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Ohmachi Y, Yamamoto M, Inaba Y, Makino S, Urai S, Matsumoto R, Bando H, Kanie K, Tsujimoto Y, Motomura Y, Sasaki Y, Oi-Yo Y, Yamamoto N, Suzuki M, Takahashi M, Iguchi G, Kanzawa M, Furukawa J, Shigemura K, Mizobuchi S, Ogawa W, Fukuoka H. The combination of doxazosin and metyrosine as a preoperative treatment for pheochromocytomas and paragangliomas. Endocrine 2024; 84:694-703. [PMID: 38206436 DOI: 10.1007/s12020-023-03681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Preoperative medical management is critical to prevent intraoperative cardiovascular complications in patients with pheochromocytomas and paragangliomas (PPGLs). Initial treatment involves α-adrenergic receptor blockers. However, while the routine use of metyrosine alongside these blockers is not strongly recommended due to a lack of evidence supporting its efficacy and associated safety concerns, there are previous studies on combination therapy with phenoxybenzamine and metyrosine. There are few reports on combination therapy with the selective α1-adrenergic receptor blocker doxazosin. Therefore, we investigated this combination treatment, which theoretically can affect perioperative outcomes in patients with PPGLs. To our knowledge, this is the first such study. METHODS This retrospective single-center observational study involved 51 patients who underwent surgical resection of PPGLs at Kobe University Hospital between 2014 and 2022. All patients received doxazosin at maximum doses. Fourteen patients received concomitant metyrosine, while 37 received doxazosin alone. Their perioperative outcomes were compared. RESULTS No severe event, such as acute coronary syndrome, was observed in either group. Intraoperatively, the doxazosin + metyrosine group exhibited a lower median minimum systolic blood pressure (56 [54-60] vs. 68 [59-74] mmHg, P = 0.03) and required lower median remifentanil (P = 0.04) and diltiazem (P = 0.02) doses than the doxazosin-alone group. CONCLUSION The combination of metyrosine and doxazosin as a preoperative treatment for PPGLs affects intraoperative circulatory hemodynamics, such as a reduced occurrence of blood pressure elevation during surgery. Further research is necessary to identify patients who will benefit most from this combination treatment.
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Affiliation(s)
- Yuka Ohmachi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Yuiko Inaba
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Department of Internal Medicine (I), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Shohei Makino
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Risa Matsumoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Keitaro Kanie
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Yasutaka Tsujimoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuma Motomura
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuriko Sasaki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuka Oi-Yo
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaki Suzuki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Michiko Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Department of Nutrition, Kobe University Hospital, Kobe, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Medical Center for Student Health, Kobe University, Kobe, Japan
- Division of Biosignal Pathophysiology, Kobe University, Kobe, Japan
| | - Maki Kanzawa
- Department of Diagnostic Pathology, Kobe University Hospital, Kobe, Japan
| | - Junya Furukawa
- Division of Urology, Department of Surgery Related, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsumi Shigemura
- Division of Urology, Department of Surgery Related, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoshi Mizobuchi
- Division of Anesthesiology, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
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Matsuo Y, Ashida K, Nagayama A, Moritaka K, Gobaru M, Yasuda J, Ogasawara N, Kurose H, Chikui K, Iwata S, Inoguchi Y, Hasuzawa N, Motomura S, Igawa T, Nomura M. Metyrosine-associated endocrinological changes in pheochromocytoma and paraganglioma. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2023; 3:e230006. [PMID: 37822367 PMCID: PMC10563611 DOI: 10.1530/eo-23-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/29/2023] [Indexed: 10/13/2023]
Abstract
Objective Metyrosine (alpha-methyl-para-tyrosine) effectively reduces catecholamine levels in patients with pheochromocytoma/paraganglioma. However, improvements in physiological and metabolic parameters and changes in endocrine function associated with metyrosine administration should be validated in comparison to surgery. This study was performed to confirm the effects of metyrosine on the physiological, metabolic, and endocrinological functions of patients with pheochromocytoma/paraganglioma in the perioperative period. Design This retrospective cohort study was performed at a single university hospital. Methods We included ten patients with pheochromocytoma/paraganglioma who received oral metyrosine after α-blocker therapy and consecutive surgeries. Urinary catecholamine metabolite levels and other clinical parameters were evaluated before and after metyrosine administration, and 1 week after surgery. Results The mean age was 53.1 ± 16.1 years. Of the ten participants (four men and six women), nine had pheochromocytoma and one had paraganglioma. The median maximum metyrosine dose was 750 mg/day. Urinary catecholamine metabolite levels significantly decreased in a dose-dependent manner after metyrosine administration. Both systolic and diastolic blood pressure significantly decreased after metyrosine and surgical treatment. Metyrosine administration significantly improved insulin sensitivity, although surgery improved the the basal insulin secretion. Additionally, serum prolactin and thyroid-stimulatory hormone levels were significantly increased by metyrosine treatment, whereas plasma renin activity was decreased. Conclusions Metyrosine significantly reduced catecholamines in patients with pheochromocytoma/paraganglioma and ensured the safety of the surgery. Adjustment of metyrosine administration may make surgical pretreatment more effective in achieving stabilized blood pressure and improving glucose metabolism. Endocrine parameters may manifest as the systemic effects of metyrosine administration.
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Affiliation(s)
- Yuko Matsuo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Ayako Nagayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Kanoko Moritaka
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Mizuki Gobaru
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Junichi Yasuda
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Naoyuki Ogasawara
- Department of Urology, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Hirofumi Kurose
- Department of Urology, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Katsuaki Chikui
- Department of Urology, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Shimpei Iwata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Yukihiro Inoguchi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Nao Hasuzawa
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Seiichi Motomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Tsukasa Igawa
- Department of Urology, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Asahi-machi, Kurume, Fukuoka, Japan
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3
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Pang Y, Li M, Jiang J, Chen X, Fu Y, Wang C, He Y, Zhao Y, Wang Y, Guan X, Zhang L, Xu X, Gan Y, Liu Y, Xie Y, Tang T, Wang J, Xie B, Liang Z, Chen D, Liu H, Chen C, Eisenhofer G, Liu L, Yi X, Chen BT. Impact of body composition and genotype on haemodynamics during surgery for pheochromocytoma and paraganglioma. J Cachexia Sarcopenia Muscle 2022; 13:2843-2853. [PMID: 36068986 PMCID: PMC9745493 DOI: 10.1002/jcsm.13071] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 07/05/2022] [Accepted: 07/24/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Maintaining intraoperative haemodynamic stability can reduce cardiovascular complications during surgery for pheochromocytoma and paraganglioma (PPGL). Risk factors such as tumour size and catecholamine levels are reported to predict haemodynamic responses during surgery for PPGL. We hypothesized that additional factors including body composition and genetic information could further improve prediction. METHODS Consecutive patients with PPGL confirmed by surgical pathology between June 2010 and June 2019 were retrospectively included. Cross-sectional computed tomography images at the L3 level were used to assess body composition parameters including skeletal muscle area and visceral fat area. Next-generation sequencing was performed using a panel containing susceptibility genes of PPGL. Differences in clinical-genetic characteristics and body composition parameters were analysed and compared in patients with and without intraoperative haemodynamic instability (HDI). RESULTS We included 221 patients with PPGL (median age 47 [38-56] years, and 52% male). Among them, 49.8% had Cluster 2 mutations (related to kinase signalling pathways), 44.8% had sarcopenia, and 52.9% experienced intraoperative HDI. Compared with patients without HDI, more patients with HDI had Cluster 2 mutations (59.8% vs. 38.5%, P = 0.002) and less had sarcopenia (35.9% vs. 54.8%, P = 0.005). Multivariate analysis showed that urine vanillylmandelic acid ≥ 58 μmol/day (adjusted odds ratio [OR] = 1.840, 95% confidence interval [CI] = 1.012-3.347, P = 0.046), tumour size ≥ 4 cm (adjusted OR = 2.278, 95% CI = 1.242-4.180, P = 0.008), and Cluster 2 mutations (adjusted OR = 2.199, 95% CI = 1.128-4.285, P = 0.021) were independent risk factors for intraoperative HDI, while sarcopenia (adjusted OR = 0.475, 95% CI = 0.266-0.846, P = 0.012) decreased the risk. CONCLUSIONS Body composition and genotype were associated with intraoperative haemodynamics in patients with PPGL. Our results indicated that inclusion of body composition and genotype in the overall assessment of patients with PPGL helped to predict HDI during surgery, which could assist in implementing preoperative and intraoperative measures to reduce perioperative complications.
