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Park SS, Ahn CH, Lee S, Lee W, Kim WW, Lee YM, Kim SJ, Sung TY, Lee KE, Kim JH, Lee SH, Koh JM. Preoperative prediction of metastatic pheochromocytoma and paraganglioma using clinical, genetic, and biochemical markers: A cohort study. J Intern Med 2024; 296:68-79. [PMID: 38659304 DOI: 10.1111/joim.13791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND The prevalence of metastatic pheochromocytoma and paraganglioma (PPGL) is approximately 15%-20%. Although there are indicators to assess metastatic risks, none of them predict metastasis reliably. Therefore, we aimed to develop and validate a scoring system using clinical, genetic, and biochemical risk factors to preoperatively predict the metastatic risk of PPGL. METHODS In the cross-sectional cohort (n = 180), clinical, genetic, and biochemical risk factors for metastasis were identified using multivariate logistic regression analysis, and a novel scoring system was developed. The scoring system was validated and compared with the age, size of tumor, extra-adrenal location, and secretory type (ASES) score in the longitudinal cohort (n = 114). RESULTS In the cross-sectional cohort, pseudohypoxia group-related gene variants (SDHB, SDHD, or VHL), methoxytyramine >0.16 nmol/L, and tumor size >6.0 cm were independently associated with metastasis after multivariate logistic regression. Using them, the gene variant, methoxytyramine, and size of tumor (GMS) score were developed. In the longitudinal cohort, Harrell's concordance index of the GMS score (0.873, 95% confidence interval [CI]: 0.738-0.941) was higher than that of the ASES score (0.713, 95% CI: 0.567-0.814, p = 0.007). In the longitudinal cohort, a GMS score ≥2 was significantly associated with a higher risk of metastasis (hazard ratio = 25.07, 95% CI: 5.65-111.20). A GMS score ≥2 (p < 0.001), but not ASES score ≥2 (p = 0.090), was associated with shorter progression-free survival. CONCLUSION The GMS scoring system, which integrates gene variant, methoxytyramine level, and tumor size, provides a valuable preoperative approach to assess metastatic risk in PPGL.
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Affiliation(s)
- Seung Shin Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Lunit, Seoul, Republic of Korea
| | - Seunghoo Lee
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Woochang Lee
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Woong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su Jin Kim
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyu Eun Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung Hun Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Min Koh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Li Q, Lan Z, Jiang Y, Wang R, Li Z, Jiang X. Validation and Evaluation of 5 Scoring Systems for Predicting Metastatic Risk in Pheochromocytoma and Paraganglioma. Am J Surg Pathol 2024; 48:855-865. [PMID: 38712603 DOI: 10.1097/pas.0000000000002238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Currently, 5 scoring systems have been proposed in the literature for predicting metastatic risk in pheochromocytoma and paraganglioma (PPGL): Pheochromocytoma of the Adrenal Gland Scaled Score (PASS), Grading System for Adrenal Pheochromocytoma and Paraganglioma (GAPP), Composite Pheochromocytoma/paraganglioma Prognostic Score (COPPS), Age, Size, Extra-adrenal location, Secretion type (ASES) score, and Size, Genetic, Age, and PASS (SGAP) model. To validate and evaluate these 5 scoring systems, we conducted a retrospective review of cases diagnosed as PPGL at the Department of Pathology, West China Hospital of Sichuan University, between January 2012 and December 2019. A total of 185 PPGL cases were included, comprising 35 cases with metastasis and 150 cases remained metastasis-free for over 8 years after surgery. The criteria of the 5 scoring systems were used for scoring and risk classification. The predictive performance of the 5 scoring systems was validated, compared, and evaluated using concordance index (C-index) and decision curve analysis (DCA). The C-indices for PASS, GAPP, and SGAP were 0.600, 0.547, and 0.547, respectively, indicating low discriminative ability. In contrast, COPPS and ASES had C-indices of 0.740 and 0.706, respectively, indicating better discriminative performance. DCA also showed that the predictive capability of COPPS was superior to that of ASES, with both outperformed PASS, while PASS had better predictive ability than GAPP and SGAP. Our analysis indicated that pathology-based scoring systems cannot accurately predict metastatic risk of PPGL. Establishing a precise prediction system requires integrating clinical, pathologic, and molecular information, using a scientific methodology for predictive factor selection and weight assessment.
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Affiliation(s)
- Qin Li
- Departments of Pathology
- Neurosurgery, West China Hospital of Sichuan University
| | - Zhigang Lan
- Department of Pathology, Chengdu Fifth People's Hospital, The Fifth People's Hospital Affiliated to Chengdu University of Traditional Chinese Medicine
| | | | | | | | - Xiaolin Jiang
- Department of Pathology, Guangyuan Central Hospital, Chengdu, Sichuan Province, China
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Iguchi DYV, Martins Filho SN, Soares IC, Siqueira SAC, Alves VAF, Assato AK, Yang JH, Almeida MQ, Villares Fragoso MCB, Fagundes GFC, Mendonca BB, Lourenço Junior DM, Hoff AO, Castroneves LA, Ferraz-de-Souza B, Giannella MLCC, Pereira MAA. Identification of Predictors of Metastatic Potential in Paragangliomas to Develop a Prognostic Score (PSPGL). J Endocr Soc 2024; 8:bvae093. [PMID: 38799767 PMCID: PMC11112433 DOI: 10.1210/jendso/bvae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Indexed: 05/29/2024] Open
Abstract
Context Paragangliomas (PGLs) are rare tumors in adrenal and extra-adrenal locations. Metastasis are found in approximately 5% to 35% of PGLs, and there are no reliable predictors of metastatic disease. Objective This work aimed to develop a prognostic score of metastatic potential in PGLs. Methods A retrospective analysis was conducted of clinical data from a cohort with PGLs and tumor histological assessment. Patients were divided into metastatic PGL (presence of metastasis) and nonmetastatic PGL (absence of metastasis ≥96 months of follow-up) groups. Univariate and multivariable analysis were performed to identify predictors of metastatic potential. A prognostic score was developed based on coefficients of multivariable analysis. Kaplan-Meier curves were generated to estimate disease-specific survival (DSS). Results Out of 263 patients, 35 patients had metastatic PGL and 110 patients had nonmetastatic PGL. In multivariable analysis, 4 features were independently related to metastatic disease and composed the Prognostic Score of Paragangliomas (PSPGL): presence of central or confluent necrosis (33 points), more than 3 mitosis/10 high-power field (HPF) (28 points), extension into adipose tissue (20 points), and extra-adrenal location (19 points). A PSPGL of 24 or greater showed similar sensitivity with higher specificity than the Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) and Grading System for Adrenal Pheochromocytoma and Paraganglioma (GAPP). PSPGL less than or equal to 20 was associated with a risk of metastasis of approximately 10%, whereas a PSPGL of 40 or greater was associated with approximately 80%. The presence of metastasis and Ki-67 of 3% or greater were related to lower DSS. Conclusion The PSPGL, composed of 4 easy-to-assess parameters, demonstrated good performance in predicting metastatic potential and good ability in estimating metastasis risk.
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Affiliation(s)
- Daniela Yone Veiga Iguchi
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | | | - Iberê Cauduro Soares
- Divisão de Anatomia Patológica, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Sheila Aparecida Coelho Siqueira
- Divisão de Anatomia Patológica, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Venâncio Avancini Ferreira Alves
- Laboratório de Investigaçãoc Médica LIM/14, Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - Aline Kawassaki Assato
- Laboratório de Investigaçãoc Médica LIM/14, Departamento de Patologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - Ji Hoon Yang
- Clínica de Endocrinologia, Hospital do Servidor Público Municipal de São Paulo, São Paulo 01532-000, Brazil
| | - Madson Q Almeida
- Laboratório de Endocrinologia Molecular e Celular LIM/25, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - Maria Candida Barisson Villares Fragoso
- Laboratório de Hormônios e Genética Molecular LIM/42, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
- Divisão de Endocrinologia e Metabologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Gustavo Freitas Cardoso Fagundes
- Laboratório de Endocrinologia Molecular e Celular LIM/25, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - Berenice B Mendonca
- Laboratório de Hormônios e Genética Molecular LIM/42, Laboratório de Sequenciamento em Larga Escala (SELA), Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - Delmar Muniz Lourenço Junior
- Laboratório de Endocrinologia Molecular e Celular LIM/25, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - Ana O Hoff
- Divisão de Endocrinologia e Metabologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Luciana Audi Castroneves
- Divisão de Endocrinologia e Metabologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Bruno Ferraz-de-Souza
- Laboratório de Endocrinologia Celular e Molecular LIM/25, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo 01246-903, Brazil
- School of Medicine, University of Notre Dame Australia, Fremantle WA 6160, Australia
| | - Maria Lucia Cardillo Correa Giannella
- Laboratório de Carboidratos e Radioimunoensaio LIM/18, Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - Maria Adelaide Albergaria Pereira
- Divisão de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
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Ding Y, Li L, Han D, Wang S, Chen X. Head and Neck Malignant Paragangliomas: Experience from a Single Institution. EAR, NOSE & THROAT JOURNAL 2024; 103:298-304. [PMID: 34654328 DOI: 10.1177/01455613211052338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: To summarize the clinicopathological and genetic features of malignant paragangliomas in head and neck cancer and to explore the appropriate treatment options for this rare lesion. Methods: Six patients harboring head and neck malignant paraganglioma from Beijing Tongren Hospital were retrospectively reviewed. The clinicopathological characteristics, gene mutations, and prognosis of these patients were analyzed. Results: Of these 6 patients, 3 were male and 3 were female; 4 patients harbored malignant carotid body tumors, and two had malignant vagal paragangliomas. Three patients had cervical lymph node metastasis, two presented with lung and bone metastasis, and 1 had lung and liver metastasis. Of the 6 patients, four underwent surgical resection, and the other two patients denied surgery and instead received chemotherapy with paclitaxel, ifosfamide, and dacarbazine. These 2 patients with vagal paraganglioma received postoperative radiotherapy. All 6 patients are still alive at the present time, with a median follow-up time of 66 months. Positive Ki-67 expression in tumor tissue ranged from 1% to 40%. Genetic mutations in SDHD, SDHB, ATR, and MAP3K13 were identified in 4 patients. Conclusions: After comprehensive treatment, head and neck malignant paraganglioma can attain a favorable prognosis. Genetic mutations are commonly detected in patients with malignant paragangliomas. This study also identified mutations in ATR and MAP3K13 in these patients.
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Affiliation(s)
- Yiming Ding
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University, Beijing, China
| | - Lifeng Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University, Beijing, China
| | - Demin Han
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University, Beijing, China
| | - Shaozhong Wang
- Otolaryngology of Qinghai Provincial People's Hospital, Xining, Qinghai Province, China
| | - Xiaohong Chen
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology Head and Neck Surgery, Ministry of Education, Capital Medical University, Beijing, China
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5
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Milinkovic M, Soldatovic I, Zivaljevic V, Bozic V, Zivotic M, Tatic S, Dundjerovic D. Comprehensive Investigation of Angiogenesis, PASS Score and Immunohistochemical Factors in Risk Assessment of Malignancy for Paraganglioma and Pheochromocytoma. Diagnostics (Basel) 2024; 14:849. [PMID: 38667494 PMCID: PMC11049119 DOI: 10.3390/diagnostics14080849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
A challenging task in routine practice is finding the distinction between benign and malignant paragangliomas and pheochromocytomas. The aim of this study is to conduct a comparative analysis of angiogenesis by assessing intratumoral microvascular density (MVD) with immunohistochemical (IHC) markers (CD31, CD34, CD105, ERG), and S100 immunoreactivity, Ki67 proliferative index, succinate dehydrogenase B (SDHB) expressiveness, tumor size with one the most utilized score Pheochromocytoma of Adrenal Gland Scales Score (PASS), using tissue microarray (TMA) with 115 tumor samples, 61 benign (PASS < 4) and 54 potentially malignant (PASS ≥ 4). We found no notable difference between intratumoral MVD and potentially malignant behavior. The group of potentially malignant tumors is significantly larger in size, has lower intratumoral MVD, and a decreased number of S100 labeled sustentacular cells. Both groups have low proliferative activity (mean Ki67 is 1.02 and 1.22, respectively). Most tumors maintain SDHB expression, only 6 cases (5.2%) showed a loss of expression (4 of them in PASS < 4 group and 2 in PASS ≥ 4). PASS score is easily available for assessment and complemented with markers of biological behavior to complete the risk stratification algorithm. Size is directly related to PASS score and malignancy. Intratumoral MVD is extensively developed but it is not crucial in evaluating the malignant potential.
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Affiliation(s)
- Marija Milinkovic
- Department of Pathology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Ivan Soldatovic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Vladan Zivaljevic
- Clinic for Endocrine Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Vesna Bozic
- Department of Pathology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | - Maja Zivotic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (S.T.); (D.D.)
| | - Svetislav Tatic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (S.T.); (D.D.)
| | - Dusko Dundjerovic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (M.Z.); (S.T.); (D.D.)
