Surgical strategy for pheochromocytoma: emphasis on the pledge of flank extraperitoneal approach in selected patients

New Perspectives on Pheochromocytoma and Paraganglioma: Toward a Molecular Classification

A molecular biology-based taxonomy has been proposed for pheochromocytoma and paraganglioma (PPGL). Data from the Cancer Genome Atlas revealed clinically relevant prognostic and predictive biomarkers and stratified PPGLs into three main clusters. Each subgroup has a distinct molecular-biochemical-imaging signature. Concurrently, new methods for biochemical analysis, functional imaging, and medical therapies have also become available. The research community now strives to match the cluster biomarkers with the best intervention. The concept of precision medicine has been long awaited and holds great promise for improved care. Here, we review the current and future PPGL classifications, with a focus on hereditary syndromes. We discuss the current strengths and shortcomings of precision medicine and suggest a condensed manual for diagnosis and treatment of both adult and pediatric patients with PPGL. Finally, we consider the future direction of this field, with a particular focus on how advanced molecular characterization of PPGL can improve a patient's outcome, including cures and, ultimately, disease prevention.

MANAGEMENT OF ENDOCRINE DISEASE: Recurrence or new tumors after complete resection of pheochromocytomas and paragangliomas: a systematic review and meta-analysis

OBJECTIVES

To systematically review the incidence and factors associated with recurrences or new tumors after apparent complete resection of pheochromocytoma or thoraco-abdomino-pelvic paraganglioma.

DESIGN

A systematic review and meta-analysis of published literature was performed.

METHODS

Pubmed and Embase from 1980 to 2012 were searched for studies published in English on patients with non-metastatic pheochromocytoma or thoraco-abdomino-pelvic paraganglioma, complete tumor resection, postoperative follow-up exceeding 1 month, and recurrence or new tumor documented by pathology, hormonal dosages, or imaging tests. Incidence rates of new events after curative surgery were calculated for each study that had sufficient information and pooled using random-effect meta-analysis.

RESULTS

In total, 38 studies were selected from 3518 references, of which 36 reported retrospective cohorts from the USA, Europe, and Asia. Patient follow-up was neither standardized nor exhaustive in the included studies. A clear description of patient retrieval methods was available for nine studies and the follow-up protocol and patient flow for four studies. Only two studies used multivariable methods to assess potential predictors of postoperative events.The overall rate of recurrent disease from 34 studies was 0.98 events/100 person-years (95% confidence interval 0.71, 1.25). Syndromic diseases and paragangliomas were consistently associated with a higher risk of a new event in individual studies and in meta-regression analysis.

CONCLUSIONS

The risk of recurrent disease after complete resection of pheochromocytoma may be lower than that previously estimated, corresponding to five events for 100 patients followed up for 5 years after complete resection. Risk stratification is required to tailor the follow-up protocol after complete resection of a pheochromocytoma or paraganglioma. Large multicenter studies are needed to this end.

Thoraco-abdominal approach to large retroperitoneal tumours

OBJECTIVES

To evaluate the thoraco-abdominal approach for resection of retroperitoneal tumours, as this approach is rarely used because, although exposure is excellent, morbidity is presumed to be increased.

PATIENTS AND METHODS

From October 2003 to September 2005, 21 patients (six female, 15 male), aged 14-76 years, underwent resection of very large and/or T4 retroperitoneal tumours through a thoraco-abdominal approach.

RESULTS

In 16 (76%) patients tumour resection was complete. There were no significant complications during surgery. After surgery, there were complications in six patients (29%), in four of whom there was no long-term impairment. One patient died at 75 days after surgery from a complicated retroperitoneal haematoma. The mean (range) estimated blood loss was 2883 (50-20 000) mL, the intensive-care unit stay was 3.85 (0-30) days and the intermediate-care unit stay 2.6 (0-9) days. With a mean follow-up of 9.6 (1-19) months, 15 patients (72%) are recurrence-free, two (10%) have progressive disease, and four (19%) have died from malignancy.