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Affiliation(s)
- Yingxian Pang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Minghao Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jingjing Jiang
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Xiang Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yan Fu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Cikui Wang
- Department of Urology, Hubei Armed Police Corps Hospital, Wuchang, P. R. China
| | - Yao He
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yuanzhe Zhao
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yong Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiao Guan
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Liang Zhang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiaowen Xu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yu Gan
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yalin Liu
- Xiangya School of Medicine, Central South University, Changsha, Hunan, P. R. China
| | - Yaoling Xie
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Tingyuan Tang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Jing Wang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Bin Xie
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Zhihao Liang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Danlei Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Haipeng Liu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Changyong Chen
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Dresden, Germany
| | - Longfei Liu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiaoping Yi
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Hunan Key Laboratory of Skin Cancer and Psoriasis, Changsha, Hunan, P. R. China.,Hunan Engineering Research Center of Skin Health and Disease, Changsha, Hunan, P. R. China.,National Engineering Research Center of Personalized Diagnostic and Therapeutic Technology, Central South University, Changsha, Hunan, P. R. China
| | - Bihong T Chen
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA, USA
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4
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Nölting S, Bechmann N, Taieb D, Beuschlein F, Fassnacht M, Kroiss M, Eisenhofer G, Grossman A, Pacak K. Personalized Management of Pheochromocytoma and Paraganglioma. Endocr Rev 2022; 43:199-239. [PMID: 34147030 PMCID: PMC8905338 DOI: 10.1210/endrev/bnab019] [Citation(s) in RCA: 142] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Indexed: 02/07/2023]
Abstract
Pheochromocytomas/paragangliomas are characterized by a unique molecular landscape that allows their assignment to clusters based on underlying genetic alterations. With around 30% to 35% of Caucasian patients (a lower percentage in the Chinese population) showing germline mutations in susceptibility genes, pheochromocytomas/paragangliomas have the highest rate of heritability among all tumors. A further 35% to 40% of Caucasian patients (a higher percentage in the Chinese population) are affected by somatic driver mutations. Thus, around 70% of all patients with pheochromocytoma/paraganglioma can be assigned to 1 of 3 main molecular clusters with different phenotypes and clinical behavior. Krebs cycle/VHL/EPAS1-related cluster 1 tumors tend to a noradrenergic biochemical phenotype and require very close follow-up due to the risk of metastasis and recurrence. In contrast, kinase signaling-related cluster 2 tumors are characterized by an adrenergic phenotype and episodic symptoms, with generally a less aggressive course. The clinical correlates of patients with Wnt signaling-related cluster 3 tumors are currently poorly described, but aggressive behavior seems likely. In this review, we explore and explain why cluster-specific (personalized) management of pheochromocytoma/paraganglioma is essential to ascertain clinical behavior and prognosis, guide individual diagnostic procedures (biochemical interpretation, choice of the most sensitive imaging modalities), and provide personalized management and follow-up. Although cluster-specific therapy of inoperable/metastatic disease has not yet entered routine clinical practice, we suggest that informed personalized genetic-driven treatment should be implemented as a logical next step. This review amalgamates published guidelines and expert views within each cluster for a coherent individualized patient management plan.
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Affiliation(s)
- Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), CH-8091 Zurich, Switzerland.,Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, 13273 Marseille, France
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), CH-8091 Zurich, Switzerland.,Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Matthias Kroiss
- Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany.,Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford OX2 6HG, UK.,Centre for Endocrinology, Barts and the London School of Medicine, London EC1M 6BQ, UK.,ENETS Centre of Excellence, Royal Free Hospital, London NW3 2QG, UK
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD 20847, USA
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5
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Meijs AC, Snel M, Corssmit EPM. Pheochromocytoma/paraganglioma crisis: case series from a tertiary referral center for pheochromocytomas and paragangliomas. Hormones (Athens) 2021; 20:395-403. [PMID: 33575936 PMCID: PMC8110488 DOI: 10.1007/s42000-021-00274-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/25/2021] [Indexed: 12/22/2022]
Abstract
Pheochromocytoma/paraganglioma (PPGL)-induced catecholamine crisis is a rare endocrine emergency leading to life-threatening hemodynamic instability causing end-organ damage or dysfunction. As it is associated with a significant mortality rate of approximately 15%, recognizing the signs and symptoms and making the appropriate diagnosis are critical. For this purpose, we report the clinical course of the crisis in four out of a total of six patients with a PPGL crisis from a cohort of 199 PPGL patients of a single tertiary referral center for PPGL patients in the Netherlands diagnosed between 2002 and 2020. Successful treatment of a PPGL crisis demands prompt diagnosis, vigorous pharmacological therapy, and emergency tumor removal if the patient continues to deteriorate.
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Affiliation(s)
- Anouk C Meijs
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Marieke Snel
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Eleonora P M Corssmit
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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6
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Gruber LM, Jasim S, Ducharme-Smith A, Weingarten T, Young WF, Bancos I. The Role for Metyrosine in the Treatment of Patients With Pheochromocytoma and Paraganglioma. J Clin Endocrinol Metab 2021; 106:e2393-e2401. [PMID: 33693908 PMCID: PMC8118583 DOI: 10.1210/clinem/dgab130] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Treatment of pheochromocytoma and paraganglioma (PPGL) requires preintervention titration of alpha- and beta-adrenergic blockade, but patients may still be at risk for complications from catecholamine excess. Metyrosine decreases catecholamine production, making it an attractive therapeutic adjunct for select patients. EVIDENCE ACQUISITION A systematic literature review was performed (Ovid Medline and Scopus databases) on December 17, 2019, including studies with humans and original data. Studies with 10 or more patients on metyrosine for PPGL were included. Studies were screened for overlapping populations, and the most comprehensive study was included. The references of included studies were reviewed for additional data. Patient data from our institution between 2000 and 2015 were also reviewed. EVIDENCE SYNTHESIS Metyrosine is well tolerated when used for a short course and can improve intraoperative outcomes in PPGL. Metyrosine should be considered when a difficult PPGL resection is expected (eg, pericardiac paraganglioma, abdominal paraganglioma with great vessel involvement), a large release of catecholamines is anticipated (eg, ablative therapy, chemotherapy), or when standard alpha- and beta-adrenergic blockade are not tolerated or cannot adequately control hypertension. Side effects are generally mild and self-limited, with sedation in a majority of patients. Extrapyramidal side effects are rare but can limit use of metyrosine. Because of its expense and limited availability, metyrosine use should be carefully planned and timed in relation to surgery. CONCLUSIONS Metyrosine is a safe addition to traditional alpha- and beta-adrenergic blockade and should be considered in those patients with PPGL at high risk for acute release of catecholamines.
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Affiliation(s)
- Lucinda M Gruber
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sina Jasim
- Division of Endocrinology, Metabolism and Lipid Research, Department of Internal Medicine Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, USA
| | | | - Toby Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Correspondence: Irina Bancos, MD, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First St. SW, Rochester, Minnesota 55905, USA. E-mail:
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7
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Jing J, Yu M, Jiang B. An Adrenal Incidentaloma Diagnosed as Dopamine-Secreting Pheochromocytoma: A Case Report. J Natl Med Assoc 2020; 113:46-50. [PMID: 32741578 DOI: 10.1016/j.jnma.2020.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/10/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Dopamine-secreting pheochromocytomas are exceedingly rare. CASE PRESENTATION A 28-year-old woman, who was admitted due to 4 hours of acute-onset abdominal pain, detected an adrenal mass incidentally. She was almost asymptomatic without a known family history. Laboratory assessments showed significant increases in dopamine levels of serum and 24-h urinary. By using preoperative a-adrenergic receptor blockers, she developed orthostatic hypotension and palpitations. When she underwent laparoscopic left adrenalectomy, she experienced rapid cyclic fluctuations in systolic blood pressure from 90 mmHg to 200 mmHg. Postoperatively, she exhibited prolonged hypotension, requiring vasopressor therapy and fluid replacement. According to histopathological diagnosis, it was a pheochromocytoma. Dopamine levels in 24-h urine and serum decreased to normal after operation. Analysis of specific gene SDHB, SDHD, RET, VHL and NF1 detected no pathogenic mutations. CONCLUSION Patients with dopamine-secreting pheochromocytomas are mostly asymptomatic, leading to a significant delay in diagnosis. There is a large possibility for dopamine-secreting pheochromocytomas to show a malignant tendency than the adrenergic and noradrenergic phenotypes. The a-adrenergic receptor blocker is not indicated for preoperative medical treatment because it can cause hypotension and cardiovascular failure. Calcium channel blockers or metyrosine may be better alternatives. All patients with pheochromocytomas should receive targeted genetic testing based on specific clinical features. SDHB, SDHD, RET, VHL and NF1 mutations are suggested for genetic testing of adrenal dopamine-secreting pheochromocytomas.
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Affiliation(s)
- Jing Jing
- Department of Endocrinology, Qingdao Municipal Hospital, Qingdao, Shandong 266071, China
| | - Minmin Yu
- Department of Endocrinology, Qingdao Municipal Hospital, Qingdao, Shandong 266071, China
| | - Bo Jiang
- Department of Urology, Qingdao Municipal Hospital, Qingdao, Shandong 266071, China.
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Gomella PT, Sanford TH, Pinto PA, Bratslavsky G, Metwalli AR, Linehan WM, Ball MW. Long-term Functional and Oncologic Outcomes of Partial Adrenalectomy for Pheochromocytoma. Urology 2020; 140:85-90. [PMID: 32109495 PMCID: PMC7255958 DOI: 10.1016/j.urology.2020.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/10/2020] [Accepted: 02/17/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the recurrence and functional outcomes in a primarily hereditary cohort of patients undergoing partial adrenalectomy for pheochromocytoma. METHODS A retrospective review from a prospectively managed database of patients undergoing partial adrenalectomy from 1995 to 2018 at the National Cancer Institute was performed. Local recurrence was defined as imaging evidence of a recurrent or de novo lesion on the operative side. Steroid dependency was defined as requiring daily steroid replacement at time of last follow-up. RESULTS One hundred and twenty-four partial adrenalectomies, removing 162 tumors, were performed in 107 patients. Most patients had a known hereditary predisposition to develop bilateral, multifocal, and recurrent pheochromocytoma. Median tumor size was 2 cm (interquartile range (IQR) 1.5-2.8). Median follow-up was 60 months (IQR 13-131). Local recurrence occurred in 17 patients (15.8%) and were managed with active surveillance or surgery. A single patient (1/106, 0.9%) developed metastatic spread of pheochromocytoma approximately 14 years after his first of 2 partial adrenalectomies and remains alive under active surveillance. Median time to recurrence was 71 months (IQR 26-127) with 10 patients (9.3%) requiring daily steroid replacement at time of last follow-up. CONCLUSION Partial adrenalectomy offers excellent oncologic and functional outcomes, sparing most patients from lifelong steroid replacement therapy. Recurrences can be easily managed with repeat surgery or active surveillance via functional work-up and imaging. Partial adrenalectomy remains the recommended surgical management for patients pre-disposed to development of bilateral, multifocal and recurrent pheochromocytoma.
