1
|
Tsiomidou S, Pamporaki C, Geroula A, Van Baal L, Weber F, Dralle H, Schmid KW, Führer D, Unger N. Clonidine suppression test for a reliable diagnosis of pheochromocytoma: When to use. Clin Endocrinol (Oxf) 2022; 97:541-550. [PMID: 35274752 DOI: 10.1111/cen.14724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In clinical practice, false-positive results in biochemical testing for suspected pheochromocytoma/paraganglioma (PPGL) are not infrequent and may lead to unnecessary examinations. We aimed to evaluate the role of the clonidine suppression test (CST) in the era of analyses of plasma-free metanephrines for the diagnosis or exclusion of PPGL in patients with adrenal tumours and/or arterial hypertension. DESIGN AND METHODS This single-centre, prospective trial investigated the use of CST in 60 patients with suspected PPGL associated with out-patient elevations of plasma normetanephrine (NMN) and/or metanephrine (MN), in most cases accompanied with hypertension or an adrenal mass. Measurements of plasma catecholamines and free metanephrines were performed by liquid chromatography with electrochemical detection and tandem mass spectrometry, respectively. RESULTS Forty-six patients entered final analysis (n = 20 with PPGL and n = 26 with a nonfunctional adrenal mass and/or hypertension). CST reliably excluded false-positive baseline NMN results with a specificity of 100%. The sensitivity of CST improved from 85% to 94% when tumours with isolated MN increase (n = 3) were not considered. In patients with elevated baseline NMN (n = 24), CST correctly identified all patients without PPGL. Patients with falsely elevated baseline NMN results (n = 7, 26.9%) exhibited increases of baseline NMN up to 1.7-fold above the upper reference limit. CONCLUSION CST qualifies as a useful diagnostic tool for differential diagnosis of borderline elevated plasma-free NMN in patients with suspected PPGL. In this context, CST helps to correctly identify all false-positive NMN screening results.
Collapse
Affiliation(s)
- Spyridoula Tsiomidou
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Aikaterini Geroula
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lukas Van Baal
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Frank Weber
- Division of Endocrine Surgery, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Henning Dralle
- Division of Endocrine Surgery, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Kurt W Schmid
- Institute of Pathology, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicole Unger
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| |
Collapse
|
2
|
Remde H, Pamporaki C, Quinkler M, Nölting S, Prejbisz A, Timmers HJLM, Masjkur J, Fuss CT, Fassnacht M, Eisenhofer G, Deutschbein T. Improved Diagnostic Accuracy of Clonidine Suppression Testing Using an Age-Related Cutoff for Plasma Normetanephrine. Hypertension 2022; 79:1257-1264. [PMID: 35378989 DOI: 10.1161/hypertensionaha.122.19019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Moderately elevated plasma normetanephrine (NMN) levels are frequent among patients with suspected pheochromocytoma and paraganglioma (PPGL). Clonidine suppression testing (CST) is recommended to distinguish patients with from those without PPGL. We aimed at evaluating the diagnostic outcome of CST in patients with moderate NMN elevations. METHODS Data from patients participating in the PMT study (Prospective Monoamine-Producing Tumor) and the ENSAT (European Network for the Study of Adrenal Tumours) registry in 6 European reference centers were analyzed retrospectively. Eighty-nine patients with suspected PPGL and moderate NMN elevations upon screening were included. During follow-up, PPGL was confirmed in 16 and excluded in 73 cases. Plasma NMN was measured by liquid chromatography tandem mass spectrometry before and 180 minutes after oral clonidine. Receiver operating characteristic analysis was performed to identify optimal cutoffs. RESULTS If published diagnostic criteria for CST (ie, NMN ≥112 ng/L and NMN suppression <40%) were applied, a sensitivity of 88% (CI, 61%-98%) and a specificity of 97% (CI, 90%-100%) were observed. An improved cutoff for plasma NMN 180 minutes after clonidine was established at 80% of the age-related upper limit of normal, resulting in a sensitivity of 94% and a specificity of 97%. False-negative CST results occurred in 2 patients with small PPGL. CONCLUSIONS This study, involving one of the largest cohorts of patients with suspected PPGL and moderately elevated NMN, confirmed the diagnostic accuracy of CST. The application of an adapted cutoff further improved sensitivity.
