Clinical and Pathological Characteristics of Hypertensive and Normotensive Adrenal Pheochromocytomas

Clinical presentation of pheochromocytoma and screening recommendations

Pheochromocytomas are neuroendocrine tumors that derive from sympathetic adrenomedullary chromaffin tissue and produce catecholamines. Due to the excess release of catecholamines, they can produce arterial hypertension, tachycardia, sweating, headache and a large number of other clinical manifestations secondary to the stimulation of α and β adrenoreceptors. Screening for pheochromocytoma is recommended in patients with paroxysmal, resistant or early-onset arterial hypertension, in cases with symptoms suggestive of catecholamine hypersecretion, patients with hereditary syndromes associated with pheochromocytomas, diabetes mellitus of atypical presentation and in adrenal incidentalomas with radiological characteristics not typical of adenoma (with > 10 Hounsfield Units on non-contrast CT). In this article we present an exhaustive review of the clinical data and complications that can be associated with pheochromocytomas, and we summarize the main indications for pheochromocytoma screening.

[Pheochromocytoma. Preoperative approach]

Pheochromocytomas are rare neuroendocrine tumors that derive from the chromaffin cells of the adrenal medulla and secrete catecholamines. The measurement of plasma or fractionated urine metanephrines is the hormonal determination of choice for the biochemical diagnosis. Once the biochemical diagnosis is confirmed, the next step is the localization study. It is recommended to request a genetic study in all patients with pheochromocytomas since 40% of cases are hereditary. Once the diagnostic study is completed, preoperative treatment with alpha blockers should be instituted at least 7-14 days before adrenalectomy. However, in low-risk patients, the omission of presurgical treatment could be considered if the surgery is performed in centers with experience and a strict monitoring of the patient is carried out during the perioperative period. This document offers a practical guide on the diagnosis and perioperative approach in patients with pheochromocytomas.

Main mechanisms and clinical implications of alterations in energy expenditure state among patients with pheochromocytoma and paraganglioma: A review

Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors with diverse clinical presentations. Alterations in energy expenditure state are commonly observed in patients with PPGL. However, the reported prevalence of hypermetabolism varies significantly and the underlying mechanisms and implications of this presentation have not been well elucidated. This review discusses and analyzes the factors that contribute to energy consumption. Elevated catecholamine levels in patients can significantly affect substance and energy metabolism. Additionally, changes in the activation of brown adipose tissue (BAT), inflammation, and the inherent energy demands of the tumor can contribute to increased resting energy expenditure (REE) and other energy metabolism indicators. The PPGL biomarker, chromogranin A (CgA), and its fragments also influence energy metabolism. Chronic hypermetabolic states may be detrimental to these patients, with surgical tumor removal remaining the primary therapeutic intervention. The high energy expenditure of PPGL has not received the attention it deserves, and an accurate assessment of energy metabolism is the cornerstone for an adequate understanding and treatment of the disease.

A Case of Generalized, Unrelenting Sweating Resulting in Social Isolation for Over Two Decades

Pheochromocytoma, a rare neuroendocrine tumor, affects less than 1 in 100,000 people per year. Individuals with pheochromocytoma usually present with headache, diaphoresis, and tachycardia; however, diaphoresis occurs in less than half of the patients. Diaphoresis or chronic persistent hyperhidrosis can significantly impact patients' lives, leading to depression, anxiety, and social isolation, as in our case. We report a patient with chronic persistent sweating for over two decades as the predominant manifestation of pheochromocytoma and sympathetic overdrive, affecting her mental and social well-being. Importantly, we would like to demonstrate the significance of long-standing sweating, which can impact an individual's mental well-being and social life. Incorporating the Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax) in the evaluation and management might be a relevant consideration. Pertinently, if medical measures and Botulinum toxin have failed to resolve excessive sweating, a thoracoscopic sympathetic block deserves consideration. Note that diaphoresis and hyperhidrosis, terms representing excessive sweating, will be used interchangeably.