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Affiliation(s)
| | - Thomas H Sanford
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD; Department of Urology, SUNY Upstate Medical University, Syracuse, NY
| | - Peter A Pinto
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD
| | - Gennady Bratslavsky
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD; Department of Urology, SUNY Upstate Medical University, Syracuse, NY
| | - Adam R Metwalli
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD; Division of Urology, Howard University, Washington, DC
| | | | - Mark W Ball
- Urologic Oncology Branch, National Cancer Institute, Bethesda, MD.
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9
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Fang F, Ding L, He Q, Liu M. Preoperative Management of Pheochromocytoma and Paraganglioma. Front Endocrinol (Lausanne) 2020; 11:586795. [PMID: 33117294 PMCID: PMC7551102 DOI: 10.3389/fendo.2020.586795] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/14/2020] [Indexed: 01/10/2023] Open
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, characterized by excessive release of catecholamines (CAs), and manifested as the classic triad of headaches, palpitations, profuse sweating, and a variety of other signs and symptoms. The diagnosis of PPGL requires both evidence of excessive release of CAs and anatomical localization of CA-secreting tumor. Surgery is the mainstay of treatment for all patients with PPGL unless contraindicated. However, without proper preparation, the release of excessive CAs, especially during surgery, can result in lethal cardiovascular complications. Herein, we briefly reviewed the pathogenesis of this disease, discussed the current approaches and evidence available for preoperative management, summarizing the results of the latest studies which compared the efficacies of preoperative management with or without α adrenergic-receptor antagonists, aiming to facilitate better understanding of the preoperative management of PPGL for the physicians.
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10
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Takekoshi K, Satoh F, Tanabe A, Okamoto T, Ichihara A, Tsuiki M, Katabami T, Nomura M, Tanaka T, Matsuda T, Imai T, Yamada M, Asada S, Kawata N, Naruse M. Correlation between urinary fractionated metanephrines in 24-hour and spot urine samples for evaluating the therapeutic effect of metyrosine: a subanalysis of a multicenter, open-label phase I/II study. Endocr J 2019; 66:1063-1072. [PMID: 31511435 DOI: 10.1507/endocrj.ej19-0125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We recently conducted an open-label phase I/II study to evaluate the efficacy and safety of preoperative and chronic treatment with metyrosine (an inhibitor of catecholamine synthesis) in pheochromocytoma/paraganglioma (PPGL) in Japan. We compared creatinine-corrected metanephrine fractions in spot urine and 24-hour urine samples (the current standard for the screening and diagnosis of PPGLs) from 16 patients to assess the therapeutic effect of metyrosine. Percent changes from baseline in urinary metanephrine (uMN) or normetanephrine (uNMN) were compared between spot and 24-hour urine samples. Mean percent changes in uMN or uNMN in spot and 24-hour urine were -26.36% and -29.27%, respectively. The difference in the percent change from baseline between uMN or uNMN in spot and 24-hour urine was small (-2.90%). The correlation coefficient was 0.87 for percent changes from baseline between uMN or uNMN measured in spot and 24-hour urine. The area under the receiver operator characteristic (ROC) curve of uMN or uNMN measured in spot urine vs. 24-hour urine (reference standard) to assess the efficacy of metyrosine treatment was 0.93. Correlations and ROCs between 24-hour urinary vanillylmandelic acid, adrenaline, and noradrenaline and 24-hour uMN or uNMN were similar to those between spot uMN or uNMN and 24-hour uMN or uNMN. No large difference was observed between spot and 24-hour urine for the assessment of metyrosine treatment by quantifying uMN or uNMN in Japanese patients with PPGLs. These results suggest that spot urine samples may be useful in assessing the therapeutic effect of metyrosine.
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Affiliation(s)
- Kazuhiro Takekoshi
- Division of Sports Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8577, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology & Metabolism, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai 980-8574, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Takahiro Okamoto
- Department of Surgery II, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama 241-0811, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume 830-0011, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Tadashi Matsuda
- Department of Urology and Andrology, Kansai Medical University, Hirakata 573-1010, Japan
| | - Tsuneo Imai
- National Hospital Organization, Higashinagoya National Hospital, Nagoya 465-8620, Japan
| | - Masanobu Yamada
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Suguru Asada
- Data Science Development Headquarters, Ono Pharmaceutical Co., Ltd., Osaka 541-8564, Japan
| | - Nobuyuki Kawata
- Clinical Development Planning, Ono Pharmaceutical Co., Ltd., Osaka 541-8564, Japan
| | - Mitsuhide Naruse
- Clinical Research Institute for Endocrinology and Metabolic Diseases, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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Abstract
Pheochromocytomas are rare neuroendocrine tumors. Extra-adrenal lesions arising from the autonomic neural ganglia are termed paraganglioma. Clinical symptoms are common between the adrenal and extra-adrenal forms and are determined by excess secretion of catecholamines. Hypertension is a critical and often dramatic feature of pheochromocytoma/paraganglioma, and its most prevalent reported symptom. However, given the rare occurrence of this cancer, in patients undergoing screening for hypertension, the prevalence ranges from 0.1% to 0.6%. Still, patients frequently come to the attention of endocrinologist when pheochromocytoma/paraganglioma is suspected as a secondary cause of hypertension. This article summarizes current clinical approaches in patients with pheochromocytoma/paraganglioma.
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Affiliation(s)
- Sergei G Tevosian
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, 1600 Southwest Archer Road, Suite H-2, Gainesville, FL 32608, USA
| | - Hans K Ghayee
- Department of Medicine, Division of Endocrinology, University of Florida, Malcom Randall VA Medical Center, Gainesville, FL 32610, USA.
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12
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Naruse M, Satoh F, Tanabe A, Okamoto T, Ichihara A, Tsuiki M, Katabami T, Nomura M, Tanaka T, Matsuda T, Imai T, Yamada M, Harada T, Kawata N, Takekoshi K. Efficacy and safety of metyrosine in pheochromocytoma/paraganglioma: a multi-center trial in Japan. Endocr J 2018; 65:359-371. [PMID: 29353821 DOI: 10.1507/endocrj.ej17-0276] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
To assess the efficacy, safety, and pharmacokinetics of metyrosine (an inhibitor of catecholamine synthesis) in patients with pheochromocytoma/paraganglioma (PPGL), we conducted a prospective, multi-center, open-label study at 11 sites in Japan. We recruited PPGL patients aged ≥12 years requiring preoperative or chronic treatment, receiving α-blocker treatment, having baseline urinary metanephrine (uMN) or normetanephrine (uNMN) levels ≥3 times the upper limit of normal values, and having symptoms associated with excess catecholamine. Metyrosine treatment was started at 500 mg/day and modified according to dose-adjustment criteria up to 4,000 mg/day. The main outcome measure was the proportion of patients who achieved at least 50% reduction in uMN or uNMN levels from baseline. Sixteen patients (11 males/5 females) aged 12-86 years participated. After 12 weeks of treatment and at the last evaluation of efficacy, the primary endpoint was achieved in 31.3% of all patients, including 66.7% of those under preoperative treatment and 23.1% of those under chronic treatment. Sedation, anemia, and death were reported in 1 patient each as serious adverse drug reactions during the 24-week treatment. Metyrosine was shown to be tolerated and to relieve symptoms by reducing excess catecholamine in PPGL patients under both preoperative and chronic treatment.
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Affiliation(s)
- Mitsuhide Naruse
- Clinical Research Institute for Endocrinology and Metabolic Diseases, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai 980-8574, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo 162-8655, Japan
| | - Takahiro Okamoto
- Department of Surgery II, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takuyuki Katabami
- Department of Metabolism and Endocrinology, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama 241-0811, Japan
| | - Masatoshi Nomura
- Department of Endocrine and Metabolic Diseases, Kyushu University Hospital, Fukuoka 812-8582, Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Chiba University Graduate School of Medicine, Chiba 260-8670, Japan
| | - Tadashi Matsuda
- Department of Urology and Andrology, Kansai Medical University Hospital, Hirakata 573-1191, Japan
| | - Tsuneo Imai
- National Hospital Organization, Higashinagoya National Hospital, Nagoya 465-8620, Japan
| | - Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
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13
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Engebretsen MH, Kildahl AN, Hoy IH, Bakken TL. Metyrosine treatment in a woman with chromosome 22q11.2 deletion syndrome and psychosis: a case study. INTERNATIONAL JOURNAL OF DEVELOPMENTAL DISABILITIES 2017; 65:116-121. [PMID: 34141331 PMCID: PMC8115566 DOI: 10.1080/20473869.2017.1401257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Background: People with 22q11.2 deletion syndrome (DS) are assumed to be especially vulnerable to developing mental illness such as psychosis. Aim: The study was established to contribute to knowledge about metyrosine medication in patients with 22q11.2 DS and psychosis. Methods: A case study was established including a woman with intellectual disability, 22q11.2 DS, and psychosis. Metyrosine medication was implemented, as conventional anti-psychotic medication was unsuccessful. Results: Effect of metyrosine medication included both psychotic symptom relief with decreased aggressive behaviour. Adjunctive milieu therapy contributed to complience. Conclusion: For patients with 22q11.2 DS and psychosis, metyrosine medication may prove effective. However, there are significant ethical dilemmas related to metyrosine medication for psychotic symptoms.
