The frequency of postoperative hypoglycemia after pheochromocytoma surgery is decreasing

BACKGROUND

Hypoglycemia after pheochromocytoma resection is one of the most common postoperative complications, with a reported incidence of 12%-43%. In recent years, we have rarely experienced postoperative hypoglycemia after pheochromocytoma surgery at our institution. We reviewed our own experience and examined factors associated with postoperative hypoglycemia in pheochromocytoma patients.

METHODS

We collected and retrospectively reviewed medical information from 53 patients with pheochromocytoma who underwent initial surgery in our department between 1996 and 2022, who did not receive steroids in the perioperative period and received the same alpha-blocker preoperatively. Subjects were divided into two groups by the midpoint of the study period: Group 1 (G1), 1996-2009; and Group 2 (G2), 2010-2022. The two groups were compared.

RESULTS

Hypoglycemia occurred significantly less often in G2 (0 patients, 0%) than in G1 (7 patients, 28%; p = 0.003). Preoperative diabetes was significantly less frequent in G2 (2 patient, 7.1%) than in G1 (8 patients, 32%; p = 0.03). Preoperative alpha-blocker dosage was significantly higher in G2 than in G1 (p = 0.04). Multivariate logistic regression analysis showed that only alpha-blockers dosage was significantly associated with the occurrence of postoperative hypoglycemia (p = 0.004).

CONCLUSION

The current study suggest that the alpha-blocker dosage might be related to the lower incidence of postoperative hypoglycemia in Pheochromocytoma patients.

A case report on pheochromocytoma mimicking as fulminant myocarditis-a diagnostic challenge

We present an exceptional case of a 53-year-old female, initially misdiagnosed with fulminant myocarditis, but later correctly diagnosed with pheochromocytoma. The presentation of the patient included a spectrum of symptoms such as headache, chest discomfort, palpitations, and dyspnea, following the intake of Domperidone. Two weeks prior to admission, the patient had experienced episodes of diarrhea and a low-grade fever. Unresolved symptoms and an unmanageable surge in blood pressure despite comprehensive fulminant myocarditis treatment prompted further investigation. The discovery of an adrenal mass via a CT scan and subsequent biochemical tests led to the confirmation of pheochromocytoma. Implementation of alpha-blockade therapy and a successful laparoscopic adrenalectomy resulted in significant clinical improvement. This case underscores the diagnostic intricacies of pheochromocytoma and highlights the need for vigilance when faced with severe, unresponsive cardiovascular symptoms.

Primary perioperative haemodynamic effects of ß-receptor blockade in patients with catecholamine-secreting tumours

Introduction

Guidelines for the treatment of catecholamine-producing tumours strictly recommend starting ß-receptor blocking medication only after α-receptor blockade has been established. This recommendation is supported only by non-surgical case reports. However, in clinical practice ß-receptor blockade is often started before the diagnosis of a phaeochromocytoma is made. As we routinely treat patients with catecholamine-producing tumours without α-receptor blockade, our aim was to evaluate haemodynamic changes in such patients with and without ß-receptor blockade.

Methods

Perioperative blood pressure was assessed prospectively for all patients. The primary outcome was the highest pre-, intra-, and postoperative systolic blood pressure in patients with or without a ß-receptor blockade. Secondary outcomes were the incidence of intraoperative systolic blood pressure peaks >250 mm Hg and hypotensive episodes. Subsequently, a propensity score matching (PSM) analysis was performed.

Results

Out of 584 phaeochromocytoma and paraganglioma resections, 383 operations were performed without α-receptor blockade (including 84 with ß-receptor blockade). Before operation and intraoperatively, patients with ß-receptor blockade presented with higher systolic blood pressure (155 [25] and 207 [62] mm Hg) than patients without ß-receptor blockade (147 [24] and 183 [52] mm Hg; P=0.006 and P=0.001, respectively). Intraoperatively, patients with ß-receptor blockade demonstrated a higher incidence of hypotensive episodes (25% without vs 41% with ß-blockade; P<0.001). After propensity score matching no difference between the groups could be confirmed.

Conclusion

Overall, patients with isolated ß-receptor blockade developed higher blood pressure before operation and intraoperatively. After propensity score matching a difference could no longer be detected. Overall, ß-receptor blockade seems to be more a sign for severe disease than a risk factor for haemodynamic instability.

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P < 0.01), along with 7.2 mmHg reduction in SBP (P < 0.01). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2= 28.032, P < 0.01). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

Hemodynamic Instability during Surgery for Pheochromocytoma: A Retrospective Cohort Analysis

BACKGROUND

Perioperative hemodynamic instability is one of the most common adverse events in patients undergoing adrenalectomy for pheochromocytoma. The aim of this study was to analyze the impact of perioperative severe hemodynamic instability.

