Recent advances in the diagnosis and treatment of pheochromocytoma

Unexpected pheochromocytoma leading to cardiac arrest during the perioperative period: a case report and literature review

BACKGROUND

Pheochromocytomas (PCCs) are rare neuroendocrine catecholamine (CA)-secreting tumours that originate from chromaffin tissue and can produce and store CAs. Unexpected PCCs pose a serious threat to the perioperative safety of patients and a considerable challenge to anaesthesiologists because of the risks of fatal hypertensive crises and other stresses.

CASE PRESENTATION

A 37-year-old woman who was scheduled for tonsillectomy and palatopharyngoplasty under general anaesthesia experienced a malignant cardiovascular event after induction, which was characterized mainly by a sharp increase in heart rate and blood pressure, ultimately leading to cardiac arrest and the occurrence of secondary long QT syndrome. Based on the perioperative clinical manifestations, measurements of plasma and urinary CAs, postoperative bilateral adrenal computed tomography results and surgical pathological results, the patient was diagnosed with an undiagnosed PCC.

CONCLUSIONS

Anaesthesiologists should pay attention to patients with recurrent chest tightness, as these patients may have an undiagnosed PCC. Extreme hypertension and tachycardia during the perioperative period may indicate a PCC. We should not automatically use beta-adrenergic receptor blockade while overlooking the importance of alpha-adrenergic receptor blockade. If a serious malignant cardiovascular event occurs in patients with an undiagnosed PCC during the perioperative period, multidisciplinary comprehensive treatment is crucial.

Intrapartum adrenalectomy for pheochromocytoma presenting in pregnancy: A case report

Pheochromocytoma is one of the rare causes of hypertension in pregnancy, occurring in one in every 50,000 pregnancies. The aim of this case report is to describe an atypical presentation of pheochromocytoma at 35 weeks gestation, where it presented with right flank pain and seizures, its preoperative medical optimization, and intrapartum concurrent surgical management. It also discusses various clinical presentations of pheochromocytoma in pregnancy, appropriate laboratory and radiological investigations, and different modalities of treatment. It is important to consider the possibility of the diagnosis of pheochromocytoma when considering the different causes of high blood pressure in a term pregnancy. Prompt antenatal diagnosis and timely management are critical to reducing maternal and perinatal morbidity and mortality rates.

Vasoactive intestinal peptide producing pheochromocytoma and intracardiac thrombosis

A case of pheochromocytoma producing vasoactive intestinal peptide (VIP) and left ventricular thrombus in the absence of cardiomyopathy or wall motion abnormalities on echocardiogram is presented along with a review of the relevant literature. A 30-year-old female of Afghani descent with past medical history of panic attacks presented with fever, cough, sore throat, vomiting, and was found to have an 11 cm adrenal mass consistent with primary adrenocortical adenoma versus carcinoma. Her tumor elicited catechols and vasoactive intestinal peptide. Her hospitalization was complicated by left ventricular thrombosis leading to an embolic injury to her right kidney, respiratory failure, need for transient dialysis and urinary tract infections. She developed a profuse secretory diarrhea and decision was made to treat with empiric octreotide infusion and imodium with improvement in symptoms. She underwent coil and particle embolization followed by resection. Followup PET gallium scan showed no evidence of residual disease or metastasis. VIP producing pheochromocytoma associated with intracardiac thrombosis is rare. Outcomes depend on prompt diagnosis of the pheochromocytoma and multidisciplinary approach to management.

Composite phaeochromocytomas-a systematic review of published literature

Introduction

Composite phaeochromocytoma is a tumour containing a separate tumour of neuronal origin in addition to a chromaffin cell tumour. This study reports on two cases from a single centre’s records and presents a systematic literature review of composite phaeochromocytomas.

Methods

In addition to describing 2 case reports, a systematic search of the Medline database from inception up to April 2020 was done for human case reports on composite phaeochromocytomas. Relevant titles and/or abstracts were screened, and full texts were reviewed to identify appropriate studies. Data was extracted and a descriptive analysis of presentation, clinical features, management strategies and outcomes was performed. The quality of included studies was assessed using a critical appraisal checklist.