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14
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Perioperative hemodynamics and outcomes of patients on metyrosine undergoing resection of pheochromocytoma or paraganglioma. Int J Surg 2017; 46:1-6. [PMID: 28803996 DOI: 10.1016/j.ijsu.2017.08.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 08/07/2017] [Indexed: 11/23/2022]
Abstract
INTRODUCTION To describe outcomes of patients with metyrosine (MET) pretreatment for abdominal surgical resection of pheochromocytoma or paraganglioma (PCC/PGL) compared with patients who had phenoxybenzamine (PBZ) pretreatment. METHODS Retrospective review of perioperative outcomes for PCC/PGL patients treated with MET and propensity-matched comparison of MET and PBZ (MET + PBZ) with PBZ alone. RESULTS MET preparation was given in 63 cases (26 laparoscopic and 37 open, of which 55 also received PBZ). All patients had wide perioperative hemodynamic oscillations. Patients with open procedures required more intravenous fluids and blood transfusions; 35% required postoperative vasopressor infusions for hypotension and 38% developed acute kidney injury. One laparoscopic procedure required postoperative vasopressor infusion, and 12% of patients developed acute kidney injury. Forty-five MET + PBZ patients were propensity-matched with PBZ-only patients. Intraoperatively, MET + PBZ patients had lower minimum systolic and diastolic blood pressures than PBZ-only patients (median systolic, 74 vs 80 mm Hg, P = 0.01; median diastolic, 42 vs 46 mm Hg, P = 0.005) and larger intraoperative blood pressure oscillations (median systolic range, 112 vs 93 mm Hg, P = 0.06; median diastolic range, 58 vs 51 mm Hg, P = 0.02). Postoperative vasopressor infusion use was similar between MET + PBZ and PBZ only (16% vs 11%, P = 0.76). Major outcomes were not different between regimens. CONCLUSION Large hemodynamic oscillations were present in our PCC/PGL patients treated with MET + PBZ. These patients had a wider range of intraoperative blood pressure variations than PBZ-only patients. No differences in postoperative comorbid outcomes were found between MET + PBZ and PBZ-only groups.
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15
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Bholah R, Bunchman TE. Review of Pediatric Pheochromocytoma and Paraganglioma. Front Pediatr 2017; 5:155. [PMID: 28752085 PMCID: PMC5508015 DOI: 10.3389/fped.2017.00155] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/26/2017] [Indexed: 01/01/2023] Open
Abstract
Pheochromocytoma (PCC) and paraganglioma (PGL) are rare chromaffin cell tumors which secrete catecholamines and form part of the family of neuroendocrine tumors. Although a rare cause of secondary hypertension in pediatrics, the presentation of hypertension in these patients is characteristic, and treatment is definitive. The gold standard for diagnosis is via measurement of plasma free metanephrines, with imaging studies performed for localization, identification of metastatic lesions and for surgical resection. Preoperative therapy with alpha-blocking agents, beta blockers, and potentially tyrosine hydroxylase inhibitors aid in a safe pre-, intra- and postoperative course. PCC and PGL are inherited in as much as 80% of pediatric cases, and all patients with mutations should be followed closely given the risk of recurrence and malignancy. While the presentation of chromaffin cell tumors has been well described with multiple endocrine neoplasia, NF1, and Von Hippel-Lindau syndromes, the identification of new gene mutations leading to chromaffin cell tumors at a young age is changing the landscape of how clinicians approach such cases. The paraganglioma-pheochromocytoma syndromes (SDHx) comprise familial gene mutations, of which the SDHB gene mutation carries a high rate of malignancy. Since the inheritance rate of such tumors is higher than previously described, genetic screening is recommended in all patients, and lifelong follow-up for recurrent tumors is a must. A multidisciplinary team approach allows for optimal health-care delivery in such children. This review serves to provide an overview of pediatric PCC and PGL, including updates on the preferred methods of imaging, guidelines on gene testing as well as management of hypertension in such patients.
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Affiliation(s)
- Reshma Bholah
- Pediatric Nephrology, Virginia Commonwealth University, Richmond, VA, United States
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16
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Lee JM, Kim MK, Ko SH, Koh JM, Kim BY, Kim SW, Kim SK, Kim HJ, Ryu OH, Park J, Lim JS, Kim SY, Shong YK, Yoo SJ. Clinical Guidelines for the Management of Adrenal Incidentaloma. Endocrinol Metab (Seoul) 2017; 32:200-218. [PMID: 28685511 PMCID: PMC5503865 DOI: 10.3803/enm.2017.32.2.200] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/09/2017] [Accepted: 06/01/2017] [Indexed: 12/20/2022] Open
Abstract
An adrenal incidentaloma is an adrenal mass found in an imaging study performed for other reasons unrelated to adrenal disease and often accompanied by obesity, diabetes, or hypertension. The prevalence and incidence of adrenal incidentaloma increase with age and are also expected to rise due to the rapid development of imaging technology and frequent imaging studies. The Korean Endocrine Society is promoting an appropriate practice guideline to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues in managing the patients with adrenal incidentaloma. After evaluating core proposition, we propose the most critical 20 recommendations from the initially organized 47 recommendations by Delphi technique.
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Affiliation(s)
- Jung Min Lee
- Department of Internal Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Mee Kyoung Kim
- Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Hyun Ko
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jung Min Koh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo Yeon Kim
- Department of Internal Medicine, Soon Chun Hyang University Bucheon Hospital, Soon Chun Hyang University College of Medicine, Bucheon, Korea
| | - Sang Wan Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Soo Kyung Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hae Jin Kim
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ohk Hyun Ryu
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Juri Park
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jung Soo Lim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Young Kee Shong
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Soon Jib Yoo
- Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea.
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17
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Gupta G, Pacak K. PRECISION MEDICINE: AN UPDATE ON GENOTYPE/BIOCHEMICAL PHENOTYPE RELATIONSHIPS IN PHEOCHROMOCYTOMA/PARAGANGLIOMA PATIENTS. Endocr Pract 2017; 23:690-704. [PMID: 28332883 DOI: 10.4158/ep161718.ra] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors known to produce and secrete high levels of circulating catecholamines and their metabolites. The biochemical characteristics of these tumors can be used to divide them into three major phenotypes. The adrenergic, noradrenergic and dopaminergic phenotypes are defined by predominant elevations in epinephrine and metanephrine, norepinephrine and normetanephrine, and dopamine and 3-methoxytyramine, respectively. There are over 15 well-identified tumor-susceptibility genes responsible for approximately 40% of the cases. The objective of this review article is to outline specific genotype/biochemical phenotype relationships. METHODS Literature review. RESULTS None. CONCLUSION Biochemical phenotype of PPGL is determined by the underlying genetic mutation and the associated molecular pathway. Identification of genotype/biochemical relationships is valuable in prioritizing testing for specific genes, making treatment decisions and monitoring disease progression. ABBREVIATIONS 3-MT = 3-methoxytyramine; EPAS1 = endothelial pas domain protein 1; FH = fumarate hydratase; HIF2A = hypoxia inducible factor type 2A; MEN2 = multiple endocrine neoplasia type 2; NF1 = neurofibromatosis type 1; PNMT = phenylethanolamine N-methyltransferase; PPGL = pheochromocytoma and paraganglioma; RET = rearranged during transfection; SDH = succinate dehydrogenase; SDHAF2 = succinate dehydrogenase complex assembly factor 2; TCA = tricarboxylic acid; TH = tyrosine hydroxylase; TMEM127 = transmembrane protein 127; VHL = von Hippel-Lindau.
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18
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Challis BG, Casey RT, Simpson HL, Gurnell M. Is there an optimal preoperative management strategy for phaeochromocytoma/paraganglioma? Clin Endocrinol (Oxf) 2017; 86:163-167. [PMID: 27696513 DOI: 10.1111/cen.13252] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/03/2016] [Accepted: 09/24/2016] [Indexed: 12/01/2022]
Abstract
Phaeochromocytomas and paragangliomas (PPGLs) are catecholamine secreting neuroendocrine tumours that predispose to haemodynamic instability. Currently, surgery is the only available curative treatment, but carries potential risks including hypertensive and hypotensive crises, cardiac arrhythmias, myocardial infarction and stroke, due to tumoral release of catecholamines during anaesthetic induction and tumour manipulation. The mortality associated with surgical resection of PPGL has significantly improved from 20-45% in the early 20th century (Apgar & Papper, AMA Archives of Surgery, 1951, 62, 634) to 0-2·9% in the early 21st century (Kinney et al. Journal of Cardiothoracic and Vascular Anesthesia, 2002, 16, 359), largely due to availability of effective pharmacological agents and advances in surgical and anaesthetic practice. However, surgical resection of PPGL still poses significant clinical management challenges. Preoperatively, alpha-adrenoceptor blockade is the mainstay of management, although various pharmacological strategies have been proposed, based largely on reports derived from retrospective data sets. To date, no consensus has been reached regarding the 'ideal' preoperative strategy due, in part, to a paucity of data from high-quality evidence-based studies comparing different treatment regimens. Here, based on the available literature, we address the Clinical Question: Is there an optimal preoperative management strategy for PPGL?
