Malignant pheochromocytoma of the bladder

Paraganglioma (pheochromocytoma) of the urinary bladder: A systematic review with a diagnostic, management and treatment algorithm

Introduction:

Paraganglioma of the urinary bladder is a rare but well-documented tumour. Herein, we provide the largest, comprehensive systematic review of the literature and aim to increase familiarity with this rare but significant neoplasm.

Methods:

A systematic review of the literature was conducted on the NCBI PubMed database. The search criteria were not limited to any specific years or languages. There were 418 articles between January 1953 and August 2020, of which 255 case reports were selected.

Results:

Paragangliomas of the urinary bladder most commonly occurred in Caucasians in the fifth decade of life, most commonly presenting with haematuria and variations of ‘micturition attacks’. Eighty percent of tumours were functionally active. The mucosa was normal in 91% of patients. In all, 25% of tumours were treated with transurethral resection alone, 65% had partial cystectomy and 5% had radical cystectomy. Alpha-blockers were administered pre-operatively in 38% of patients and the risk of intra-operative hypertensive crisis was over three times greater in those who did not receive an alpha-blocker. The tumour was confined to the bladder in 75% of cases. Metastasis occurred in 20% of cases, most commonly to iliac nodes. The mean follow-up time was 26.5 months. In cases that documented follow-up, 18.6% had recurrence, most commonly in lymph nodes and bone.

Conclusion:

All patients presenting with micturition attacks or haematuria with a computed tomography showing an enhancing, well-defined submucosal bladder lesion and/or cystoscopy showing a lesion with normal overlying mucosa should be worked up for a possible paraganglioma of the urinary bladder.

Level of evidence:

Not applicable

Pheochromocytoma of the Urinary Bladder with Recurrence 10 Years Later

Pheochromocytoma of the bladder is a rare bladder tumor. We report a case of an 80-year-old female who presents with recurrent bladder tumors consistent with pheochromocytoma of the bladder, discovered 10 years post-resection of a prior pheochromocytoma of the urinary bladder. She was treated with partial cystectomy and was found to be symp tom free at 6-month follow-up.

Management of bladder pheochromocytoma by transurethral resection

Bladder pheochromocytoma is the most common extra-adrenal genitourinary tumor. Endoscopic management is feared due to the risk of intra-operative hypertensive crisis. We described a case of successful endoscopic management of a bladder pheochromocytoma and discussed its technical aspects.

Primary paraganglioma of seminal vesicle

INTRODUCTION

Paragangliomas are rare tumors arising from neural crest tissue located outside the adrenal gland. Primary seminal vesicle paraganglioma is extremely rare entity.

PRESENTATION OF CASE

A 26-year-old male patient presented with symptoms and signs of acute appendicitis where a CT of abdomen and pelvis showed an inflamed appendix and incidental finding of left seminal vesicle mass. The patient underwent uneventful laparoscopic appendectomy followed by transrectal ultrasound (TRUS) guided seminal vesicle biopsies. Histopathology revealed a neuroendocrine neoplasm consistent with paraganglioma. Surgical excision of the left seminal vesicle was carried out.

DISCUSSION

Paraganglioma of genitourinary tract is rare. The urinary bladder is the most common site, followed by the urethra, pelvis and ureter. Seminal vesicle paragangliomas were reported in association with other genitourinary organ involvement such as bladder and prostate. Isolated seminal vesicle paraganglioma is extremely rare and surgical excision remains the standard treatment for localized paraganglioma.

CONCLUSION

Primary tumors of seminal vesicle are rare and represent a diagnostic challenge. Differential diagnosis includes a list of benign and malignant tumors. Primary seminal vesicle paraganglioma is a rare but important diagnosis to be included in the differential diagnosis.

Pheochromocytoma of the urinary bladder: a systematic review of the contemporary literature

Background

Pheochromocytoma (paraganglioma) of the urinary bladder is a rare tumor. Herein we sought to review the contemporary literature on pheochromocytomas of the urinary bladder in order to further illustrate the presentation, treatment options and outcomes of patients diagnosed with these tumors.