Collapse
Affiliation(s)
- Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany (H.R., C.T.F., M.F., T.D.)
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (C.P., J.M., G.E.)
| | | | - Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich and University of Zurich, Switzerland (S.N.).,Department of Medicine IV, University Hospital, LMU Munich, Germany (S.N.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P.)
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands (H.J.L.M.T.)
| | - Jimmy Masjkur
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (C.P., J.M., G.E.)
| | - Carmina T Fuss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany (H.R., C.T.F., M.F., T.D.)
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany (H.R., C.T.F., M.F., T.D.)
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (C.P., J.M., G.E.).,Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (G.E.)
| | | |
Collapse
|
3
|
Pheochromocytoma and Paraganglioma: From Clinical Findings to Diagnosis. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 54:271-280. [PMID: 33312023 PMCID: PMC7729715 DOI: 10.14744/semb.2020.14826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022]
Abstract
The majority of pheochromocytoma (PCC) and paraganglioma (PGL) are endocrine active tumors, and they cause clinical symptoms by secreting excess one or more catecholamines (epinephrine, norepinephrine, and dopamine) and their inactive metabolites (metanephrine, normetanephrine, 3-metoxythromine). Although signs and symptoms regarding excess catecholamine often develop in PCC and PGL (PPGL), non-functional PPGLs may present with local compression symptoms. Persistent, sometimes worsening hypertension is the most common finding and occurs in 80-90% of the patients. Classically defined symptom triad; headache, sweating and palpitations are seen in only 25% of the patients with PCC. The difference of clinical symptoms may be related to the tumor secretion, epinephrine or norepinephrine. All patients with signs and symptoms suggestive of catecholamine excess should be screened by biochemical tests regardless of whether they have hypertension or not. Not all patients with newly diagnosed hypertension need to be screened, but only patients with additional tips for catecholamine excess should be screened. Approximately 20% of the PPGLs are diagnosed in childhood, and the male/female ratio is 2/1. 60-90% of pediatric patients present with hypertension. PPGL in pregnancy is rare, and the estimated incidence ranges between 1/15000-1/54000. Although early diagnosis is the most important factor in preventing mortality, diagnosis is not as easy as it is a rare condition. Hypertension is a common complication in pregnancy, occurring in 5-10%. Computed tomography should not be used as the imaging method during pregnancy; the first choice is magnetic resonance imaging with gadolinium or without contrast. Plasma free metanephrine or 24-hour urinary fractionated metanephrine level is recommended as a screening test for the diagnosis of PPGL in the Endocrine Society Clinical Practice Guideline. In suspicious situations, tests should be repeated. Since 40% of these patients have germline mutations, genetic tests are recommended for all patients with PPGL regardless of family history and age. Preoperative knowledge of germline mutations affects the surgical approach and the extent of adrenalectomy. After the biochemical diagnosis is made in PPGL, the tumor is localized with imaging methods to make the operation plan. In this review, we aimed to evaluate the clinical findings, diagnostic tests, and imaging studies for tumor localization in PPGL.