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Affiliation(s)
- B G Challis
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - R T Casey
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
- Department of Medical Genetics, National Institute for Health Research Biomedical Research Centre, Cambridge, UK
| | - H L Simpson
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - M Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
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19
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Mitsis A, Hadjilouka C, Skarpari M, Myrianthefs M. An unusual case of pheochromocytoma mimicking both acute coronary syndrome and central nervous system infection. Case report and literature review. Hellenic J Cardiol 2017; 58:372-377. [PMID: 28108355 DOI: 10.1016/j.hjc.2016.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 12/16/2016] [Accepted: 12/23/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Andreas Mitsis
- Cardiology Department, Larnaca General Hospital, Larnaca, Cyprus.
| | | | - Maria Skarpari
- Department of Internal Medicine, Larnaca General Hospital, Larnaca, Cyprus
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20
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Bole D, Simon B. Pheochromocytoma-Induced Hyperglycemia Leading To Misdiagnosis Of Type 1 Diabetes Mellitus. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161210.cr] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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21
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Pisarska M, Pędziwiatr M, Budzyński A. Perioperative hemodynamic instability in patients undergoing laparoscopic adrenalectomy for pheochromocytoma. Gland Surg 2016; 5:506-511. [PMID: 27867865 DOI: 10.21037/gs.2016.09.05] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Perioperative hemodynamic instability still remains the biggest surgical and anesthetic challenge in surgery for pheochromocytoma. The aim of this review was to discuss pre-, intra- and postoperative factors that may impact on hemodynamic condition of a patient. It describes patients' preparation with appropriate medication, principles of surgical technique as well as risk factors for development of hemodynamic instability in postoperative period. Currently the gold standard in the treatment of pheochromocytoma is preoperative use of alpha-blockers and laparoscopic surgery. This approach allowed improving outcomes by lowering both mortality and morbidity.
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Affiliation(s)
- Magdalena Pisarska
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland;; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland;; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
| | - Andrzej Budzyński
- 2 Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland;; Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Kraków, Poland
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Waingankar N, Bratslavsky G, Jimenez C, Russo P, Kutikov A. Pheochromocytoma in Urologic Practice. Eur Urol Focus 2016; 1:231-240. [PMID: 28078330 DOI: 10.1016/j.euf.2015.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
CONTEXT Pheochromocytoma is regularly encountered in urological practice and requires a thoughtful and careful clinical approach. OBJECTIVE To review clinical aspects of management of pheochromocytoma in urologic practice. EVIDENCE ACQUISITION A systematic review of English-language literature was performed through year 2015 using the Medline database. Manuscripts were selected with consensus of the coauthors and evaluated using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. EVIDENCE SYNTHESIS Findings and recommendations of the evaluated manuscripts are discussed with an emphasis on the description of presentation, diagnosis, evaluation, and perioperative care. CONCLUSION In addition to surgical expertise, appropriate management of pheochromocytoma in urologic practice requires nuanced understanding of pathophysiology, genetics, and endocrinological principles. When skillfully managed, the vast majority of patients with pheochromocytoma should expect an excellent prognosis. PATIENT SUMMARY In this article we review the clinical approach to patients with pheochromocytoma, a tumor that stems from the innermost part of the adrenal gland and that often secretes excessive amounts of powerful hormones such as noradrenaline and adrenaline. Significant expertise is required to appropriately manage patients with these tumors. TAKE HOME MESSAGE In addition to surgical expertise, appropriate management of pheochromocytoma in urologic practice requires nuanced understanding of pathophysiology, genetics, and endocrinological principles. When skillfully managed, vast majority of patients with pheochromocytoma should expect an excellent prognosis.
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Affiliation(s)
| | | | - Camilo Jimenez
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul Russo
- Memorial Sloan Kettering Cancer Center, New York, New York
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Soto-Pina AE, Franklin C, Rani CSS, Gottlieb H, Hinojosa-Laborde C, Strong R. A Novel Model of Dexamethasone-Induced Hypertension: Use in Investigating the Role of Tyrosine Hydroxylase. ACTA ACUST UNITED AC 2016; 358:528-36. [DOI: 10.1124/jpet.116.234005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 07/08/2016] [Indexed: 01/15/2023]
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24
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Luiz HV, Tanchee MJ, Pavlatou MG, Yu R, Nambuba J, Wolf K, Prodanov T, Wesley R, Adams K, Fojo T, Pacak K. Are patients with hormonally functional phaeochromocytoma and paraganglioma initially receiving a proper adrenoceptor blockade? A retrospective cohort study. Clin Endocrinol (Oxf) 2016; 85:62-9. [PMID: 26998836 PMCID: PMC4899243 DOI: 10.1111/cen.13066] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/14/2016] [Accepted: 03/13/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pharmacological treatment is mandatory in patients with hormonally functional phaeochromocytoma and paraganglioma (PHAEO/PGL). We evaluated if patients initially diagnosed with hormonally functional PHAEO/PGL by various medical subspecialties received proper adrenoceptor blockade, and analysed factors predicting the prescription of adequate treatment. METHODS In a retrospective cohort study, we reviewed data from patients initially diagnosed with hormonally functional PHAEO/PGL outside the National Institutes of Health and Cedars-Sinai Medical Center, who were referred to these institutions between January 2001 and April 2015. Logistic regression was used to assess factors associated with proper adrenoceptor blockade. RESULTS A total of 381 patients were included. Adequate pharmacological treatment was prescribed to 69·3%, of which 93·1% received α-adrenoceptor blockers. Regarding patients who were inappropriately treated, 53% did not receive any medication. Independent predictors of the prescription of a proper blockade were the diagnosis by endocrinologists [odds ratio (OR) 4·14; 95% confidence interval (CI), 2·51-6·85; P < 0·001], the presence of high blood pressure (OR 5·94; 95% CI, 3·11-11·33; P < 0·001) and the evidence of metastasis (OR 5·96; 95% CI, 1·93-18·46; P = 0·002). CONCLUSIONS Although most patients received adequate pharmacological treatment, almost one-third were either not treated or received inappropriate medications. The diagnosis by endocrinologists, the presence of high blood pressure and the evidence of metastatic disease were identified as independent predictors of a proper blockade. These results highlight the need to educate physicians about the importance of starting adequate adrenoceptor blockade in all patients with hormonally functional PHAEO/PGL.
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Affiliation(s)
- Henrique Vara Luiz
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive, Bethesda, MD 20892
- Department of Endocrinology and Diabetology, Hospital Garcia de Orta, Avenida Torrado da Silva, 2801-951 Almada, Portugal
| | - Mary Jane Tanchee
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive, Bethesda, MD 20892
- Section of Endocrinology and Metabolism, University of Santo Tomas Hospital, España, Manila, Philippines
| | - Maria G. Pavlatou
- Clinical Neuroendocrinology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD 20892
| | - Run Yu
- Division of Endocrinology and Carcinoid and Neuroendocrine Tumor Center, Cedars-Sinai Medical Center, B-131, 8700 Beverly Blvd, Los Angeles, CA 90048
| | - Joan Nambuba
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive, Bethesda, MD 20892
| | - Katherine Wolf
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive, Bethesda, MD 20892
| | - Tamara Prodanov
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive, Bethesda, MD 20892
| | - Robert Wesley
- Warren Grant Magnuson Clinical Center, National Institutes of Health, Building 10, Room 228, 10 Center Drive, Bethesda, MD 20892
| | - Karen Adams
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive, Bethesda, MD 20892
| | - Tito Fojo
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Building 10, Room 12C-103, 10 Center Drive, Bethesda, MD 20892
| | - Karel Pacak
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive, Bethesda, MD 20892
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Khakimova GR, Kozina EA, Kucheryanu VG, Ugrumov MV. Reversible Pharmacological Induction of Motor Symptoms in MPTP-Treated Mice at the Presymptomatic Stage of Parkinsonism: Potential Use for Early Diagnosis of Parkinson's Disease. Mol Neurobiol 2016; 54:3618-3632. [PMID: 27194433 DOI: 10.1007/s12035-016-9936-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/10/2016] [Indexed: 12/23/2022]
Abstract
A crucial event in the pathogenesis of Parkinson's disease is the death of dopaminergic neurons of the nigrostriatal system, which are responsible for the regulation of motor function. Motor symptoms first appear in patients 20-30 years after the onset of the neurodegeneration, when there has been a loss of an essential number of neurons and depletion of compensatory reserves of the brain, which explains the low efficiency of treatment. Therefore, the development of a technology for the diagnosing of Parkinson's disease at the preclinical stage is of a high priority in neurology. In this study, we have developed at an experimental model a fundamentally novel for neurology approach for diagnosis of Parkinson's disease at the preclinical stage. This methodology, widely used for the diagnosis of chronic diseases in the internal medicine, is based on the application of a challenge test that temporarily increases the latent failure of a specific functional system, thereby inducing the short-term appearance of clinical symptoms. The provocation test was developed by a systemic administration of α-methyl-p-tyrosine (αMpT), a reversible inhibitor of tyrosine hydroxylase to MPTP-treated mice at the presymptomatic stage of parkinsonism. For this, we first selected a minimum dose of αMpT, which caused a decrease of the dopamine level in the striatum of normal mice below the threshold at which motor dysfunctions appear. Then, we found the maximum dose of αMpT at which a loss of dopamine in the striatum of normal mice did not reach the threshold level, and motor behavior was not impaired. We showed that αMpT at this dose induced a decrease of the dopamine concentration in the striatum of MPTP-treated mice at the presymptomatic stage of parkinsonism below a threshold level that results in the impairment of motor behavior. Finally, we proved that αMpT exerts a temporal and reversible influence on the nigrostriatal dopaminergic system of MPTP-treated mice with no long-term side effects on other catecholaminergic systems. Thus, the above experimental data strongly suggest that αMpT-based challenge test might be considered as the provocation test for Parkinson's disease diagnosis at the preclinical stage in the future clinical trials.
