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Haciyanli M, Acar T, Ozsay O, Acar N, Haciyanli SG, Gur EO, Dilek ON. Single Stage Bilateral Adrenalectomy (Cortical-Sparing) and Pancreatectomy (Corpus-Sparing) in a Patient with Von Hippel-Lindau Disease. SISLI ETFAL HASTANESI TIP BULTENI 2024; 58:233-236. [PMID: 39021689 PMCID: PMC11249989 DOI: 10.14744/semb.2023.03743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/08/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2024]
Abstract
Von Hippel-Lindau (VHL) disease is an autosomal dominant syndrome and affects many organs. We aim to report an adult patient with VHL disease having bilateral adrenal pheochromocytoma and multiple neuroendocrine tumors of the pancreas who was successfully treated with simultaneous function-preserving adrenalectomy and pancreatectomy. A 27-year-old woman was admitted to hospital with hypertension. The computed tomography of the abdomen revealed a solid tumor in both adrenal glands with the sizes of 12x7 cm on the right and 4x4 cm on the left. She also had two pancreatic solid masses in the head and three in the tail with varying sizes. The laboratory tests are all within normal limits except elevated 24-hour urinary metanephrine and normetanephrine. I-123 MIBG scanning showed increased uptake in both adrenal glands. Fine needle aspiration biopsy of the tumor on head of pancreas via endoscopic ultrasonography showed neuroendocrine tumor. Those findings were compatible with bilateral pheochromocytoma and multiple pancreatic neuroendocrine tumors and genetic tests revealed the mutation which confirmed the diagnosis of VHL disease. After suppression with alpha-1 inhibitor, right total, left cortical-sparing adrenalectomy, Whipple procedure for the pancreatic head lesions and spleen-preserving distal pancreatectomy were performed and pancreatic corpus was preserved. This case showed that multiple function-preserving procedures can be safely performed with oncological principles in patients with VHL disease.
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Affiliation(s)
- Mehmet Haciyanli
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Türkiye
| | - Turan Acar
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Türkiye
| | - Oguzhan Ozsay
- Department of General Surgery, Samsun 19 Mayis University Faculty of Medicine, Samsun, Türkiye
| | - Nihan Acar
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Türkiye
| | - Selda Gucek Haciyanli
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Türkiye
| | - Emine Ozlem Gur
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Türkiye
| | - Osman Nuri Dilek
- Department of General Surgery, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Türkiye
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Wang Y, Liu Z, Zhao W, Cao C, Xiao L, Xiao J. Diversities of Mechanism in Patients with VHL Syndrome and diabetes: A Report of Two Cases and Literature Review. Diabetes Metab Syndr Obes 2024; 17:1611-1619. [PMID: 38616993 PMCID: PMC11015853 DOI: 10.2147/dmso.s443495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/23/2024] [Indexed: 04/16/2024] Open
Abstract
Background Von Hippel-Lindau (VHL) syndrome is characterized by tumorous lesions affecting multiple organs. Pancreatic involvement in VHL syndrome can present as endocrine tumors and pancreatic cysts, which can interfere with both exocrine and endocrine functions of the pancreas. Diabetes is an uncommon complication of VHL syndrome. Purpose This study aims to summarize the various mechanisms of diabetes in VHL syndrome by reporting two cases and conducting a literature review. Methods We analyzed the clinical and imaging data of two patients with VHL syndrome and diabetes. Additionally, we reviewed the existing literature to explore the clinical diversities and management strategies for VHL syndrome complicated with diabetes. Results The first patient presented with liver metastasis of pancreatic neuroendocrine tumor and multiple pheochromocytoma. After surgery, the patient's diabetic control improved, as evidenced by a significant reduction in insulin dosage. This indicates a potential insulin resistance due to elevated metanephrine levels prior to surgery and partial insulin deficiency caused by distal pancreatectomy. The second patient had multiple hemangioblastomas, as well as multiple pancreatic cysts and positive pancreatic islet autoantibodies. Diabetes in this case may be attributed to pancreatic lesions and the coexistence of autoimmune insulitis. A literature review of other patients with VHL combined with diabetes revealed multiple mechanisms, including increased catecholamine levels, pancreatic lesions, surgical removal of pancreatic tissue, endocrine treatment, and possibly the coexistence of autoimmune insulitis. Conclusion VHL syndrome complicated with diabetes involves diverse mechanisms.