CONCLUSIONS

The thoraco-abdominal approach permits excellent exposure of the retroperitoneum for large and/or T4 tumours, allowing radical surgery in cases considered otherwise inoperable. Additional advantages are the possibilities of early vascular control and easy surgical extension of the procedure. These facts, combined with the reasonable morbidity found in our series, support the integration of the thoraco-abdominal approach in the regular options for urological surgery.

New therapeutic and surgical approaches for sporadic and hereditary pheochromocytoma

Pheochromocytoma is a rare, surgically correctable cause of hypertension. Modern medical blockade has significantly improved patient survival and morbidity. The last decade has seen the identification of the genes responsible for several hereditary causes of pheochromocytoma. Evaluation of these patients has demonstrated different catecholamine profiles associated with the different syndromes. Genetic testing and new, more sensitive catecholamine tests are allowing better, earlier diagnosis of affected patients. Some patients with small tumors deemed nonfunctional by traditional methods may be safely observed until function is demonstrated. Laparoscopic surgery has supplanted the use of open surgery in the management of these tumors. Adrenocortical-sparing surgery may be performed using laparoscopy in patients with hereditary forms of pheochromocytoma.

[Pheochromocytoma and von Recklinghausen's disease]

The association between von Recklinghausen's disease and pheochromocytoma is present about 10% of cases. We report a case of 49 years old women who presented with elevated blood pressure and von Recklinghausen's neurofibromatosis. Laboratory examination showed a marked level in the urinary excretion of cathecholamine. The computed tomography showed a right adrenal tumor suggesting a pheochromocytoma. The adrenalectomy was realised by transabdominal approach and the histological examination confirmed a benign pheochromocytoma. The authors discuss the pathogenetic hypothesis of this rare pathological association, the diagnostic methods and the therapeutic procedure.

Iatrogenic pheochromocytomatosis: a previously unreported result of laparoscopic adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy is now regarded as the procedure of choice for treatment of small or benign adrenal tumors, including pheochromocytoma. However, long-term outcomes have not been critically assessed. We report here 3 cases of pheochromocytomatosis recurring 3 to 4 years after laparoscopic adrenalectomy. We postulate laparoscopic-induced seeding of tumor as the mechanism of recurrence.

METHODS

We retrospectively reviewed the cases of 3 patients with documented biochemical and radiolabeled metaiodobenzylguanidine evidence of recurrent pheochromocytoma after prior presumed curative laparoscopic adrenalectomy.

RESULTS

Original pheochromocytomas were 5.5 to 6.5 cm in diameter. At the time of laparoscopic adrenalectomy, tumors were not believed to be malignant, based on clinical or histopathologic data. However, on 3- to 4-year follow-up, each patient developed symptoms, elevated urinary catecholamine levels, and metaiodobenzylguanidine imaging consistent with recurrence. At reoperation, multiple small tumor nodules were found in the adrenal bed near the site of the initial laparoscopic resection. The original operative notes suggested some possible method of local seeding: tumor fragmentation and spillage or excessive tumor manipulation.

CONCLUSIONS

Pheochromocytoma recurrence may occur as a result of local spillage of tumor during laparoscopic adrenalectomy. The relative risk of recurrence between open and laparoscopic resection needs to be assessed. Long-term follow-up will continue to be important, regardless of operative approach.

Endoscopic retroperitoneal adrenalectomy: lessons learned from 111 consecutive cases

OBJECTIVE

To evaluate the effectiveness of endoscopic retroperitoneal adrenalectomy (ERA).

SUMMARY BACKGROUND DATA

Minimally invasive adrenalectomy has become the procedure of choice for benign adrenal pathology. Although the adrenal glands are located in the retroperitoneum, most surgeons prefer the transperitoneal laparoscopic approach to adrenal tumors.

METHODS

Clinical characteristics and outcomes of 111 ERAs from January 1994 to December 1999 were evaluated.