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Affiliation(s)
- Gulnara R Khakimova
- Laboratory of Neural and Neuroendocrine Regulations, Institute of Developmental Biology RAS, 26 Vavilov St, Moscow, 119334, Russia
| | - Elena A Kozina
- Laboratory of Neural and Neuroendocrine Regulations, Institute of Developmental Biology RAS, 26 Vavilov St, Moscow, 119334, Russia
| | - Valerian G Kucheryanu
- Laboratory of General Pathology of the Nervous System, Institute of General Pathology and Pathophysiology RAMS, 8 Baltiiskaya St, Moscow, 125315, Russia
| | - Michael V Ugrumov
- Laboratory of Neural and Neuroendocrine Regulations, Institute of Developmental Biology RAS, 26 Vavilov St, Moscow, 119334, Russia. .,Department of Psychology, Faculty of Social Sciences, The National Research University Higher School of Economics, 20 Myasnitskaya St, Moscow, 101000, Russia.
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26
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Pourian M, Mostafazadeh DB, Soltani A. Does this patient have pheochromocytoma? A systematic review of clinical signs and symptoms. J Diabetes Metab Disord 2016; 15:11. [PMID: 27034920 PMCID: PMC4815191 DOI: 10.1186/s40200-016-0230-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 03/02/2016] [Indexed: 11/27/2022]
Abstract
Context Pheochromocytoma is a rare disease but with high mortality if it is not being diagnosed early. Several biochemical tests with high accuracy have been obtained, but the clinical threshold for request of these tests is not determined clearly. Objectives To determine the Likelihood Ratios of clinical symptoms and signs in diagnosing pheochromocytoma. And also meta-analysis of their sensitivity in this disease. Data sources MEDLINE was searched for relevant English-language articles dated 1960 to February 2014. Bibliographies were searched to find additional articles. Study selection We included original studies describing the sensitivity and/or likelihood ratios of signs and symptoms in clinical suspicion of pheochromocytoma. Their method of diagnosis should have been based on pathology. We excluded specific subtypes or syndromes related to pheochromocytoma, or specific ages or gender. Also we excluded studies before 1993 (JNC5) which no definition of hypertension was presented. 37 articles were chosen finally. Data extraction Two authors reviewed data from articles independently and gave discrepancies to third author for decision. The aim was extraction of raw numbers of patients having defined signs or symptoms, and draw 2 × 2 tables if data available. We meta-analyzed sensitivities by Statsdirect and Likelihood Ratios by Meta-disc soft wares. Because our data was heterogeneous based on I2 > 50 % (except negative Likelihood ratio of hypertension), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test. Data synthesis The most prevalent signs and symptoms reported were hypertension (pooled sensitivity of 80.7 %), headache (pooled sensitivity of 60.4 %), palpitation (pooled sensitivity of 59.3 %) and diaphoresis (pooled sensitivity of 52.4 %). The definition of orthostatic hypotension was different among studies. The sensitivity was 23–50 %. Paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias based on Funnel plot and Egger test (P value < 0.05). Seven of the articles had control group, and could be used for calculating LR of signs/symptoms. Diaphoresis (LR+ 2.2, LR- 0.45), Palpitation (LR+ 1.9, LR- 0.52) and headache (LR+ 1.6, LR- 0.24) were significant symptoms in clinical diagnosis of pheochromocytoma. Other signs and symptoms had been reported in only one study and could not have been meta-analyzed. Classic triad of headache, palpitation and diaphoresis in hypertensive patients had the LR+ 6.312 (95 % CI 0.217–183.217) and LR- 0.139 (95 % CI 0.059–0.331). Surprisingly, hypertension was not important in clinical suspicion of pheochromocytoma, and even normotension increased the probability of the disease. Conclusions By available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, to specify the value of clinical findings. Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.
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Affiliation(s)
- M Pourian
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Davani B Mostafazadeh
- Evidence based Practice Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - A Soltani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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27
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Soltani A, Pourian M, Davani BM. Does this patient have Pheochromocytoma? a systematic review of clinical signs and symptoms. J Diabetes Metab Disord 2016; 15:6. [PMID: 26998444 PMCID: PMC4797176 DOI: 10.1186/s40200-016-0226-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 03/06/2016] [Indexed: 12/05/2022]
Abstract
Context Pheochromocytoma is a rare disease but with high mortality if it is not being diagnosed early. Several biochemical tests with high accuracy have been obtained, but the clinical threshold for request of these tests is not determined clearly. Objectives To determine the Likelihood Ratios of clinical symptoms and signs in diagnosing pheochromocytoma. And also meta-analysis of their sensitivity in this disease. Data sources MEDLINE was searched for relevant English-language articles dated 1960 to February 2014. Bibliographies were searched to find additional articles. Study selection We included original studies describing the sensitivity and/or likelihood ratios of signs and symptoms in clinical suspicion of pheochromocytoma. Their method of diagnosis should have been based on pathology. We excluded specific subtypes or syndromes related to pheochromocytoma, or specific ages or gender. Also we excluded studies before 1993 (JNC5) which no definition of hypertension was presented. 37 articles were chosen finally. Data extraction Two authors reviewed data from articles independently and gave discrepancies to third author for decision. The aim was extraction of raw numbers of patients having defined signs or symptoms, and draw 2 × 2 tables if data available. We meta-analyzed sensitivities by Statsdirect and Likelihood Ratios by Meta-disc soft wares. Because our data was heterogeneous based on I2 > 50 % (except negative Likelihood ratio of hypertension), we used random effect model for doing meta-analysis. We checked publication bias by drawing Funnel plot for each sign/symptom, and also Egger test. Data synthesis The most prevalent signs and symptoms reported were hypertension (pooled sensitivity of 80.7 %), headache (pooled sensitivity of 60.4 %), palpitation (pooled sensitivity of 59.3 %) and diaphoresis (pooled sensitivity of 52.4 %). The definition of orthostatic hypotension was different among studies. The sensitivity was 23–50 %. Paroxysmal hypertension, chest pain, flushing, and weakness were the signs/symptoms which had publication bias based on Funnel plot and Egger test (P value < 0.05). Seven of the articles had control group, and could be used for calculating LR of signs/symptoms. Diaphoresis (LR+ 2.2, LR-0.45), Palpitation (LR+ 1.9, LR-0.52) and headache (LR+ 1.6, LR-0.24) were significant symptoms in clinical diagnosis of pheochromocytoma. Other signs and symptoms had been reported in only one study and could not have been meta-analyzed. Classic triad of headache, palpitation and diaphoresis in hypertensive patients had the LR+ 6.312 (95 % CI 0.217–183.217) and LR-0.139 (95 % CI 0.059–0.331). Surprisingly, hypertension was not important in clinical suspicion of pheochromocytoma, and even normotension increased the probability of the disease. Conclusions By available data, there is no single clinical finding that has significant value in diagnosis or excluding pheochromocytoma. Combination of certain symptoms, signs and para-clinical exams is more valuable for physicians. Further studies should be done, to specify the value of clinical findings.Until that time the process of diagnosis will be based on clinical suspicion and lab tests followed by related imaging.
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Affiliation(s)
- Akbar Soltani
- Evidence based Practice Research Center, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mandana Pourian
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Mostafazadeh Davani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Wachtel H, Kennedy EH, Zaheer S, Bartlett EK, Fishbein L, Roses RE, Fraker DL, Cohen DL. Preoperative Metyrosine Improves Cardiovascular Outcomes for Patients Undergoing Surgery for Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2015; 22 Suppl 3:S646-54. [PMID: 26374407 DOI: 10.1245/s10434-015-4862-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Indexed: 01/24/2023]
Affiliation(s)
- Heather Wachtel
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Edward H Kennedy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Salman Zaheer
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Edmund K Bartlett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren Fishbein
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Debbie L Cohen
- Division of Renal, Electrolytes, and Hypertension, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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29
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Failure of metyrosine therapy for preoperative management of pheochromocytoma: a case report. Can J Anaesth 2015; 62:1303-7. [DOI: 10.1007/s12630-015-0480-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 07/16/2015] [Accepted: 09/01/2015] [Indexed: 11/26/2022] Open
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30
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Gerlach RM, Barrus AB, Ramzy D, Hernandez Conte A, Khoche S, McCartney SL, Swaminathan M. CASE 7---2015: Perioperative Considerations for a Cardiac Paraganglioma...Not Just Another Cardiac Mass. J Cardiothorac Vasc Anesth 2015; 29:1065-70. [PMID: 25980595 DOI: 10.1053/j.jvca.2015.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Danny Ramzy
- Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Swapnil Khoche
- University of California, San Diego Medical Center, San Diego, CA
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31
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Lenders JWM, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SKG, Murad MH, Naruse M, Pacak K, Young WF. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2014; 99:1915-42. [PMID: 24893135 DOI: 10.1210/jc.2014-1498] [Citation(s) in RCA: 1565] [Impact Index Per Article: 156.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim was to formulate clinical practice guidelines for pheochromocytoma and paraganglioma (PPGL). PARTICIPANTS The Task Force included a chair selected by the Endocrine Society Clinical Guidelines Subcommittee (CGS), seven experts in the field, and a methodologist. The authors received no corporate funding or remuneration. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. The Task Force reviewed primary evidence and commissioned two additional systematic reviews. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, European Society of Endocrinology, and Americal Association for Clinical Chemistry reviewed drafts of the guidelines. CONCLUSIONS The Task Force recommends that initial biochemical testing for PPGLs should include measurements of plasma free or urinary fractionated metanephrines. Consideration should be given to preanalytical factors leading to false-positive or false-negative results. All positive results require follow-up. Computed tomography is suggested for initial imaging, but magnetic resonance is a better option in patients with metastatic disease or when radiation exposure must be limited. (123)I-metaiodobenzylguanidine scintigraphy is a useful imaging modality for metastatic PPGLs. We recommend consideration of genetic testing in all patients, with testing by accredited laboratories. Patients with paraganglioma should be tested for SDHx mutations, and those with metastatic disease for SDHB mutations. All patients with functional PPGLs should undergo preoperative blockade to prevent perioperative complications. Preparation should include a high-sodium diet and fluid intake to prevent postoperative hypotension. We recommend minimally invasive adrenalectomy for most pheochromocytomas with open resection for most paragangliomas. Partial adrenalectomy is an option for selected patients. Lifelong follow-up is suggested to detect recurrent or metastatic disease. We suggest personalized management with evaluation and treatment by multidisciplinary teams with appropriate expertise to ensure favorable outcomes.
