a right laparoscopic adrenalectomy. Histopathological examination revealed that the tumor consisted of a pheochromocytoma and ganglioneuroma. The final diagnosis was composite pheochromocytoma-ganglioneuroma. Five years after surgery, no recurrence was observed.

Conclusion

Preoperative diagnosis of composite pheochromocytoma-ganglioneuroma is difficult; therefore, histopathological examination is necessary for a definitive diagnosis. Pheochromocytoma management requires lifelong follow-up.

Global trends and current status in pheochromocytoma: a bibliometric analysis of publications in the last 20 years

Objective

Pheochromocytoma is a rare catecholamine-producing neuroendocrine tumour originating from the chromaffin cells of the adrenal medulla or extra-adrenal paraganglia. However, there are few bibliometric studies on Pheochromocytoma. Therefore, this study was employed to summarize the global trends and current status in pheochromocytoma by bibliometric analysis.

Materials and methods

The Web of Science (WOS) core collection database was searched for publications relating to pheochromocytoma from 2001 to 2021. Bibliometric analysis was used to examine the data, and Microsoft Excel was utilized to create bar graphs. In addition, VOSviewer was used to carry out co-authorship analysis, co-citation analysis and co-occurrence analysis. CiteSpace was used to analyze the keywords citation bursts.

Results

A total of 8,653 publications published in 1,806 journals by 38,590 authors in 6,117 organizations from 100 countries/regions were included in our study. Among them, USA was the leading countries in terms of total publications and sum of time cited, whereas Eunice Kennedy Shriver Natl Inst Child Hlth & Hum was the leading institutions. The main publications for pheochromocytoma-related articles were Journal of clinical endocrinology &metabolism. Pacak karel and Eisenhofer Graeme were the main contributing authors. The studies on pheochromocytoma could be grouped into five clusters: Treatment, Mechanism, Etiology, Radiology and Hormones study. Moreover, the radiology study, etiology study and some specific keywords such germlines mutation, mesenchymal stem-cells, autophagy, neuroinflammation, neurotoxicity, and hemodynamic instability, may become the hot spots of future.

Conclusion

Although the number of articles on pheochromocytoma has fluctuated slightly over the past 20 years, there has been an overall upward trend. In general, precision medicine research on pheochromocytoma, especially metastatic pheochromocytoma, in terms of diagnosis, treatment, and etiology will be a hot research topic in the future. This study helps to understand the research perspectives, hot spots and trends of pheochromocytoma and provide new insight and a basis for future pheochromocytoma research quickly.

Impact of Current Technology in Laparoscopic Adrenalectomy: 20 Years of Experience in the Treatment of 254 Consecutive Clinical Cases

BACKGROUND

Laparoscopic adrenalectomy (LA), which avoids large abdomen incisions, is considered the gold standard technique for the treatment of benign small- and medium-size adrenal masses (<6 cm) and weighing < 100 g. A trascurable mortality and morbidity rate, short hospitalization and patient rapid recovery are the main advantages compared to traditional surgery. During the past decade, a new surgical technology has been developed that expedites a "clipless" adrenalectomy. Here, the authors analyze a clinical series of 254 consecutive patients who were affected by adrenal gland neoplasms and underwent LA by the transabdominal lateral approach over the two last decades. A literature review is also presented.

METHODS

Preoperative, intraoperative and postoperative data from 254 patients who underwent LA between January 2003 and December 2022 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in the case of pheochromocytoma (PCC) while spironolactone and potassium were employed to treat Conn's disease. The same surgeon (CG) performed all the LA and utilized the same laparoscopic transabdominal lateral approach. Different dissection tools-ultrasonic, bipolar or mixed scissors-and hemostatic agents were used during this period. The following results were obtained: 254 patients were included in the study; functioning tumors were diagnosed in 155 patients, 52 patients were affected by PCCs, 55 by Conn's disease, 48 by Cushing's disease. Surgery mean operative time was 137.33 min (range 100-180 min) during the learning curve adrenalectomies and 98.5 min (range 70-180) in subsequent procedures. Mean blood loss was respectively 160.2 mL (range 60-280) and 96.98 mL (range 50-280) in the first 30 procedures and the subsequent ones. Only three conversions (1.18%) to open surgery occurred. No mortality or postoperative major complications were observed, while minor complications occurred in 19 patients (3.54%). In 153 out of 155 functioning neoplasms, LA was effective in the normalization of the endocrine profile. According to our experience, a learning curve consisting of 30 cases was identified. In fact, a lower operative time and a lower complication rate was reported following 30 LA.