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Affiliation(s)
- Yanlei Wang
- Department of Endocrinology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, People’s Republic of China
| | - Zhaoxiang Liu
- Department of Endocrinology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, People’s Republic of China
| | - Wenhui Zhao
- Department of Endocrinology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, People’s Republic of China
| | - Chenxiang Cao
- Department of Endocrinology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, People’s Republic of China
| | - Luqi Xiao
- Department of Endocrinology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, People’s Republic of China
| | - Jianzhong Xiao
- Department of Endocrinology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, 102218, People’s Republic of China
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Kenborg L, Ebbehoj A, Ejerskov C, Handrup MM, Østergaard JR, Hove H, Doser K, Krøyer A, Mulvihill JJ, Winther JF, Stochholm K. Endocrine morbidity in neurofibromatosis 1: a nationwide, register-based cohort study. Eur J Endocrinol 2023; 189:190-198. [PMID: 37542520 DOI: 10.1093/ejendo/lvad101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE Previous studies have found that neurofibromatosis 1 (NF1) is associated with an increased risk for endocrine disorders, but no comprehensive overview of the risk for specific endocrine disorders has been published. We assessed endocrine morbidity in individuals with NF1 from information on hospital admissions, surgery for endocrine disorders, and relevant medication. DESIGN A nationwide population registry-based cohort study. METHODS We identified 2467 individuals with NF1 diagnosed between 1977 and 2013 from the Danish National Patient Register and the RAREDIS database and 20 132 randomly sampled age- and sex-matched population comparisons. Information on endocrine diseases was identified using registrations of discharge diagnoses, surgery, and medication prescriptions. The rates of endocrine disorders in individuals with NF1 were compared with those in the comparison cohort in Cox proportional hazard models. RESULTS Individuals with NF1 had a higher rate than the comparison group of any endocrine discharge diagnosis (hazard ratio [HR] 1.72, 95% confidence interval [CI]: 1.58-1.87), endocrine-related surgery (2.03, 1.39-2.96), and prescribed medications (1.32, 1.23-1.42). Increased HRs were observed for diseases and surgical operations of several glands, including pheochromocytoma, and for osteoporosis, and osteoporotic fractures. Decreased rates were observed with drugs for type 2 diabetes. Women with NF1 had higher HRs for surgery of the ovaries, uterus, and sterilization, but lower rates of surgeries of cervix and prescriptions for birth control pills. CONCLUSIONS Neurofibromatosis 1 is associated with a variety of endocrine disorders, surgery, and medication related to endocrine disease. Awareness of endocrine morbidity is important in the clinical follow-up of individuals with NF1.
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Affiliation(s)
- Line Kenborg
- Childhood Cancer Research Group, Danish Cancer Society Research Center, 2100 Copenhagen E, Denmark
| | - Andreas Ebbehoj
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Cecilie Ejerskov
- Centre for Rare Diseases, Department of Paediatric and Adolescent Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Mette Møller Handrup
- Centre for Rare Diseases, Department of Paediatric and Adolescent Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - John R Østergaard
- Centre for Rare Diseases, Department of Paediatric and Adolescent Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Hanne Hove
- The RAREDIS Database, Centre for Rare Diseases, Department of Paediatrics, Copenhagen University Hospital, 2100 Copenhagen E, Denmark
- Centre for Rare Diseases, Department of Paediatrics, Rigshospitalet, 2100 Copenhagen E, Denmark
| | - Karoline Doser
- Childhood Cancer Research Group, Danish Cancer Society Research Center, 2100 Copenhagen E, Denmark
| | - Anja Krøyer
- Childhood Cancer Research Group, Danish Cancer Society Research Center, 2100 Copenhagen E, Denmark
| | - John J Mulvihill
- Department of Pediatrics, University of Oklahoma, Norman, OK 73019-3073, United States
| | - Jeanette F Winther
- Childhood Cancer Research Group, Danish Cancer Society Research Center, 2100 Copenhagen E, Denmark
- Faculty of Health, Department of Clinical Medicine, Aarhus University and University Hospital, 8200 Aarhus N, Denmark
| | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, 8200 Aarhus N, Denmark
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Zhan-Moodie S, Revere AS, Hilton LR, Bolduc A. Robotic Adrenalectomy in a Patient With Neurofibromatosis Type 1 and Pheochromocytoma. Cureus 2023; 15:e37097. [PMID: 37168184 PMCID: PMC10166392 DOI: 10.7759/cureus.37097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 04/07/2023] Open
Abstract