Methods

A comprehensive review of the current literature was conducted according to the PRISMA guidelines by accessing the NCBI PubMed database and using the search terms “paraganglioma, pheochromocytoma, bladder.” This search resulted in the identification of 186 articles published between January 1980 and April 2012 of which 80 articles were ultimately included in our analysis.

Results

Pheochromocytomas usually occurred in young adult Caucasians (mean age, 43.3 years; range,11–84 years). According to the literature, the most common symptoms and signs of pheochromocytomas of the urinary bladder were hypertension, headache, and hematuria. Of the 77 cases that commented on catecholamine production, 65 patients had biochemically functional tumors. Approximately 20% of patients were treated by transurethral resection alone, 70% by partial cystectomy and 10% by radical cystectomy. The 75 patients with follow-up information had a mean follow-up of 35 months. At the time of last follow-up, 15 (14.2%) had disease recurrence, 10 (9.4%) had metastasis, and 65 (61.3%) were alive.

Conclusions

Pheochromocytomas of the urinary bladder tend to be functional and occur mostly in young adult Caucasians. Patients with localized tumors have an extremely favorable prognosis and may be managed by less aggressive modalities, whereas patients with metastatic disease have a significant reduction in survival rates despite aggressive treatment.

Bladder pheochromocytoma encountered on sonography

Pheochromocytomas of the bladder are rare neoplasms, constituting < 0.06% of all vesical tumours. Common presenting features of this tumour include episodes of sweating, hypertension, haematuria and postmicturition syncope. We describe a case of bladder pheochromocytoma in a 66-year-old man whose only symptom of macroscopic haematuria was initially assessed with ultrasonography. Clinical presentation highlights the need for a high index of suspicion during sonographic evaluation of bladder neoplasms because such tumours might present without symptoms of adrenergic excess.

I-123 MIBG imaging and intraoperative localization of metastatic pheochromocytoma: a case report

The authors describe the diagnostic use of I-123 MIBG scintigraphy in a 61-year-old man who was thought to have a recurrence 25 years after a left adrenalectomy for a pheochromocytoma. Preoperative I-123 MIBG scintigraphy was performed twice along with intraoperative gamma probe localization of the lesions. The preoperative MIBG scintigraphy revealed three pathologic processes in the upper left abdomen, whereas computed tomographic scanning identified only one site of involvement. All three metastatic lesions were removed successfully with the aid of a gamma probe. Preoperative I-123 MIBG scintigraphy, combined with intraoperative gamma probe identification of I-123 MIBG foci, is feasible and a valuable tool to detect malignant masses possibly overlooked by other imaging techniques.

Unusual cause of early preeclampsia: bladder paraganglioma

Ten to twenty percent of paragangliomas occur at extra-adrenal locations and less than 1% are at the urinary bladder. The most common presenting symptom of bladder paraganglioma is hypertensive attacks precipitated by micturition and hematuria. Paraganglioma of the urinary bladder occurring at pregnancy is extremely rare. We present a case of bladder paraganglioma as an unusual cause of early preeclampsia. After termination of the pregnancy, surgical resection was performed and the histopathologic diagnosis of paraganglioma confirmed. At 24 months of follow-up the patient felt well and was normotensive without any foci of paraganglioma. Although rare, paraganglioma must be considered in the differential diagnosis of early preeclampsia.

Paraganglioma of the urinary bladder: can biologic potential be predicted?

BACKGROUND

Paraganglioma of the urinary bladder is rarely encountered and its biologic behavior is uncertain. The authors sought to determine the prognostic factors that would predict patient outcome.

METHODS

The Mayo Clinic experience over 53 years with paraganglioma of the bladder was reviewed. All histologic slides from 16 patients were reviewed by the authors. Eight cases were examined immunohistochemically with cytokeratin (AE1/3, cytokeratin 7, and cytokeratin 20), vimentin, S-100 protein, neuroendocrine markers (chromogranin, synaptophysin, and neuron specific enolase), p53 protein, and MIB-1. DNA ploidy was determined by digital image analysis in formalin fixed, paraffin embedded tissue. The mean follow-up was 6.3 years (range, 0.4-16.4 years).