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Affiliation(s)
- Jacques W M Lenders
- Radboud University Medical Center (J.W.M.L.), 6500 HB Nijmegen, The Netherlands; VA Medical Center and University of California, San Francisco (Q.-Y.D.), San Francisco, California 94121; University Hospital Dresden (G.E.), 01307 Dresden, Germany; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, (A.-P.G.-R.), F-75015 Paris, France; Université Paris Descartes (A.-P.G.-R.), F-75006 Paris, France; Mayo Clinic (S.K.G.G., M.H.M.), Rochester, Minnesota 55905; National Hospital Organisation Kyoto Medical Center (M.N.), Kyoto 612-8555; Japan; Eunice Kennedy Shriver National Institute of Child Health & Human Development (K.P.), Bethesda, Maryland 20892; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
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32
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The Clinical Manifestations, Diagnosis, and Treatment of Adrenal Emergencies. Emerg Med Clin North Am 2014; 32:465-84. [DOI: 10.1016/j.emc.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Shuch B, Ricketts CJ, Metwalli AR, Pacak K, Linehan WM. The genetic basis of pheochromocytoma and paraganglioma: implications for management. Urology 2014; 83:1225-32. [PMID: 24642075 DOI: 10.1016/j.urology.2014.01.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/05/2013] [Accepted: 01/02/2014] [Indexed: 02/09/2023]
Abstract
Chromaffin cells are catecholamine-producing cells derived from neural crest tissue. Chromaffin tumors are rare tumors arising from these cells and are divided into pheochromocytoma arising from adrenal tissue and paraganglioma arising from extra-adrenal ganglia. Previously, ∼10% were believed to be hereditary, but advances in genome sequencing have shown that roughly 35% of apparently sporadic tumors have a hereditary component. In this review, we describe both classic and newly discovered hereditary chromaffin tumors syndromes and provide recommendations for genetic testing. In many cases, the genes associated with these conditions are linked to common kidney cancer pathways familiar to urologic oncologists.
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Affiliation(s)
- Brian Shuch
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Christopher J Ricketts
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Adam R Metwalli
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Karel Pacak
- Developmental Endocrinology Branch, Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD
| | - W Marston Linehan
- Urologic Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD.
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Tsirlin A, Oo Y, Sharma R, Kansara A, Gliwa A, Banerji MA. Pheochromocytoma: a review. Maturitas 2014; 77:229-38. [PMID: 24472290 DOI: 10.1016/j.maturitas.2013.12.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/14/2013] [Indexed: 12/19/2022]
Abstract
Pheochromocytomas are catecholamine producing neuroendocrine tumors that can be adrenal or extra-adrenal in origin. The classic symptoms of pheochromocytoma are headache, palpitation, anxiety and diaphoresis and the tumor can occur at any age with equal gender distribution. In patients with an established mutation or hereditary syndrome the condition may manifest at a younger age than in those with sporadic disease. Pheochromocytoma can be associated with certain genetic syndromes such as multiple endocrine neoplasia type 2 (MEN 2), neurofibromatosis (NF) and von Hippel-Lindau (VHL) syndrome. Pheochromocytoma is diagnosed with biochemical confirmation of hormonal excess followed by anatomical localization (CT or MRI). The mainstay of definitive therapy is surgical resection. In this review, we discuss in detail about the symptomatology, diagnosis, genetic aspects and management of pheochromocytoma.
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Affiliation(s)
- A Tsirlin
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - Y Oo
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - R Sharma
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States.
| | - A Kansara
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - A Gliwa
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
| | - M A Banerji
- Department of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, United States
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35
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Stefanidis D, Goldfarb M, Kercher KW, Hope WW, Richardson W, Fanelli RD. SAGES guidelines for minimally invasive treatment of adrenal pathology. Surg Endosc 2013; 27:3960-80. [PMID: 24018761 DOI: 10.1007/s00464-013-3169-z] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 08/02/2013] [Indexed: 02/07/2023]
Affiliation(s)
- Dimitrios Stefanidis
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, CMC Surgical Specialty Center, Suite 300, 1025 Morehead Medical Plaza, Charlotte, NC, 28204, USA,
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Fishbein L, Orlowski R, Cohen D. Pheochromocytoma/Paraganglioma: Review of perioperative management of blood pressure and update on genetic mutations associated with pheochromocytoma. J Clin Hypertens (Greenwich) 2013; 15:428-34. [PMID: 23730992 PMCID: PMC4581847 DOI: 10.1111/jch.12084] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 02/04/2023]
Abstract
Pheochromocytomas and paragangliomas are rare tumors with high morbidity rates caused by excessive catecholamine secretion, even though the majority of tumors are benign. The use of perioperative blockade regimens, together with improved surgical techniques, has greatly impacted the perioperative morbidity associated with these tumors. The old dogma of the "tumor of tens" no longer holds true. For example, at least one third of all pheochromocytomas and paragangliomas are hereditary, with mutations in 1 of 10 well-characterized susceptibility genes, and one quarter of all tumors are malignant. This review focuses on the perioperative management of pheochromocytoma and paragangliomas and the clinical implications of the associated genetic mutations.
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Affiliation(s)
- Lauren Fishbein
- Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
- Division of Endocrinology, Diabetes and MetabolismUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Robert Orlowski
- Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Debbie Cohen
- Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
- Renal and Hypertension DivisionUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
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Badri M, Gibbons AV, Popii V, Yih D, Cohen-Stein DL, Patel SM. Perioperative management of a patient with a nonresectable pheochromocytoma. Endocr Pract 2013; 19:e74-6. [PMID: 23425647 DOI: 10.4158/ep12343.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the clinical course of a patient with a nonresectable pheochromocytoma during urgent hip surgery. METHODS To describe the clinical management and postoperative outcome of the patient and review the relevant literature. RESULTS An 85-year-old male with a nonresectable pheochromocytoma required urgent hip surgery following a traumatic hip fracture. He was perioperatively managed with phenoxybenzamine, metyrosine, and metoprolol to avoid potential pheochromocytoma-related complications. He remained hemodynamically stable and recovered from the surgery without complications. CONCLUSIONS This case illustrates the successful management of a patient requiring urgent surgery in the setting of a nonresectable pheochromocytoma, which is rarely described in the literature.
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Affiliation(s)
- Marwan Badri
- Department of Internal Medicine, Lankenau Medical Center, Wynnewood, Pennsylvania 19096, USA.
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Därr R, Lenders JWM, Hofbauer LC, Naumann B, Bornstein SR, Eisenhofer G. Pheochromocytoma - update on disease management. Ther Adv Endocrinol Metab 2012; 3:11-26. [PMID: 23148191 PMCID: PMC3474647 DOI: 10.1177/2042018812437356] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pheochromocytomas are rare endocrine tumors that can present insidiously and remain undiagnosed until death or onset of clear manifestations of catecholamine excess. They are often referred to as one of the 'great mimics' in medicine. These tumors can no longer be regarded as a uniform disease entity, but rather as a highly heterogeneous group of chromaffin cell neoplasms with different ages of onset, secretory profiles, locations, and potential for malignancy according to underlying genetic mutations. These aspects all have to be considered when the tumor is encountered, thereby enabling optimal management for the patient. Referral to a center of specialized expertise for the disease should be considered wherever possible. This is not only important for surgical management of patients, but also for post-surgical follow up and screening of disease in patients with a hereditary predisposition to the tumor. While preoperative management has changed little over the last 20 years, surgical procedures have evolved so that laparoscopic resection is the standard of care and partial adrenalectomy should be considered in all patients with a hereditary condition. Follow-up testing is essential and should be recommended and ensured on a yearly basis. Managing such patients must now also take into account possible underlying mutations and the appropriate selection of genes for testing according to disease presentation. Patients and family members with identified mutations then require an individualized approach to management. This includes consideration of distinct patterns of biochemical test results during screening and the appropriate choice of imaging studies for tumor localization according to the mutation and associated differences in predisposition to adrenal, extra-adrenal and metastatic disease.
