Phaeochromocytoma--investigation and management of 10 cases

Sudden Death Due to Neck Paraganglioma: A Pediatric Case Report and Review of the Literature

Neck paragangliomas are relatively rare neuroendocrine nonsecretory tumors. They are mainly observed among adults and are often asymptomatic, causing a frequent delay in diagnosis. In pediatric cases, neck paragangliomas can be associated with adrenergic symptoms that may lead to complications.A report of a sudden death due to a carotid paraganglioma in a young girl is reported. Autopsy revealed a thoracic arotic dissection and a 4-cm jugulocarotidian mass in the absence of traumatic injuries. Histology showed no evidence of underlying aortic disease, including signs of Marfan syndrome, and a paraganglioma. Postmortem biochemistry analysis showed blood metanephrines levels 100 times higher than normal range. The cause of death was an aortic dissection complicating a neck paraganglioma. The manner of death was concluded as natural.Our case highlighted the importance for forensic pathologist to consider the diagnosis of paraganglioma in case of sudden hypertensive complications, especially among young people.

Renovascular hypertension in children

Renovascular disease is an uncommon but important cause of hypertension in children. It is usually diagnosed after a long delay because blood pressure is infrequently measured in children and high values are generally dismissed as inaccurate. Many children with renovascular disease have abnormalities of other blood vessels (aorta, cerebral, intestinal, or iliac). Individuals suspected of having the disorder can be investigated further with CT, MRI, or renal scintigraphy done before and after administration of an angiotensin-converting-enzyme inhibitor, but angiography is still the gold standard. Most children with renovascular disease will need interventional or surgical treatment. Endovascular treatment with or without stenting will cure or reduce high blood pressure in more than half of all affected children. Surgical intervention, if needed, should be delayed preferably until an age when the child is fully grown. Modern treatment provided by a multidisciplinary team of paediatric nephrologists, interventional radiologists, and vascular surgeons offers good long-term treatment results.

Carotid body tumor in a 13-year-old child: Case report and review of the literature

Carotid body tumor (CBT), an extra-adrenal paraganglioma, represents an uncommon entity arising in chemoreceptor tissue located at the carotid bifurcation. Only a few cases have been reported in the literature in the pediatric age group less than 14 years of age, primarily as case reports. Surgical excision is advisable in almost all ages, however, in childhood, it is known to carry risks and difficulties due to the smaller size of the involved anatomical structures. We report an unusual case of a large (50 x 43 x 30 mm) carotid paraganglioma of Shamblin type III in a 13-year-old female, living at high altitude until the age of 9 years. This cervical mass was present, but smaller in size, several years before admission. However, an intense hypoxic stimulus at high altitude for 2 months at the age of 13 years probably induced a fast growing period of the lesion. The tumor was removed en bloc with the involved carotid segments and vascular continuity was restored by means of a common carotid to internal carotid saphenous vein interposition graft. No malignant behavior or regional metastatic spread of the resected mass was demonstrated. Furthermore, no inheritance pattern between family members was confirmed. A clinical update on CBTs in childhood a propos of this case report is undertaken.

Feocromocitoma: uma causa rara de hipertensão arterial na infância

OBJETIVO: Relatar o caso de um adolescente com feocromocitoma, uma causa rara de hipertensão arterial na infância. DESCRIÇÃO: Adolescente internado em unidade de terapia intensiva infantil em decorrência de emergência hipertensiva, conseqüente à presença de feocromocitoma em adrenal esquerda, diagnosticado por meio de tomografia computadorizada do abdome e pela dosagem de adrenalina e noradrenalina urinárias. O paciente foi submetido à adrenalectomia esquerda, após o uso de alfa-bloqueador para controle do quadro hipertensivo. O anatomopatológico confirmou o diagnóstico do tumor. No pós-operatório, o paciente permaneceu estável, possibilitando a suspensão dos anti-hipertensivos. COMENTÁRIOS: Os feocromocitomas são tumores capazes de produzir catecolaminas, especialmente adrenalina e/ou noradrenalina. Cerca de 85 a 95% dos tumores são únicos, benignos e encontrados na medula adrenal. O feocromocitoma é um tumor de incidência rara e apenas 10 a 20% ocorrem na infância, representando uma causa rara de hipertensão arterial. Esta última é um sinal freqüente na maioria das crianças (80%), podendo ser acompanhada por cefaléia e sudorese. A encefalopatia hipertensiva consiste em uma forma de apresentação excepcional da doença. O diagnóstico pode ser realizado, na maioria dos casos, pela tomografia de abdome e pela dosagem das catecolaminas e seus metabólitos produzidos pelo tumor. O tratamento de escolha consiste na ressecção completa do tumor após o preparo farmacológico do paciente com o uso de alfa-bloqueador. No pós-operatório, a maioria dos pacientes evolui com controle do quadro de hipertensão arterial.