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Qin S, Xu Y, Yu S, Han W, Fan S, Ai W, Zhang K, Wang Y, Zhou X, Shen Q, Gong K, Sun L, Zhang Z. Molecular classification and tumor microenvironment characteristics in pheochromocytomas. eLife 2024; 12:RP87586. [PMID: 38407266 PMCID: PMC10942623 DOI: 10.7554/elife.87586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Pheochromocytomas (PCCs) are rare neuroendocrine tumors that originate from chromaffin cells in the adrenal gland. However, the cellular molecular characteristics and immune microenvironment of PCCs are incompletely understood. Here, we performed single-cell RNA sequencing (scRNA-seq) on 16 tissues from 4 sporadic unclassified PCC patients and 1 hereditary PCC patient with Von Hippel-Lindau (VHL) syndrome. We found that intra-tumoral heterogeneity was less extensive than the inter-individual heterogeneity of PCCs. Further, the unclassified PCC patients were divided into two types, metabolism-type (marked by NDUFA4L2 and COX4I2) and kinase-type (marked by RET and PNMT), validated by immunohistochemical staining. Trajectory analysis of tumor evolution revealed that metabolism-type PCC cells display phenotype of consistently active metabolism and increased metastasis potential, while kinase-type PCC cells showed decreased epinephrine synthesis and neuron-like phenotypes. Cell-cell communication analysis showed activation of the annexin pathway and a strong inflammation reaction in metabolism-type PCCs and activation of FGF signaling in the kinase-type PCC. Although multispectral immunofluorescence staining showed a lack of CD8+ T cell infiltration in both metabolism-type and kinase-type PCCs, only the kinase-type PCC exhibited downregulation of HLA-I molecules that possibly regulated by RET, suggesting the potential of combined therapy with kinase inhibitors and immunotherapy for kinase-type PCCs; in contrast, the application of immunotherapy to metabolism-type PCCs (with antigen presentation ability) is likely unsuitable. Our study presents a single-cell transcriptomics-based molecular classification and microenvironment characterization of PCCs, providing clues for potential therapeutic strategies to treat PCCs.
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Affiliation(s)
- Sen Qin
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Yawei Xu
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Shimiao Yu
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Wencong Han
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Shiheng Fan
- Shenzhen Institute of Ladder for Cancer ResearchShenzhenChina
| | - Wenxiang Ai
- Shenzhen Institute of Ladder for Cancer ResearchShenzhenChina
| | - Kenan Zhang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Yizhou Wang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Xuehong Zhou
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Qi Shen
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Kan Gong
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Luyang Sun
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
| | - Zheng Zhang
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Department of Urology, Peking University First Hospital, Peking University Health Science CenterBeijingChina
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Sharma S, Fishbein L. Diagnosis and Management of Pheochromocytomas and Paragangliomas: A Guide for the Clinician. Endocr Pract 2023; 29:999-1006. [PMID: 37586639 DOI: 10.1016/j.eprac.2023.07.027] [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: 05/08/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE The aim of this review was to provide a practical approach for clinicians regarding the diagnosis and management of pheochromocytomas and paragangliomas (PPGLs). METHODS A literature search of PubMed was carried out using key words, including pheochromocytoma, paraganglioma, treatment, diagnosis, screening, and management. The discussion of diagnosis and management of PPGL is based on the evidence available from prospective studies when available and mostly from cohort studies, cross-sectional studies, and expert consensus. RESULTS PPGL are neuroendocrine tumors arising from the chromaffin cells of adrenal medulla and sympathetic and parasympathetic ganglia, respectively. PPGL can be localized or metastatic, and they may secrete catecholamines, causing a variety of symptoms and potentially catastrophic and lethal complications if left untreated. The rarity of these tumors along with heterogeneous clinical presentation often poses challenges for the diagnosis and management. PPGL can be associated with several familial syndromes which are important to recognize. CONCLUSION The last few years have witnessed an exponential growth in the knowledge around PPGL. This review aims at providing a comprehensive discussion of current concepts for clinicians regarding clinical presentation, diagnostic tools, and management strategies for PPGL.
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Affiliation(s)
- Sona Sharma
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Duke University, Durham, North Carolina
| | - Lauren Fishbein
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Rocky Mountain Regional Veteran's Administration Medical Center, Endocrinology Section, University of Colorado School of Medicine, Aurora, Colorado.
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de la Fouchardière C, Haissaguerre M, Decaussin-Petrucci M, Renaudin K, Deschamps F, Mirallié E, Murez T, Pattou F, Rocher L, Savoie PH, Faron M, Taieb D, Tabarin A, Bertherat J, Gimenez-Roqueplo AP, Amar L, Baudin E, Libé R. [French recommendations for malignant pheochromocytomas and paragangliomas by the national ENDOCAN-COMETE network]. Bull Cancer 2023; 110:1063-1083. [PMID: 37573200 DOI: 10.1016/j.bulcan.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/22/2023] [Accepted: 06/05/2023] [Indexed: 08/14/2023]
Abstract
Pheochromocytomas and paragangliomas are rare neuroendocrine tumors, developed respectively in the adrenal medulla and in extra-adrenal locations. Their malignancy is defined by the presence of distant metastases. Forty percent of them are inherited and can be part of different hereditary syndromes. Their management is ensured in France by the multidisciplinary expert centers of the ENDOCAN-COMETE national network "Cancers of the Adrenal gland", certified by the National Cancer Institute and discussed within multidisciplinary team meetings. The diagnostic and therapeutic work-up must be standardized, based on an expert analysis of clinical symptoms, hormonal biological secretions, genetics, morphological and specific metabolic imaging. In the context of a heterogeneous survival sometimes beyond seven to ten years, therapeutic intervention must be justified. This is multidisciplinary and relies on surgery, interventional radiology, external or internal radiotherapy and medical treatments such as sunitinib or dacarbazine and temodal chemotherapy. The personalized approach based on functional imaging fixation status and genetics is progressing despite the extreme rarity of this disease.
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Affiliation(s)
| | - Magalie Haissaguerre
- CHU de Bordeaux, hôpital Haut Lévêque, service d'endocrinologie, centre coordonnateur ENDOCAN-COMETE, Pessac, France
| | | | - Karine Renaudin
- CHU de Nantes, hôpital Hôtel-Dieu, anatomo-pathologie, Nantes, France
| | - Fréderic Deschamps
- Gustave-Roussy Cancer Campus, département de radiologie interventionnelle, Villejuif, France
| | - Eric Mirallié
- CHU de Nantes, hôpital Hôtel-Dieu, chirurgie cancérologique, digestive et endocrinienne, Institut des maladies de l'appareil digestif, Nantes, France
| | - Thibaut Murez
- CHU de Montpellier, département d'urologie et transplantation rénale, Montpellier, France
| | - François Pattou
- CHRU de Lille, département de chirurgie endocrinienne et métabolique, Lille, France
| | - Laurence Rocher
- Université Paris-Saclay, BIOMAPS, hôpital Antoine-Béclère, service de radiologie, Clamart, France
| | - Pierre-Henri Savoie
- Hôpital d'instruction des Armées Sainte-Anne, service d'urologie, Toulon, France
| | - Matthieu Faron
- Gustave-Roussy Cancer Campus, service de chirurgie viscérale oncologique, Villejuif, France
| | - David Taieb
- La Timone University Hospital, CERIMED, Aix-Marseille University, département de médecine nucléaire, Marseille, France
| | - Antoine Tabarin
- CHU de Bordeaux, hôpital Haut Lévêque, service d'endocrinologie, centre coordonnateur ENDOCAN-COMETE, Pessac, France
| | - Jérôme Bertherat
- Hôpital Cochin, CHU de Paris-Centre, service d'endocrinologie, centre coordonnateur ENDOCAN-COMETE, Paris, France
| | | | - Laurence Amar
- Hôpital européen Georges-Pompidou, service d'hypertension artérielle, Paris, France
| | - Eric Baudin
- Gustave-Roussy Cancer Campus, service de cancérologie endocrine, centre coordonnateur ENDOCAN-COMETE, Villejuif, France
| | - Rossella Libé
- Hôpital Cochin, CHU de Paris-Centre, service d'endocrinologie, centre coordonnateur ENDOCAN-COMETE, Paris, France.
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Pamporaki C, Berends AMA, Filippatos A, Prodanov T, Meuter L, Prejbisz A, Beuschlein F, Fassnacht M, Timmers HJLM, Nölting S, Abhyankar K, Constantinescu G, Kunath C, de Haas RJ, Wang K, Remde H, Bornstein SR, Januszewicz A, Robledo M, Lenders JWM, Kerstens MN, Pacak K, Eisenhofer G. Prediction of metastatic pheochromocytoma and paraganglioma: a machine learning modelling study using data from a cross-sectional cohort. Lancet Digit Health 2023; 5:e551-e559. [PMID: 37474439 PMCID: PMC10565306 DOI: 10.1016/s2589-7500(23)00094-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Pheochromocytomas and paragangliomas have up to a 20% rate of metastatic disease that cannot be reliably predicted. This study prospectively assessed whether the dopamine metabolite, methoxytyramine, might predict metastatic disease, whether predictions might be improved using machine learning models that incorporate other features, and how machine learning-based predictions compare with predictions made by specialists in the field. METHODS In this machine learning modelling study, we used cross-sectional cohort data from the PMT trial, based in Germany, Poland, and the Netherlands, to prospectively examine the utility of methoxytyramine to predict metastatic disease in 267 patients with pheochromocytoma or paraganglioma and positive biochemical test results at initial screening. Another retrospective dataset of 493 patients with these tumors enrolled under clinical protocols at National Institutes of Health (00-CH-0093) and the Netherlands (PRESCRIPT trial) was used to train and validate machine learning models according to selections of additional features. The best performing machine learning models were then externally validated using data for all patients in the PMT trial. For comparison, 12 specialists provided predictions of metastatic disease using data from the training and external validation datasets. FINDINGS Prospective predictions indicated that plasma methoxytyramine could identify metastatic disease at sensitivities of 52% and specificities of 85%. The best performing machine learning model was based on an ensemble tree classifier algorithm that used nine features: plasma methoxytyramine, metanephrine, normetanephrine, age, sex, previous history of pheochromocytoma or paraganglioma, location and size of primary tumours, and presence of multifocal disease. This model had an area under the receiver operating characteristic curve of 0·942 (95% CI 0·894-0·969) that was larger (p<0·0001) than that of the best performing specialist before (0·815, 0·778-0·853) and after (0·812, 0·781-0·854) provision of SDHB variant data. Sensitivity for prediction of metastatic disease in the external validation cohort reached 83% at a specificity of 92%. INTERPRETATION Although methoxytyramine has some utility for prediction of metastatic pheochromocytomas and paragangliomas, sensitivity is limited. Predictive value is considerably enhanced with machine learning models that incorporate our nine recommended features. Our final model provides a preoperative approach to predict metastases in patients with pheochromocytomas and paragangliomas, and thereby guide individualised patient management and follow-up. FUNDING Deutsche Forschungsgemeinschaft.
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Affiliation(s)
| | - Annika M A Berends
- Department of Endocrinology, Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Angelos Filippatos
- University Hospital Carl Gustav Carus, Institute of Lightweight Engineering and Polymer Technology, TU Dresden, Dresden, Germany; Machine Design Laboratory, Department of Mechanical Engineering & Aeronautics, University of Patras, Patras, Greece
| | - Tamara Prodanov
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Leah Meuter
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - Felix Beuschlein
- Department of Internal Medicine IV, University Hospital LMU, Ludwig Maximilian University of Munich, Munich, Germany; Department of Endocrinology, Diabetology, and Clinical Nutrition, University Hospital, University of Zurich, Zurich, Switzerland
| | - Martin Fassnacht
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University of Würzburg, Würzburg, Germany
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Svenja Nölting
- Department of Internal Medicine IV, University Hospital LMU, Ludwig Maximilian University of Munich, Munich, Germany; Department of Endocrinology, Diabetology, and Clinical Nutrition, University Hospital, University of Zurich, Zurich, Switzerland
| | - Kaushik Abhyankar
- University Hospital Carl Gustav Carus, Institute of Lightweight Engineering and Polymer Technology, TU Dresden, Dresden, Germany
| | | | - Carola Kunath
- Department of Medicine III, TU Dresden, Dresden, Germany
| | - Robbert J de Haas
- Department of Radiology, Medical Imaging Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Katharina Wang
- Department of Internal Medicine IV, University Hospital LMU, Ludwig Maximilian University of Munich, Munich, Germany
| | - Hanna Remde
- Department of Internal Medicine, Division of Endocrinology and Diabetes, University of Würzburg, Würzburg, Germany
| | | | | | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Human Cancer Genetics Programme, Spanish National Cancer Reserch Centre, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Jacques W M Lenders
- Department of Medicine III, TU Dresden, Dresden, Germany; Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology, Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Graeme Eisenhofer
- Department of Medicine III, TU Dresden, Dresden, Germany; Institute of Clinical Chemistry and Laboratory Medicine, TU Dresden, Dresden, Germany
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10
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Hanschell H, Diaz-Cano S, Blanes A, Talat N, Galatá G, Aylwin S, Schulte KM. Lesion-based indicators predict long-term outcomes of pheochromocytoma and paraganglioma- SIZEPASS. Front Endocrinol (Lausanne) 2023; 14:1235243. [PMID: 37600698 PMCID: PMC10436571 DOI: 10.3389/fendo.2023.1235243] [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: 06/06/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Aim We seek a simple and reliable tool to predict malignant behavior of pheochromocytoma and paraganglioma (PPGL). Methods This single-center prospective cohort study assessed size of primary PPGLs on preoperative cross-sectional imaging and prospectively scored specimens using the Pheochromocytoma of the Adrenal Gland Scaled Score (PASS). Multiplication of PASS points with maximum lesion diameter (in mm) yielded the SIZEPASS criterion. Local recurrence, metastasis or death from disease were surrogates defining malignancy. Results 76 consecutive PPGL patients, whereof 58 with pheochromocytoma and 51 female, were diagnosed at a mean age of 52.0 ± 15.2 years. 11 lesions (14.5%) exhibited malignant features at a median follow-up (FU) of 49 months (range 4-172 mo). Median FU of the remaining cohort was 139 months (range 120-226 mo). SIZEPASS classified malignancy with an area under the curve (AUC) of 0.97 (95%CI 0.93-1.01; p<0.0001). Across PPGL, SIZEPASS >1000 outperformed all known predictors of malignancy, with sensitivity 91%, specificity 94%, and accuracy 93%, and an odds ratio of 72 fold (95%CI 9-571; P<0.001). It retained an accuracy >90% in cohorts defined by location (adrenal, extra-adrenal) or mutation status. Conclusions The SIZEPASS>1000 criterion is a lesion-based, clinically available, simple and effective tool to predict malignant behavior of PPGLs independently of age, sex, location or mutation status.