CONCLUSIONS

LA is a safe procedure, even for masses larger than 6 cm and PCCs. Undoubtedly, the development of surgical technology has made it possible reducing operative times, performing a "clipless" adrenalectomy and extending the indications in the treatment of more complex patients. A multidisciplinary team, in referral high-volume centers, is recommended in the management of adrenal pathology. A 30-procedure learning curve is necessary to improve surgical outcomes.

Anesthetic Management of Laparoscopic Adrenalectomy for a Patient with Concomitant Pheochromocytoma and Bilateral Carotid Artery Stenosis

Symptomatic carotid stenosis and pheochromocytoma both require timely surgical intervention. Following a transient ischemic attack (TIA), a 46-year-old man was diagnosed with bilateral carotid artery stenosis and scheduled for carotid endarterectomy. He was a poor candidate for minimally invasive options due to prior neck radiation. Simultaneously, he began experiencing difficulty with diabetes management and elevated blood pressures and was ultimately diagnosed with pheochromocytoma. This unique situation required coordination to determine the appropriate timing of the two interventions. This case highlights the importance of communication and coordination amongst medical specialists and consideration for anesthetic management of patients with concomitant pheochromocytoma and carotid stenosis.

Risk factors for postoperative complications after pheochromocytoma and/or paraganglioma: a single-center retrospective study

Background

Perioperative complications are higher in patients with pheochromocytoma and/or paraganglioma. The aim of this study was to identify the risk factors of postoperative complications after pheochromocytoma and/or paraganglioma resection surgery.

Method

We retrospectively reviewed 438 patients who underwent laparoscopic or open surgery for pheochromocytoma and/or paraganglioma at our center between January 2014 and December 2019. Demographic characteristics and intraoperative and postoperative data were recorded. Complications were defined as deviations from the normal postoperative course and Clavien-Dindo classification was used to grade the severity of postoperative complication. Patients with complications of grade II or above were included for analysis. Binary logistic regression was used to determine the risk factors for postoperative complications.

Results

The median age of the patients was 47 years old. There were 295 cases (67.4%) of phepchromocytoma and 143 cases (32.6%) of paraganglioma. Three hundred sixty-seven (87.8%) patients had laparoscopic approach, and 55 (12.6%) patients had laparotomy; the conversion rate from laparoscopy to laparotomy was 3.7%. Eighty-seven complications occurred in 65 patients (14.8%). No death occurred in our study and transfusion (36, 8.2%) was the most common complication. The mean follow-up length was 14 months. Independent risk factors for postoperative complications included a tumor size larger than 5.6 cm (OR = 2.427, 95% CI 1.284-4.587, P = 0.006), laparotomy (OR 2.590, 95% CI 1.230-5.453, P = 0.012), conversion to laparotomy (OR = 8.384, 95% CI 2.247-31.285, P = 0.002), and the operation time longer than 188 min (OR = 3.709, 95% CI 1.847-7.450, P < 0.001).

Conclusion

Complications were not uncommon after pheochromocytoma and/or paraganglioma surgery. Tumor size, surgical type, and operation time were determined as the risk factors for postoperative complications. These factors should be considered to improve perioperative management.

Computed Tomography-Based Machine Learning Differentiates Adrenal Pheochromocytoma From Lipid-Poor Adenoma

OBJECTIVES

To assess the accuracy of computed tomography (CT)-based machine learning models for differentiating subclinical pheochromocytoma (sPHEO) from lipid-poor adenoma (LPA) in patients with adrenal incidentalomas.

PATIENTS AND METHODS

The study included 188 tumors in the 183 patients with LPA and 92 tumors in 86 patients with sPHEO. Pre-enhanced CT imaging features of the tumors were evaluated. Machine learning prediction models and scoring systems for differentiating sPHEO from LPA were built using logistic regression (LR), support vector machine (SVM) and random forest (RF) approaches.