Angioplasty for renovascular hypertension in children: 20-year experience

OBJECTIVE

Our aim was to evaluate the clinical outcomes, safety, and efficacy of percutaneous transluminal angioplasty for renovascular hypertension in children.

METHODS

A retrospective review of data for all children with renovascular hypertension who underwent percutaneous transluminal angioplasty at a single center between 1984 and 2003 was performed. Patients with renal transplants and inflammatory multisystem diseases were excluded.

RESULTS

Thirty-three children, 1.9 to 17.9 years of age (median: 10.3 years), underwent renal angioplasty and/or stenting. Underlying syndromes were present in 10. On angiograms, 16 had bilateral renal artery stenosis, 15 intrarenal disease, 8 aortic stenosis, and 7 cerebrovascular disease. Forty-eight percutaneous transluminal angioplasty procedures were performed, including 15 stenting procedures. There was a high rate of restenosis after stenting (7 of 19 cases, compared with 2 of 27 cases after balloon dilation). Outcomes were cured (ie, blood pressure normal without treatment) for 9 patients, improved blood pressure with same or reduced treatment for 7, blood pressure maintained in >95th percentile because of cerebrovascular disease for 2, no change in blood pressure despite technical success for 10, and technical failure for 5. Blood pressure control improved in 11 of 13 children who had main renal artery disease alone and in 6 of 20 with associated intrarenal disease or stenoses in other vascular beds. There was 1 procedure-related death and 5 minor complications.

CONCLUSIONS

Angioplasty produced clinically worthwhile improvement for approximately 50% of patients. High incidence rates of extrarenal involvement and intrarenal disease and a high restenosis rate after stenting accounted for poor blood pressure control in the rest.

Impaired differential renal function in a child with pheochromocytoma

We report a girl with extra-adrenal pheochromocytoma complicated with impaired renal function of the ipsilateral kidney, discussing aetiologies. A 14-year-old girl presented with uncontrolled hypertension, high urinary vanillylmandelic acid level and a 5 x 6 cm mass at the right renal hilum. Her blood pressure was under control with propranolol, prazosin, and nifedipine before surgery, and with sodium nitroprusside during surgical intervention. The total tumour removal required reconstruction of the right renal vein. Histopathology confirmed pheochromocytoma. Dimercaptosuccinic acid (DMSA) after surgery showed low uptake of isotope by the right kidney; it was unclear if this was due to the surgery or the tumour causing renal artery stenosis, but fortunately her blood pressure returned to normal thereafter. We recommend obtaining a DMSA in the preoperative evaluation of pheochromocytoma.

Paraganglioma (pheochromocytoma) of the posterior mediastinum: a case report and review of the literature

Pheochromocytoma is an uncommon tumor in the pediatric population. Paraganglioma, or extra-adrenal pheochromocytoma, accounts for only a small fraction of pediatric pheochromocytomas, with most of these tumors presenting within the abdominal cavity. Herein the authors report the extremely rare case of a biochemically active paraganglioma presenting as a posterior mediastinal mass in an 8-year-old boy.

