Urinary catecholamine and metadrenaline to creatinine ratios in dogs with a phaeochromocytoma

Reference intervals for plasma, urinary, and salivary concentrations of free metanephrines in dogs: Relevance to the diagnosis of pheochromocytoma

BACKGROUND

Measurement of free metanephrines is recommended for screening of pheochromocytoma (PCC) but requires appropriate reference intervals (RIs).

HYPOTHESIS/OBJECTIVES

To report RIs for plasma, urinary and salivary concentrations of free metanephrines and to determine the diagnostic performance of plasma free normetanephrine (pNMN) and metanephrine (pMN) concentrations in dogs with PCC, hypercortisolism (HC), and nonadrenal illness (NAI).

ANIMALS

Eighty healthy dogs, 11 PCC dogs, 25 HC dogs, 6 NAI dogs.

METHODS

Plasma, urine, and saliva were collected prospectively from healthy dogs, and free metanephrine concentrations were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS). In addition, medical records of dogs that had plasma free metanephrine concentrations measured by LC-MS/MS between 2018-2021 were studied retrospectively.

RESULTS

The RIs for free metanephrines in plasma, urine and saliva are reported. Dogs with PCC had significantly higher pNMN than dogs with HC (P < .001) and NAI (P = .002). The PCC dogs had significantly higher pMN than HC dogs (P < .001), but not higher than NAI dogs (P = .29). Using the upper reference limit, pNMN (>3.56 nmol/L) showed high sensitivity (100%, 95% confidence interval [CI]: 72-100) and specificity (94%, 95% CI: 79-99) for diagnosis of PCC, whereas pMN (>2.49 nmol/L) showed moderate sensitivity (73%, 95% CI: 39-94) and high specificity (94%, 95% CI: 79-99).

CONCLUSIONS AND CLINICAL IMPORTANCE

With establishment of these RIs, biochemical testing for PCC in dogs can be substantially improved. Measurement of pNMN is superior to pMN in dogs with PCC.

Quantification of normetanephrine in canine urine using ELISA: evaluation of factors affecting results

Catecholamine release increases in dogs with pheochromocytomas and in situations of stress. Although plasma catecholamines degrade rapidly, their metabolites, normetanephrine (NME) and metanephrine (ME), are stable in acidified urine. Our aim was to verify a human urine ELISA kit for the quantification of NME and ME in canine urine and to determine the effects on metabolite stability of sampling time (morning or midday) and day (ordinary or day spent in a clinic). We analyzed 179 urine samples from 17 healthy dogs. For NME, the mean intra-assay CV was 6.0% for all samples and 4.3% for the canine control; inter-assay CVs were 3.3, 3.8, and 12% for high and low concentration human urine positive controls supplied in the ELISA kit and a positive canine control, respectively; spike-recovery was 90-101%. For ME, mean intra-assay CV was 6.5% for samples and 9.0% for the canine control; inter-assay CVs were 12.7, 7.2, and 22.5% for high and low concentration human urine positive controls supplied in the ELISA kit and a positive canine control, respectively; spike-recovery was 85-89%. Dilution recovery was unsatisfactory for both metabolites. Based on our verification results, NME was selected for remaining analyses. We found no effect on NME concentrations of acidification or room temperature storage for up to 24 h. The NME:creatinine ratio was higher after the first of 3 clinic days compared to the same morning (111.2 ± 5.5 vs. 82.9 ± 5.3; p < 0.0001), but not on the other days. NME verification results were generally superior to ME. Dilution studies were unsatisfactory for both metabolites. Given that NME was stable without acidification at room temperature, urine samples can be collected at home. The clinic environment can cause higher NME:creatinine ratios, especially in unaccustomed dogs.

Urinary free metanephrines measurement in dogs with adrenal gland diseases using a new simple liquid chromatography tandem mass spectrometry method

Measurement of urinary metanephrines in spot samples is used for the diagnosis of canine pheochromocytoma (PC). We describe a simple analytical method based on liquid chromatography tandem mass spectrometry (LC-MS/MS) for measuring free metanephrine (MN) and normetanephrine (NMN) in spot urine samples. Using the developed method, we evaluated the stability of urinary free-MN and free-NMN at various storing conditions. In addition, we assessed the feasibility of urinary free-MN and -NMN measurement for diagnosing PC. Urine samples were mixed with stable isotope internal standards and thereafter purified by ultrafiltration. The purified samples were analyzed by LC-MS/MS in the multiple reaction monitoring mode after separation on a multimode octa decyl silyl column. The coefficient of variation of free-MN and -NMN measurement was 7.6% and 5.5%, respectively. The linearity range was 0.5–10 µg/l for both analytes. Degradation was less than 10% for both analytes under any of the storage conditions. The median free-NMN ratio to creatinine of 9 PC dogs (595, range 144–47,961) was significantly higher (P<0.05) than that of 13 dogs with hypercortisolism (125, range 52–224) or 15 healthy dogs (85, range 50–117). The developed method is simple and may not require acidification of spot urine. The results of this preliminary retrospective study suggest that the measurement of urinary free metanephrines is a promising tool for diagnosing canine PC.