RESULTS

The LR model performed better than other models. The LR model (M1) including three CT features: CT_pre value, shape, and necrosis/cystic changes had an area under the receiver operating characteristic curve (AUC) of 0.917 and an accuracy of 0.864. The LR model (M2) including three CT features: CT_pre value, shape and homogeneity had an AUC of 0.888 and an accuracy of 0.832. The S2 scoring system (sensitivity: 0.859, specificity: 0.824) had comparable diagnostic value to S1 (sensitivity: 0.815; specificity: 0.910).

CONCLUSIONS

Our results indicated the potential of using a non-invasive imaging method such as CT-based machine learning models and scoring systems for predicting histology of adrenal incidentalomas. This approach may assist the diagnosis and personalized care of patients with adrenal tumors.

The ADRENAL score: A comprehensive scoring system for standardized evaluation of adrenal tumor

OBJECTIVES

To propose an original and standardized scoring system to quantify the functional and anatomical characteristics of adrenal tumor.

MATERIALS AND METHODS

Four groups of consecutive adrenalectomies (n = 458) with heterogeneity in tumor characteristics and surgical approaches, including 212 laparoscopic cases (Group 1) and 105 robotic cases (Group 2) from The First Affiliated Hospital of Nanchang University, 28 robotic cases from Temple University Hospital (Group 3) and 113 laparoscopic cases from The First Affiliated Hospital of Guangxi Medical University (Group 4). All patients were followed up for 4.5 to 5.5 years. Six parameters including functional status or suspicion of malignancy, tumor size, relationship to adjacent organs, intratumoral enhancement on CT, nearness of the tumor to major vessels and body mass index were assessed and scored on a 0, 1 and 2 points scale. Correlation between the sum of the 6 scores and tumor laterality (ADRENAL score) verse operative time (OT), estimated blood loss (EBL), perioperative complications, transfusion, conversion and length of hospital stay was analyzed.

RESULTS

ADRENAL score was a strong predictor of both OT and EBL in all four groups (p < 0.05 for all tests). In Group 2 and 4, higher ADRENAL score seemed to correlate with longer hospital stay. No statistically significant correlation between ADRENAL score and complication, transfusion or conversion was noted yet.

CONCLUSIONS

ADRENAL score appears to be a valid predictor of surgical outcomes. It may provide a common reference for adrenal surgery training program, preoperative risk assessment and stratified comparative analysis of adrenal surgeries via different techniques and approaches.

Comparison of lateral transperitoneal and retroperitoneal approaches for homolateral laparoscopic adrenalectomy

Background

There is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for homolateral laparoscopic adrenalectomy. The aim of this study is to compare lateral transperitoneal and retroperitoneal approach for left-sided and right-sided laparoscopic adrenalectomy respectively.

Methods

Between January 2014 and December 2019, 242 patients underwent left-sided and 252 patients underwent right-sided laparoscopic adrenalectomy. For left side, transperitoneal approach was used in 132 (103 with tumors < 5 cm and 29 with tumors ≥ 5 cm) and retroperitoneal approach in 110 (102 with tumors < 5 cm and 8 with tumors ≥ 5 cm). For right side, transperitoneal approach was used in 139 (121 with tumors < 5 cm and 18 with tumors ≥ 5 cm) and retroperitoneal approach in 113 (102 with tumors < 5 cm and 11 with tumors ≥ 5 cm). Patient characteristics and perioperative outcomes were recorded. For each side, both approaches were compared for tumors < 5 cm and ≥ 5 cm respectively.

Results

For left-sided tumors < 5 cm, transperitoneal approach demonstrated shorter operative time, less blood loss and longer time to oral intake. For left-sided tumors ≥ 5 cm, the peri-operative data of both approaches was comparable. For right-sided tumors < 5 cm, transperitoneal approach demonstrated shorter operative time and less blood loss. For right-sided tumors ≥ 5 cm, the peri-operative data was comparable.

Conclusions

Lateral transperitoneal and retroperitoneal approach are both effective for laparoscopic adrenalectomy. Lateral transperitoneal approach is faster with less blood loss for tumors < 5 cm.