METHODS

We present a retrospective, single-center analysis in a major tertiary hospital of all consecutive patients undergoing elective adrenalectomy from 2005 to 2019 for pheochromocytoma. Severe perioperative hypertension and hypotension were evaluated, defined as changes in blood pressure larger than 30% of the preoperative patient-specific mean arterial pressure (MAP).

RESULTS

Unilateral adrenalectomy was performed in 67 patients. Intraoperative episodes of hemodynamic instability occurred in 97% of all patients (n = 65), severe hypertension occurred in 24 patients (36%), and severe hypotensive episodes occurred in 62 patients (93%). Patients with more than five severe hypotensive episodes (n = 29) received higher preoperative alpha-adrenergic blockades (phenoxybenzamine 51 ± 50 mg d^-1 vs. 29 ± 27 mg d^-1; p = 0.023) and had a longer mean ICU stay (39.6 ± 41.5 h vs. 20.6 ± 19.1 h, p = 0.015).

CONCLUSION

Intraoperative hypotensive, rather than hypertensive, episodes occurred during adrenalectomy. The occurrence of more than five hypotensive episodes correlated well with a significantly longer hospital stay and ICU time.

Multimodality Imaging Evaluation of Primary Right Atrial Paraganglioma: A Case Report and Literature Review

Background

Cardiac paraganglioma (CPGL) accounts for 1–3% of cardiac tumors and is usually benign. In total, 35–50% of CPGL lesions secrete catecholamines, causing hypertension, excessive sweating, palpitations, headache, and other symptoms. Preoperative imaging evaluation is important to determine the location of the cardiac mass, its blood supply vessels, and the relationship with surrounding structures. Multimodal imaging techniques combine with morphological and functional information to provide powerful methods for preoperative diagnosis and lesion localization. Furthermore, they can assist to reduce the incidence of intraoperative and postoperative complications and improve patient prognosis.

Case Report

A 67-year-old woman suffered from paroxysmal palpitations with a heart rate of 110 beats per minute 1 month ago. Urine catecholamine and methoxyepinephrine levels were significantly increased. The patient had a 5-year history of hypertension with a maximum blood pressure of 160/100 mmHg. Computed tomography (CT) examination found a soft tissue mass in the right atrium with heterogeneous and significant enhancement, whose blood supply was from the left ileal branch artery. The patient then underwent cardiac magnetic resonance (CMR). The lesion showed inhomogeneous iso signals on the T1-weighted image (T1WI), slightly high signals on the T2 fat-suppression image, inhomogeneous high signals on the diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) images. The mass exhibited heterogeneous and significant enhancement on the first perfusion and delayed scans after intravenous contrast injection. However, abnormal signals were surprisingly found in the patient’s right lung, and the possibility of metastatic lesions could not be excluded. The patient underwent F-18 fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) to rule out metastatic lesions. A fluorodeoxyglucose (FDG)-avid soft tissue mass was shown in the right atrium, with the maximum standardized uptake value (SUVmax) at about 15.2, as well as a pathological intake of brown fat throughout the body. Combined with clinical symptoms, CPGL was considered without significant sign of metastasis in 18F-FDG PET/CT. Finally, the patient underwent surgical resection and the post-operative pathology confirmed a CPGL.

Conclusion

The combination of 18F-FDG PET/CT with the CMR containing different image acquisition sequences provides a powerful aid for preoperative non-invasive diagnosis, localization, and staging of CPGL, which helps to reduce intraoperative and postoperative complications and improve patient prognosis.

Carbon dioxide embolism during posterior retroperitoneal adrenalectomy

We report a case of massive carbon dioxide embolism associated with injury to the inferior vena cava, during posterior retroperitoneoscopic adrenalectomy. The presenting clinical features were tachycardia, rapid oxygen desaturation and severe respiratory acidosis, without evidence of bleeding. The patient was resuscitated by increasing the fraction of inspired oxygen, administering intravenous fluid and converting to an open procedure to suture the vein. This case demonstrates that gas embolism due to vessel injury during posterior retroperitoneal adrenalectomy may arise without evidence of bleeding, severe hypotension or an abrupt increase in end-tidal carbon dioxide. Using a high carbon dioxide insufflation pressure in the retroperitoneal space enhances visualisation of the surgical field by decreasing small-calibre vessel bleeding. However, it can contribute to, and delay recognition of, carbon dioxide embolism. Knowledge of the clinical features of carbon dioxide embolism, careful monitoring and vigilance for intra-operative surgical challenges can assist with the detection of this rare but potentially fatal complication.