Results

There were 62 studies included, with a total of 94 patients. Of 91 patients where data was available, the median (range) age of patients was 48 (4–86) years. Of 90 patients where information was provided, 57% were female. In at least 28% of patients, a genetic cause was identified. Common presenting features include abdominal pain, palpable mass, cardiovascular and gastrointestinal symptoms. The most common tumour component with phaeochromocytoma is ganglioneuroma; other components include ganglioneuroblastoma, neuroblastoma and malignant peripheral nerve sheath tumours. In patients with follow-up data (n=48), 85% of patients were alive and well at a median (range) follow-up time of 18 (0.5–168) months.

Conclusion

Composite phaeochromocytoma is a rare tumour, with a significant genetic predisposition. This review summarises available epidemiological data, which will be useful for clinicians managing this rare condition.

Pseudopheochromocytoma

Pseudopheochromocytoma manifests as severe, symptomatic paroxysmal hypertension without significant elevation in catecholamine and metanephrine levels and lack of evidence of tumor in the adrenal gland. The clinical manifestations are similar but not identical to those in excess circulating catecholamines. The underlying symptomatic mechanism includes augmented cardiovascular responsiveness to catecholamines alongside heightened sympathetic nervous stimulation. The psychological characteristics are probably attributed to the component of repressed emotions related to a past traumatic episode or repressive coping style. Successful management can be achieved by strong collaboration between a hypertension specialist and a psychiatrist or psychologist with expertise in cognitive-behavioral panic management.

Acute airway obstruction due to retropharyngeal haematoma caused by a large fish bone in a patient with hypertension caused by a pheochromocytoma

Retropharyngeal haematoma (RH) is an extremely rare but potentially life-threatening condition that requires an early diagnosis and immediate management. Acute complications arise from compression and obstruction of the upper airway and oesophagus with the risk of consecutive aspiration. We present the case of a 48-year-old man with formation of a RH after accidental ingestion of a large fish bone with hypertension as comorbidity caused by a so far undiagnosed pheochromocytoma. The patient presented with acute onset of retropharyngeal pain, dysphonia and dysphagia secondary to fish bone foreign body ingestion. His medical history was significant for uncontrolled hypertension. CT showed a large RH extending from the oropharynx to the superior mediastinum. The patient underwent emergency tracheostomy, surgical debridement and removal of the fish bone. Antihypertensive medication was utilised to control his labile blood pressure. The postoperative CT scan revealed an adrenal pheochromocytoma that was subsequently resected.

Malignant pheochromocytoma: Hepatectomy for liver metastases

Malignant pheochromocytoma accounts for approximately 10% of pheochromocytoma cases. The main site of distant metastasis is the liver. Hypertensive crisis due to catecholamine oversecretion is potentially fatal. We present a case of malignant pheochromocytoma with multiple liver metastases. A 60-year-old female with repeated hypertensive episodes was diagnosed with malignant pheochromocytoma. She underwent a left adrenalectomy and partial hepatectomy with resection of segment 6. Catecholamine levels remained high after surgery and she received repeated cycles of chemotherapy. Four months after surgery, multiple liver metastases were detected. In spite of ongoing chemotherapy, catecholamine levels eventually became uncontrollable. Serum and urine noradrenaline and vanillylmandelic acid levels increased, but adrenaline and dopamine levels stayed within the normal range. Preoperative liver imaging revealed multiple metastases in all segments except segment 4. Percutaneous transhepatic portal vein embolization (PTPE) of the right and lateral branches of the portal vein was performed. The functional liver volume of segment 4 increased after PTPE. Right hepatectomy, lateral segmentectomy and partial resection of segment 1 were performed 10 mo after the initial surgery. Intraoperative ultrasonography detected two small tumors in segment 4, which were treated with intraoperative microwave coagulation therapy. Noradrenaline levels normalized immediately after the second hepatectomy. As there was increased telomerase activity in the resected specimen, she received adjuvant chemotherapy. She remained in good health for 2 years. However, further metastases eventually occurred and she subsequently died due to a brain hemorrhage. Hepatectomy may be a therapeutic option for reduction of tumor mass in pheochromocytoma with liver metastases.