Multivisceral fibromuscular dysplasia in childhood: case report and review of the literature

We report here a 9-year-old girl with fibromuscular dysplasia of many muscular arteries including both renal and internal carotid arteries, the celiac artery, superior mesenteric artery, and one external carotid artery. She suffered from severe renovascular hypertension with beginning secondary cardiac decompensation, typical angina abdominalis, and neurological signs, including severe headaches and hemianopsia. Surgery was performed for all major vessels and the outcome is good 2.5 years after the operation. The clinical presentation, differential diagnosis, and treatment options of fibromuscular dysplasia in childhood are discussed and the literature is reviewed.

Adrenal masses in the newborn

The incidence of neonatal adrenal tumors is increasing due to the expanded use and accuracy of prenatal ultrasonography in routine obstetric care. Although adrenal and juxtarenal masses may represent benign lesions (adrenal hemorrhage, subdiapragmatic extralobar pulmonary sequestration), the majority of masses either are premalignant or malignant. Previous algorithms for the diagnosis and management of these lesions have been guided primarily by the high incidence of neuroblastomas within this group. Improved insight into the relatively benign behavior of many neonatal neuroblastomas has stimulated debate regarding the appropriate management schema for neonatal adrenal masses. Moreover, the increasing recognition of benign juxtarenal lesions further challenges the conventional dogma. This review discusses the major categories of adrenal masses to help generate a rational algorithm for diagnosis and therapy.

Pheochromocytoma. Special considerations in children

Pheochromocytoma is a rare but important tumor in children. Appropriate evaluation and management are essential for a favorable outcome. Pheochromocytomas are more often multifocal and extra-adrenal in children when compared with adults. This pattern makes the diagnosis, localization, and surgical management more challenging. Nonetheless, the standard biochemical evaluation is usually diagnostic, and MR imaging is currently the best tool for tumor localization. The possibility of a familial syndrome must always be considered and should always be thoroughly evaluated when children present with a pheochromocytoma. Conversely, children with a familial syndrome should undergo annual screening for pheochromocytoma from a young age. Given the greater likelihood of a metachronous recurrence in children, consideration should be given to adrenal-sparing surgery in selected patients. When managed appropriately, the outlook for pheochromocytoma in children is excellent. Unfortunately, the uncommon malignant tumors are still difficult to treat. Perhaps the unique genetic characteristics of pheochromocytoma will ultimately be exploited in the management of the aggressive forms of this disease.

[Pheochromocytoma: pediatric features]

Pheochromocytoma is a rare tumor in children which explains, together with its miscellaneous symptomatology, why the diagnosis may be delayed. The localization of the tumor(s) rests mainly on MIBG scintigraphy, and CT scan and/or magnetic resonance imaging. Thanks to a systematic preoperative treatment of hypertension and major progress in anesthesia, the operative mortality of pheochromocytomas in children is nowadays very low. Nevertheless two major problems remain: 1) the difficulty of diagnosing and treating the malignant forms, 2) the high frequency of recurrences, sometimes many years after the removal of the primary tumor. A regular long term supervision is therefore necessary after the surgical treatment.

Pheochromocytoma and paraganglioma in children: a report of 24 cases of the French Society of Pediatric Oncology

Pheochromocytoma and paraganglioma of childhood are rare neuroendocrine tumors. Urinary catecholamine measurements, metaiobenzylguanidine (MIBG) scanning, computed tomographic scanning, and magnetic resonance imaging have greatly facilitated diagnosis. Prognosis after surgical resection is excellent. In this retrospective series collected from French oncology centers, the risk of tumor progression was studied in order to assess prognostic factors and the optimal diagnostic and therapeutic management. Medical records of 24 children with paraganglioma were reviewed. This tumor occurred at a median age of 12.5 years and in most cases was revealed by arterial hypertension. The diagnosis was made by the demonstration of urinary excretion of catecholamines and their metabolites. Six patients had bilateral adrenal pheochromocytomas; two patients had extra-adrenal paragangliomas. In eight patients, the paraganglioma occurred as a familial disease. Surgical excision was the only therapeutic procedure. With a follow-up of 5.2 years, 14 of the patients are still in first complete remission and 6 have developed metastases or shown tumor progression. Despite a high long-term survival rate, the risk of malignancy and of multifocal involvement is of concern and is associated with a significant rate of late events. The outcome depends on adequacy of tumor resection and must be serially assessed.