Pheochromocytoma Mimicking Acute Coronary Syndrome: A Case Report

Pheochromocytoma is a rare catecholamine-secreting tumor with highly variable clinical presentations. We herein report a patient who presented to the emergency department with precordia pain, elevated myocardial enzymes, T-wave inversions on electrocardiogram and segmental ventricular wall motion abnormalities on echocardiography, which is normally managed as suspected acute coronary syndrome (ACS). However, the urgent coronary angiography showed normal coronary arteries. During his hospital stay, a sudden increase in blood pressure allowed us to suspect a pheochromocytoma, which was confirmed by elevated levels of catecholamines and by the finding of a right adrenal mass on magnetic resonance imaging. The tumor was successfully excised and the patient is now asymptomatic. This case illustrates that pheochromocytoma can present as a mimic of ACS but this is often difficult to diagnose at first glance and often misleads clinicians into making an incorrect diagnosis. In addition, clinicians should be familiar with clinical manifestations of pheochromocytoma, which can help raise clinical suspicion and facilitate the early diagnosis and treatment of pheochromocytoma.

Presentation and management of pheochromocytomas and paragangliomas: about 40 cases

Background

Pheochromocytoma and paraganglioma are rare neuroendocrine tumors of the chromaffin tissue, which may produce catecholamines. The aim of our study was to analyze the clinical and para-clinical aspects as well as the therapeutic and evolutionary aspects of pheocromocytomas and paragangliomas based on a series of 40 cases.

Methods

Our retrospective population-based research study includes 40 patients. Then, a statistical analysis was carried out using the SPSS software (version21).

Results

Our study involves 40 patients, including 23 women (57, 5%) and 17 men (42,5%). The mean age at the time of the diagnosis was 43.8 ± 16.8 years. The circumstances of the discovery were mainly characterized by adrenal incidentaloma and hypertension. The biological diagnosis was based on the dosage of urinary metanephrines and plasma-free metanephrines in, respectively, 61.5% and 18% of cases. A computerized tomography scan and/or a magnetic resonance imaging scan could help to locate the tumor in 100% of cases. Our series includes 3 cases of bilateral pheochromocytoma, 3 cases of paragangliomas and 1 case of malignant pheochromocytoma, while a hereditary form was retained in 3 patients. In fact, thirty-two patients were operated; cure was clinically labeled in 100% and biologically in 87.5% of patients.

Conclusions

The main points for improvement that our study has revealed are; a patient follow-up after surgery, which was not always regular, and an insufficient screening for genetic diseases associated with pheochromocytomas and paragangliomas.

Cardiogenic Shock and Guillain-Barré Syndrome as the First Manifestations of Pheochromocytoma

Febrile congestive heart failure is a rare first manifestation of pheochromocytoma. Herein, the case of a 31-year-old female with febrile congestive heart failure and subsequent cardiogenic shock is presented. After intensive care unit (ICU) admission and further evaluating the right adrenal mass observed in abdominal ultrasonography, the diagnosis of pheochromocytoma was confirmed. Then, she was scheduled for the right adrenalectomy. Before surgery, she complained of acute-onset progressive muscle weakness in the lower limbs, followed by the upper limbs. After further investigation, she was diagnosed with Guillain-Barré syndrome and treated with intravenous immunoglobulin (IVIG). She recovered well after the right adrenalectomy, and during the subsequent 18 months, the follow-up did not reveal any complications, and left ventricular function recovered to normal.

Hypertension in Pheochromocytoma and Paraganglioma: Evaluation and Management in Pediatric Patients

PURPOSE OF REVIEW

The rare catecholamine-secreting tumors, pheochromocytomas and paragangliomas (PPGL), account for a minority of cases of secondary hypertension in pediatrics. As such, perioperative blood pressure (BP) management in pediatric patients presents a distinct challenge. This review will expand the practitioner's knowledge of antihypertensive treatment options for the pediatric patient with PPGL with a focus on literature in the past several years.

RECENT FINDINGS

There continue to be only small case series and single-center experiences to provide guidelines regarding BP management. While phenoxybenzamine has been more routinely used, selective α₁-blockers, such as doxazosin, as well as calcium channel blockers, have also been utilized with success in pediatric patients. While the concept of obligatory α-adrenergic blockade for adult patients has been recently challenged, international guidelines and current practice patterns among pediatric clinicians continue to support preoperative α-adrenergic blockade to ensure the best possible patient outcomes. Selective α₁-blockers and calcium channel blockers are becoming more commonly used given the high cost, limited availability, and undesirable side effect profile of phenoxybenzamine.