Hypertension in pheochromocytoma: characteristics and treatment

Pheochromocytoma is a tumor of the chromaffin cells in the adrenal medulla and sympathetic paraganglia, which synthesizes and secretes catecholamines. Norepinephrine, epinephrine, and dopamine all act on their target receptors, which causes a physiologic change in the body. High circulating levels of catecholamines can lead to severe hypertension and can have devastating effects on multiple body systems (eg, cardiovascular, cerebrovascular), and can lead to death if untreated. Although surgical treatment represents the only modality of ultimate cure, pharmacologic preoperative treatment remains the mainstay of successful outcome.

Factors influencing arterial stiffness in pheochromocytoma and effect of adrenalectomy

The aim of the study was to evaluate arterial stiffness and its modulating factors measured by carotid-femoral pulse wave velocity (PWV) and central augmentation index (AI) in patients with pheochromocytoma (PHEO) before and after surgery. Forty-five patients with PHEO and 45 healthy controls were investigated using an applanation tonometer (SphygmoCor, AtCor Medical). The gender, age, BMI and lipid profiles were comparable among both groups. The main difference in basic characteristic was as expected for fasting plasma glucose (P<0.001) and all blood pressure modalities. PWV in PHEO was significantly higher than in controls (7.2+/-1.4 vs. 5.8+/-0.5 ms(-1); P<0.001). Between-group difference in PWV remained significant even after the adjustment for age, heart rate, fasting plasma glucose and each of brachial (P<0.001) and 24 h blood pressure parameters (P<0.01). The difference in AI between groups did not reach the statistical significance (19+/-14 vs. 16+/-13%; NS). In multiple regression analysis, age (P<0.001), mean blood pressure (P=0.002), high-sensitive C-reactive protein (hs-CRP) (P=0.007) and 24 h urine norepinephrine (P=0.007) were independently associated with PWV in PHEO. In addition, 27 patients with PHEO were studied 1 year after tumor removal. Successful tumor removal led to a significant decrease in PWV (7.0+/-1.2 vs. 6.0+/-1.1 ms(-1); P<0.001). In conclusion, patients with PHEO have an increase in PWV, which is reversed by the successful tumor removal. Age, mean blood pressure, hs-CRP and norepinephrine levels are independent predictors of PWV.

[Anaesthesia for endocrine tumor removal]

Endocrine tumors could be defined by their ability to produce structural proteins or hormones common to nervous and endocrine cells. They might induce physiological transforms or outcome adverse events which should be well known in order to prevent or treat them early. The goal of this review was to describe these changes, to describe preoperative assessment, and to discuss intraoperative monitoring and drugs choice based on the literature from the last 30 years. As an example, it should be noticed that: (1) preoperative blood pressure control is essential to prepare phaeochromocytoma for surgery. It should be followed during anaesthesia by intensive fluid load, reversible anaesthetic drugs and rational cardiovascular medications use (as for example remifentanil, sevoflurane, calcium channel blockers and esmolol), and after surgery by narrow clinical and biological monitoring; (2) after medullar thyroid cancer, main adverse events include cervical compressive haematoma and recurrent laryngeal nerve injury as for any thyroid surgery; (3) during pituitary surgery, air embolism might be expected, whereas water dysregulation (diabetes insipidus), corticotroph insufficiency, cerebrospinal fluid (CSF) leak might occur postoperatively. In acromegaly, difficult endotracheal intubation is possible whereas severe Cushing's syndrome may be complicated with hypertensive cardiac failure, infections, thrombosis, delayed cicatrisation; (4) somatostatine analogs are a keystone in carcinoid tumors preoperative and anaesthetic management.