Surgery for Pheochromocytoma: A Single-Center Review of 60 Cases from South Africa

BACKGROUND

There is a paucity of data on the presentation and surgical management of pheochromocytoma in developing nations, particularly in Africa.

METHODS

This study was a retrospective review, which included all patients managed by the Groote Schuur Hospital/University of Cape Town Endocrine Surgery unit for pheochromocytoma and abdominal paragangliomas, from January 2002 to June 2019.

RESULTS

Sixty patients were included in the study, of which 33% were male and 67% female. The mean age was 47 years (range 14-81). The median tumor size was 6 cm, with 45% larger than 6 cm. 92% were located in the adrenal gland (87% unilateral, 5% bilateral), and 8% were extra-adrenal. The conversion rate for laparoscopic cases was 20%, with 55% of cases overall completed laparoscopically. Eleven patients with tumors > 6 cm were initially attempted laparoscopically, of which 3 were converted to open, without any associated increased morbidity. A major adverse event was recorded for 5 cases (8%), including 1 mortality. Overall morbidity, blood loss, operating time and hospital stay were all significantly reduced in the laparoscopic group. There were 5 patients with malignant disease (8%).

CONCLUSION

This large series, from an established academic endocrine surgery unit in Africa, can serve as a benchmark for units with similar settings and resource limitations, to compare their surgical management and perioperative outcomes.

Large Adrenal Lesion Series in a Tertiary Care Center in Northern India: Diagnostic and Operative Challenges

Large adrenal tumors pose varied challenges to surgeons in terms of diagnosis, planning surgical approach, and also intra-operative difficulties in resection. The aim of this study is to discuss challenges in the management of large and difficult adrenal lesions. A retrospective analysis was done on data of all patients with large adrenal lesions/paragangliomas managed from 1 June 2016 to 30 August 2018. Forty-eight patients with adrenal lesions underwent treatment in 2 years duration. Pain in the abdomen was the most common presentation. Mean age was 34.4 years (range 2-60), female to male (23:25) and right to left side to bilateral tumor 30:16:2. Thirty-one (64.6%) patients had large adrenal masses (size > 6 cm). Surgical approaches included open transperitoneal adrenalectomy (n = 20) and laparoscopic transperitoneal (n = 9 and 2 others had conversion to open procedure). Challenges faced are described in the table below: [Table: see text] There were no major peri-operative morbidities, but two patients died in perioperative period. Large adrenal tumors pose a challenge in surgical planning, approach, and resection and need careful planning and multidisciplinary team approach to have the best outcomes.

Severe hemodynamic instability during elective surgery for a patient with a giant pheochromocytoma: A case report

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A huge pheochromocytoma measuring 16 cm × 15 cm × 10 cm is rare.

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Despite adequate preoperative and intraoperative management, the patient developed severe hypertension followed by a hypotension crisis which were almost lethal.

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Through multidisciplinary management with appropriate resuscitative measures, the huge tumor was resected en bloc with a R0 resection.

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The patient recovered well postoperatively and was free of hypertension.

Introduction

We present a patient with a huge pheochromocytoma who ran a stormy intraoperative course.

Presentation of case

A 57-year-old woman underwent elective open surgery for a giant pheochromocytoma (16 × 15 × 10 cm) after adequate preoperative medical preparation. The patient developed severe hypertension on tumor mobilization followed bylife-threatening hypotensionwhen the tumor was removed. The hemodynamic instability was successfully managed. Histology showed a pheochromocytomawith tumor-free resection margins. The patient fully recoveredandthe hypertension completely resolved after the operation.

Discussion

This is a rare and educational case report on a patient with a huge pheochromocytoma who was successfully managed by a multidisciplinary team of specialists.

Conclusion

Pheochromocytoma should be resected if technically possible. A multidisciplinary team approach is required for proper management.

Use of desflurane during anesthesia for resection of extra-adrenal pheochromocytoma: a case report

BACKGROUND

Although various agents are used during anesthesia for surgical resection of pheochromocytoma, application of desflurane has rarely been reported. We report the use of desflurane in a case receiving resection of extra-adrenal pheochromocytoma.