Surgery for Pheochromocytoma: A Single-Center Review of 60 Cases from South Africa

BACKGROUND

There is a paucity of data on the presentation and surgical management of pheochromocytoma in developing nations, particularly in Africa.

METHODS

This study was a retrospective review, which included all patients managed by the Groote Schuur Hospital/University of Cape Town Endocrine Surgery unit for pheochromocytoma and abdominal paragangliomas, from January 2002 to June 2019.

RESULTS

Sixty patients were included in the study, of which 33% were male and 67% female. The mean age was 47 years (range 14-81). The median tumor size was 6 cm, with 45% larger than 6 cm. 92% were located in the adrenal gland (87% unilateral, 5% bilateral), and 8% were extra-adrenal. The conversion rate for laparoscopic cases was 20%, with 55% of cases overall completed laparoscopically. Eleven patients with tumors > 6 cm were initially attempted laparoscopically, of which 3 were converted to open, without any associated increased morbidity. A major adverse event was recorded for 5 cases (8%), including 1 mortality. Overall morbidity, blood loss, operating time and hospital stay were all significantly reduced in the laparoscopic group. There were 5 patients with malignant disease (8%).

CONCLUSION

This large series, from an established academic endocrine surgery unit in Africa, can serve as a benchmark for units with similar settings and resource limitations, to compare their surgical management and perioperative outcomes.

Long-term blood pressure outcomes of laparoscopic adrenalectomy in trHTN patients

Background and Objectives

Treatment resistant hypertension (trHTN) is a common clinical problem faced by many clinicians. Laparoscopic adrenalectomy effectively trims blood pressure (BP) elevation secondary to various functional adrenal disorders. However, the impact of adrenalectomy on BP within trHTN patients has never been reported. Our present study aims to investigate the effect of adrenalectomy on BP management within trHTN patients, and to explore clinical predictors for postoperative BP normalization.

Patients and Methods

In our current study, 117 patients diagnosed with trHTN and performed with unilateral adrenalectomy were consecutively enrolled, demographic and medical information were documented for baseline data collection. BP was measured with a standard electronic sphygmomanometer twice a day. Long-term periodical interview was conducted and 109 (93.2%) enrolled patients were successfully followed-up at an averaged 36.2 months.

Results

At follow-up, 27/109 (25%) trHTN patients acquired BP normalization and 68/109 (62%) patients acquired BP improvement. Mean taking anti-hypertensive agents reduced from presurgical 4.24 to present 1.21 (P = 0.000), along with 7.2 mmHg reduction in SBP (P = 0.000). Image macro-adenoma and hypokalemia history were found to be the two strongest predictors for postoperative BP normalization. (χ2 = 28.032, P = 0.000). The incidence of adverse postoperative events was quite small.

Conclusions

In summary, this current study implicates that adrenalectomy is an efficacious and safe surgical strategy for BP management in trHTN patients. Patients with both unilateral macro-adenoma and hypokalemia are more prone to acquire postoperative BP normalization.

Laparoscopic resection of a large clinically silent paraganglioma at the organ of Zuckerkandl: a rare case report and review of the literature

Background

Large paraganglioma of the Zuckerkandl organ (POZ) is extremely rare. The patient can occasionally be paucisymptomatic, further obscuring the diagnosis and carrying high mortality. Recommended treatment for large paraganglioma (PGL) is open surgical removal. We report a case of successful laparoscopic resection of a large POZ with normal blood pressure in a 45-year-old man.

Case presentation

A 45-year-old man was hospitalized because of hyperglycemia. Computed tomography of the abdomen and the serum and urinary catecholamine levels confirmed the diagnosis of large POZ. But his blood pressure was normal and he underwent laparoscopic tumor excision successfully. During 6 months follow-up after laparoscopy, serum and urinary catecholamines were normal but glycaemia remained high level. DNA analysis of the succinate dehydrogenase complex subunits B (SDHB) and SDHD revealed no mutation.

Conclusions

POZ is an unusual mass and preoperative diagnosis can be difficult in clinically silent cases. PGL cannot be excluded in patients with normal blood pressure. Even a large POZ can be excised laparoscopically by following proper techniques.