RESULTS

Paraganglioma usually occurred in young adult women (mean age, 45 years; range, 16-74 years). The male-to-female ratio was 1 to 3. The common symptoms and signs were hypertension and hematuria. The tumors were usually located intramurally in the lateral and posterior wall of the bladder and were multifocal in 3 cases (18%). Seven patients were treated by transurethral resection, eight by partial cystectomy, and one by radical cystectomy. T classification was T1 (1 patient), T2 (9 patients), T3 (2 patients), and T4b (4 patients). At the time of diagnosis, one patient had distant metastasis and one had regional lymph node metastasis. One patient developed metastasis 1 year after diagnosis and died of the disease 1.5 years later. None of the patients with T1 or T2 tumors had recurrence or tumor progression. All tumors were aneuploid. The mean MIB-1 labeling index was 1.5% (range, 0.03-7.0%). The tumor cells displayed immunoreactivity for S-100 protein and neuroendocrine markers and were negative for p53 (except 1 case) and cytokeratin.

CONCLUSIONS

Paraganglioma of the urinary bladder occurs mostly in young adult women. Patients with tumor of advanced classification (>/=T3) are at risk of recurrence, metastasis, and dying of the disease, whereas patients in this study with T1 or T2 disease had favorable outcomes after complete tumor resection.

"The" pheochromocytoma: a benign, intra-adrenal, hypertensive, sporadic unilateral tumor. Does it exist?

This study aims to examine the frequency of the pheochromocytoma (pheo), defined as a "benign, intra-adrenal, hypertensive, sporadic, unilateral tumor." Three large series amounting to 310 subphrenic chromaffin tumors operated over periods of 17, 23, and 41 years, respectively, have been reviewed. Among those combined 310 pheos, 48 (15.5%) were malignant (i.e., metastatic) and 262 (84.5%) were benign; 42 (13.5%) were ectopic (35% of malignant tumors versus 9.5% of benign tumors); 230 (74.2%) were hypertensive (74% of benign tumors versus 73% of malignant tumors); 29 (9.4%) were bilateral, including 23 patients with a family history; 41 (13.2%) of patients had MEN II type A or B syndrome; and 20 (6.5%) occurred in a phacomatosis setting. Some of the patients had a non-MEN family history of pheo (n = 5), seemingly sporadic hyperparathyroidism (n = 4), or other associated neuroendocrine tumor (n = 9). Sometimes several of these features were combined. Finally 125 (40.3%) cases fitted the classic description of the tumor, 47.0% at the time of initial presentation and 40.3% at the end of follow-up. Late occurrence of metastases or metachronous diagnosis of familial disease make lifelong follow-up mandatory. Genetic studies may be indicated in pheochromocytoma patients.

High incidence of malignant pheochromocytoma in a surgical unit. 26 cases out of 100 patients operated from 1971 to 1991

In this surgical series of 100 pheochromocytomas (PH), where 91 cases were studied and followed up, the frequency of malignancy appears high (29%) on macroscopic criteria observed at the first operation (25 out 26 cases of malignant PH) or thanks to the occurrence of metastases (1 case out of 26 malignant PH). While some clinical signs are suggestive, there is no excretory profile predictive of malignancy. Isolated or predominant secretion of dopamine is not specific of malignancy event if it occurs more frequently and severely in malignant PH. Bilateral involvement, occurring in the setting of phacomatosis or of multiple endocrine neoplasia (MEN II), or in a sporadic case, is not a predictor for malignancy. Contrarily, extraadrenal involvement is a major feature indicative of malignancy. A CT scan which demonstrates possible locoregional invasion, and a MIGB scan revealing distant localizations raise the suspicion of malignancy. The preferred surgical approach is via a laparotomy, thus allowing the exploration of all possible abdominal chromaffin site and the search for intraabdominal metastases. Intraoperative MIBG scanning checks the completeness of the excision. Flow cytometric DNA ploidy studies have been performed in 25 of our patients. The follow up of benign or malignant PH, after excision "for cure" must be life-long: clinically, biologically and by MIGB scan. Persistence of the disease after surgery or recurrence with unresectable metastases can benefit from MIGB and chemotherapy.