Urinary vanillylmandelic acid:creatinine ratio in dogs with pheochromocytoma

Pheochromocytoma diagnosis in dogs is challenging because biochemical tests are not always available. In humans, urinary vanillylmandelic acid (VMA) is part of a pheochromocytoma biochemical diagnostic profile, whereas its diagnostic accuracy is currently unknown in dogs with pheochromocytoma. Prospectively, VMA was determined by HPLC and expressed as the ratio with respect to urinary creatinine (VMA:C). The diagnostic accuracy of the VMA:C ratio was evaluated by analyzing the receiver operating characteristic (ROC) curve in 10 healthy dogs, 8 dogs with pituitary-dependent hypercortisolism, 8 dogs with adrenal-dependent hypercortisolism, and 7 dogs with pheochromocytoma. The pheochromocytoma diagnosis was confirmed by histology and immunohistochemistry in all tumors. The VMA:C ratio was significantly higher in dogs with pheochromocytoma (158 [53.4 to 230.8] × 10^-3) than in dogs with adrenal-dependent hypercortisolism (48.1 [24.3 to 144.9] × 10^-3; P < 0.05), dogs with pituitary-dependent hypercortisolism (37.5 [32 to 47.1] × 10^-3; P < 0.001), and healthy dogs (33.8 [13.3 to 87.9] × 10^-3; P < 0.001). When using a VMA:C ratio >58.2 × 10^-3 for pheochromocytoma diagnosis, a sensitivity of 85.7% and a specificity of 88.4% were obtained. Nevertheless, when using a cut-off ratio of 4 times the median VMA:C ratio determined in healthy dogs, there was no overlap (100% specificity). The area under the ROC curve indicated that the VMA:C ratio test could be used to discriminate between dogs with and without pheochromocytoma, what leads to the conclusion that it is useful for pheochromocytoma diagnosis in dogs.

Retrospective evaluation of toceranib phosphate (Palladia®) use in the treatment of inoperable, metastatic, or recurrent canine pheochromocytomas: 5 dogs (2014-2017)

BACKGROUND

Effective treatment options for inoperable, metastatic, or recurrent canine pheochromocytomas are lacking. In humans, specific germline mutations exist that drive the development of pheochromocytomas. Pharmaceutical blockade of these abnormalities with small molecule inhibitors are an effective treatment strategy. Similar mutations may exist in the dog, and thus, treatment with similar small molecule inhibitors may provide a survival advantage. The purpose of this study was to assess the role of toceranib phosphate in the treatment of inoperable, metastatic, or recurrent canine pheochromocytomas.

RESULTS

Retrospectively, medical records of dogs that had a diagnosis or suspect diagnosis of a pheochromocytoma were reviewed for information regarding response to toceranib phosphate and overall outcome. Five dogs were identified that fit the inclusion criteria. All five experienced clinical benefit (1 partial response, 4 stable disease). Progression-free interval (PFI) for the dog with the partial response was 61 weeks. PFI for the two dogs with stable measurable disease were 36 weeks and 28 weeks. PFI in the two dogs with stable metastatic disease were at least 11 weeks and 18 weeks.

CONCLUSIONS

Based on this limited series of dogs, the results suggest that toceranib may have biological activity in dogs with primary and metastatic pheochromocytomas. Larger studies are needed to define the use and response to toceranib in dogs with gross, microscopic, and metastatic pheochromocytoma.