Collapse
|
4
|
Golani T, Fishman B, Sharabi Y, Olswang-Kutz Y, Leibowitz A, Grossman E, Shlomai G. The association between systolic blood pressure reduction during clonidine suppression testing and the decrease in plasma catecholamines and metanephrines. J Clin Hypertens (Greenwich) 2020; 22:1924-1931. [PMID: 32882089 DOI: 10.1111/jch.14014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
Borderline isolated norepinephrine (NE) and normetanephrine (NMT) elevation is common among patients with suspected pheochromocytoma and paraganglioma (PPGL). The clonidine suppression test (CST) may help establish the etiology in these cases. Prolonged laboratory processing and/or paucity of reliable biochemical assays may limit the utility of CST. The aim of this study was to evaluate whether blood pressure (BP) reduction during CST is associated with alterations in plasma NMT/NE, thereby potentially providing an immediate indication of CST results. In this cross-sectional study, the authors included all consecutive patients with suspected PPGL who underwent CST from January 1, 2014, to December 31, 2019. Linear regression models were conducted to evaluate the association between BP reduction and decrease in plasma NMT/NE. The final analysis included 36 patients (17 males). The decrease in systolic BP (SBP) 90 minutes postclonidine was associated with a decrease in plasma NMT (R = 0.668, P = .025) and NE (R = 0.562, P = .005). A 40% decrease in NMT and NE correlated with a 9.74% and 7.16% decrease in SBP, respectively. Subgroup analyses demonstrated that the association between SBP reduction and the decrease in plasma NMT (R = 0.764, P = .046) and NE (R = 0.714, P = .003) strengthens among patients with hypertension and among those with diabetes mellitus (R = 0.974, P = .026 for NMT). In conclusion, SBP reduction during CST is associated with plasma NMT and NE decrease. Therefore, the decrease in SBP 90 minutes postclonidine may serve as an immediate complementary clinical tool for PPGL diagnosis.
Collapse
Affiliation(s)
- Tiran Golani
- Department of Internal Medicine D and Hypertension unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Boris Fishman
- Department of Internal Medicine D and Hypertension unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehonatan Sharabi
- Department of Internal Medicine D and Hypertension unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Olswang-Kutz
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Metabolic Lab, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Avshalom Leibowitz
- Department of Internal Medicine D and Hypertension unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ehud Grossman
- Department of Internal Medicine D and Hypertension unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gadi Shlomai
- Department of Internal Medicine D and Hypertension unit, The Chaim Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Institute of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
| |
Collapse
|
5
|
Chen Cardenas SM, Duan D, Rooper LM, Santhanam P, Cooper DS, Ladenson PW. Misdiagnosis of Paraganglioma by 123I-mIBG Without Stable Iodine Blockade of Thyroidal Radioiodine Uptake. J Endocr Soc 2020; 4:bvaa099. [PMID: 32793847 PMCID: PMC7414919 DOI: 10.1210/jendso/bvaa099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/13/2020] [Indexed: 01/02/2023] Open
Abstract
Iodine-123/iodine-131 (123I/131I)-metaiodobenzylguanidine (mIBG) scan is an established tool for the localization and treatment of neuroendocrine tumors such as paragangliomas (PGL). To minimize thyroid irradiation by the radioactive iodine in the mIBG preparation, blockade of thyroidal iodine uptake with high doses of stable iodine used to be given routinely as part of all mIBG protocols. As 123I is now more frequently utilized than 131I, concern about thyroid radiation has lessened and thyroid blockade is often considered unnecessary. However, in certain situations, the lack of thyroid blockade can significantly impact treatment decisions. This report describes 2 patients who had mediastinal masses incidentally discovered on CT scans, and on further evaluation were found to have symptoms suggesting catecholamine excess with mildly elevated plasma normetanephrine levels. 123I-mIBG scans were performed without thyroid blockade, which demonstrated accumulation of tracer in the masses that were therefore deemed positive for PGL. Both patients underwent surgical resection of the masses with their surgical pathology revealing ectopic thyroid tissue (ETT). These cases illustrate that if appropriate thyroid blockade is not performed, ETT concentrating radioiodine from mIBG can lead to falsely positive mIBG scans and unnecessary surgical procedures. We conclude that in the setting of a mass suspicious for PGL in a location potentially representing ETT, such as the mediastinum, thyroid blockade should be employed for mIBG protocols to avoid false positive scans caused by ETT.