International multicentre review of perioperative management and outcome for catecholamine-producing tumours

BACKGROUND

Surgery for catecholamine-producing tumours can be complicated by intraoperative and postoperative haemodynamic instability. Several perioperative management strategies have emerged but none has been evaluated in randomized trials. To assess this issue, contemporary perioperative management and outcome data from 21 centres were collected.

METHODS

Twenty-one centres contributed outcome data from patients who had surgery for phaeochromocytoma and paraganglioma between 2000 and 2017. The data included the number of patients with and without α-receptor blockade, surgical and anaesthetic techniques, complications and perioperative mortality.

RESULTS

Across all centres, data were reported on 1860 patients with phaeochromocytoma or paraganglioma, of whom 343 underwent surgery without α-receptor blockade. The majority of operations (78·9 per cent) were performed using minimally invasive techniques, including 16·1 per cent adrenal cortex-sparing procedures. The cardiovascular complication rate was 5·0 per cent overall: 5·9 per cent (90 of 1517) in patients with preoperative α-receptor blockade and 0·9 per cent (3 of 343) among patients without α-receptor blockade. The mortality rate was 0·5 per cent overall (9 of 1860): 0·5 per cent (8 of 517) in pretreated and 0·3 per cent (1 of 343) in non-pretreated patients.

CONCLUSION

There is substantial variability in the perioperative management of catecholamine-producing tumours, yet the overall complication rate is low. Further studies are needed to better define the optimal management approach, and reappraisal of international perioperative guidelines appears desirable.

Meta-analysis of α-blockade versus no blockade before adrenalectomy for phaeochromocytoma

BACKGROUND

Preoperative α-blockade in phaeochromocytoma surgery is recommended by all guidelines to prevent intraoperative cardiocirculatory events. The aim of this meta-analysis was to assess the benefit of such preoperative treatment compared with no treatment before adrenalectomy for phaeochromocytoma.

METHODS

A systematic literature search was undertaken in MEDLINE, Web of Science and CENTRAL without language restrictions. Randomized and non-randomized comparative studies investigating preoperative α-blockade in phaeochromocytoma surgery were included. Data on perioperative safety, effectiveness and outcomes were extracted. Pooled results were calculated as an odds ratio or mean difference with 95 per cent confidence interval.

RESULTS

A total of four retrospective comparative studies were included investigating 603 patients undergoing phaeochromocytoma surgery. Mortality, cardiovascular complications, mean maximal intraoperative systolic and diastolic BP, and mean maximal intraoperative heart rate did not differ between patients with or without α-blockade. The certainty of the evidence was very low owing to the inferior quality of studies.

CONCLUSION

This meta-analysis has shown a lack of evidence for preoperative α-blockade in surgery for phaeochromocytoma. RCTs are needed to evaluate whether preoperative α-blockade can be abandoned.

Changing pattern of pheochromocytoma and paraganglioma in a stable UK population

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.

Pheochromocytoma-related cardiomyopathy presenting as broken heart syndrome: Case report and literature review

•

This is a case report of a rare adrenal tumor that manifested as acute coronary syndrome.

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Adrenalectomy for pheochromocytoma presents a risk for intraoperative hemodynamic instability.

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Preoperative medical care is essential to reduce intraoperative complications.

•

This case exemplifies the importance of the various symptoms that are prevalent with excessive circulating adreno-receptor agents.

Introduction

Pheochromocytoma are neuroendocrine tumors that arise from sympathetic chromaffin cells within the adrenal medulla. They principally secrete catecholamines, potentially causing life-threatening cardiovascular complications. A myriad of symptomatology and clinical findings are associated with pheochromocytoma, including a catecholamine-induced dilated cardiomyopathy.

Presentation of case

A 50-year-old woman presented with retrosternal chest pain and underwent diagnostic evaluation for acute coronary syndrome. Cardiac catheterization demonstrated patent coronary arteries and a pattern of ventricular hypokinesis consistent with takotsubo cardiomyopathy, also known as broken heart syndrome. Further imaging with abdominal CT revealed an adrenal mass. Laboratory markers supported the clinical picture of pheochromocytoma. Right adrenalectomy was performed and our patient was symptom-free at discharge on post-operative day three.

Discussion

Alpha and beta adrenergic blockade are used in a critical care setting to prevent perioperative hemodynamic instability as well as catecholamine-induced heart failure in the setting of pheochromocytoma. Patients commonly require vasopressors in the postoperative period due to the rapid reduction in circulating catecholamines following resection. Discharge planning should include recommendations for genetic counseling to screen for syndromic causes of pheochromocytoma that increase the risk for other neoplasms.