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Affiliation(s)
- Helena Hanschell
- Department of Endocrine Surgery, Division of Surgery, King’s College Hospital Foundation Trust, London, United Kingdom
| | - Salvador Diaz-Cano
- Reader in Cellular and Molecular Pathology (Division of Cancer Studies), King’s Health Partners, London, United Kingdom
| | - Alfredo Blanes
- Department of Pathology, University Hospital of Malaga, Malaga, Spain
| | - Nadia Talat
- Department of Endocrine Surgery, Division of Surgery, King’s College Hospital Foundation Trust, London, United Kingdom
| | - Gabriele Galatá
- Department of Endocrine Surgery, Division of Surgery, King’s College Hospital Foundation Trust, London, United Kingdom
| | - Simon Aylwin
- Department of Endocrinology, Division of Medicine, King’s College Hospital Foundation Trust, London, United Kingdom
| | - Klaus Martin Schulte
- Department of Endocrine Surgery, Division of Surgery, King’s College Hospital Foundation Trust, London, United Kingdom
- Department of Surgery, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, ACT, Australia
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11
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Genotype-Phenotype Correlations and Clinical Outcomes in 155 Cases of Pheochromocytoma and Paraganglioma. World J Surg 2023; 47:690-698. [PMID: 36550325 DOI: 10.1007/s00268-022-06862-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumours, often associated with germline mutations that influence the disease biology and clinical course. We aimed to describe the genotypic and phenotypic characteristics of a consecutive series of PPGL patients and correlate mutation status with clinical outcomes. METHODS We performed a retrospective cohort study of all PPGL patients who presented to a tertiary referral centre between March 2005 and February 2022. Genotypic, phenotypic and follow-up data were analysed. RESULTS A total of 140 patients were included. Of these, 94 (67%) patients underwent genetic testing and a mutation was detected in 36 (38%) patients. Mutation presence was associated with younger age, smaller tumour size and bilateral adrenal tumours. Disease recurrence occurred at a median time of 5.4 (IQR 2.8-11.0) years after treatment in 21 (15%) patients, of which 14 (67%) had a mutation in a susceptibility gene. Recurrence pattern was influenced by mutation type; higher local recurrence risk for SDHA, SDHB, and MEN2B disease, and higher metastatic risk for SDHB, VHL and MEN2A disease. Recurrence occurred in three (3%) patients with mutation absence. Multivariate analysis revealed that age ≤40 years and mutation presence were associated with increased risk of disease recurrence. CONCLUSIONS Genotypic characteristics strongly influence disease presentation and recurrence risk, which may occur more than 5 years after initial treatment. Routine genetic testing of PPGL patients is warranted given the high prevalence of mutations, allowing for prognostication and tailored follow-up. In the presence of germline mutations, follow-up should be life-long.
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12
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Advances in Adrenal and Extra-adrenal Paraganglioma: Practical Synopsis for Pathologists. Adv Anat Pathol 2023; 30:47-57. [PMID: 36136370 DOI: 10.1097/pap.0000000000000365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Adrenal paraganglioma (or "pheochromocytoma") and extra-adrenal paraganglioma, collectively abbreviated PPGL, are rare but spectacular nonepithelial neuroendocrine neoplasms. These are the most inheritable neoplasia of all, with a metastatic potential in a varying degree. As of such, these lesions demand careful histologic, immunohistochemical, and genetic characterization to provide the clinical team with a detailed report taking into account the anticipated prognosis and risk of syndromic/inherited disease. While no histologic algorithm, immunohistochemical biomarker, or molecular aberration single-handedly can identify potentially lethal cases upfront, the combined analysis of various risk parameters may stratify PPGL patients more stringently than previously. Moreover, the novel 2022 WHO Classification of Endocrine and Neuroendocrine Tumors also brings some new concepts into play, not least the reclassification of special neuroendocrine neoplasms (cauda equina neuroendocrine tumor and composite gangliocytoma/neuroma-neuroendocrine tumor) previously thought to belong to the spectrum of PPGL. This review focuses on updated key diagnostic and prognostic concepts that will aid when facing this rather enigmatic tumor entity in clinical practice.
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13
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Jin B, Han W, Guo J, Tian J, He S, Gong Y, Zhou J, He Q, Shen Q, Zhang Z. Initial characterization of immune microenvironment in pheochromocytoma and paraganglioma. Front Genet 2022; 13:1022131. [PMID: 36568391 PMCID: PMC9768187 DOI: 10.3389/fgene.2022.1022131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
Due to fewer adverse events, faster onset of action, and longer durable responses compared to chemotherapy, immunotherapy has been widely used to treat advanced solid tumors. Moreover, immunotherapy can improve the autoimmune status, thus allowing patients to benefit from the treatment in the long term. The immune microenvironment status is closely associated with the response to chemotherapies. Here, we analyzed the characteristics of the immune microenvironment in pheochromocytoma and paraganglioma (PPGL). Immunohistochemistry showed that PD-L1 is sparely expressed in PPGL with low positive rates and low expression levels, an expression pattern, that is, not correlated with tumor malignancy. Moreover, the level of intratumoral CD4+ and CD8+ lymphocyte infiltration in PPGL is low, suggesting that the immune microenvironment in PPGL may be in "immune desertification" or "immune rejection" states in which CD4+ and CD8+ lymphocyte infiltration is prevented, rendering immunotherapy less effective. In sum, our results indicate that PPGL is a microsatellite-stable tumor with low tumor mutational burden (TMB) levels, weak neoantigen production, and poor tumor antigenicity, hinting at a poor response of PPGL to chemotherapies.
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Affiliation(s)
- Bo Jin
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Wencong Han
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China
| | - Jingjing Guo
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Jie Tian
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China
| | - Shiming He
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China
| | - Yanqing Gong
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China
| | - Jingcheng Zhou
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China
| | - Qun He
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China
| | - Qi Shen
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China,*Correspondence: Zheng Zhang, ; Qi Shen,
| | - Zheng Zhang
- Department of Urology, Peking University First Hospital, Peking University, Beijing, China,Institute of Urology, Peking University, Beijing, China,National Urological Cancer Center, Beijing, China,*Correspondence: Zheng Zhang, ; Qi Shen,
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14
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Savoie PH, Murez T, Neuville P, Van Hove A, Rocher L, Fléchon A, Camparo P, Ferretti L, Branger N, Rouprêt M. French AFU Cancer Committee Guidelines Update 2022-2024: Adrenal tumor - Assessment of an adrenal incidetaloma and oncological management. Prog Urol 2022; 32:1040-1065. [PMID: 36400477 DOI: 10.1016/j.purol.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The objective of this publication is to recall the initial work-up when faced with an adrenal incidentaloma and, if necessary, to establish the oncological management of an adrenal malignant tumor. MATERIAL AND METHODS The multidisciplinary working group updated French urological guidelines about oncological assessment of the adrenal incidentaloma, established by the CCAFU in 2020, based on an exhaustive literature review carried out on PubMed. RESULTS Although the majority of the adrenal masses are benign and non-functional, it is important to investigate them, as a percentage of these can cause serious endocrine diseases or be cancers. Malignant adrenal tumors are mainly represented by adrenocortical carcinomas (ACC), malignant pheochromocytomas (MPC) and adrenal metastases (AM). The malignancy assessment of an adrenal incident includes a complete history, a physical examination, a biochemical/hormonal assessment to look for subclinical hormonal secretion. Diagnostic hypotheses are sometimes available at this stage, but it is the morphological and functional imaging and the histological analysis, which will make it possible to close the malignancy assessment and make the oncological diagnosis. CONCLUSIONS ACC and MPC are mainly sporadic but a hereditary origin is always possible. ACC is suspected preoperatively but the diagnosis of certainty is histological. The diagnosis of MPC is more delicate and is based on clinic, biology and imagery. The diagnosis of certainty of AM requires a percutaneous biopsy. At the end, the files must be discussed within the COMETE - adrenal cancer network (Appendix 1).
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Affiliation(s)
- P H Savoie
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de chirurgie urologique, hôpital d'instruction des armées Sainte-Anne, 2, boulevard Sainte-Anne, BP 600, 83800 Toulon cedex 09, France.
| | - T Murez
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et de transplantation rénale, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
| | - P Neuville
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - A Van Hove
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Hôpital européen, 6, rue Désirée-Clary, 13003 Marseille, France
| | - L Rocher
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, hôpital Antoine-Béclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Université Paris-Saclay, BIOMAPS, 63, avenue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France
| | - A Fléchon
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - P Camparo
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Institut de pathologie des Hauts-de-France, 51, rue Jeanne-d'Arc, 80000 Amiens, France
| | - L Ferretti
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; MSP Bordeaux Bagatelle, 203, route de Toulouse, 33401 Talence, France
| | - N Branger
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille, France
| | - M Rouprêt
- Comité de Cancérologie de l'Association française d'urologie, groupe organes génitaux externes, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et transplantation rénale, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
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15
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Bima C, Bioletto F, Lopez C, Bollati M, Arata S, Procopio M, Gesmundo I, Ghigo E, Maccario M, Parasiliti-Caprino M. Clinical and Pathological Tools for Predicting Recurrence and/or Metastasis in Patients with Pheochromocytoma and Paraganglioma. Biomedicines 2022; 10:biomedicines10081813. [PMID: 36009360 PMCID: PMC9404897 DOI: 10.3390/biomedicines10081813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
Pheochromocytomas and paragangliomas are endocrine tumors belonging to the family of neural crest cell-derived neoplasms. They have an extremely variable clinical course, characterized by a non-negligible percentage of relapse and/or metastasis after radical surgery. To date, there are no reliable methods to predict the metastatic potential of these neoplasms, despite several clinical, molecular, and histopathological factors that have been extensively studied in the literature as predictors of the recurrence and/or metastasis in these neoplasms with different performances and results. In this review, we aimed to discuss and analyze the most important clinical and histopathological tools for predicting recurrence risk in patients affected by pheochromocytomas or paragangliomas. Thus, we compared the main available predictive models, exploring their applications in stratifying patients’ risks. In conclusion, we underlined the importance of simple and validated tools to better define disease aggressiveness and establish tailored patients’ treatments and follow-ups.
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16
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Kimura N, Ishikawa M, Shigematsu K. Colorectal paragangliomas with immunohistochemical deficiency of succinate dehydrogenase subunit B. Endocr J 2022; 69:523-528. [PMID: 34853215 DOI: 10.1507/endocrj.ej21-0630] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Recent progress in paraganglioma (PGL) revealed genotype-phenotype relationship, especially succinate dehydrogenase complex subunit B (SDHB) gene mutation-related to the extra-adrenal origin and metastasis. SDHB-immunohistochemistry can detect all types of SDH-subunit mutations, and is a useful tool to detect SDH-mutation tumors. PGLs usually occur along with sympathetic, and parasympathetic chains, however, colorectal paraganglioma is extremely rare. We have experienced one sigmoid colon PGL and one rectal PGL. These colorectal PGLs: a sigmoid colon PGL measuring 25 mm associated with a gastrointestinal stromal tumor (GIST) of the stomach, and a rectal PGL measuring 75 × 45 mm with elevated norepinephrine level were analyzed by immunohistochemistry for INSM1, chromogranin A, synaptophysin, tyrosine hydroxylase, dopamine-beta-hydroxylase, and SDHB and SDHA. The tumors were strongly positive for above markers, however, negative for SDHB. Both PGLs negative for SDHB immunohistochemistry were defined SDHB-deficient PGLs. Histologic grading of the PGLs by GAPP was well differentiated in sigmoid PGL versus poorly differentiated in rectal PGL. Although these PGLs were the same Stage II of TNM classification, the patient with sigmoid colon PGL had neither recurrence nor metastasis for 5 years after the operation, however, the patient with rectal PGL suffered the recurrent multiple metastases and expired 5 years after the operation. Herein, we compared these colorectal PGLs in regard to the patients' prognostic factors. Patient prognosis with these colorectal PGLs was mostly related to the tumor size and histologic grade under the same situation of SDH-deficiency.