A 27-year-old female with a past medical history of neurofibromatosis type 1 (NF1) presented with obstructive hydrocephalus due to a thalamic tumor. The neurosurgery team attempted an operative intervention twice, but both times, the patient experienced a hypertensive emergency and unstable supraventricular tachycardia upon induction of anesthesia. After the second failed surgery, a pheochromocytoma was suspected and the workup demonstrated a left pheochromocytoma. Pheochromocytomas in patients with NF1 are known to be more dangerous and labile, requiring in-depth discussion and preparation by personnel in endocrinology, anesthesia, neurosurgery, and minimally invasive surgery. Once the patient was stable and deemed fit for surgery, a robotic adrenalectomy followed by ventriculoperitoneal shunt placement began. After induction of anesthesia, the patient went into hypertensive emergency again. However, the anesthesia team was prepared and quickly resolved this with medical therapy. Minimally invasive surgeons had the patient's live vitals displayed on their robotic monitors to increase their awareness of patient hemodynamics. This provided live feedback on the surgeons' effect as they removed the pheochromocytoma. Surgeons also performed vein clamping to preemptively see the effects of adrenalectomy. When vein clamping demonstrated safety to proceed, adrenalectomy was completed without complication. This case not only highlights the rare pathology of a woman with NF1 with pheochromocytoma, but it also demonstrates the importance of preparedness and communication among a multidisciplinary team in complex cases to ensure a successful outcome. Novel techniques were also used in performing a robotic-assisted adrenalectomy that can aid other adrenal surgeons.
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Henriques Vieira I, Almeida V, Moreno C, Paiva I. An Uncommon Presentation of Pheochromocytoma in Neurofibromatosis Type 1 and the Importance of Long-Term Follow-Up. ACTA MEDICA PORT 2023; 36:55-58. [PMID: 35394421 DOI: 10.20344/amp.16604] [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: 05/24/2021] [Revised: 02/16/2022] [Accepted: 03/03/2022] [Indexed: 01/09/2023]
Abstract
Neurofibromatosis type 1 (NFT1) is a disease caused by mutations in the tumor suppressor gene NF1. It is associated with a higher incidence of chromaffin cell tumors which are usually adrenal, unilateral and benign. The presence of these tumors during pregnancy is extremely rare and frequently associated with fatal outcomes. We report the case of a female patient with NFT1, who presented with paroxysmal spells of headache, palpitations, dizziness and pre-cordial discomfort, starting immediately after the delivery of her third child. Diagnostic work-up came to reveal a bilateral pheochromocytoma and the patient underwent bilateral adrenalectomy. Over 12 years after the initial surgery, metastatic disease was diagnosed, and a reintervention was performed. This is a rare presentation of bilateral malignant pheochromocytoma in a patient with NFT1, with postpartum occurrence of the first symptoms. This text focuses the important details and challenges found at each stage of diagnosis and follow-up.
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Affiliation(s)
| | - Vânia Almeida
- Anatomical Pathology Unit. Coimbra Hospital and University Centre. Coimbra. Medical School. University of Coimbra. Coimbra. Portugal
| | - Carolina Moreno
- Endocrinology Department. Coimbra Hospital and University Centre. Coimbra. Medical School. University of Coimbra. Coimbra. Portugal
| | - Isabel Paiva
- Endocrinology Department. Coimbra Hospital and University Centre. Coimbra. Portugal
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Ferreira Barros II, Manso F, Caldas E Silva AI, Silva Lopes Pereira MR. Screening for Hereditary Pheochromocytoma in a Patient with Neurofibromatosis Type 1: A Case Report. TOUCHREVIEWS IN ENDOCRINOLOGY 2021; 17:79-82. [PMID: 35118451 DOI: 10.17925/ee.2021.17.1.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022]
Abstract
Pheochromocytoma (PHEO) is a rare tumour that arises from adreno-medullary chromaffin cells and secretes catecholamines. These hormones are also secreted by paragangliomas, which derive from extra-adrenal cells of the sympathetic paravertebral ganglia. At least one-third of PHEOs are familial. Neurofibromatosis type 1 (NF1), or von Recklinghausen's disease, is diagnosed upon clinical criteria, and the study of PHEO is advised if hypertension is present. The incidence of PHEO in NF1 is 0.1-5.7% and explains hypertension in 20-50% of these patients. Recent advances in the treatment of this condition and preoperative preparation allow us to reduce its high cardiovascular morbimortality. Here we present the case of a 31-year-old female with known NF1 who presented with 5 months' history of non-specific symptoms and an episode of intraoperative hypertensive crisis. The workup detected a left sided PHEO, which was treated surgically. Our case illustrates the high prevalence of hereditary PHEO and how its presentation can go unnoticed. It reinforces the significance of screening for PHEO in patients with NF1.