Conclusion

We present a case report of a rare adrenal tumor in a middle-aged woman that manifested as acute coronary syndrome. A presumptive diagnosis of takotsubo cardiomyopathy on cardiac catheterization led to further investigation. Abdominal imaging located an adrenal mass that correlated with laboratory studies positive for high levels of catecholamines and their metabolites. The tumor was excised and the patient recovered without complications.

Two-step technique of early adrenal artery ligation in open adrenalectomy of giant right adrenal pheochromocytomas: Three case reports

Introduction

Surgical manipulation of a pheochromocytoma carries the risk of releasing catecholamines into bloodstream leading to severe intraoperative hypertension.

Case presentation

We present three patients with right adrenal pheochromocytoma over 10 cm diameter: a 40‐year‐old woman, 63‐year‐old man, and 66‐year‐old woman. They were diagnosed by 123I‐MIBG scintigraphy and received preoperative antihypertensive treatment with 16 mg/day of doxazosin. Open adrenalectomy was performed with early right adrenal artery ligation between the inferior vena cava and ventral aorta (Step 1) as well as between the tumor and upper pole of the right kidney (Step 2). There was no severe intraoperative hypertension, and no recurrence was observed over 33 months, postoperatively.

Conclusion

Early adrenal artery ligation may stop tumor blood supply and significantly reduce the catecholamine release. Our technique was thought to be safe and useful for preventing severe intraoperative hypertension in giant right adrenal pheochromocytoma.

Current diagnostic imaging of pheochromocytomas and implications for therapeutic strategy

The topic of pheochromocytomas is becoming increasingly popular as a result of major advances in different medical fields, including laboratory diagnosis, genetics, therapy, and particularly in novel advances in imaging techniques. The present review article discusses current clinical, biochemical, genetic and histopathological aspects of the diagnosis of pheochromocytomas and planning of pre-surgical preparation and subsequent surgical treatment options. The main part of the paper is focused on the role of morphological imaging methods (primarily computed tomography and magnetic resonance imaging) and functional imaging (scintigraphy and positron emission tomography) in the diagnosis and staging of pheochromocytomas.

Factors affecting the haemodynamic behaviour of patients undergoing pheochromocytoma and paraganglioma removal: A review

Pheochromocytoma and paraganglioma are catecholamine-secreting tumours associated with major haemodynamic upheavals. The cardiovascular and other organ-related morbidity and even mortality has been ascribed to the major haemodynamic effects of these tumours. Many factors affect the nature and intensity of these haemodynamic changes. The rarity of these tumours as well as their extremely varied clinical presentation preclude conduct of randomized-controlled trials that may provide evidence in terms of these factors and the ways to predict and control them. Many retrospective studies and case reports, however, do provide some insight into their haemodynamic behaviour. Factors such as tumour pathology, associated genetic syndromes, anatomical attributes and perioperative drug therapy affect the haemodynamics of patients with these unique tumours. Knowledge of these factors and their presumed and known association with haemodynamic behaviour of the patients is important during the perioperative care of these patients. The review focuses on the tumour-related, patient-related and the perioperative care-related factors that affect the haemodynamic behaviour of these patients during the surgical removal of these tumours.

Perioperative Management of Pheochromocytoma

Pheochromocytomas are rare neuroendocrine tumors that produce and store catecholamines. Without adequate preparation, the release of excessive amounts of catecholamines, especially during anesthetic induction or during surgical removal, can produce life-threatening cardiovascular complications. This review focuses on the perioperative management of pheochromocytoma/paragangliomas, initially summarizing the clinical aspects of the disease and then highlighting the current evidence available for preoperative, intraoperative, and postoperative anesthetic management.

Clinical features and retroperitoneal laparoscopic resection of adrenal schwannoma in 19 patients

OBJECTIVE

To explore the diagnostic and therapeutic principles of the rare adrenal schwannoma.

METHODS

We objectively analyzed the detailed clinical data of 19 patients with adrenal schwannoma treated in a large comprehensive medical center in China between January 2009 and March 2014, including general information, clinical manifestations, imaging, adrenal-related endocrine tests, treatment, pathology, and follow-up records.

RESULTS

Patients included 16 females and 3 males ranging from 23 to 66 years of age (mean, 48.3 ± 12.6 years), of whom 15 were discovered incidentally. Four patients reported mild abdominal discomfort. Each patient had one unilateral lesion, ranging in diameter from 4.0 to 8.8 cm (mean, 6.2 ± 1.2 cm). Lesions were hypoechoic in 16 patients and cystic-solid in 3 patients. Computed tomography (CT) scanning revealed soft tissue density, mostly with calcifications and clear boundaries. Average values in normal and enhanced CT were 28.7 ± 7.2 Hounsfield units (HU) and 59.7 ± 5.4 HU, respectively. Indicators of adrenal-related endocrine tests were normal, except that catecholamines levels were slightly low in 2 patients with excessively large lesions. All patients underwent uncomplicated retroperitoneal laparoscopic surgery, with subsequent pathology confirmation of adrenal schwannoma. The patients have been followed for 6 months to 4 years, with no recurrence.