CASE PRESENTATION

A 51-year-old female was transferred to our hospital for sustained hypertension. A diagnosis of extra-adrenal pheochromocytoma was made based on increased plasma catecholamine levels and radiographic findings. Surgical resection was planned after controlling blood pressure. General anesthesia was induced with propofol and fentanyl, followed by maintenance with desflurane 4.3% and remifentanil 0.2-0.4 μg/kg/min. Blood pressure and heart rate were stable during induction, tracheal intubation, and tumor manipulation. Blood pressure abruptly decreased to 62/40 mmHg after removal of the tumor, which was treated with noradrenaline. The surgery was completed uneventfully and the postoperative course was also uneventful.

CONCLUSION

Desflurane was safely used in combination with remifentanil during anesthesia for resection of extra-adrenal pheochromocytoma.

Preoperative risk factors for haemodynamic instability during pheochromocytoma surgery in Chinese patients

OBJECTIVE

Pheochromocytoma surgery carries a high risk of haemodynamic instability (HI). However, there are few studies investigating the risk factors for HI for pheochromocytoma surgery in a Chinese population. Therefore, our objective was to identify preoperative risk factors for HI during surgery in a Chinese population with pheochromocytoma.

PATIENTS AND METHODS

In this retrospective study, 134 patients undergoing surgery for pheochromocytoma at a single university-affiliated hospital between November 2002 and July 2017 were enrolled. Demographics, comorbidities, preoperative medical preparation, operation details and perioperative haemodynamics of these patients were retrospectively collected and analysed. Multivariable logistic regression analysis was performed to identify the preoperative risk factors for intraoperative HI.

RESULTS

32.8% (44/134) patients suffered from intraoperative HI. According to the result of multivariate analysis, tumour diameter >50 mm (odds ratio [OR] 2.526; 95% confidence interval [CI] 1.163-5.485; P = .019), diabetes/prediabetes (OR 2.251; 95% CI 1.039-4.876; P = .040) and preoperative systolic blood pressure fluctuation >50 mm Hg (OR 3.163; 95% CI 1.051-9.522, P = .041) were independent predictors for intraoperative HI. The observed incidence of HI was 8.9%, 42.6%, 47.8% and 60% when zero, one, two or three risk factors were present, respectively.

CONCLUSIONS

HI is common among Chinese patients undergoing surgery for pheochromocytoma. Our study identified three predictive factors for intraoperative HI: a large tumour diameter, diabetes/prediabetes and a great preoperative systolic blood pressure fluctuation. Furthermore, patients are more likely to suffer from HI when they have more predictive risk factors. Identification of these risk factors can help to improve perioperative management.

Malignancy in Pheochromocytoma or Paraganglioma: Integrative Analysis of 176 Cases in TCGA

Methods of diagnosing malignant pheochromocytoma (PCC) or paraganglioma (PGL) are needed. However, there are no reliable histopathologic criteria to distinguish malignant PCC/PGLs. The recent genomic analysis of The Cancer Genome Atlas (TCGA) provides in-depth information enabling more accurate diagnosis of disease entities. Therefore, we investigated genomic expression differences and mutational differences of malignant PCC/PGLs with TCGA. As of December 2014, TCGA had acquired multigenomic analysis of 176 PCC/PGL samples. Clinical information, mutation status, and 20,531 gene messenger RNA (mRNA) expression dataset of normalized RNA-sequencing mRNA read counts were downloaded from TCGA, and integrated into a table. Of the 176 PCC/PGL samples in the dataset, 14 had metastasis and 162 exhibited no metastasis. mRNA expression and mutations were compared in these two groups. There were 76 males in the dataset of 176 TCGA samples. Mean age was 47.6 ± 15.2 years (19-83 years). There was no significant gender or race difference between metastatic and non-metastatic groups. mRNA expression of malignant PCC/PGLs was upregulated in five pathways of cell cycle (BUB1, BUB1B, CCNB2, CDC2, ESPL1), calcium signaling (CCNB2, CDC2, PRKCB1), regulation of actin cytoskeleton (DIAPH3, FGF18, IQGAP3), gap junction (CDC2, PRKCB1), and phosphatidylinositol (PRKCB1, TTK). Disease-free survival rates were significantly correlated with the presence or absence of mutations, such as RP11-798G7.5, HERC2, SETD2, TGDS, TRHDE, FKBP9, and BMS1. TCGA showed differences in mRNA expression and mutations between metastatic and non-metastatic PCC/PGLs. The improved recognition of genetic causes can help to achieve proper diagnosis and provide appropriate treatment of PCC/PGL.