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Affiliation(s)
| | - Fernando Manso
- General Surgery Department, Hospital de Braga, Braga, Portugal
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Bancos I, Atkinson E, Eng C, Young WF, Neumann HPH. Maternal and fetal outcomes in phaeochromocytoma and pregnancy: a multicentre retrospective cohort study and systematic review of literature. Lancet Diabetes Endocrinol 2021; 9:13-21. [PMID: 33248478 PMCID: PMC7758862 DOI: 10.1016/s2213-8587(20)30363-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/17/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Phaeochromocytoma or paraganglioma (collectively known as PPGL) in pregnant women can lead to severe complications and death due to associated catecholamine excess. We aimed to identify factors associated with maternal and fetal outcomes in women with PPGL during pregnancy. METHODS We did a multicentre, retrospective study of patients with PPGL and pregnancy between Jan 1, 1980, and Dec 31, 2019, in the International Pheochromocytoma and Pregnancy Registry and a systematic review of studies published between Jan 1, 2005, and Dec 27, 2019 reporting on at least five cases. The inclusion criteria were pregnancy after 1980 and PPGL before or during pregnancy or within 12 months post partum. Eligible patients from the retrospective study and systematic review were included in the analysis. Outcomes of interest were maternal or fetal death and maternal severe cardiovascular complications of catecholamine excess. Potential variables associated with these outcomes were evaluated by logistic regression. FINDINGS The systematic review identified seven studies (reporting on 63 pregnancies in 55 patients) that met the eligibility criteria and were of adequate quality. A further 197 pregnancies in 186 patients were identified in the International Pheochromocytoma and Pregnancy Registry. After excluding 11 pregnancies due to potential overlap, the final cohort included 249 pregnancies in 232 patients with PPGL. The diagnosis of PPGL was made before pregnancy in 37 (15%) pregnancies, during pregnancy in 134 (54%), and after delivery in 78 (31%). Of 144 patients evaluated for genetic predisposition for phaeochromocytoma, 95 (66%) were positive. Unrecognised PPGL during pregnancy (odds ratio 27·0; 95% CI 3·5-3473·1), abdominal or pelvic tumour location (11·3; 1·5-1440·5), and catecholamine excess at least ten-times the upper limit of the normal range (4·7; 1·8-13·8) were associated with adverse outcomes. For patients diagnosed during pregnancy, α-adrenergic blockade therapy was associated with fewer adverse outcomes (3·6; 1·1-13·2 for no α-adrenergic blockade vs α-adrenergic blockade), whereas surgery during pregnancy was not associated with better outcomes (0·9; 0·3-3·9 for no surgery vs surgery). INTERPRETATION Unrecognised and untreated PPGL was associated with a substantially higher risk of either maternal or fetal complications. Appropriate case detection and counselling for premenopausal women at risk for PPGL could prevent adverse pregnancy-related outcomes. FUNDING US National Institutes of Health.