CONCLUSION

Our results demonstrate that the onset of adrenal schwannoma is always occult, without typical clinical manifestations and adrenal-related endocrine abnormalities, and the pre-operative diagnosis depends primarily on imaging features of hypoechoic calcifications and mild enhancement. Diagnosis can be confirmed by postoperative pathology. Even with large diameter lesions, retroperitoneal laparoscopic surgery is still the preferred approach, with good prognosis.

A rare case of clinically and biochemically silent giant right pheochromocytoma: case report and review of literature

Non-secreting pheochromocytomas are rare adrenal tumours. We report the case of a clinically and biochemically silent giant pheochromocytoma that presented as bilateral pulmonary embolisms. Successful surgical resection was performed. Multiple endocrine neoplasia 2 syndrome and neurofibromatosis type 1 were clinically excluded. Subsequent DNA analysis of the succinate dehydrogenase complex subunits B and D (SDHB and SDHD), and Von Hippel-Lindau (VHL) genes revealed no mutations.

[Anesthetic management during pheochromocytoma surgery : Current strategies]

BACKGROUND

Surgery-related mortality in patients with pheochromocytoma or paraganglioma has dramatically decreased over the last few decades. This effect has often been attributed to perioperative α‑receptor blockade. However, this has never been tested in a randomized trial and many other changes have contributed to this improvement. At the same time α‑receptor blockade was introduced, short-acting and well controllable agents became available for intraoperative arterial blood pressure management. Subsequently, surgical techniques improved and led almost exclusively to minimally invasive techniques, while improvements in the diagnostic techniques allow earlier and more precise detection of catecholamine-producing tumors.

METHODS

Conduction of a randomized, controlled study to investigate the effect of α‑receptor blockade on mortality is hampered by the rarity of the disease. With the currently low mortality rate, several thousands of patients would be needed to test such a hypothesis. Accordingly, intraoperative management is generally based on expert opinion. Hypertensive episodes are treated by intravenous administration of sodium nitroprusside, urapidil or nitroglycerine. Depending on the individual case a short-acting β‑blocker and magnesium might be added. Hypotension following tumor removal is treated with intravenous fluid infusion and continuous norepinephrine administration. Adrenal gland-sparing resection of pheochromocytoma does not seem to increase the risk of arterial hypertension.

CONCLUSION

Future research should focus on identification of risk factors for intraoperative hypertensive episodes and the question whether a time-consuming, unreliable α‑receptor blockade, burdened with significant side effects, is still needed.

Copy number variations alter methylation and parallel IGF2 overexpression in adrenal tumors

Overexpression of insulin growth factor 2 (IGF2) is a hallmark of adrenocortical carcinomas and pheochromocytomas. Previous studies investigating the IGF2/H19 locus have mainly focused on a single molecular level such as genomic alterations or altered DNA methylation levels and the causal changes underlying IGF2 overexpression are still not fully established. In the current study, we analyzed 62 tumors of the adrenal gland from patients with Conn's adenoma (CA, n=12), pheochromocytomas (PCC, n=10), adrenocortical benign tumors (ACBT, n=20), and adrenocortical carcinomas (ACC, n=20). Gene expression, somatic copy number variation of chr11p15.5, and DNA methylation status of three differential methylated regions of the IGF2/H19 locus including the H19 imprinting control region were integratively analyzed. IGF2 overexpression was found in 85% of the ACCs and 100% of the PCCs compared to 23% observed in CAs and ACBTs. Copy number aberrations of chr11p15.5 were abundant in both PCCs and ACCs but while PCCs retained a diploid state, ACCs were frequently tetraploid (7/19). Loss of either a single allele or loss of two alleles of the same parental origin in tetraploid samples resulted in a uniparental disomy-like genotype. These copy number changes correlated with hypermethylation of the H19 ICR suggesting that the lost alleles were the unmethylated maternal alleles. Our data provide conclusive evidence that loss of the maternal allele correlates with IGF2 overexpression in adrenal tumors and that hypermethylation of the H19 ICR is a consequence thereof.