Adenosine for per-operative blood pressure control in an infant with neuroblastoma

We describe a child with a localised pelvic neuroblastoma and a hypertensive crisis during the first weeks of life due to elevated systemic norepinephrine of tumoural origin. In spite of treatment with high doses of alpha-blockers, blood pressure did not respond fully and the boy had a very unstable circulation. Surgery was performed at one month of age. Adenosine, a potent short-acting vasodilator, was used for peroperative blood pressure control to protect the patient from an uncontrolled hypertensive crisis. During tumour manipulation the child became hypertensive with systolic pressure exceeding 130 mm Hg and adenosine infusion (100 micrograms.kg-1.min-1) was started with a prompt normalisation of the blood pressure. Adenosine infusion could be discontinued after tumour removal. Norepinephrine, dopamine, homovanillic acid and vanillylmandelic acid in urine were elevated preoperatively and normalised at follow up. Plasma concentrations of norepinephrine and dopamine were elevated preoperatively. Norepinephrine increased during hypertension due to tumour manipulation. Plasma neuropeptide Y increased during tumour manipulation but still within the normal range for infants. It is concluded that adenosine can be used peroperatively in children with severe hypertension and in this case no adverse effects of adenosine were noted. Furthermore, tumour synthesis and systemic release of norepinephrine, but not neuropeptide Y, contributed to hypertension in this child with neuroblastoma.

Multiple neuropeptide immunoreactivities in a renin-producing human paraganglioma

BACKGROUND

A case of a renin-producing paraganglioma of adrenal origin with metastases to the retroperitoneal area, paravaginal area, and the ovary is reported with immunohistochemical findings indicating expression of multiple neuropeptide immunoreactivities. The patient was 23 years old at the time of diagnosis, and died from metastatic spread of the tumor 7 years later.

METHODS

Tumor tissue was examined by light microscopy, indirect immunohistochemistry, and electron microscopy.

RESULTS

The tumor tissue investigated contained several cells exhibiting opioid peptide-like immunoreactivities (i.e., enkephalin and dynorphin-like immunoreactivity [LI]). A lower number of cells displayed neuropeptide Y-, galanin-, somatostatin-, neurotensin-, substance P-, peptide histidine-isoleucine-, cholecystokinin-, renin-, and calbindin-LI.

CONCLUSION

To the authors' knowledge, galanin, dynorphin, peptide histidine-isoleucine, cholecystokinin, and calbindin have not been reported previously to occur in paraganglioma, and renin has been reported to occur very rarely. A review of recent literature suggest that enkephalin-, neuropeptide Y-, and somatostatin-like immunoreactivities may be useful as diagnostic markers for paragangliomas.

Renovascular disease in childhood

Fifty-four children referred for investigation of hypertension had renovascular disease. In eight patients it was associated with neurofibromatosis, in three with idiopathic hypercalcemia of infancy, and in five cases it followed an arteritic illness. Fibromuscular dysplasia was the underlying abnormality in the majority of cases (46%). Twenty-six patients (48%) were first seen with accelerated hypertension; 38 children (70%) had bilateral renal arterial disease, and in 41 (76%), disease of the small intrarenal vessels was found. Renal vein renin ratios indicated unilateral disease in 31 cases; the results correlated with arteriography findings in 32 (62%) of 51 patients. Eleven children also had the middle aortic syndrome, and 9 of 16 patients, investigated by cerebral arteriography because of cranial bruits or focal neurologic signs, had cerebral vascular abnormalities. Twenty patients were treated surgically--10 by reconstructive procedures, 11 by nephrectomy or heminephrectomy, and 6 by transluminal angioplasty. Of these, 9 (45%) are normotensive with no treatment, 10 have a decreased requirement for antihypertensive drugs, and 1 had no improvement. Thirty-four patients were treated medically because of the extent of their disease; two patients have died of hypertensive complications. We conclude that renal vascular disease in children is often widespread, may be associated with intracerebral vascular disease, frequently affects both kidneys, including both intrarenal and extrarenal vessels, and is therefore not always amenable to surgical intervention and cure.