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Affiliation(s)
- Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA.
| | - Elizabeth Atkinson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Charis Eng
- Genomic Medicine Institute, Lerner Research Institute, and Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Hartmut P H Neumann
- Section for Preventive Medicine, Faculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
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Barros IIF, Manso F, Silva AICE, Pereira MRSL. Screening for Hereditary Pheochromocytoma in a Patient with Neurofibromatosis Type 1: A Case Report. EUROPEAN ENDOCRINOLOGY 2021. [DOI: 10.17925/ee.2021.1.1.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Phase II Clinical Trial of Pembrolizumab in Patients with Progressive Metastatic Pheochromocytomas and Paragangliomas. Cancers (Basel) 2020; 12:cancers12082307. [PMID: 32824391 PMCID: PMC7465458 DOI: 10.3390/cancers12082307] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/07/2020] [Accepted: 08/14/2020] [Indexed: 02/06/2023] Open
Abstract
Metastatic pheochromocytomas and paragangliomas (MPPGs) are rare endocrine malignancies that are associated with high rates of morbidity and mortality because of their large tumor burden and location, progression, and release of catecholamines. Systemic therapies for MPPGs are limited. MPPGs are characterized by pseudohypoxia that may prevent immune system recognition. We conducted a phase II clinical trial of pembrolizumab in patients with progressive MPPGs. The primary endpoint was the non-progression rate at 27 weeks. The secondary endpoints included the objective response and clinical benefit rates, progression free and overall survival duration, and safety. We also determined whether PDL-1 expression and the presence of infiltrating mononuclear inflammatory cells in the primary tumor were associated with clinical response and hereditary background. Eleven patients were included in this trial, four (36%) with germline mutations and seven (64%) with hormonally active tumors. Four patients (40%, 95% confidence interval (CI) 12–74%) achieved the primary endpoint. The objective response rate was 9% (95% CI: 0–41%). The clinical benefit rate was 73% (95% CI: 39–94%). Four patients had grade 3 adverse events related to pembrolizumab. No patients experienced grade 4 or 5 adverse events or a catecholamine crisis. Progression free survival time was 5.7 months (95% CI: 4.37—not reached). The median survival duration was 19 months (95% CI: 9.9—not reached). PDL-1 expression and the presence of infiltrating mononuclear inflammatory cells in the primary tumor did not seem to be associated with disease response. Single-agent pembrolizumab has modest treatment efficacy in patients with progressive MPPGs. Positive responses seemed to be independent of patients’ hereditary backgrounds, tumor hormonal status, and the presence of infiltrating mononuclear inflammatory cells or PDL-1 expression in the primary tumor.
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Cvasciuc IT, Gull S, Oprean R, Lim KH, Eatock F. Changing pattern of pheochromocytoma and paraganglioma in a stable UK population. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:78-85. [PMID: 32685043 DOI: 10.4183/aeb.2020.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Context Pheochromocytomas and paragangliomas (PCC/PGLs) are diagnosed variously with increasing incidence and changing clinical and pathology pattern. Objective The aim was to further characterize PCC/PGLs in a stable population. Methods A retrospective, single institution study analysed adrenalectomies for PCC/PGLs between January 2010 - January 2019. Demographics, symptoms, blood pressure, preoperative hormones, imaging, histology, hospital stay, complications and three subgroups [based on the modality of diagnosis - incidentaloma group (IG), genetic group (GG) and symptomatic group (SG)] were noted. Results 86 patients included IG 51 (59.3%), GG 10 (11.62%) and SG 25 patients (29.06%). Incidence was 5.30 cases/1 million population. 33.34% of the IG had a delayed diagnosis with a mean interval of 22.95 months (4-120 months). Females presented more often with paroxysmal symptoms (PS) (p=0.011). Patients with PS and classic symptoms were younger (p=0.0087, p=0.0004) and those with PS required more inotropes postoperatively (p=0.014). SG had higher preoperative hormone levels (p=0.0048), larger tumors (p=0.0169) and more likely females. GG are younger compared with those from the IG (p=0.0001) or SG (p= 0.178). Conclusion Majority of patients had an incidental and delayed diagnosis. If symptomatic, patients are more likely to be young females with higher hormone levels and larger tumors.