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Affiliation(s)
- Noriko Kimura
- Department of Clinical Research, and Department of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate 041-8512, Japan
| | - Misawo Ishikawa
- Department of Diagnostic Pathology, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi 498-8502, Japan
| | - Kazuto Shigematsu
- Department of Pathology, Japanese Red Cross, Nagasaki-Genbaku Hospital, Nagasaki 852-8511, Japan
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17
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Mete O, Asa SL, Gill AJ, Kimura N, de Krijger RR, Tischler A. Overview of the 2022 WHO Classification of Paragangliomas and Pheochromocytomas. Endocr Pathol 2022; 33:90-114. [PMID: 35285002 DOI: 10.1007/s12022-022-09704-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 12/12/2022]
Abstract
This review summarizes the classification of tumors of the adrenal medulla and extra-adrenal paraganglia as outlined in the 5th series of the WHO Classification of Endocrine and Neuroendocrine Tumors. The non-epithelial neuroendocrine neoplasms (NENs) known as paragangliomas produce predominantly catecholamines and secrete them into the bloodstream like hormones, and they represent a group of NENs that have exceptionally high genetic predisposition. This classification discusses the embryologic derivation of the cells that give rise to these lesions and the historical evolution of the terminology used to classify their tumors; paragangliomas can be sympathetic or parasympathetic and the term pheochromocytoma is used specifically for intra-adrenal paragangliomas that represent the classical sympathetic form. In addition to the general neuroendocrine cell biomarkers INSM1, synaptophysin, and chromogranins, these tumors are typically negative for keratins and instead have highly specific biomarkers, including the GATA3 transcription factor and enzymes involved in catecholamine biosynthesis: tyrosine hydroxylase that converts L-tyrosine to L-DOPA as the rate-limiting step in catecholamine biosynthesis, dopamine beta-hydroxylase that is present in cells expressing norepinephrine, and phenylethanolamine N-methyltransferase, which converts norepinephrine to epinephrine and therefore can be used to distinguish tumors that make epinephrine. In addition to these important tools that can be used to confirm the diagnosis of a paraganglioma, new tools are recommended to determine genetic predisposition syndromes; in addition to the identification of precursor lesions, molecular immunohistochemistry can serve to identify associations with SDHx, VHL, FH, MAX, and MEN1 mutations, as well as pseudohypoxia-related pathogenesis. Paragangliomas have a well-formed network of sustentacular cells that express SOX10 and S100, but this is not a distinctive feature, as other epithelial NENs also have sustentacular cells. Indeed, it is the presence of such cells and the association with ganglion cells that led to a misinterpretation of several unusual lesions as paragangliomas; in the 2022 WHO classification, the tumor formerly known as cauda equina paraganglioma is now classified as cauda equina neuroendocrine tumor and the lesion known as gangliocytic paraganglioma has been renamed composite gangliocytoma/neuroma and neuroendocrine tumor (CoGNET). Since the 4th edition of the WHO, paragangliomas have no longer been classified as benign and malignant, as any lesion can have metastatic potential and there are no clear-cut features that can predict metastatic behavior. Moreover, some tumors are lethal without metastatic spread, by nature of local invasion involving critical structures. Nevertheless, there are features that can be used to identify more aggressive lesions; the WHO does not endorse the various scoring systems that are reviewed but also does not discourage their use. The identification of metastases is also complex, particularly in patients with germline predisposition syndromes, since multiple lesions may represent multifocal primary tumors rather than metastatic spread; the identification of paragangliomas in unusual locations such as lung or liver is not diagnostic of metastasis, since these may be primary sites. The value of sustentacular cells and Ki67 labeling as prognostic features is also discussed in this new classification. A staging system for pheochromocytoma and extra-adrenal sympathetic PGLs, introduced in the 8th Edition AJCC Cancer Staging Manual, is now included. This paper also provides a summary of the criteria for the diagnosis of a composite paragangliomas and summarizes the classification of neuroblastic tumors. This review adopts a practical question-answer framework to provide members of the multidisciplinary endocrine oncology team with a most up-to-date approach to tumors of the adrenal medulla and extra-adrenal paraganglia.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON, Canada.
- Endocrine Oncology Site, Princess Margaret Cancer Centre, Toronto, ON, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Anthony J Gill
- Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Sydney, Australia
| | - Noriko Kimura
- Department of Clinical Research, Division of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
| | - Ronald R de Krijger
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arthur Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
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18
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Pheochromocytomas and Abdominal Paragangliomas: A Practical Guidance. Cancers (Basel) 2022; 14:cancers14040917. [PMID: 35205664 PMCID: PMC8869962 DOI: 10.3390/cancers14040917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare. They can be discovered incidentally by imaging with computed tomography or magnetic resonance imaging and during hormonal surveillance in patients with known genetic variants that are associated with PPGLs. As most PPGLs are functioning, a hormonal work-up evaluating for catecholamine excess is recommended. Classical symptoms, such as tachycardia, hypertension and headache, can be present, but when the PPGL is discovered as an incidentaloma, symptoms may be lacking or be more discrete. PPGLs carry malignant potential, and patients should undergo close surveillance, as recurrence of disease or metastasis may develop. Genetic susceptibility for multifocal disease has gained more attention, and germline variants are commonly detected, thus facilitating detection of hereditary cases and afflicted family members. Any patient with a PPGL should be managed by an expert multidisciplinary team consisting of endocrinologists, radiologists, surgeons, pathologists and clinical geneticists. Abstract Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare tumors arising from the adrenal medulla or the sympathetic nervous system. This review presents a practical guidance for clinicians dealing with PPGLs. The incidence of PPGLs has risen. Most cases are detected via imaging and less present with symptoms of catecholamine excess. Most PPGLs secrete catecholamines, with diffuse symptoms. Diagnosis is made by imaging and tests of catecholamines. Localized disease can be cured by surgery. PPGLs are the most heritable of all human tumors, and germline variants are found in approximately 30–50% of cases. Such variants can give information regarding the risk of developing recurrence or metastases as well as the risk of developing other tumors and may identify relatives at risk for disease. All PPGLs harbor malignant potential, and current histological and immunohistochemical algorithms can aid in the identification of indolent vs. aggressive tumors. While most patients with metastatic PPGL have slowly progressive disease, a proportion of patients present with an aggressive course, highlighting the need for more effective therapies in these cases. We conclude that PPGLs are rare but increasing in incidence and management should be guided by a multidisciplinary team.
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Kakizawa K, Yamashita M, Nakashima M, Kawauchi Y, Ikeya A, Matsushita A, Sasaki S, Oki Y. Retroperitoneal Paraganglioma With Asymptomatic Follicular Lymphoma: A Case Report. J Endocr Soc 2021; 5:bvab171. [PMID: 34877445 PMCID: PMC8645164 DOI: 10.1210/jendso/bvab171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Paraganglioma (PGL) is a rare tumor originating from extra-adrenal paraganglionic chromaffin tissues, and most sympathetic PGLs have excessive catecholamine secretion. However, nonfunctional PGLs are sometimes found. Although malignant PGL is defined by metastasis to nonchromaffin tissues, it is difficult to predict malignancies due to the lack of reliable markers of potential malignancies. We report the case of a 69-year-old Japanese woman with an incidental retroperitoneal tumor and multiple enlarged mesenteric lymph nodes simultaneously. The patient had no subjective symptoms and there were no laboratory findings suggesting catecholamine hypersecretion. Both the retroperitoneal tumor and the enlarged mesenteric lymph nodes showed high accumulation of fluorodeoxyglucose (FDG), whereas metaiodobenzylguanidine (MIBG) was accumulated only at the retroperitoneal tumor. Although a retroperitoneal tumor was diagnosed as nonfunctional PGL by examination including MIBG scintigraphy, the cause of enlarged mesenteric lymph nodes could not be diagnosed by imaging and biochemical tests. As a result of retroperitoneal tumor resection and mesenteric lymph nodes sampling, histopathological examination revealed that a retroperitoneal tumor was PGL and enlarged mesenteric lymph nodes were follicular lymphoma. To reveal an underlying genetic factor, we performed whole exome sequencing of genomic DNA, and we identified 2 possible candidate variants in SDHD and DLST, but the pathogenicity of these variants remains uncertain in the present case. This rare case reinforces the importance of histopathological diagnosis of nonchromaffin tissue lesions in patients with PGL for the appropriate treatment strategy.
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Affiliation(s)
- Keisuke Kakizawa
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Miho Yamashita
- Department of Internationalization Center, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Mitsuko Nakashima
- Department of Biochemistry, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yuto Kawauchi
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Akira Ikeya
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Akio Matsushita
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Shigekazu Sasaki
- Second Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Yutaka Oki
- Department of Internal Medicine, Hamamatsu Kita Hospital, Hamamatsu, Shizuoka, 431-3113, Japan
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20
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Snezhkina A, Pavlov V, Dmitriev A, Melnikova N, Kudryavtseva A. Potential Biomarkers of Metastasizing Paragangliomas and Pheochromocytomas. Life (Basel) 2021; 11:1179. [PMID: 34833055 PMCID: PMC8619623 DOI: 10.3390/life11111179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/28/2021] [Accepted: 10/30/2021] [Indexed: 02/07/2023] Open
Abstract
Paragangliomas and pheochromocytomas (PPGLs) are rare neuroendocrine tumors originating from paraganglionic tissue in many sites of the body. Most PPGLs are characterized by nonaggressive behavior but all of them have the potential to metastasize. PPGLs represent a great diagnostic dilemma as it is difficult to recognize tumors that are likely to be metastasizing; criteria of malignancy can be found both in benign and metastatic forms. This review aims to analyze the current knowledge of the nature of metastasizing PPGLs paying particular attention to head and neck paragangliomas (HNPGLs). Potential predictors of the malignancy risk for PPGLs were summarized and discussed. These data may also help in the development of diagnostic and prognostic strategies, as well as in the identification of novel potential therapeutic targets for patients with PPGLs.
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Affiliation(s)
- Anastasiya Snezhkina
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (V.P.); (A.D.); (N.M.)
| | | | | | | | - Anna Kudryavtseva
- Engelhardt Institute of Molecular Biology, Russian Academy of Sciences, 119991 Moscow, Russia; (V.P.); (A.D.); (N.M.)
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21
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Fukuzawa T, Yamaki S, Irie M, Sasaki H, Kudo H, Nakamura M, Ando R, Okubo R, Endo Y, Hashimoto M, Tada K, Nakajima Y, Sato K, Endo R, Aoki H, Kuniyoshi S, Saito K, Wada M. Retroperitoneal paraganglioma with hypertensive crisis during laparoscopic surgery. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.102029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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22
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Liu Z, Ma J, Jimenez C, Zhang M. Pheochromocytoma: A Clinicopathologic and Molecular Study of 390 Cases From a Single Center. Am J Surg Pathol 2021; 45:1155-1165. [PMID: 34280940 DOI: 10.1097/pas.0000000000001768] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pheochromocytomas are rare neuroendocrine tumors arising from chromaffin cells in the adrenal medulla. They may occur sporadically or in the context of hereditary syndromes. All pheochromocytomas are considered to have malignant potential (defined as risk of metastasis, not local invasion). The use of grading systems with incorporated clinical and histopathologic parameters can help but not definitively predict the metastatic potential of pheochromocytomas. The recent discovery of susceptibility genes provided new insights into the pathogenesis and introduced additional approaches to estimate the metastatic risk of pheochromocytoma. However, the prevalence of these genetic signatures in pheochromocytomas has yet to be fully addressed. Therefore, in the present study, we retrospectively reviewed cases of pheochromocytoma from 1980 to 2018 in the archives of our institution. Three hundred ninety cases were identified, and their clinicopathologic characteristics and genetic statuses were analyzed. About 25% of the cases had metastases, which were more common in older patients (median, 49 y) than in younger ones. Univariate and multivariate analyses revealed that older age, Hispanic ethnicity, metastasis, and large primary tumor size were markedly associated with poor overall survival. In contrast, family history of pheochromocytoma, lack of symptoms, and bilateral adrenal involvement were associated with better survival. About 37% of the pheochromocytomas were associated with inherited syndromes. About 52% of tested patients had pathogenic mutations of pheochromocytoma susceptibility genes. Of these, succinate dehydrogenase B gene mutation had the strongest association with metastasis. These data support that genetic testing should be offered to all patients with pheochromocytoma.
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Affiliation(s)
| | | | - Camilo Jimenez
- Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX
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23
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Moog S, Castinetti F, DoCao C, Amar L, Hadoux J, Lussey-Lepoutre C, Borson-Chazot F, Vezzosi D, Drui D, Laboureau S, Raffin Sanson ML, Lamartina L, Pierre P, Batisse Ligner M, Hescot S, Al Ghuzlan A, Renaudin K, Libé R, Laroche S, Deniziaut G, Gimenez-Roqueplo AP, Jannin A, Leboulleux S, Guerin C, Faron M, Baudin E. Recurrence-Free Survival Analysis in Locally Advanced Pheochromocytoma: First Appraisal. J Clin Endocrinol Metab 2021; 106:2726-2737. [PMID: 33782697 DOI: 10.1210/clinem/dgab202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT The behavior of locally advanced pheochromocytoma (LAP) remains unknown. OBJECTIVE We characterized the population with LAP and recurrence-free survival (RFS). METHODS This retrospective multicentric study was run within the ENDOCAN-COMETE network and French Group of Endocrine Tumors (GTE) from 2003 to 2018, including patients from 11 French referral centers with LAP as defined by capsular invasion, vascular invasion, adipose tissue invasion, and/or positive locoregional lymph nodes at diagnosis without evidence of distant metastasis. The main outcome measure was recurrence, defined as tumor reappearance, including local site and/or distant metastasis. The primary endpoint was RFS analysis; secondary endpoints were characterization, overall survival (OS), and prognostic factors of recurrence. RESULTS Among 950 patients, 90 (9%) exhibited LAP criteria and 55 met inclusion criteria (median age, 53 years; 61% males; 14% with germline mutation; 84% with catecholamine excess). LAP was defined by 31 (56%) capsular invasions, 27 (49%) fat invasions, 6 (11%) positive lymph nodes, and 22 (40%) vascular invasions. After median follow-up of 54 months (range, 6-180), 12 patients (22%) had recurrences and 3 (5%) died of metastatic disease. Median RFS was 115 months (range, 6-168). Recurrences were local in 2 patients, distant in 2, and both local and distant in 8 patients. Median OS of patients was not reached. Size above 6.5 cm (P = 0.019) and Ki-67 > 2% (P = 0.028) were identified as independent significant prognostic factors in multivariate analysis. CONCLUSION LAP represents 9% of pheochromocytoma's population and has a metastatic behavior. This study paves the way for future pathological TNM classification.