Collapse
Affiliation(s)
- Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daisy Duan
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lisa M Rooper
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul W Ladenson
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
6
|
Wan W, Nguyen B, Graybill S, Kim J. Clonidine suppression testing for pheochromocytoma in neurofibromatosis type 1. BMJ Case Rep 2019; 12:12/6/e228263. [PMID: 31243023 DOI: 10.1136/bcr-2018-228263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Compared with the general population, rates of pheochromocytoma are higher in neurofibromatosis type 1 (NF1) patients. However, pheochromocytoma testing is often plagued by false positive results. Here we present a patient with NF1, elevated urinary metanephrine levels, and an indeterminate adrenal nodule. Clonidine suppression testing aided diagnosis and led to definitive surgical treatment that confirmed a pheochromocytoma. Pheochromocytoma screening and clonidine suppression testing can both aid in the evaluation for catecholamine-secreting tumours.
Collapse
Affiliation(s)
- WingYee Wan
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Bichle Nguyen
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Sky Graybill
- Endocrinology Department, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Jonathan Kim
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| |
Collapse
|
7
|
Rednam SP, Erez A, Druker H, Janeway KA, Kamihara J, Kohlmann WK, Nathanson KL, States LJ, Tomlinson GE, Villani A, Voss SD, Schiffman JD, Wasserman JD. Von Hippel-Lindau and Hereditary Pheochromocytoma/Paraganglioma Syndromes: Clinical Features, Genetics, and Surveillance Recommendations in Childhood. Clin Cancer Res 2018; 23:e68-e75. [PMID: 28620007 DOI: 10.1158/1078-0432.ccr-17-0547] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 11/16/2022]
Abstract
Von Hippel-Lindau disease (vHL) is a hereditary tumor predisposition syndrome that places affected individuals at risk for multiple tumors, which are predominantly benign and generally occur in the central nervous system or abdomen. Although the majority of tumors occur in adults, children and adolescents with the condition develop a significant proportion of vHL manifestations and are vulnerable to delayed tumor detection and their sequelae. Although multiple tumor screening paradigms are currently being utilized for patients with vHL, surveillance should be reassessed as the available relevant clinical information continues to expand. We propose a new vHL screening paradigm similar to existing approaches, with important modifications for some tumor types, placing an emphasis on risks in childhood. This includes advancement in the timing of surveillance initiation and increased frequency of screening evaluations. Another neuroendocrine-related familial condition is the rapidly expanding hereditary paraganglioma and pheochromocytoma syndrome (HPP). The tumor spectrum for patients with HPP syndrome includes paragangliomas, pheochromocytomas, renal cancer, and gastrointestinal stromal tumors. The majority of patients with HPP syndrome harbor an underlying variant in one of the SHDx genes (SDHA, SDHB, SDHC, SDHD, SDHA, and SDHAF2), although other genes also have been described (MAX and TMEM127). Annual screening for elevated plasma or urine markers along with complete blood count and biennial whole-body MRI accompanied by focal neck MRI is recommended for older children and adults with HPP syndrome to detect tumors early and to decrease morbidity and mortality from HPP-related tumors. Clin Cancer Res; 23(12); e68-e75. ©2017 AACRSee all articles in the online-only CCR Pediatric Oncology Series.
Collapse
Affiliation(s)
- Surya P Rednam
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Ayelet Erez
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israel
| | - Harriet Druker
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine A Janeway
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts
| | - Junne Kamihara
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts
| | - Wendy K Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Katherine L Nathanson
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lisa J States
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gail E Tomlinson
- Department of Pediatrics, Division of Hematology and Oncology and Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Anita Villani
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Stephan D Voss
- Department of Radiology, Children's Hospital, Boston, Massachusetts
| | - Joshua D Schiffman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.,Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jonathan D Wasserman
- Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
8
|
A comparison of plasma-free metanephrines with plasma catecholamines in the investigation of suspected pheochromocytoma. J Hypertens 2011; 29:2422-8. [DOI: 10.1097/hjh.0b013e32834c1e68] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|