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Affiliation(s)
- I T Cvasciuc
- Royal Victoria Hospital, United Kingdom of Great Britain and Northern Ireland
| | - S Gull
- Royal Victoria Hospital, United Kingdom of Great Britain and Northern Ireland
| | - R Oprean
- Ulster Hospital, Dundonald, Belfast, United Kingdom of Great Britain and Northern Ireland
| | - K H Lim
- Altnagelvin Area Hospital, Londonderry, United Kingdom of Great Britain and Northern Ireland
| | - F Eatock
- Royal Victoria Hospital, United Kingdom of Great Britain and Northern Ireland
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Al-Sharefi A, Javaid U, Perros P, Ealing J, Truran P, Nag S, Kamaruddin S, Abouglila K, Cains F, Lewis L, James RA. Clinical Presentation and Outcomes of Phaeochromocytomas/Paragangliomas in Neurofibromatosis Type 1. EUROPEAN ENDOCRINOLOGY 2019; 15:95-100. [PMID: 31616500 PMCID: PMC6785954 DOI: 10.17925/ee.2019.15.2.95] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 04/25/2019] [Indexed: 12/23/2022]
Abstract
Introduction: Patients with neurofibromatosis type 1 (NF1) are at risk of developing phaeochromocytomas/paragangliomas (PHAEO/PG). Unlike in other familial PHAEO/PG syndromes, there are no published guidelines regarding screening in asymptomatic or normotensive patients with NF1. This strategy may be associated with preventable morbidities in those patients who ultimately present with symptomatic PHAEO/PG. Objective: To describe the mode of presentation and the incidence of adverse clinical outcomes attributed to PHAEO/PG in NF1. Methods: A retrospective study was performed in a tertiary referral centre in collaboration with a national complex NF1 centre. Hospital records and databases between 1998–2018 were searched. Results: Twenty-seven patients with NF1 and PHAEO/PG were identified. In all but one, PHAEO/PG was diagnosed after NF1. The median age at the time of diagnosis of PHAEO/PG was 43 years (range 22–65) and 21/27 (78%) were females. The diagnosis was mostly incidental in 13/27 (48%) while classical PHAEO/PG symptoms were found in 15/27 (56%), and hypertension was found in 14/27 (52%) of NF1 patients prior to PHAEO/PG diagnosis. No patient had undergone biochemical screening for PHAEO/PG. Metastatic disease was evident in 2/27 patients, 8 suffered potentially avoidable complications attributed to PHAEO/PG (including two deaths). Conclusion: The course of PHAEO/PG in NF1 is associated with an unpredictable presentation and potentially avoidable adverse outcomes. We recommend that routine biochemical screening for PHAEO/PG should be part of the care package offered to all patients with NF1 by regular measurements of plasma free or urinary fractionated metanephrines starting from early adolescence and repeated every 3 years.
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Affiliation(s)
- Ahmed Al-Sharefi
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
| | - Usman Javaid
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
| | - Petros Perros
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
| | - John Ealing
- Manchester Centre for Clinical Neuroscience, Salford Royal NHS Foundation Trust, Manchester, UK.,Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Peter Truran
- Department of Endocrine Surgery, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Sath Nag
- Department of Endocrinology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Shafie Kamaruddin
- Department of Endocrinology, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Kamal Abouglila
- Department of Endocrinology, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Fiona Cains
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Lauren Lewis
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Robert Andrew James
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
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Ronen JA, Gavin M, Ruppert MD, Peiris AN. Glycemic Disturbances in Pheochromocytoma and Paraganglioma. Cureus 2019; 11:e4551. [PMID: 31275775 PMCID: PMC6592834 DOI: 10.7759/cureus.4551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In this review article, we aimed to analyze the available data on pheochromocytomas and paragangliomas as it pertains to their not as well-recognized association with significant glycemic abnormalities in the preoperative, perioperative, and postoperative settings as well as how they should be managed clinically. Pheochromocytomas are rare adrenal tumors that account for about 0.1% of hypertension. Paragangliomas, on the other hand, are even less common and have fewer clinical manifestations. Both types of tumors may have unusual modes of presentation which can challenge even the most experienced clinicians and are easy to overlook, resulting in post-mortem diagnosis. We wish to draw further attention to the life-threatening effects on glucose and insulin homeostasis that can occur in the form of hyperglycemic and hypoglycemic states. Hyperglycemia is a result of a glucose intolerant state created in the setting of catecholamine excess, which can present in the form of resistant diabetes, diabetic ketoacidosis (DKA), or even hyperglycemic hyperosmolar states (HHS). In many reported cases, these abnormalities resolve with resection of the tumor. However, past clinicians have also described a state of "reactive hypoglycemia" that can occur following tumor resection, further emphasizing the need for very close perioperative and postoperative monitoring. Severe hypoglycemia may also occur with inherited diseases linked to pheochromocytoma such as von Hippel-Lindau (VHL) disease as well as predominantly epinephrine-producing tumors, given some of the dramatic downstream effects of alpha and beta adrenoceptor agonization. While much of the data remains anecdotal, clinicians will benefit from the awareness of the protean manifestations of these tumors and the varied and lesser-known effects on glucose and insulin homeostasis.