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Affiliation(s)
- Sophie Moog
- Endocrine Oncology Unit, Gustave Roussy, F-94805, Villejuif, France
| | - Frédéric Castinetti
- Aix Marseille Université, INSERM, U1251, Department of Endocrinology, Marseille Medical Genetics (MMG), centre de référence des maladies rares de l'hypophyse (HYPO), hôpital de la Conception, France, Assistance Publique-Hôpitaux de Marseille (AP-HM), 13005 Marseille, France
| | | | - Laurence Amar
- Department of hypertension, AP-HP, Hôpital Européen Georges Pompidou, 75015 Paris, France
- Université de Paris, INSERM, PARCC, Equipe labellisée contre le cancer, F-75015 Paris, France
| | - Julien Hadoux
- Endocrine Oncology Unit, Gustave Roussy, F-94805, Villejuif, France
| | - Charlotte Lussey-Lepoutre
- Université de Paris, INSERM, PARCC, Equipe labellisée contre le cancer, F-75015 Paris, France
- Sorbonne University, Department of Nuclear Medicine, AP-HP, Pitié-Salpêtrière, 75013 Paris, France
| | - Françoise Borson-Chazot
- Fédération d'endocrinologie, Hôpital Louis Pradel, Hospices Civils de Lyon, EA 7425, Université Lyon1, 69500 Lyon, France
| | - Delphine Vezzosi
- Department of Endocrinology, CHU Toulouse, 40031 Toulouse, France
| | - Delphine Drui
- Department of Endocrinology, L'institut du thorax, 44200 CHU Nantes, France
| | | | - Marie-Laure Raffin Sanson
- Department of Endocrinology&Nutrition, AP-HP, Hôpital Ambroise Paré, 92100 Boulogne-Billancourt, France
| | - Livia Lamartina
- Endocrine Oncology Unit, Gustave Roussy, F-94805, Villejuif, France
| | - Peggy Pierre
- Department of Endocrinology, CHU Tours, 37044 Tours, France
| | - Marie Batisse Ligner
- Department of Endocrinology, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Ségolène Hescot
- Médecine Nucléaire, Institut Curie, 35 rue Dailly, 92210 Saint Cloud, France
| | - Abir Al Ghuzlan
- Department of Anatomopathology, Gustave Roussy, 94805 Villejuif, France
| | - Karine Renaudin
- Department of Anatomopathology, CHU de Nantes, 44200 Nantes, France
| | - Rosella Libé
- Department of Endocrinology, AP-HP, Hôpital Cochin, 75014 Paris, France
| | - Suzanne Laroche
- Department of Endocrinology, AP-HP, Hôpital La Pitié Salpêtrière, 75013 Paris, France
| | - Gabrielle Deniziaut
- Department of Anatomopathology, AP-HP, Hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - Anne-Paule Gimenez-Roqueplo
- Université de Paris, INSERM, PARCC, Equipe labellisée contre le cancer, F-75015 Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital européen Georges Pompidou, Service de Génétique, F-75015 Paris, France
| | - Arnaud Jannin
- Department of Endocrinology, CHU Lille, 59000 Lille, France
| | | | - Carole Guerin
- Aix Marseille University, Assistance Publique-Hopitaux de Marseille, Department of Endocrine Surgery, La Conception Hospital, 13005 Marseille, France
| | - Matthieu Faron
- Department of biostatistics and epidemiology and INSERM U1018 CESP équipe ONCOSTAT, Institut Gustave Roussy, 94805 Villejuif, France
| | - Eric Baudin
- Endocrine Oncology Unit, Gustave Roussy, F-94805, Villejuif, France
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24
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Torres-Costa M, Flores B, Torregrosa N, González M, Ríos A, Febrero B, Flores D, Rodríguez P, Carbonell P, Ortuño MI, Rodríguez JM. Malignant prediction in paragangliomas: analysis for clinical risk factors. Langenbecks Arch Surg 2021; 406:2441-2448. [PMID: 34101001 DOI: 10.1007/s00423-021-02222-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Paragangliomas are infrequent neuroendocrine tumours whose only criterion for malignancy is presence of metastases; thus, all paragangliomas show malignant potential. Actually, different risk factors have been analyzed to predict metastases but they remain unclear. PURPOSE To analyze clinical, histological, and genetic factors to predict the occurrence of metastasis. PATIENTS AND METHOD A multicentre retrospective observational analysis was performed between January 1990 and July 2019. Patients diagnosed with paraganglioma were selected. Clinical, histological, and genetic features were analyzed for the prediction of malignancy. RESULTS A total of 83 patients diagnosed with paraganglioma were included, of which nine (10.8%) had malignant paraganglioma. Tumour size was greater in malignant tumours than in benign (6 cm vs. 4 cm, respectively; p = 0.027). The most frequent location of malignancy was the thorax-abdomen-pelvis area observed in six cases (p = 0.024). No differences were observed in histological differentiation, age, symptoms, and catecholaminergic production. The most frequent genetic mutation was SDHD followed by SDHB but no differences were observed between benign and malignant tumours. In the univariate analysis for predictive factors for malignancy, location, tumour size, and histological differentiation showed statistical significance (p = 0.025, p = 0.014, and p = 0.046, respectively); however, they were not confirmed as predictive factors for malignancy in the multivariate analysis. CONCLUSION In this study, no risk factors for malignancy have been established; therefore, we recommend follow-up of all patients diagnosed with paraganglioma.
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Affiliation(s)
- Miquel Torres-Costa
- Department of Surgery, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain.
| | - Benito Flores
- Department of Surgery, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Nuria Torregrosa
- Department of Surgery, Hospital General Universitario Santa Lucía, Cartagena, Spain
| | - Miguel González
- Department of Surgery, Hospital Universitario Reina Sofía, Murcia, Spain
| | - Antonio Ríos
- Department of Surgery, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Beatriz Febrero
- Department of Surgery, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | - Diego Flores
- Department of Surgery, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Pablo Rodríguez
- Department of Surgery, Hospital General Universitario Santa Lucía, Cartagena, Spain
| | - Pablo Carbonell
- Center for Biochemistry and Clinical Genetics, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | - María Isabel Ortuño
- Department of Pathology, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | - José Manuel Rodríguez
- Department of Surgery, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
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25
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Abstract
Abdominal paragangliomas and pheochromocytomas (PPGLs) are rare neuroendocrine tumors of the infradiaphragmatic paraganglia and adrenal medulla, respectively. Although few pathologists outside of endocrine tertiary centers will ever diagnose such a lesion, the tumors are well known through the medical community-possible due to a combination of the sheer rarity, their often-spectacular presentation due to excess catecholamine secretion as well as their unrivaled coupling to constitutional susceptibility gene mutations and hereditary syndromes. All PPGLs are thought to harbor malignant potential, and therefore pose several challenges to the practicing pathologist. Specifically, a responsible diagnostician should recognize both the capacity and limitations of histological, immunohistochemical, and molecular algorithms to pinpoint high risk for future metastatic disease. This focused review aims to provide the surgical pathologist with a condensed update regarding the current strategies available in order to deliver an accurate prognostication of these enigmatic lesions.
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Affiliation(s)
- C Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden.
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden.
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26
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Fishbein L, Del Rivero J, Else T, Howe JR, Asa SL, Cohen DL, Dahia PLM, Fraker DL, Goodman KA, Hope TA, Kunz PL, Perez K, Perrier ND, Pryma DA, Ryder M, Sasson AR, Soulen MC, Jimenez C. The North American Neuroendocrine Tumor Society Consensus Guidelines for Surveillance and Management of Metastatic and/or Unresectable Pheochromocytoma and Paraganglioma. Pancreas 2021; 50:469-493. [PMID: 33939658 DOI: 10.1097/mpa.0000000000001792] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the medical management and surveillance of metastatic and unresectable pheochromocytoma and paraganglioma held on October 2 and 3, 2019. The panelists consisted of endocrinologists, medical oncologists, surgeons, radiologists/nuclear medicine physicians, nephrologists, pathologists, and radiation oncologists. The panelists performed a literature review on a series of questions regarding the medical management of metastatic and unresectable pheochromocytoma and paraganglioma as well as questions regarding surveillance after resection. The panelists voted on controversial topics, and final recommendations were sent to all panel members for final approval.
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Affiliation(s)
- Lauren Fishbein
- From the Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Tobias Else
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - James R Howe
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center and University Health Network, Toronto, Case Western Reserve University, Cleveland, OH
| | - Debbie L Cohen
- Renal Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Patricia L M Dahia
- Division of Hematology and Medical Oncology, Department of Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Douglas L Fraker
- Division of Endocrine and Oncologic Surgery, Department of Surgery, University of Pennsylvania and Abramson Cancer Center, Philadelphia, PA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Pamela L Kunz
- Division of Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Kimberly Perez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Nancy D Perrier
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel A Pryma
- Department of Radiology and Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mabel Ryder
- Endocrine Oncology Tumor Group, Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | - Aaron R Sasson
- Division of Surgical Oncology, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY
| | - Michael C Soulen
- Department of Radiology, University of Pennsylvania, Philadelphia, PA
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX
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27
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De Filpo G, Maggi M, Mannelli M, Canu L. Management and outcome of metastatic pheochromocytomas/paragangliomas: an overview. J Endocrinol Invest 2021; 44:15-25. [PMID: 32602077 DOI: 10.1007/s40618-020-01344-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/23/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Metastatic pheochromocytomas and paragangliomas (PPGLs) occur in about 5-26% of cases and are characterized by a heterogeneous prognosis. Metastases can be synchronous at the initial diagnosis, but they can occur also many years after surgery for the primary tumor. To date, the treatment of patients affected by metastatic PPGLs represents a clinical challenge because of the lack of guidelines. AIM The aim of this article is to review the available management options and their impact on the outcomes of patients with metastatic PPGLs. RESULTS Generally, treatments are not curative. Surgery, when possible, can be used to reduce hormonal symptoms and cardiovascular morbidity. Chemotherapy plays a role in patients with high burden tumor and rapid disease progression. Tyrosine kinases inhibitors (TKIs) might be considered for their ability to block the angiogenesis and cell growth. Radiation therapy and interventional radiology techniques can help in the management of local metastases to control symptoms and avoid tumor progression. On the other hand, peptide receptor radionuclide therapy (PRRT), using 90Y or 177Lu-DOTATATE, could be a promising therapy. In addition, high specific 131I-MIBG was approved by the Food and Drug Administration (FDA) in the US for the treatment of patients affected by metastatic and unresectable 131I-MIBG positive PPGLs. Considering the different pathways involved in the pathogenesis of PPGLs, several target therapies have been proposed and are under evaluation in clinical trials. CONCLUSIONS The choice of the appropriate treatment should be based on multidisciplinary and personalized approach taking into account the rarity and the variability of these tumors.
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Affiliation(s)
- G De Filpo
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy.
| | - M Maggi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - M Mannelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - L Canu
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
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28
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Savoie PH, Murez T, Fléchon A, Rocher L, Ferretti L, Morel-Journel N, Camparo P, Méjean A. [French ccAFU guidelines - update 2020-2022: malignancy assessment of an adrenal incidentaloma]. Prog Urol 2020; 30:S331-S352. [PMID: 33349429 DOI: 10.1016/s1166-7087(20)30756-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION - The objective of this publication is to recall the initial oncological management of adrenal incidentalomas. MATERIAL & METHODS - The multidisciplinary working group updated french urological guidelines established by the CCAFU in 2018, based on an exhaustive literature review carried out on PubMed. RESULTS - Although the majority of the adrenal masses are benign and non-functional, it is important to investigate them, as a percentage of these can cause serious endocrine diseases or be cancers. Malignant adrenal tumors are mainly represented by Adrenocortical Carcinomas (ACC), malignant pheochromocytomas (MPC) and adrenal metastases (AM). The malignancy assessment of an adrenal incident includes a complete history, a physical examination, a biochemical / hormonal assessment to look for subclinical hormonal secretion. Diagnostic hypotheses are sometimes available at this stage, but it is the morphological and functional imaging and the histological analysis which will make it possible to close the malignancy assessment and make the oncological diagnosis. CONCLUSIONS - AC and MPC are mainly sporadic but a hereditary origin is always possible. ACC is suspected preoperatively but the diagnosis of certainty is histological. The diagnosis of MPC is more delicate and is based on clinic, biology and imagery. The diagnosis of certainty of AM requires a percutaneous biopsy. At the end, the files must be discussed within the COMETE - adrenal cancer network (Appendix 1).