Evaluation of an ELISA for metanephrines in feline urine

Catecholamines can be used to evaluate neuroendocrine tumors, stress, and potentially pain, but catecholamines degrade rapidly. Their metabolites normetanephrine (NME) and metanephrine (ME) have better stability in urine. In cats, urine sampling in a home environment would be beneficial to reduce effects of clinical stress and simplify sampling. We evaluated a human urine ELISA for analysis of NME and ME in feline urine, and investigated the effects of acidification, cat tray pellets, and storage time at room temperature up to 8.5 h. In 26 feline urine samples, mean NME concentration was 192 ± 80 ng/mL, mean intra- and inter-assay CV was 6.5% and 4.2%, respectively, and spike recovery was 98-101%, but dilutional recovery was unsatisfactory. For ME, mean intra- and inter-assay CV was 10.2% and 4.1%, respectively. Mean urine ME concentration was 32.1 ± 18.3 ng/mL, close to the kit's lowest standard, and spike recovery was 65-90%; the ELISA could not be validated for ME. The stability study, performed for NME on 12 urine samples, did not identify differences between acidified and non-acidified samples, cat tray pellets, or storage time, and no interaction effects. The ME ELISA was not suitable for feline urine; performance of the NME ELISA was acceptable, except for dilution recovery. For analysis of NME, feline urine can be sampled at home using cat tray pellets and stored at room temperature up to 8.5 h without acidification.

Effects of Trilostane on urinary Catecholamines and their metabolites in dogs with Hypercortisolism

BACKGROUND

Glucocorticoids influence the synthesis and metabolism of catecholamines (epinephrine and norepinephrine) and metanephrines (metanephrine and normetanephrine). The aim of this study was to measure urinary catecholamines and metanephrines in dogs with hypercortisolism before and during trilostane therapy. Urine samples were collected during initial work up and during therapy with trilostane in 14 dogs with hypercortisolism and in 25 healthy dogs. Epinephrine, norepinephrine, metanephrine and normetanephrine were measured using high-pressure liquid chromatography and expressed as ratios to urinary creatinine concentration.

RESULTS

Untreated dogs with hypercortisolism had significantly higher epinephrine, norepinephrine, and normetanephrine:creatinine ratios compared to healthy dogs. During trilostane therapy, urinary catecholamines and their metabolites did not decrease significantly. However, dogs with low post-ACTH cortisol concentrations during trilostane therapy had less increased epinephrine, norepinephrine and normetanephrine:creatinine ratios compared to healthy dogs. There was no correlation of urinary catecholamines and their metabolites with baseline or post-ACTH cortisol or endogenous ACTH concentrations during trilostane therapy.

CONCLUSION

Influences between steroid hormones and catecholamines seem to occur, as dogs with hypercortisolism have significantly higher urinary epinephrine, norepinephrine, and normetanephrine:creatinine ratios. Once-daily trilostane therapy does not lead to a significant decrease in catecholamines and their metabolites. Trilostane-treated dogs still have increased urinary epinephrine, norepinephrine and normetanephrine:creatinine ratios during trilostane therapy.

Urinary and plasma catecholamines and metanephrines in dogs with pheochromocytoma, hypercortisolism, nonadrenal disease and in healthy dogs

Background

Diagnosis of pheochromocytoma (PC) is based on a combination of clinical suspicion, finding an adrenal mass, increased plasma, and urine concentrations of catecholamine metabolites and is finally confirmed with histopathology. In human medicine, it is controversial whether biochemically testing plasma is superior to testing urine.

Objectives

To measure urinary and plasma catecholamines and metanephrines in healthy dogs, dogs with PC, hypercortisolism (HC), and nonadrenal diseases (NAD) and to determine the test with the best diagnostic performance for dogs with PC.

Animals

Seven PC dogs, 10 dogs with HC, 14 dogs with NAD, 10 healthy dogs.

Methods

Prospective diagnostic clinical study. Urine and heparin plasma samples were collected and stored at −80°C before analysis using high‐pressure liquid chromatography (HPLC) coupled to electrochemical detection or tandem mass spectrometry were performed. Urinary variables were expressed as ratios to urinary creatinine concentration.

Results

Dogs with PC had significantly higher urinary normetanephrine and metanephrine : creatinine ratios and significantly higher plasma‐total and free normetanephrine and plasma‐free metanephrine concentrations compared to the 3 other groups. There were no overlapping results of urinary normetanephrine concentrations between PC and all other groups, and only one PC dog with a plasma normetanephrine concentration in the range of the dogs with HC and NAD disease. Performances of total and free plasma variables were similar. Overlap of epinephrine and norepinephrine results between the groups was large with both urine and plasma.

Conclusion and clinical importance

Measurement of normetanephrine is the preferred biochemical test for PC and urine was superior to plasma.

Comparison of plasma free metanephrines between healthy dogs and 3 dogs with pheochromocytoma

BACKGROUND

Adrenomegaly and hypertension are common clinical entities in canine medicine for which testing for pheochromocytoma is recommended. Yet, a validated biochemical test for the diagnosis of pheochromocytoma in dogs does not exist. In human medicine, plasma free metanephrine testing is the diagnostic standard for the biochemical diagnosis of pheochromocytoma.