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Affiliation(s)
- Joshua A Ronen
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Meredith Gavin
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Misty D Ruppert
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Alan N Peiris
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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Clinical Syndromes and Genetic Screening Strategies of Pheochromocytoma and Paraganglioma. J Kidney Cancer VHL 2018; 5:14-22. [PMID: 30613466 PMCID: PMC6308242 DOI: 10.15586/jkcvhl.2018.113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/30/2018] [Indexed: 12/20/2022] Open
Abstract
Pheochromocytomas (PCCs) are rare neuroendocrine tumors that originate from chromaffin cells of the adrenal medulla, and paragangliomas (PGLs) are extra-adrenal pheochromocytomas. These can be mainly found in clinical syndromes including multiple endocrine neoplasia (MEN), von Hippel–Lindau (VHL) syndrome, neurofibromatosis-1 (NF-1) and familial paraganglioma (FPGL). PCCs and PGLs are thought to have the highest degree of heritability among human tumors, and it has been estimated that 60% of the patients have genetic abnormalities. This review provides an overview of the clinical syndrome and the genetic screening strategies of PCCs and PGLs. Comprehensive screening principles and strategies, along with specific screening based on clinical symptoms, biochemical tests and immunohistochemistry, are discussed.
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14
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Deljou A, Kohlenberg JD, Weingarten TN, Bancos I, Young WF, Schroeder DR, Martin DP, Sprung J. Hemodynamic instability during percutaneous ablation of extra-adrenal metastases of pheochromocytoma and paragangliomas: a case series. BMC Anesthesiol 2018; 18:158. [PMID: 30400849 PMCID: PMC6220566 DOI: 10.1186/s12871-018-0626-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background Surgical manipulation of pheochromocytomas and paragangliomas (PPGLs) may induce large hemodynamic oscillations due to catecholamine release. Little is known regarding hemodynamic instability during percutaneous ablation of PPGLs. We examined intraprocedural hemodynamic variability and postoperative complications related to percutaneous ablation of extra-adrenal metastases of PPGL. Methods From institutional PPGL registry we identified patients undergoing ablation of extra-adrenal PPGL metastases from January 1, 2000, through December 31, 2016. We reviewed medical records for clinical characteristics and hospital outcomes. Tumors were categorized as functional or nonfunctional based on preprocedural fractionated catecholamine and metanephrine profiles. Results Twenty-one patients (14 female [67%]) underwent 38 ablations. Twenty-four ablations were performed in patients with functional metastatic lesions, and 14 were in nonfunctional lesions. Intraprocedural use of potent vasodilators for hypertension was higher for patients with functional tumors (P = 0.02); use of vasopressors for hypotension was similar for functional and nonfunctional tumors (P = 0.74). Mean (±SD) intraprocedural blood pressure range (maximum–minimum blood pressure) during 38 procedures was greater for functional than nonfunctional tumors [systolic: 106 (±48) vs 64 (±30) mm Hg, P = 0.005; diastolic: 58 (±22) vs 35 (±14) mm Hg, P = 0.002; mean arterial: 84 (±43) vs 47 (±29) mm Hg, P = 0.007]. Complications included 5 unplanned intensive care unit admissions (3 for precautionary monitoring, 1 for recalcitrant hypotension, and 1 for hypertensive crisis), 1 case of postoperative bleeding, and 1 death. Conclusions Substantial hemodynamic instability may develop during ablation of functional and nonfunctional PPGL metastases. When anesthesia is provided for ablation of metastatic PPGLs in radiology suites, preparation for hemodynamic management should match standards used for surgical resection.
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Affiliation(s)
- Atousa Deljou
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jacob D Kohlenberg
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN, 55905, USA.,Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN, 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN, 55905, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN, 55905, USA.