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Affiliation(s)
- P-H Savoie
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de chirurgie urologique, hôpital d'instruction des armées Sainte-Anne, BP 600, 83800 Toulon Cedex 09, France.
| | - T Murez
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; service d'urologie et de transplantation rénale, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier Cedex 5, France
| | - A Fléchon
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France
| | - L Rocher
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, hôpital Antoine-Béclère, AP-HP, 157 rue de la Porte-de-Trivaux, 92140 Clamart, France; Université Paris-Saclay, BIOMAPS, 63, avenue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France
| | - L Ferretti
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; MSP Bordeaux Bagatelle 203, route de Toulouse, 33401 Talence, France
| | - N Morel-Journel
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Lyon, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite
| | - P Camparo
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Institut de pathologie des Hauts-de-France, 51, rue Jeanne-d'Arc, 80000 Amiens, France
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe vessie, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et transplantation rénale, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
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Sherlock M, Scarsbrook A, Abbas A, Fraser S, Limumpornpetch P, Dineen R, Stewart PM. Adrenal Incidentaloma. Endocr Rev 2020; 41:bnaa008. [PMID: 32266384 PMCID: PMC7431180 DOI: 10.1210/endrev/bnaa008] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup, and clinical symptoms and signs are required in every case. Adrenocortical carcinoma remains a real concern but is restricted to <2% of all cases. Functional adrenal incidentaloma lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Afroze Abbas
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Sheila Fraser
- Department of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Padiporn Limumpornpetch
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Rosemary Dineen
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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Wachtel H, Hutchens T, Baraban E, Schwartz LE, Montone K, Baloch Z, LiVolsi V, Krumeich L, Fraker DL, Nathanson KL, Cohen DL, Fishbein L. Predicting Metastatic Potential in Pheochromocytoma and Paraganglioma: A Comparison of PASS and GAPP Scoring Systems. J Clin Endocrinol Metab 2020; 105:5900767. [PMID: 32877928 PMCID: PMC7553245 DOI: 10.1210/clinem/dgaa608] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/31/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) and the Grading System for Adrenal Pheochromocytoma and Paraganglioma (GAPP) are scoring systems to predict metastatic potential in pheochromocytomas (PCC) and paragangliomas (PGLs). The goal of this study is to assess PASS and GAPP as metastatic predictors and to correlate with survival outcomes. METHODS The cohort included PCC/PGL with ≥5 years of follow-up or known metastases. Surgical pathology slides were rereviewed. PASS and GAPP scores were assigned. Univariable and multivariable logistic regression, Kaplan-Meier survival analysis, and Cox proportional hazards were performed to assess recurrence-free survival (RFS) and disease-specific survival (DSS). RESULTS From 143 subjects, 106 tumors were PCC and 37 were PGL. Metastases developed in 24%. The median PASS score was 6.5 (interquartile range [IQR]: 4.0-8.0) and median GAPP score was 3.0 (IQR: 2.0-4.0). Interrater reliability was low-moderate for PASS (intraclass correlation coefficient [ICC]: 0.6082) and good for GAPP (ICC 0.7921). Older age (OR: 0.969, P = .0170) was associated with longer RFS. SDHB germline pathogenic variant (OR: 8.205, P = .0049), extra-adrenal tumor (OR: 6.357, P < .0001), Ki-67 index 1% to 3% (OR: 4.810, P = .0477), and higher GAPP score (OR: 1.537, P = .0047) were associated with shorter RFS. PASS score was not associated with RFS (P = .1779). On Cox regression, a GAPP score in the moderately differentiated range was significantly associated with disease recurrence (HR: 3.367, P = .0184) compared with well-differentiated score. CONCLUSION Higher GAPP scores were associated with aggressive PCC/PGL. PASS score was not associated with metastases and demonstrated significant interobserver variability. Scoring systems for predicting metastatic PCC/PGL may be improved by incorporation of histopathology, clinical data, and germline and somatic tumor markers.
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Affiliation(s)
- Heather Wachtel
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Endocrine and Oncologic, Surgery, Philadelphia, Pennsylvania
- The Abramson Cancer Center, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Correspondence and Reprint Requests: Heather Wachtel, MD, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia PA 19104, USA. E-mail:
| | - Troy Hutchens
- Hospital of the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania
| | - Ezra Baraban
- Hospital of the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania
| | - Lauren E Schwartz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Hospital of the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania
| | - Kathleen Montone
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Hospital of the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania
| | - Zubair Baloch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Hospital of the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania
| | - Virginia LiVolsi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Hospital of the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia, Pennsylvania
| | - Lauren Krumeich
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Endocrine and Oncologic, Surgery, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Endocrine and Oncologic, Surgery, Philadelphia, Pennsylvania
- The Abramson Cancer Center, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine L Nathanson
- The Abramson Cancer Center, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Hospital of the University of Pennsylvania, Division of Translational Medicine and Human Genetics, Philadelphia, Pennsylvania
| | - Debbie L Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Hospital of the University of Pennsylvania, Department of Medicine, Division of Renal, Electrolytes and Hypertension, Philadelphia, Pennsylvania
| | - Lauren Fishbein
- University of Colorado School of Medicine, Department of Medicine, Division of Endocrinology, Metabolism and Diabetes and the Division of Biomedical Informatics and Personalized Medicine, Aurora, Colorado
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Choi HR, Yap Z, Choi SM, Choi SH, Kim JK, Lee CR, Lee J, Jeong JJ, Nam KH, Chung WY, Kang SW. Long-term outcomes of abdominal paraganglioma. Ann Surg Treat Res 2020; 99:315-319. [PMID: 33304858 PMCID: PMC7704273 DOI: 10.4174/astr.2020.99.6.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/22/2020] [Accepted: 09/18/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Paragangliomas (PGL) are rare neuroendocrine tumors derived from chromaffin cells of the autonomic nervous system. We aim to describe our experience and the long-term outcome of abdominal PGL over the last decade. Methods A retrospective review of patients diagnosed with PGL in our hospital between November 2005 and June 2017 was conducted. All nonabdominal PGL were excluded and the clinicopathological features and long-term outcomes of the patients were analyzed. Results A total of 46 patients were diagnosed with abdominal PGL. The average age of diagnosis was 55.4 years and there was no sex predilection. The average tumor size was 5.85 cm and they were predominantly located in the infrarenal position (50%). The mean follow-up period was 42 months (range, 1.8–252 months). All patients with metastases had Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) of ≥4. One patient presented with synchronous metastases while 2 developed local recurrence and distant metastases. One presented with only local recurrence. One patient died 5 years after diagnosis. Conclusion Abdominal PGL is a rare tumor with excellent long-term prognosis. Recurrence although uncommon, can occur decades after initial diagnosis. Long-term follow-up is therefore recommended for all patients with PGL, especially in patients with PASS of ≥4.
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Affiliation(s)
- Hye Ryeon Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Zeng Yap
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Hyung Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyong Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Cho Rok Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jandee Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Ju Jeong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kee-Hyun Nam
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woong Youn Chung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Wook Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Abstract
PURPOSE OF REVIEW Although the majority of pheochromocytoma and paraganglioma are benign, 15-17% develop metastatic disease, being present at the initial diagnosis in about 11-31% of cases. The natural course of metastasized disease is highly heterogeneous, with an overall 5-year survival rate varying between 40% and 85%. For individual patients, overall survival, progression-free survival, and clinical outcome are difficult to predict. Management of metastasized pheochromocytoma and paraganglioma is challenging. Currently available therapeutic options are surgical debulking, treatment with radiopharmaceuticals (I-MIBG, Y and Lu-DOTATATE), chemotherapy and targeted therapy. RECENT FINDINGS The pathogenesis of pheochromocytoma and paraganglioma (PPGL) is largely driven by genomic alterations in PPGL susceptibility genes related to three different clusters: altered pseudo-hypoxic signaling (cluster-1), altered MAP-kinase signaling (cluster-2) and altered Wnt signaling (cluster-3). Novel targeted therapies (tyrosine kinase inhibitors) and potential future therapeutic options, guided by improved knowledge about the oncogenic cluster 1-3 signaling pathways, will be discussed. SUMMARY Treatment of metastasized pheochromocytoma and paraganglioma remains challenging. Profiling of gene expression and methylation can serve as a powerful tool for characterizing disease clusters and for guiding targeted therapy to improve selectivity and efficacy. Current knowledge of signatures involved in molecular signaling, metabolism, and resistance mechanisms of PPGLs suggests that therapeutic regimens can be optimized to each molecular subtype.
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Main AM, Rossing M, Borgwardt L, Grønkær Toft B, Rasmussen ÅK, Feldt-Rasmussen U. Genotype-phenotype associations in PPGLs in 59 patients with variants in SDHX genes. Endocr Connect 2020; 9:793-803. [PMID: 32688340 PMCID: PMC7487185 DOI: 10.1530/ec-20-0279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/19/2020] [Indexed: 12/31/2022]
Abstract
Phaeochromocytomas and paragangliomas (PPGLs) are tumours of the adrenal medulla and extra-adrenal sympathetic nervous system which often secrete catecholamines. Variants of the SDHX (SDHA, -AF2, -B, -C, -D) genes are a frequent cause of familial PPGLs. In this study from a single tertiary centre, we aimed to characterise the genotype-phenotype associations in patients diagnosed with germline variants in SDHX genes. We also assessed whether systematic screening of family members resulted in earlier detection of tumours. The study cohort comprised all individuals (n = 59) diagnosed with a rare variant in SDHX during a 13-year period. Patient- and pathology records were checked for clinical characteristics and histopathological findings. We found distinct differences in the clinical and histopathological characteristics between genetic variants in SDHB. We identified two SDHB variants with distinct phenotypical patterns. Family screening for SDHB variants resulted in earlier detection of tumours in two families. Patients with SDHA, SDHC and SDHD variants also had malignant phenotypes, underlining the necessity for a broad genetic screening of the proband. Our study corroborates previous findings of poor prognostic markers and found that the genetic variants and clinical phenotype are linked and, therefore, useful in the decision of clinical follow-up. Regular tumour screening of carriers of pathogenic variants may lead to an earlier diagnosis and expected better prognosis. The development of a combined algorithm with clinical, genetic, morphological, and biochemical factors may be the future for improved clinical risk stratification, forming a basis for larger multi-centre follow up studies.
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Affiliation(s)
- Ailsa Maria Main
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Correspondence should be addressed to A M Main or U Feldt-Rasmussen: or
| | - Maria Rossing
- Center for Genomic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Line Borgwardt
- Center for Genomic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Birgitte Grønkær Toft
- Department of Pathology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Åse Krogh Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Copenhagen University Hospital, Rigshospitalet, and Faculty of Health, Institute of Clinical and Scientific Research, Copenhagen, Denmark
- Correspondence should be addressed to A M Main or U Feldt-Rasmussen: or
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Thompson LDR, Gill AJ, Asa SL, Clifton-Bligh RJ, de Krijger RR, Kimura N, Komminoth P, Lack EE, Lenders JWM, Lloyd RV, Papathomas TG, Sadow PM, Tischler AS. Data set for the reporting of pheochromocytoma and paraganglioma: explanations and recommendations of the guidelines from the International Collaboration on Cancer Reporting. Hum Pathol 2020; 110:83-97. [PMID: 32407815 DOI: 10.1016/j.humpath.2020.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The International Collaboration on Cancer Reporting (ICCR) is a not-for-profit to develop evidence-based, internationally agreed-upon standardized data sets for each anatomic site, to be used throughout the world. Providing global standardization of pathology tumor classification, staging, and other reporting elements will lead to improved patient management and enhanced epidemiological research. METHODS Pheochromocytoma and paraganglioma are uncommon and are frequently overlooked in registry data sets. Malignant criteria have previously been defined only when there was metastatic disease. RESULTS With recent recognition of a significant inheritance association and the development of risk stratification tools, this data set was created in order to obtain more meaningful outcomes and management data, using similar criteria across the global pathology community. Issues related to key core and non-core elements, especially clinical hormonal status, familial history, tumor focality, proliferative fraction, adverse or risk stratification features, and ancillary techniques, are discussed in the context of daily application to these types of specimens. CONCLUSIONS The ICCR data set, developed by an international panel of endocrine organ specialists, establishes a pathology-standardized reporting guide for pheochromocytoma and paraganglioma.
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Affiliation(s)
- Lester D R Thompson
- Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, CA, USA.
| | - Anthony J Gill
- University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Group Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia; Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Department of Pathology, Case Western Reserve University, Cleveland, OH, USA; University Health Network, Toronto, Canada.
| | - Roderick J Clifton-Bligh
- University of Sydney, Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
| | - Ronald R de Krijger
- Department of Pathology, University Medical Centre and Princess Maxima Centre, Utrecht, the Netherlands.
| | - Noriko Kimura
- Department of Diagnostic Pathology, Department of Clinical Research, Pathology Division, National Hospital Organization Hakodate Hospital, Japan.
| | - Paul Komminoth
- University of Zürich, Institute of Pathology, City Hospital Triemli, Zürich, Switzerland.
| | - Ernest E Lack
- Department of Endocrine Pathology, The Joint Pathology Center, Silver Spring, MD, USA.
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Medicine III, University Hospital Carl Gustav Carus and Medical Faculty, Technical University Dresden, Dresden, Germany.
| | - Ricardo V Lloyd
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Wisconsin, USA.
| | - Thomas G Papathomas
- Institute of Metabolism and Systems Research, University of Birmingham, United Kingdom.
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Arthur S Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, USA.