Nonepithelial neoplasms arising within vesical diverticula

Two cases of rare vesical tumors, a paraganglioma and a malignant fibrous histiocytoma, are reported. The occurrence of these tumors within the urinary bladder is rare; their occurrence within bladder diverticula appears unique. The clinical, radiologic, and pathologic findings are summarized.

Malignant phaeochromocytoma: clinical, biochemical and scintigraphic characterization

We have evaluated thirty patients with malignant metastatic phaeochromocytoma with regard to clinical features, indices of catecholamine secretion, histology of lesions and a number of imaging procedures including scintigraphy with the recently developed sympathetic tissue-seeking radiopharmaceutical 131I-metaiodobenzylguanidine (131I-MIBG). The primary tumour was extra-adrenal in 13 cases. The commonest site of metastases was the axial skeleton (20 cases), followed by liver (four cases), lymph nodes (four cases), peritoneum (two cases) and lung (three cases). The malignancies were indolent, the mean time following the initial diagnosis was 9.18 years (range 0 to 33 years) and the mean duration of known metastases 3.71 years (range 0 to 18 years). There was a wide range of abnormalities in plasma and urinary catecholamines which did not correlate with the extent of tumour spread, histological pattern (mitotic index, Zellballen pattern, capsular or vascular invasion pleomorphism or necrosis) or 131I-MIBG uptake by tumour deposits. 131I-MIBG scintigraphy was found to be a useful technique for determining the extent of metastatic disease in most cases (26 of 30) and in some patients (16 of 30) was more sensitive than other radiological procedures. No false positive scans were encountered.

Phaeochromocytoma of the urinary bladder localized by selective venous sampling and computed tomography

Clinical and biochemical evidence of a catecholamine-secreting tumour was documented in a 19-year-old female presenting with malignant hypertension. The tumour was successfully localized to the pelvis by means of plasma noradrenaline assay from multiple sites, after previous attempts at localization had failed. Subsequently, computed tomographic (CT) scan allowed correct pre-operative localization to the urinary bladder.

Primary vesical pheochromocytoma

Pheochromocytoma of the urinary bladder is a rare neoplasm that often occurs with the unique symptom complex of micturitional attacks due to increased catecholamine secretion during detrusor activity. Analysis of 3 of our patients is added to a discussion of 97 cases reported in the world literature. Therapeutic decision is complicated by the absence of unequivocal histologic criteria of malignancy for these tumors. Future perspectives in determining the malignant potential of pheochromocytoma are presented and our treatment plan elaborated.

Malignant phaeochromocytoma: report of a case and a critical review

A right adrenal phaeochromocytoma is described in a 64-year-old man. Metastases to bone and subsequent death following cord compression occurred within 2 years of diagnosis. Twenty-seven cases in the English literature have been reviewed since 1968. In three of these, the pathological proof was unsatisfactory for the diagnosis of malignancy, and one further case was inadequately documented. The variation in incidence of malignancy found in large retrospective series may relate to inconsistency in pathological criteria, as well as to selective reporting of cases.

Phaeochromocytomas of the Bladder

Phaeochromocytomas of the bladder are rare, only about 100 cases having been reported previously. Four adults with these lesions have been managed at Hammersmith Hospital in the past 10 years. Three patients had hypertension, together with syncopal attacks and/or headaches, induced by micturition. The fourth patient presented with haematuria. After control of blood pressure and localization of the tumours by various combinations of cystoscopy, intravenous urography, venous sampling, ultrasound, angiography and computerized coaxial tomography (CT scanning), 3 patients underwent partial cystectomy, and the fourth pelvic exenteration. Two patients were apparently cured of the disease, but 2 were not. One developed nodal metastases and recurrence of hypertension after 18 months and one rapidly developed metastases in the lungs and elsewhere. Effective therapy probably requires a high index of suspicion in diagnosing the condition and possibly an aggressive surgical and radiotherapeutic policy.

Pheochromocytoma of bladder

A typical case of pheochromocytoma of the bladder is presented, and reported cases are reviewed.