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15
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Al-Sharefi A, Perros P, James RA. Phaeochromocytoma/paraganglioma and adverse clinical outcomes in patients with neurofibromatosis-1. Endocr Connect 2018; 7:EC-18-0208. [PMID: 30120202 PMCID: PMC6198184 DOI: 10.1530/ec-18-0208] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/08/2018] [Accepted: 08/15/2018] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Phaeochromocytomas/paragangliomas (PHAEO/PG) are linked to hereditary syndromes including neurofibromatosis type 1 (NF-1). Current guidelines do not recommend biochemical screening for PHAEO/PG in asymptomatic or normotensive patients with NF-1. This strategy may miss preventable morbidities in those patients who ultimately present with symptomatic PHAEO/PG. Our aim was to review the literature and extract data on mode of presentation and the incidence of reported adverse outcomes. METHODS PubMed and EMBASE literature search using the keywords "Phaeochromocytoma", "Paraganglioma" and "Neurofibromatosis" was performed looking for reported cases from 2000 to 2018. RESULTS 73 reports of NF-1 patients with PHAEO/PG were found. Patients were predominately women (n=40) with a median age of 46 years (range 16-82). PHAEO/PG was found incidentally in most patients, 36/73 did not present with typical symptoms while 27 patients were normotensive at diagnosis. 31 patients had adverse outcomes including metastases and death. CONCLUSION Given the protean presentation of PHAEO/PG, relying on symptomology and blood pressure status as triggers for screening is associated with adverse outcomes. Further studies are required to ascertain whether biochemical screening in asymptomatic and normotensive patients with NF-1 can reduce the rate of adverse outcomes.
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Affiliation(s)
- Ahmed Al-Sharefi
- A Al-Sharefi, Department of Endocrinology , Royal Victoria Infirmary , Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Petros Perros
- P Perros, Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Robert Andrew James
- R James, Department of Endocrinology , Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
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Sivaskandarajah GA, Arnason TG. Unsuspected Von Hippel-Lindau syndrome in acute-onset resistant hypertension. BMJ Case Rep 2018; 2018:bcr-2018-225162. [PMID: 30042107 DOI: 10.1136/bcr-2018-225162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The discovery of adrenal lesions during routine testing for hypertension requires focused consideration for adrenal overproduction of cortisol, aldosterone or metanephrines. An otherwise healthy 25-year-old woman presented with headaches, diaphoresis and hot flushes with grossly elevated urine catecholamines, normetanephrines and norepinephrine levels, yet normal metanephrines, epinephrine/epinephrine, cortisol and aldosterone levels. Subsequent functional uptake studies and scans identified bilateral adrenal adenomas consistent with phaeochromocytomas. There was no family history of phaeochromocytomas or familial syndromes; however, a targeted genetic analysis for causes of familial phaeochromocytomas identified a heterozygous germline mutation in the VHL gene consistent with Von Hippel-Lindau syndrome. In this case, the identification of the VHL mutation led to careful screening and detection of clinically occult central nervous system hemangioblastomas and pancreatic neuroendocrine tumours. Verified genetic mutations facilitated best practices for long-term surveillance protocols, preconception counselling and screening of blood relatives. The patient responded well to surgical treatment and has ongoing multidisciplinary long-term surveillance.
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Affiliation(s)
| | - Terra G Arnason
- Department of Medicine, University of Saskatchewan College of Medicine, Saskatoon, Saskatchewan, Canada
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17
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Crona J, Beuschlein F, Pacak K, Skogseid B. Advances in adrenal tumors 2018. Endocr Relat Cancer 2018; 25:R405-R420. [PMID: 29794126 PMCID: PMC5976083 DOI: 10.1530/erc-18-0138] [Citation(s) in RCA: 14] [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: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 12/14/2022]
Abstract
This review aims to provide clinicians and researchers with a condensed update on the most important studies in the field during 2017. We present the academic output measured by active clinical trials and peer-reviewed published manuscripts. The most important and contributory manuscripts were summarized for each diagnostic entity, with a particular focus on manuscripts that describe translational research that have the potential to improve clinical care. Finally, we highlight the importance of collaborations in adrenal tumor research, which allowed for these recent advances and provide structures for future success in this scientific field.
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Affiliation(s)
- J Crona
- Department of Medical SciencesUppsala University, Uppsala, Sweden
| | - F Beuschlein
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Munich, Germany
- Klinik für EndokrinologieDiabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - K Pacak
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - B Skogseid
- Department of Medical SciencesUppsala University, Uppsala, Sweden
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