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Schreiner F, Beuschlein F. Disease monitoring of patients with pheochromocytoma or paraganglioma by biomarkers and imaging studies. Best Pract Res Clin Endocrinol Metab 2020; 34:101347. [PMID: 31662271 DOI: 10.1016/j.beem.2019.101347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, a large proportion of which secrete catecholamines. PPGL are associated with a high cardiovascular morbidity and come with a risk of malignancy. The therapy of choice is surgical resection. Nevertheless, PPGL are associated with a lifelong risk of tumor persistence or recurrence. Currently, there are no clinical, biochemical, histopathological or imaging characteristics, which can predict or exclude malignant behavior or tumor recurrence. Therefore, long-term follow-up is recommended even after apparent complete surgical removal. Early detection of recurrence is essential to reduce cardiovascular morbidity and mortality due to catecholamine secretion, to prevent morbidity by mass effects of paraganglioma (PGL) or by metastatic spread of disease. Due to the rarity of these tumors, no prospective data on long-term surveillance exist. In fact, current recommendations are based on retrospective analyses, expert opinions and case studies. The aim of this review is to provide an overview on the current state of knowledge with regard to known factors that increase the risk of recurrence and might impact disease monitoring as well as the available possibilities for biochemical and imaging follow-up. Based on this overview, we aim to propose a practical approach for a patient-oriented follow-up after surgical removal of a PPGL.
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Affiliation(s)
- Florentine Schreiner
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zurich, Switzerland; Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.
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36
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Jasim S, Jimenez C. Metastatic pheochromocytoma and paraganglioma: Management of endocrine manifestations, surgery and ablative procedures, and systemic therapies. Best Pract Res Clin Endocrinol Metab 2020; 34:101354. [PMID: 31685417 DOI: 10.1016/j.beem.2019.101354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metastatic pheochromocytomas and paragangliomas (MPPGs) are rare neuroendocrine tumors. Most patients present with advanced disease that is associated with manifestations of catecholamine release. Surgical resection of the primary tumor and ablative therapies of metastases-whenever possible-may improve clinical outcomes and, perhaps, lengthen the patient's overall survival. Significant steps in understanding the genetic alterations linked to MPPGs and scientific progress made on cancers that share a similar pathogenesis are leading to the recognition of potential systemic therapeutic options. Data derived from clinical trials evaluating targeted therapies such as tyrosine kinase inhibitors, radiopharmaceuticals, immunotherapy, and combinations of these will likely improve the outcomes of patients with advanced and progressive MPPGs. Exemplary of this success is the recent approval in the United States of the high-specific-activity iodine131 meta-iodine-benzylguanidine (MIBG) for patients with unresectable and progressive MPPGs that express the noradrenaline transporter. This review will discuss the therapeutic approaches for patients with MPPGs.
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Affiliation(s)
- Sina Jasim
- The Division of Endocrinology, Metabolism and Lipid Research, Campus box 8127, Washington University, School of Medicine, 660 S. Euclid Ave., St. Louis, Missouri 63110, USA
| | - Camilo Jimenez
- The Department of Endocrine Neoplasia and Hormonal Disorders at the University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA.
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Patel D, Phay JE, Yen TWF, Dickson PV, Wang TS, Garcia R, Yang AD, Kim LT, Solórzano CC. Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2020; 27:1338-1347. [PMID: 32112213 DOI: 10.1245/s10434-020-08221-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 01/10/2023]
Abstract
This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Roberto Garcia
- Division of Surgical Oncology, National Cancer Institute of Panama/Paitilla Medical Center, Panama City, Panama
| | - Anthony D Yang
- Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lawrence T Kim
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
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Molecular Profiling of Pheochromocytoma and Abdominal Paraganglioma Stratified by the PASS Algorithm Reveals Chromogranin B as Associated With Histologic Prediction of Malignant Behavior. Am J Surg Pathol 2020; 43:409-421. [PMID: 30451732 DOI: 10.1097/pas.0000000000001190] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pheochromocytomas (PCCs) and abdominal paragangliomas (PGLs), collectively abbreviated PPGL, are believed to exhibit malignant potential-but only subsets of cases will display full-blown malignant properties. The Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) algorithm is a proposed histologic system to detect potential for aggressive behavior, but little is known regarding the coupling to underlying molecular genetics. In this study, a total of 92 PPGLs, previously characterized for susceptibility gene status and mRNA expressional profiles, were histologically assessed using the PASS criteria. A total of 32/92 PPGLs (35%) exhibited a PASS score ≥4, including all 8 cases with malignant behavior (7 with known metastases and 1 with extensively infiltrative local recurrence). Statistical analyzes between expressional data and clinical parameters as well as individual PASS criteria yielded significant associations to Chromogranin B (CHGB), BRCA2, HIST1H3B, BUB1B, and RET to name a few, and CHGB had the strongest correlation to both PASS and metastasis/local recurrence of all analyzed genes. Evident CHGB downregulation was observed in PPGLs with high PASS and overtly malignant behavior, and was also associated with shorter disease-related survival. This finding was validated using quantitative real-time polymerase chain reaction, in which CHGB expression correlated with both PASS and metastasis/local recurrence with consistent findings obtained in the TCGA cohort. Moreover, immunohistochemical analyses of subsets of tumors showed a correlation between high PASS scores and negative or weak CHGB protein expression. Patients with PPGLs obtaining high PASS scores postoperatively, also exhibited low preoperative plasma levels of CHGB. These data collectively point out CHGB as a possible preoperative and postoperative marker for PPGLs with potential for aggressive behavior.
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Yamazaki Y, Gao X, Pecori A, Nakamura Y, Tezuka Y, Omata K, Ono Y, Morimoto R, Satoh F, Sasano H. Recent Advances in Histopathological and Molecular Diagnosis in Pheochromocytoma and Paraganglioma: Challenges for Predicting Metastasis in Individual Patients. Front Endocrinol (Lausanne) 2020; 11:587769. [PMID: 33193100 PMCID: PMC7652733 DOI: 10.3389/fendo.2020.587769] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PHEO/PGL) are rare but occasionally life-threatening neoplasms, and are potentially malignant according to WHO classification in 2017. However, it is also well known that histopathological risk stratification to predict clinical outcome has not yet been established. The first histopathological diagnostic algorithm for PHEO, "PASS", was proposed in 2002 by Thompson et al. Another algorithm, GAPP, was then proposed by Kimura et al. in 2014. However, neither algorithm has necessarily been regarded a 'gold standard' for predicting post-operative clinical behavior of tumors. This is because the histopathological features of PHEO/PGL are rather diverse and independent of their hormonal activities, as well as the clinical course of patients. On the other hand, recent developments in wide-scale genetic analysis using next-generation sequencing have revealed the molecular characteristics of pheochromocytomas and paragangliomas. More than 30%-40% of PHEO/PGL are reported to be associated with hereditary genetic abnormalities involving > 20 genes, including SDHXs, RET, VHL, NF1, TMEM127, MAX, and others. Such genetic alterations are mainly involved in the pathogenesis of pseudohypoxia, Wnt, and kinase signaling, and other intracellular signaling cascades. In addition, recurrent somatic mutations are frequently detected and overlapped with the presence of genetic alterations associated with hereditary diseases. In addition, therapeutic strategies specifically targeting such genetic abnormalities have been proposed, but they are not clinically applicable at this time. Therefore, we herein review recent advances in relevant studies, including histopathological and molecular analyses, to summarize the current status of potential prognostic factors in patients with PHEO/PGL.
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Affiliation(s)
- Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Xin Gao
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Alessio Pecori
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Kei Omata
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yoshikiyo Ono
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- *Correspondence: Hironobu Sasano,
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Gao X, Yamazaki Y, Pecori A, Tezuka Y, Ono Y, Omata K, Morimoto R, Nakamura Y, Satoh F, Sasano H. Histopathological Analysis of Tumor Microenvironment and Angiogenesis in Pheochromocytoma. Front Endocrinol (Lausanne) 2020; 11:587779. [PMID: 33244312 PMCID: PMC7685215 DOI: 10.3389/fendo.2020.587779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/09/2020] [Indexed: 12/14/2022] Open
Abstract
Pheochromocytomas (PHEOs) are relatively rare catecholamine-producing tumors derived from adrenal medulla. Tumor microenvironment (TME) including neoangiogenesis has been explored in many human neoplasms but not necessarily in PHEOs. Therefore, in this study, we examined tumor infiltrating lymphocytes (CD4 and CD8), tumor associated macrophages (CD68 and CD163), sustentacular cells (S100p), and angiogenic markers (CD31 and areas of intratumoral hemorrhage) in 39 cases of PHEOs in the quantitative fashion. We then compared the results with pheochromocytoma of the adrenal gland scaled score (PASS), grading system for pheochromocytoma and paraganglioma (GAPP) and the status of intra-tumoral catecholamine-synthesizing enzymes (TH, DDC, and PNMT) as well as their clinicopathological factors. Intratumoral CD8 (p = 0.0256), CD31 (p = 0.0400), and PNMT (p = 0.0498) status was significantly higher in PHEOs with PASS <4 than PASS ≧4. In addition, intratumoral CD8+ lymphocytes were also significantly more abundant in well-than moderately differentiated PHEO according to GAPP score (p = 0.0108) and inversely correlated with tumor size (p = 0.0257). Intratumoral CD68+ cells were significantly higher in PHEOs with regular or normal histological patterns than those not (p = 0.0370) and inversely correlated with tumor size (p = 0.0457). The status of CD163 was significantly positively correlated with that of CD8 positive cells (p = 0.0032). The proportion of intratumoral hemorrhage areas was significantly higher in PHEOs with PASS ≧4 (p = 0.0172). DDC immunoreactivity in tumor cells was significantly positively correlated with PASS score (p = 0.0356) and TH status was significantly higher in PHEOs harboring normal histological patterns (p = 0.0236) and cellular monotony (p = 0.0219) than those not. Results of our present study did demonstrate that abundant CD8+ and CD68+ cells could represent a histologically low-scored tumor. In particular, PHEOs with increased intratumoral hemorrhage should be considered rather malignant. In addition, abnormal catecholamine-producing status of tumor cells such as deficient PNMT and TH and increased DDC could also represent more aggressive PHEOs.
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Affiliation(s)
- Xin Gao
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Alessio Pecori
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Kei Omata
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- *Correspondence: Hironobu Sasano,
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Cornu E, Belmihoub I, Burnichon N, Grataloup C, Zinzindohoué F, Baron S, Billaud E, Azizi M, Gimenez-Roqueplo AP, Amar L. Phéochromocytome et paragangliome. Rev Med Interne 2019; 40:733-741. [DOI: 10.1016/j.revmed.2019.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/27/2019] [Accepted: 07/17/2019] [Indexed: 12/20/2022]
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Savoie PH, Murez T, Fléchon A, Sèbe P, Rocher L, Camparo P, Morel-Journel N, Ferretti L, Méjean A. [French ccAFU guidelines - Update 2018-2020: Adrenal cancer]. Prog Urol 2019; 28 Suppl 1:R177-R195. [PMID: 31610872 DOI: 10.1016/j.purol.2019.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To update French oncology guidelines concerning adrenal cancer. METHODS Comprehensive Medline search between 2016 and 2018 upon diagnosis, treatment and follow-up of adrenal cancer to update 2013 guidelines. Level of evidence was evaluated according to AGREE-II. RESULTS Adrenal cancers are mainly represented by adrenocortical carcinomas (AC), malignant pheochromocytomas (MPC) and adrenal metastases (AM). Medical background of these tumors is either the exploration of hormonal or tumor symptoms, or an adrenal incidentaloma. Etiological explorations are based on hormonal biochemical assessment, morphological and functional imaging and histological analysis. AC and MPC are mostly sporadic but hereditary origin is still possible. The suspicion of AC is driven mainly by radiological signs of malignancy, signs of local invasion or distant metastasis, and type of hormonal secretion but the accurate diagnosis is histological. The diagnosis of MPC is clinical, biological and radiological. The diagnosis of MS involves a percutaneous biopsy. Medical files for primitive adrenal cancer should be discussed within the COMETE - Adrenal Cancer Network (Appendix 1). Oncological adjuvant treatments are specific for the histological type. In the AC, their indication depends on the risk of recurrence and is based on mitotane, external radiotherapy or chemotherapy. In the MPC, it is based on internal radiotherapy and chemotherapy. Metastatic forms treatment is exceptionally surgical. Debulking is uncommon. For metastatic unresectable AC, treatment is based on mitotane monotherapy or triple chemotherapy. For metastatic unresectable MPC, treatment is based on exclusive metabolic radiotherapy or triple chemotherapy. Recurrences are frequent and sometimes delayed, which justifies a close and long follow-up. CONCLUSION The curative treatment of Adrenal cancers is surgical provided. This treatment is rarely sufficient alone, the prognosis is then pejorative.
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Affiliation(s)
- P-H Savoie
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital d'instruction des armées Sainte-Anne, BP 600, 83800 Toulon cedex 09, France.
| | - T Murez
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie et transplantation rénale, CHU Lapeyronie, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France.
| | - A Fléchon
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'oncologie médicale, centre Léon-Bérard, 28, rue Laennec, 69008 Lyon, France.
| | - P Sèbe
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, groupe hospitalier Diaconesses Croix Saint Simon, 125, rue d'Avron, 75020 Paris, France.
| | - L Rocher
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de radiologie, HU Paris Sud, site Kremlin-Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France.
| | - P Camparo
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Centre de pathologie, 51, rue de Jeanne-D'Arc, 80000 Amiens, France.
| | - N Morel-Journel
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, centre hospitalier Lyon Sud (Pierre Bénite), HCL groupement hospitalier du Sud, 69495 Pierre Bénite cedex, France.
| | - L Ferretti
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, MSP de Bordeaux-Bagatelle, 203, route de Toulouse, BP 50048, 33401 Talence cedex, France.
| | - A Méjean
- Comité de cancérologie de l'Association française d'urologie, groupe organes génitaux externes, maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, hôpital européen Georges-Pompidou, université Paris Descartes, AP-HP, 75015 Paris, France.