RESULTS

Ninety-five patients underwent 111 ERAs (79 unilateral, 16 bilateral). Indications were Cushing syndrome (n = 22), Cushing disease (n = 8), ectopic adrenocorticotropic hormone syndrome (n = 6), Conn's adenoma (n = 25), pheochromocytoma (n = 19), incidentaloma (n = 11), and other (n = 4). Tumor size varied from 0.1 to 8 cm. Median age was 50 years. Unilateral ERA required 114 minutes, with median blood loss of 65 mL. Bilateral ERA lasted 214 minutes, with median blood loss of 121 mL. The conversion rate to open surgery was 4.5%. The complication rate was 11%. Median postoperative hospital stay was 2 days for unilateral ERA and 5 days for bilateral ERA. The death rate was 0.9%. At a median follow-up of 14 months, the recurrence rate of disease was 0.9%.

CONCLUSION

For benign adrenal tumors less than 6 cm, ERA is recommended.

Adrenal pheochromocytoma remains a frequently overlooked diagnosis

BACKGROUND

Adrenal pheochromocytoma is potentially lethal if undetected and is associated with long-term morbidity.

METHODS

Records of patients (11 men, 18 women) with confirmed pheochromocytoma were studied with respect to clinicopathological features and outcome.

RESULTS

Pheochromocytoma was diagnosed in 4 of 8,486 (0.05%) autopsies and accounted for 3 of the 4 immediate causes of death. Operative mortality occurred in 1 patient with undiagnosed tumor. Hypertensive-related complications occurred in 6 patients before diagnosis. Malignancy was documented in 7 patients with distant metastases (n = 4) or locally invasive tumors (n = 3). During a median follow-up of 4 years, 23 patients are alive and free of disease (79%). Four of the 6 patients (67%) who died had distant metastases compared with 2 of 23 patients (9%) without distant metastases (P = 0.04). Persistent hypertension and diabetes requiring treatment were present in 8 (35%) and 4 (17%) of 23 patients respectively.

CONCLUSIONS

Fatal complications preceded diagnosis in a significant proportion of patients with pheochromocytoma. The presence of distant metastases was associated with poor survival.

Posterior or laparoscopic approach for adrenalectomy

BACKGROUND

The pathologies and size of adrenal lesions removed through the open posterior and laparoscopic routes share remarkable similarities. This study aims at comparing the relative merits of these two approaches.

METHODS

Patients with adrenal tumors operated on by posterior approach (n = 56) and transabdominal laparoscopic approach (n = 12) between January 1981 and May 1997 were retrospectively reviewed.

RESULTS

The two groups were comparable in terms of age, and the position, size, and weight of the tumor. The operative time of posterior adrenalectomy was significantly shorter than that of laparoscopic adrenalectomy (median 120 minutes versus 160 minutes), whereas laparoscopic adrenalectomy was associated with less parenteral analgesic requirement (median 0 mg versus 225 mg), a shorter hospital stay (median 3 days versus 5 days), and a shorter duration off work (median 11 days versus 26 days). The estimated blood loss was also significantly reduced in the laparoscopic group (median 50 mL versus 150 mL).

CONCLUSIONS

Laparoscopic adrenalectomy is replacing posterior adrenalectomy to become the procedure of choice for the majority of patients undergoing adrenalectomy.

The von Hippel-Lindau tumor suppressor gene. A rare and intriguing disease opening new insight into basic mechanisms of carcinogenesis

The von Hippel-Lindau (VHL) disease is an inherited tumor susceptibility syndrome featuring a high variety of benign and malignant tumors. The gene has been localized and cloned at 3p25-26. Recent functional analysis defined the VHL gene product as an inhibitor of the transcription elongation process. Its possible involvement in the vascularization process may explain the histologic features of VHL tumors providing insight into basic mechanism of tumorigenesis. Direct genetic testing is available for patients affected with VHL. Seventy to eighty percent of the germline mutations expected could be detected. As first geno/phenotype correlations have been established, we are now beginning to understand the diversity of this fascinating disease at the molecular level. As mutational analysis proved to be of striking prognostic significance, gene testing became an important tool for the management of the disease. The VHL gene was also found to be responsible for tumorigenesis in the corresponding sporadic tumors, especially in the clear cell type of renal cell carcinomas. The understanding of the normal and disturbed function of the VHL gene product will enable us to develop treatment strategies based on and targeted at the molecular cause of the disease. In this review we summarize the current knowledge about genetics, clinics, and function of VHL.