OBJECTIVES

The purpose of this study was to investigate the utility of measurement of plasma free metanephrines in dogs for the diagnosis of pheochromocytoma.

METHODS

Plasma free metanephrines were measured in 11 healthy dogs and in 3 dogs confirmed to have a pheochromocytoma. The metanephrine assays were performed at a reference laboratory using high-performance liquid chromatography with electrochemical detection.

RESULTS

The plasma free metanephrine and normetanephrine concentrations in 11 healthy dogs were normally distributed and were used to create tentative reference intervals. All 3 dogs with histologically confirmed pheochromocytoma clearly had higher concentrations of plasma free metanephrines.

CONCLUSIONS

This pilot study demonstrates the potential utility of plasma free metanephrines levels for the biochemical diagnosis of pheochromocytoma in dogs.

Pathologic and Cardiovascular Characterization of Pheochromocytoma-Associated Cardiomyopathy in Dogs

Pheochromocytoma-associated catecholamine-induced cardiomyopathy is a well-known entity in man, nonhuman primates, and mice but has not been described in dogs. In this retrospective study, 9 dogs were identified with pheochromocytomas and concurrent cardiovascular pathology observed histologically ( n = 6), echocardiographically ( n = 4), and/or electrocardiographically ( n = 5). Cardiac lesions included multifocal cardiomyocyte necrosis with contraction bands, cardiomyocyte degeneration, myocardial hemorrhage, lymphohistiocytic myocarditis, and interstitial fibrosis. Clinical procedures, including electrocardiographic and echocardiographic examinations, Doppler blood pressure measurement, and auscultation, were available for 5 dogs and consistently revealed concentric or mixed (eccentric and concentric) ventricular hypertrophy. Additional changes observed included arrhythmias, systemic hypertension, and heart murmurs. The myocardial lesions observed in this series of dogs are similar to those observed in humans with pheochromocytoma-associated catecholamine-induced cardiomyopathy. Since the clinical manifestations of catecholamine-induced cardiac disease are amenable to medical treatment, recognition of this cardiomyopathy has the potential to reduce morbidity and mortality in dogs with pheochromocytoma.

Endocrine emergencies in dogs and cats

Success in treatment of endocrine emergencies is contingent on early recognition and treatment. Many endocrine diseases presenting emergently have nonspecific signs and symptoms. In addition, these endocrine crises are often precipitated by concurrent disease, further making early identification difficult. This article concentrates on recognition and emergency management of the most common endocrine crises in dogs and cats.

Metabolic complications of endocrine surgery in companion animals

Metabolic complications of endocrine surgery occur commonly and precautions should be taken to avoid potentially life-threatening situations and to lessen expense associated with a more extended hospital stay. Common complications of endocrine surgery as well as prevention strategies will be reviewed for pancreatic, parathyroid, and adrenal surgery.

Urinary catecholamine and metanephrine to creatinine ratios in dogs with hyperadrenocorticism or pheochromocytoma, and in healthy dogs

BACKGROUND

Urinary catecholamines and metanephrines are used for the diagnosis of pheochromocytoma (PHEO) in dogs. Hyperadrenocorticism (HAC) is an important differential diagnosis for PHEO.

OBJECTIVES

To measure urinary catecholamines and metanephrines in dogs with HAC.

ANIMALS

Fourteen dogs with HAC, 7 dogs with PHEO, and 10 healthy dogs.

METHODS

Prospective clinical trial. Urine was collected during initial work-up in the hospital; in dogs with HAC an additional sample was taken at home 1 week after discharge. Parameters were measured using high-pressure liquid chromatography and expressed as ratios to urinary creatinine concentration.

RESULTS

Dogs with HAC had significantly higher urinary epinephrine, norepinephrine and normetanephrine to creatinine ratios than healthy dogs. Urinary epinephrine, norepinephrine, and metanephrine to creatinine ratios did not differ between dogs with HAC and dogs with PHEO, whereas the urinary normetanephrine to creatinine ratio was significantly higher (P= .011) in dogs with PHEO (414, 157.0-925.0, median, range versus (117.5, 53.0-323.0). Using a cut-off ratio of 4 times the highest normetanephrine to creatinine ratio measured in controls, there was no overlap between dogs with HAC and dogs with PHEO. The variables determined in urine samples collected at home did not differ from those collected in the hospital.

CONCLUSION AND CLINICAL IMPORTANCE

Dogs with HAC might have increased concentrations of urinary catecholamines and normetanephrine. A high concentration of urinary normetanephrine (4 times normal), is highly suggestive of PHEO.