Adrenal Tumors in Young Adults: Case Reports and Literature Review

The current high detection rate of adrenal tumors (4–10% of general population) is attributable to a widespread use of variety of imaging studies, especially a computed tomography. Most of them represent clinically silent and biologically indolent incidentalomas, but some adrenal tumors may pose a significant clinical challenge. Thus, in every patient with an adrenal tumor, a decision on further management is made after careful hormonal and radiological evaluation. All hormonally active tumors and those with radiological features suggesting malignancy are qualified for surgery. Approximately 80% of adrenal tumors are adrenocortical adenomas, hypertrophy, or nodular adrenocortical hyperplasia. Other histopathological diagnoses include pheochromocytoma, adrenocortical carcinoma, metastases, mesenchymal tumors, lymphomas, cysts, and ganglioneuromas. Adrenal tumors are more commonly diagnosed and better studied in elderly patients. In younger patients, under 40 years old, focal adrenal lesions are relatively rare, and histological distribution of diagnoses differs from that in elderly individuals. Younger patients are more likely to display endocrine symptoms, which raise the suspicion of an adrenal mass. In the current study, we present a case series of seven adrenal tumors occurring in young patients. The cases presented below, along with the literature review, demonstrate that the diagnosis and treatment of adrenal tumors are crucial due to endocrinopathy-derived complications and a potential risk of malignancy.

Diaphoresis as the Prominent Manifestation of Pheochromocytoma

OBJECTIVE

Pheochromocytoma is a rare neuroendocrine tumor, affecting 0.6 to 0.8 of 100,000 people per year. The "classic triad" of headache, diaphoresis, and tachycardia is well documented in the literature, although its clinical utility has come into question. Diaphoresis is part of the "classic triad" and occurs in <50% of patients with pheochromocytoma. There are few reports of diaphoresis as the sole symptom of pheochromocytoma. Our objective is to report a patient with diaphoresis as the only prominent manifestation of pheochromocytoma.

CASE DESCRIPTION

A 20-year-old man presented with 5 years of worsening diaphoresis; diffuse, but predominantly in the upper half of his body. No other symptoms were present. His blood pressure was 138/82 mm Hg and had a heart rate of 60 bpm. The physical examination was unremarkable. Thyrotoxicosis, infection (including tuberculosis), and lymphoma/leukemia were ruled out. The 24-hour urine norepinephrine level was 1002 ug/24hours (0-135 ug/24 hours), plasma normetanephrine was 2873 pg/mL (0-145 pg/mL), and plasma norepinephrine was 2869 pg/mL (0-874 pg/mL). Computed tomography of the abdomen revealed a 4.0 × 3.1 × 4.3 cm left adrenal mass. After pre-operative preparation with doxazosin, the patient underwent laparoscopic left adrenalectomy. The diaphoresis resolved. Pathology confirmed a completely resected pheochromocytoma. Genetic testing for germline mutations was negative.

DISCUSSION

This patient was a young adult and did not exhibit features of pheochromocytoma common to the pediatric/adolescent or adult populations. Monosymptomatic presentations are sparse in the literature.

CONCLUSION

This case reflects an atypical presentation of pheochromocytoma, a disease with high cardiovascular morbidity and mortality, and helps to establish the need to better quantify individual symptoms of patients to better understand the entire spectrum of this disease.

A case of normotensive incidentally discovered adrenal pheochromocytoma

Pheochromocytomas are catecholamine-producing neuroendocrine tumors that arise from the adrenal medulla. The clinical presentation includes headache, palpitation, and hypertension, but pheochromocytomas are sometimes clinically silent. The present case highlights the importance of biochemical testing for pheochromocytoma in patients with adrenal incidentaloma, even if they are completely normotensive and asymptomatic.

Clinical evaluation and treatment of phaeochromocytoma

Phaeochromocytoma and extra adrenal paraganglioma are rare neuroendocrine tumours and have the potential to secrete adrenaline, noradrenaline and dopamine causing a myriad of clinical symptoms. Prompt diagnosis is essential for clinicians and requires a multidisciplinary specialist approach for the clinical and laboratory investigation, diagnosis, treatment and follow-up of patients. This paper is an integrated review of the clinical and laboratory evaluation and treatment of patients suspected to have phaeochromocytoma or paraganglioma, highlighting recent developments and best practices from recent published clinical guidelines.