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Predictors of recurrence of pheochromocytoma and paraganglioma: a multicenter study in Piedmont, Italy. Hypertens Res 2019; 43:500-510. [PMID: 31586159 DOI: 10.1038/s41440-019-0339-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/06/2019] [Accepted: 09/05/2019] [Indexed: 12/31/2022]
Abstract
The available data on the natural history of pheochromocytomas and paragangliomas after radical surgery are heterogeneous and discordant. The aim of our retrospective multicenter study was to find predictors of recurrence in patients with pheochromocytomas and sympathetic paragangliomas submitted to radical surgery in Piedmont (a region in northwest Italy). We collected data from 242 patients diagnosed between 1990 and 2016. Forty-two patients (17.4%) had disease recurrence. Multivariate analysis showed that genetic mutation (HR = 3.62; 95% CI 1.44-9.13; p = 0.006), younger age (HR = 0.97; 95% CI 0.95-0.99; p = 0.031) and larger tumor size (HR = 1.01; 95% CI 1.00-1.02; p = 0.015) were independently associated with a higher recurrence risk of pheochromocytoma and paraganglioma; in pheochromocytomas, genetic mutation (HR = 3.4; 95% CI 1.00-11.48; p = 0.049), younger age (HR = 0.97; 95% CI 0.94-0.99; p = 0.02), higher tumor size (HR = 1.01; 95% CI 1.00-1.03; p = 0.043) and PASS value (HR = 1.16; 95% CI 1.03-1.3; p = 0.011) were associated with recurrence. Moreover, tumor size was the only predictor of metastatic pheochromocytoma and paraganglioma (HR = 4.6; 95% CI 1.4-15.0; p = 0.012); tumor size (HR = 3.93; 95% CI 1.2-16.4; p = 0.026) and PASS value (HR = 1.27; 95% CI 1.06-1.53; p = 0.007) were predictors of metastatic pheochromocytoma. In conclusion, our findings suggest that the recurrence of pheochromocytoma and sympathetic paraganglioma develops more frequently in younger subjects, patients with a family history of chromaffin tissue neoplasms, mutations in susceptibility genes, larger tumors and higher values of PASS. We recommend genetic testing in all patients with PPGL and strict follow-up at least on an annual basis.
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Intricacies of the Molecular Machinery of Catecholamine Biosynthesis and Secretion by Chromaffin Cells of the Normal Adrenal Medulla and in Pheochromocytoma and Paraganglioma. Cancers (Basel) 2019; 11:cancers11081121. [PMID: 31390824 PMCID: PMC6721535 DOI: 10.3390/cancers11081121] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/11/2022] Open
Abstract
The adrenal medulla is composed predominantly of chromaffin cells producing and secreting the catecholamines dopamine, norepinephrine, and epinephrine. Catecholamine biosynthesis and secretion is a complex and tightly controlled physiologic process. The pathways involved have been extensively studied, and various elements of the underlying molecular machinery have been identified. In this review, we provide a detailed description of the route from stimulus to secretion of catecholamines by the normal adrenal chromaffin cell compared to chromaffin tumor cells in pheochromocytomas. Pheochromocytomas are adrenomedullary tumors that are characterized by uncontrolled synthesis and secretion of catecholamines. This uncontrolled secretion can be partly explained by perturbations of the molecular catecholamine secretory machinery in pheochromocytoma cells. Chromaffin cell tumors also include sympathetic paragangliomas originating in sympathetic ganglia. Pheochromocytomas and paragangliomas are usually locally confined tumors, but about 15% do metastasize to distant locations. Histopathological examination currently poorly predicts future biologic behavior, thus long term postoperative follow-up is required. Therefore, there is an unmet need for prognostic biomarkers. Clearer understanding of the cellular mechanisms involved in the secretory characteristics of pheochromocytomas and sympathetic paragangliomas may offer one approach for the discovery of novel prognostic biomarkers for improved therapeutic targeting and monitoring of treatment or disease progression.
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Koopman K, Gaal J, de Krijger RR. Pheochromocytomas and Paragangliomas: New Developments with Regard to Classification, Genetics, and Cell of Origin. Cancers (Basel) 2019; 11:cancers11081070. [PMID: 31362359 PMCID: PMC6721302 DOI: 10.3390/cancers11081070] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022] Open
Abstract
Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors that arise in the adrenal medulla and in extra-adrenal locations, such as the head, neck, thorax, abdomen, and pelvis. Classification of these tumors into those with or without metastatic potential on the basis of gross or microscopic features is challenging. Recent insights and scoring systems have attempted to develop solutions for this, as described in the latest World Health Organization (WHO) edition on endocrine tumor pathology. PCC and PGL are amongst the tumors most frequently accompanied by germline mutations. More than 20 genes are responsible for a hereditary background in up to 40% of these tumors; somatic mutations in the same and several additional genes form the basis for another 30%. However, this does not allow for a complete understanding of the pathogenesis or targeted treatment of PCC and PGL, for which surgery is the primary treatment and for which metastasis is associated with poor outcome. This review describes recent insights into the cell of origin of these tumors, the latest developments with regard to the genetic background, and the current status of tumor classification including proposed scoring systems.
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Affiliation(s)
- Karen Koopman
- Martini Hospital, 9728 NT Groningen, The Netherlands
| | - Jose Gaal
- Department of Pathology, Isala Hospital, 8025AB Zwolle, The Netherlands
| | - Ronald R de Krijger
- Department of Pathology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands.
- Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands.
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Jimenez C, Erwin W, Chasen B. Targeted Radionuclide Therapy for Patients with Metastatic Pheochromocytoma and Paraganglioma: From Low-Specific-Activity to High-Specific-Activity Iodine-131 Metaiodobenzylguanidine. Cancers (Basel) 2019; 11:cancers11071018. [PMID: 31330766 PMCID: PMC6678905 DOI: 10.3390/cancers11071018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/03/2019] [Accepted: 07/17/2019] [Indexed: 12/13/2022] Open
Abstract
Low-specific-activity iodine-131–radiolabeled metaiodobenzylguanidine (I-131-MIBG) was introduced last century as a potential systemic therapy for patients with malignant pheochromocytomas and paragangliomas. Collective information derived from mainly retrospective studies has suggested that 30–40% of patients with these tumors benefit from this treatment. A low index of radioactivity, lack of therapeutic standardization, and toxicity associated with intermediate to high activities (absorbed radiation doses) has prevented the implementation of I-131-MIBG’s in clinical practice. High-specific-activity, carrier-free I-131-MIBG has been developed over the past two decades as a novel therapy for patients with metastatic pheochromocytomas and paragangliomas that express the norepinephrine transporter. This drug allows for a high level of radioactivity, and as yet is not associated with cardiovascular toxicity. In a pivotal phase two clinical trial, more than 90% of patients achieved partial responses and disease stabilization with the improvement of hypertension. Furthermore, many patients exhibited long-term persistent antineoplastic effects. Currently, the high-specific-activity I-131-MIBG is the only approved therapy in the US for patients with metastatic pheochromocytomas and paragangliomas. This review will discuss the historical development of high-specific-activity I-131-MIBG, its benefits and adverse events, and future directions for clinical practice applicability and trial development.
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Affiliation(s)
- Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA.
| | - William Erwin
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA
| | - Beth Chasen
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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[Tumors of the adrenal glands : Update]. DER PATHOLOGE 2019; 40:467-492. [PMID: 31250089 DOI: 10.1007/s00292-019-0618-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Nodular hyperplasias and adenomas are by far the most frequently resected tumors of the adrenal cortex followed by pheochromocytomas, which are either discovered incidentally or become conspicuous due to hormonal hypersecretions. Cortical nodes and adenomas are easy to diagnose using simple staining methods. Uncertain cortical carcinomas, pheochromocytomas and other tumors of the adrenal region require additional immunohistochemical staining methods. Determination of the dignity of tumors of the adrenal cortex necessitates at least the Weiss score (possibly in its modified form), for oncocytic tumors the Bisceglia score and for pediatric tumors the Wieneke score. The Ki-67 index must also be taken into consideration. For pheochromocytomas the PASS and the GAPP systeme are used.
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Pierre C, Agopiantz M, Brunaud L, Battaglia-Hsu SF, Max A, Pouget C, Nomine C, Lomazzi S, Vignaud JM, Weryha G, Oussalah A, Gauchotte G, Busby-Venner H. COPPS, a composite score integrating pathological features, PS100 and SDHB losses, predicts the risk of metastasis and progression-free survival in pheochromocytomas/paragangliomas. Virchows Arch 2019; 474:721-734. [DOI: 10.1007/s00428-019-02553-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 11/30/2022]
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Stenman A, Zedenius J, Juhlin CC. The Value of Histological Algorithms to Predict the Malignancy Potential of Pheochromocytomas and Abdominal Paragangliomas-A Meta-Analysis and Systematic Review of the Literature. Cancers (Basel) 2019; 11:cancers11020225. [PMID: 30769931 PMCID: PMC6406721 DOI: 10.3390/cancers11020225] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 12/26/2022] Open
Abstract
Pheochromocytomas (PCCs) and abdominal paragangliomas (PGLs), collectively abbreviated PPGLs, are neuroendocrine tumors of the adrenal medulla and paraganglia, respectively. These tumors exhibit malignant potential but seldom display evidence of metastatic spread, the latter being the only widely accepted evidence of malignancy. To counter this, pre-defined histological algorithms have been suggested to stratify the risk of malignancy: Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) and the Grading system for Adrenal Pheochromocytoma and Paraganglioma (GAPP). The PASS algorithm was originally intended for PCCs whereas the GAPP model is proposed for stratification of both PCCs and PGLs. In parallel, advances in terms of coupling overtly malignant PPGLs to the underlying molecular genetics have been made, but there is yet no combined risk stratification model based on histology and the overall mutational profile of the tumor. In this review, we systematically meta-analyzed previously reported cohorts using the PASS and GAPP algorithms and acknowledge a “rule-out” way of approaching these stratification models rather than a classical “rule-in” strategy. Moreover, the current genetic panorama regarding possible molecular adjunct markers for PPGL malignancy is reviewed. A combined histological and genetic approach will be needed to fully elucidate the malignant potential of these tumors.
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Affiliation(s)
- Adam Stenman
- Department of Oncology-Pathology, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, 171 76 Stockholm, Sweden.
| | - Jan Zedenius
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Breast, Endocrine Tumours and Sarcoma, Karolinska University Hospital, 171 76 Stockholm, Sweden.
| | - Carl Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, 171 76 Stockholm, Sweden.
- Department of Pathology and Cytology, Karolinska University Hospital, 171 76 Stockholm, Sweden.
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Konosu-Fukaya S, Omata K, Tezuka Y, Ono Y, Aoyama Y, Satoh F, Fujishima F, Sasano H, Nakamura Y. Catecholamine-Synthesizing Enzymes in Pheochromocytoma and Extraadrenal Paraganglioma. Endocr Pathol 2018; 29:302-309. [PMID: 30155766 DOI: 10.1007/s12022-018-9544-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In chromaffin cells, tyrosine hydroxylase (TH), aromatic L-amino acid decarboxylase (AADC), dopamine β-hydroxylase (DBH), and phenylethanolamine N-methyltransferase (PNMT) are mainly involved in catecholamine synthesis. In this study, we evaluated the association between the status of catecholamine-synthesizing enzymes and histopathological features of pheochromocytoma and extraadrenal paraganglioma with special emphasis upon their postoperative clinical behavior. Immunohistochemical evaluation of TH, DBH, AADC, PNMT, Ki 67, and S-100 was performed in 29 pheochromocytoma and 10 extraadrenal paraganglioma and one lymph node harboring metastatic pheochromocytoma. Among these cases, metastasis was subsequently developed in three cases. Urinary normetanephrine (U-NM) levels were significantly higher in clinical metastatic cases than non-metastatic ones. Ki 67 labeling index was significantly higher in both clinical metastatic cases and the Adrenal Gland Scaled Score (PASS) score of ≧ 4 cases than PASS < 4 cases, although this score was originally used in pheochromocytoma. H-score of AADC and DBH were significantly lower in PASS ≧ 4 cases than those with < 4 cases, and in the cases associated with intratumoral necrosis (n = 4), the presence of spindle shaped tumor cells (n = 4), and large nests of cells or diffuse growth (n = 5). Lower status of intratumoral AADC could be related to poor differentiation of tumor cells in both catecholamine production and morphology and could be related to aggressive biological behavior of both pheochromocytoma and extraadrenal paraganglioma.
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Affiliation(s)
- Sachiko Konosu-Fukaya
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, 983-8536, Japan
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Omata
- Division of Nephrology, Endocrinology, and Vascular Medicine, Department of Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuta Tezuka
- Division of Nephrology, Endocrinology, and Vascular Medicine, Department of Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology, and Vascular Medicine, Department of Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yayoi Aoyama
- Department of Pathology, Tohoku University Hospital, Sendai, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology, and Vascular Medicine, Department of Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiyoshi Fujishima
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Pathology, Tohoku University Hospital, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Pathology, Tohoku University Hospital, Sendai, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, 983-8536, Japan.
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan.
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