Primary adrenal teratoma: Clinical characteristics and retroperitoneal laparoscopic resection in five adults

Primary adrenal teratoma is extremely rare. To investigate the clinical characteristics and further enrich the limited knowledge on its diagnosis and treatment, the present study retrospectively analyzed the detailed clinical data of five patients with primary adrenal teratomas treated in the Peking Union Medical College Hospital (Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China) between March 2009 and February 2014. The five patients were female, aged from 16 to 51 years (mean, 36.0±16.3 years), with solitary lesions that were incidentally found on routine physical examinations. The tumor size ranged from 2.4 to 9.0 cm (mean, 6.0±2.7 cm). Ultrasonography revealed a mixed echo in four patients, and computed tomography showed mixed density masses with fat components and calcification in three patients. Adrenal-related endocrine tests were normal in all five patients, and no abnormalities were found in the three patients who underwent somatostatin receptor scintigraphy examination. All patients were treated with retroperitoneal laparoscopic surgery, with no complications, and the resected tumors were identified as mature cystic teratomas pathologically. To date, the patients have been followed up for 4-60 months post-operatively, with no recurrence. In conclusion, this rare adrenal teratoma is an occult entity to which reproductive females are susceptible. The tumor exhibits no typical clinical manifestations or adrenal-related laboratory abnormalities, and the pre-operative diagnosis mainly relies on imaging characteristics of a heterogeneous lesion containing fat components with scattered and marginal calcifications. The preferred treatment is retroperitoneal laparoscopic surgery, and the prognosis is good.

Malignant pheochromocytoma with lung metastasis after right adrenalectomy for pheochromocytoma eleven years ago

A 30-year-old woman had multiple masses on right adrenalectomy site, posterior mediastinum, and left lung on computed tomography (CT) and positron emission tomography. She had a right adrenalectomy for pheochromocytoma eleven years ago. She received proper alpha and beta blocker and completed surgical resection. Pheochromocytoma was confirmed by histopathology. Here we report the case of metastatic malignant pheochromocytoma with very poor prognosis.

Anesthetic management for resection of para-aortic paraganglioma and unexpected aortic resection: A case report

Paragangliomas account for 15-20% of pheochromocytomas derived from chromaffin cells and secretes catecholamines. It has a high mortality rate due to hypertension and challenging anesthetic management. The present report is of a case of the successful management of paraganglioma resection with unexpected aortic resection. The patient presented for paraganglioma resection. The blood pressure (BP) was well controlled with α blockade followed by β blockade prior to surgery. The patient was under general anesthesia, with multiple intravenous lines, catheters and an arterial line. Induction was achieved by the administration of narcotic and volatile agents. During the procedure, the aorta was found to require resection in order to complete the tumor resection. The BP changed markedly with clamping and unclamping, tumor vein ligation and tumor resection. The increased BP due to catecholamine release and unclamping was controlled with phentolamine, nitroprusside, esmolol and labetolol. Drops in BP due to tumor vein ligation and clamping were managed with norepinephrine and vasopressin. With close communication and monitoring, the surgery on the patient was successfully completed and the patient was discharged days later in a hemodynamically stable condition. The diagnosis was further confirmed by pathology. This was a challenging case of paraganglioma resection with unexpected aortic resection. The success achieved suggests that the resection of paraganglioma and an aortic segment requires delicate anesthetic management. The key are α blockade and β blockade as necessary to control BP pre-operatively, frequent communication between the anesthesiologist and surgeons, intra-operative intervention in excess catecholamine release with phentolamine, nitroprusside and labetalol prior to tumor removal, and vasopressin for catecholamine deficiency when clamping or subsequent to tumor removal. It is a delicately orchestrated process requiring team work.

Incidentally detected inoperable malignant pheochromocytoma with hepatic metastasis treated by transcatheter arterial chemoembolization

Malignant pheochromocytoma (PCC) is a rare condition. Although the liver is the second most frequent site of metastasis in malignant PCC, no definite treatments have been established. Herein, we report a case of liver metastasis of PCC that was successfully treated by transcatheter arterial chemoembolization (TACE). A 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. He had undergone right adrenalectomy in May 2005 and PCC had been confirmed on the basis of histopathological findings. Liver biopsy was performed, and metastatic PCC was diagnosed. The lesion appeared inoperable because of invasion of the portal vein and metastases in the lymph nodes along the hepatoduodenal ligament. Thus, TACE was performed instead. After TACE, symptoms including dizziness and cold sweating improved, and the patient's serum catecholamine levels decreased. On the basis of this case, we believe that TACE may be a useful treatment for liver metastasis in malignant PCC.