Perioperative Management of Pheochromocytoma

Pheochromocytomas are rare neuroendocrine tumors that produce and store catecholamines. Without adequate preparation, the release of excessive amounts of catecholamines, especially during anesthetic induction or during surgical removal, can produce life-threatening cardiovascular complications. This review focuses on the perioperative management of pheochromocytoma/paragangliomas, initially summarizing the clinical aspects of the disease and then highlighting the current evidence available for preoperative, intraoperative, and postoperative anesthetic management.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

"Unclassical" Combination of Smell Dysfunction, Altered Abdominal Nociception and Human Hypertension Associated "Classical" Adrenal-Augmentation

We report a 33-year-old female patient, who arrived to the emergency ward with an abdominal pain that suddenly started 10 days before admission. Simultaneously, the patient developed sudden arterial hypertension and smell disturbances. Conventional medical treatment for pain and arterial hypertension was effortless. Laboratory tests ruled out pancreatitis. Metanephrines in her urine were also normal. A dual-phase intravenous contrast computed tomography of the abdomen showed a large mass within left adrenal gland. Adrenocortical adenoma was diagnosed. The mass was not hypervascularized but positive for synaptophysin and chromogranin A. Importantly, these proteins are heavily involved with acetylcholine metabolism. The triad of olfactory disorders, pain and arterial hypertension normalized after surgically extracting the adrenal mass. To our knowledge, this medical case is the first reported patient exhibiting immediate recovery of such unclassical triad of local and remote findings. The function and dysfunction of key nanocholinergic pathways involved with smell, blood pressure and nociception would explain the pathophysiology of this unique medical case.

The transabdominal minimally invasive approach to the isolated adrenal mass

Tumor size, previous abdominal operation, medical comorbidities and surgeon skill set are factors to determine if a minimally invasive approach is feasible for patients with benign adrenal pathology, as patient outcomes are far superior with this approach. Laparoscopic techniques have largely replaced the open operations, and are often viewed as the standard of care for many general surgery operations. For this reason, general surgeons are very familiar with the anatomy within the peritoneal cavity. Often, the skill set from one advanced laparoscopic procedure may translate to another, potentially allowing a low volume adrenal surgeon but high volume laparoscopic surgeon to safely perform transabdominal laparoscopic adrenalectomy.

Multiple nodal locoregional recurrence of pheochromocytoma

INTRODUCTION

Malignancy is present in 10% of pheochromocytomas (PCC) and is defined as local/vascular infiltration of surrounding tissues or the presence of chromaffin cells deposits in distant organs. The presence of isolated nodal recurrence is very rare and only 7 cases have been reported in the medical literature.

PRESENTATION OF THE CASE

The case of a 32-y male with a symptomatic recurrence of a previously operated (2-years ago) PCC is presented. Radiological and functional imaging studies confirmed the presence of multiple nodules in the surgical site. A radical left nephrectomy with extensive lymphatic clearance in order to get an R0 resection was performed. The pathologist confirmed the diagnosis of massive locoregional nodal invasion.

DISCUSSION

A detailed histological report and a thorough genetic study must be considered in every operated PCC in order to identify mutations and profiles of risk for malignancy. When recurrence or metastastic disease is suspected, imaging and functional exams are done in order to obtain a proper staging. Radical surgery for the metastatic disease is the only treatment that may provide prolonged survival. If an R0 resection is not possible, then a debulking surgery is a good option when the benefit/risk ratio is acceptable.

CONCLUSION

Isolated lymph nodal recurrence is very rare in malignant PCC, with only 7 cases previously published. The role of surgery is essential to get long-term survival because provides clinical and functional control of the disease.