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Waguespack SG, Rich T, Grubbs E, Ying AK, Perrier ND, Ayala-Ramirez M, Jimenez C. A current review of the etiology, diagnosis, and treatment of pediatric pheochromocytoma and paraganglioma. J Clin Endocrinol Metab 2010; 95:2023-37. [PMID: 20215394 DOI: 10.1210/jc.2009-2830] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PHEO/PGL) are neuroendocrine tumors that arise from sympathetic and parasympathetic paraganglia. Diagnosed rarely during childhood, PHEO/PGL are nonetheless important clinical entities, particularly given our evolving understanding of their pathophysiology. EVIDENCE ACQUISITION We identified articles through the U.S. National Library of Medicine by using the search terms pheochromocytoma and paraganglioma. Results were narrowed to manuscripts that included children and studies related to the genetics of PHEO/PGL. Web-based resources for genetic disorders were also used. For all articles, we performed subsequent reference searches and verification of source data. EVIDENCE SYNTHESIS Up to 20% of PHEO/PGL are diagnosed in children. Most are functional tumors, and clinical presentation includes symptoms related to catecholamine hypersecretion and/or tumor mass effect. Increasingly, PHEO/PGL are identified during presymptomatic screening in children with genetic syndromes associated with PHEO/PGL (multiple endocrine neoplasia type 2, von Hippel-Lindau disease, and the paraganglioma syndromes). Plasma and/or urine metanephrines are the best diagnostic test for a functional tumor, and the management of pediatric patients is similar to adults. Genetic counseling should be undertaken in all cases. Although most pediatric PHEO/PGL are benign, these tumors can occasionally metastasize, a condition for which no curative treatment exists. CONCLUSIONS Although PHEO/PGL are rarely diagnosed during childhood, the pediatric provider should be able to recognize and screen for such tumors, particularly in the context of a known genetic predisposition. Optimal care of these children includes a multidisciplinary team approach at centers experienced in the evaluation and treatment of these uncommon yet fascinating endocrine neoplasms.
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Affiliation(s)
- S G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, The Children's Cancer Hospital, University of Texas M. D. Anderson Cancer Center, PO Box 301402, Unit 1461, Houston, Texas 77230-1402, USA.
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Abstract
ABSTRACT
The anesthetic management of pheochromocytoma is complicated and challenging. However, preoperative pharmacologic preparation has greatly improved perioperative outcome, and modern anesthetic drugs combined with advanced monitoring contribute to intraoperative stability. There is great regional and international variation in which intraoperative anesthetic technique is employed and there are little data to suggest one approach over another. Nevertheless, most management principles are universal. Progress lies in improved data collection that is increasingly available with electronic anesthesia information systems.
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Venkatesan AM, Locklin J, Lai EW, Adams KT, Fojo AT, Pacak K, Wood BJ. Radiofrequency ablation of metastatic pheochromocytoma. J Vasc Interv Radiol 2009; 20:1483-90. [PMID: 19875067 PMCID: PMC3608423 DOI: 10.1016/j.jvir.2009.07.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 06/02/2009] [Accepted: 07/13/2009] [Indexed: 01/20/2023] Open
Abstract
In the present report on the preliminary safety and effectiveness of radiofrequency (RF) ablation for pheochromocytoma metastases, seven metastases were treated in six patients (mean size, 3.4 cm; range, 2.2-6 cm). alpha- and beta-adrenergic and catecholamine synthesis inhibition and intraprocedural anesthesia monitoring were used. Safety was assessed by recording ablation-related complications. Complete ablation was defined as a lack of enhancement within the ablation zone on follow-up computed tomography. No serious adverse sequelae were observed. Complete ablation was achieved in six of seven metastases (mean follow-up, 12.3 months; range, 2.5-28 months). In conclusion, RF ablation may be safely performed for metastatic pheochromocytoma given careful attention to peri-procedural management.
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Affiliation(s)
- Aradhana M Venkatesan
- Center for Interventional Oncology, Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland 20892, USA.
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Kelley SR, Goel TK, Smith JM. Pheochromocytoma presenting as acute severe congestive heart failure, dilated cardiomyopathy, and severe mitral valvular regurgitation: a case report and review of the literature. JOURNAL OF SURGICAL EDUCATION 2009; 66:96-101. [PMID: 19486873 DOI: 10.1016/j.jsurg.2008.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 11/13/2008] [Accepted: 11/30/2008] [Indexed: 05/27/2023]
Affiliation(s)
- Scott R Kelley
- Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio 45220, USA.
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Mediastinal Paragangliomas: The Mayo Clinic Experience. Ann Thorac Surg 2008; 86:946-51. [PMID: 18721588 DOI: 10.1016/j.athoracsur.2008.04.105] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2007] [Revised: 04/26/2008] [Accepted: 04/29/2008] [Indexed: 11/23/2022]
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Eisenhofer G, Rivers G, Rosas AL, Quezado Z, Manger WM, Pacak K. Adverse drug reactions in patients with phaeochromocytoma: incidence, prevention and management. Drug Saf 2008; 30:1031-62. [PMID: 17973541 DOI: 10.2165/00002018-200730110-00004] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The dangers of phaeochromocytomas are mainly due to the capability of these neuroendocrine tumours to secrete large quantities of vasoactive catecholamines, thereby increasing blood pressure and causing other related adverse events or complications. Phaeochromocytomas are often missed, sometimes only becoming apparent during therapeutic interventions that provoke release or interfere with the disposition of catecholamines produced by the tumours. Because phaeochromocytomas are rare, evidence contraindicating use of specific drugs is largely anecdotal or based on case reports. The heterogeneous nature of the tumours also makes adverse reactions highly variable among patients. Some drugs, such as dopamine D(2) receptor antagonists (e.g. metoclopramide, veralipride) and beta-adrenergic receptor antagonists (beta-blockers) clearly carry high potential for adverse reactions, while others such as tricyclic antidepressants seem more inconsistent in producing complications. Other drugs capable of causing adverse reactions include monoamine oxidase inhibitors, sympathomimetics (e.g. ephedrine) and certain peptide and corticosteroid hormones (e.g. corticotropin, glucagon and glucocorticoids). Risks associated with contraindicated medications are easily minimised by adoption of appropriate safeguards (e.g. adrenoceptor blockade). Without such precautions, the state of cardiovascular vulnerability makes some drugs and manipulations employed during surgical anaesthesia particularly dangerous. Problems arise most often when drugs or therapeutic procedures are employed in patients in whom the tumour is not suspected. In such cases, it is extremely important for the clinician to recognise the possibility of an underlying catecholamine-producing tumour and to take the most appropriate steps to manage and treat adverse events and clinical complications.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Clinical Chemistry and Laboratory Medicine, University of Dresden, Dresden, Germany.
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Udelsman R. Adrenal. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Curti BD, Longo DL. Intensive Care of the Cancer Patient. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ludwig AD, Feig DI, Brandt ML, Hicks MJ, Fitch ME, Cass DL. Recent advances in the diagnosis and treatment of pheochromocytoma in children. Am J Surg 2007; 194:792-6; discussion 796-7. [DOI: 10.1016/j.amjsurg.2007.08.028] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 08/13/2007] [Accepted: 08/13/2007] [Indexed: 01/31/2023]
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Abstract
Pheochromocytomas are rare neuroendocrine tumors with a highly variable clinical presentation, but they most commonly present as spells of headaches, sweating, palpitations, and hypertension. Patients with pheochromocytoma may develop complicated and potentially lethal cardiovascular and other complications, especially in the setting of diagnostic or interventional procedures (e.g. upon induction of anesthesia or during surgery). The serious and potentially lethal nature of such complications is due to the potent effect of paroxysmal release of catecholamines. Because this warrants prompt diagnosis and treatment, the physician should be aware of the clinical manifestations and complications of catecholamine excess and be able to provide proper preoperative management to minimize catecholamine-related pre-, intra-, and postoperative adverse events. The following clinical scenario and discussion aim to enhance the knowledge of the physician regarding the behavior of pheochromocytoma and to outline current approaches to comprehensive preoperative management of patients suffering from this tumor.
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Affiliation(s)
- Karel Pacak
- Section on Medical Neuroendocrinology, National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive MSC-1109, Bethesda, Maryland 20892-1109, USA.
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Paul S, Jain SH, Gallegos RP, Aranki SF, Bueno R. Functional Paraganglioma of the Middle Mediastinum. Ann Thorac Surg 2007; 83:e14-6. [PMID: 17532372 DOI: 10.1016/j.athoracsur.2007.02.090] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 01/29/2007] [Accepted: 02/28/2007] [Indexed: 11/27/2022]
Abstract
We describe a 49-year-old woman with refractory hypertension resulting from a functional paraganglioma of the middle mediastinum. After aggressive medical antihypertensive control and reduction of catecholamine production, she underwent surgical resection requiring transection and subsequent reconstruction of the aorta on cardiopulmonary bypass and circulatory arrest. We believe that this is the first report of a functionally active paraganglioma of the mediastinum requiring resection with cardiopulmonary bypass and aortic reconstruction.
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Affiliation(s)
- Subroto Paul
- Division of Thoracic Surgery, Brigham & Women's Hospital, Boston, Massachusetts 02115, USA
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Abstract
Pheochromocytomas and paragangliomas are rare neural crest-derived tumors of sympathetic (generally catecholamine producing) or parasympathetic (rarely catecholamine producing) origin. Patients affected by these tumors present with a variable clinical picture, often making diagnosis troublesome. Surgery is the treatment of choice, but requires appropriate medical management before, during, and after tumor resection. Appropriate follow-up of patients is particularly important to identify recurrences, remaining disease, or developing malignancy. Currently, however, no firm guidelines exist about what form follow-up should take. There is also a general lack of prospective studies establishing the best approaches for management and treatment of the tumor. Choice of the many available different therapeutic options instead usually depends on institutional experience and clinical setting, which may vary for different groups of patients. At the First International Symposium on Pheochromocytoma (ISP2005), held in Bethesda in October 2005, a panel of experts addressed and discussed the many therapeutic options and problems associated with management and treatment of patients with pheochromocytoma, reporting their personal experience and sharing their opinions with those of patient representatives. The aim of this special Discussion Session was to reconcile differences of opinion and reach agreement about appropriate management and therapeutic options. This article summarizes the discussion and the recommendations derived from that session.
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Affiliation(s)
- Massimo Mannelli
- Endocrinology Unit, Department of Clinical Physiopathology, University of Florence, Viale Pieraccini 6, 50139 Florence, Italy.
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