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Eisenhofer G, Pamporaki C, Lenders JWM. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev 2023; 44:862-909. [PMID: 36996131 DOI: 10.1210/endrev/bnad011] [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: 09/28/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
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Lopez AG, Fraissinet F, Lefebvre H, Brunel V, Ziegler F. Pharmacological and analytical interference in hormone assays for diagnosis of adrenal incidentaloma. ANNALES D'ENDOCRINOLOGIE 2019; 80:250-258. [DOI: 10.1016/j.ando.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/27/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
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Boyd J, Leung AA, Sadrzadeh HS, Pamporaki C, Pacak K, Deutschbein T, Fliedner S, Kline GA. A high rate of modestly elevated plasma normetanephrine in a population referred for suspected PPGL when measured in a seated position. Eur J Endocrinol 2019; 181:301-309. [PMID: 31370003 PMCID: PMC7446766 DOI: 10.1530/eje-19-0176] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/10/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine rate of high plasma normetanephrine or metanephrine (PNM-PMN) in a large sample of patients according to PNM-PMN posture and age-adjusted references. DESIGN Retrospective re-analysis of PNM-PMN from a Canadian reference laboratory (n = 5452), 2011-2015; most were in seated position (n = 5112) rather than supine (n = 340). An international PPGL database demonstrated expected distribution of supine PNM-PMN in PPGL patients. METHODS All PNM-PMN from a tertiary referral laboratory were reviewed. Any PNM-PMN result greater than 2× upper reference limit (URL) was considered likely true PPGL. Results 1-2× URL were uncertain, requiring additional testing/follow-up despite most being false positive given the rarity of PPGL. The rate of results in the 1-2× URL category were calculated for each group according to collection posture and differing published URL: seated, supine or supine age adjusted. RESULTS When collected and interpreted by seated URL, 19.6% of PNM required additional testing; only 4.6% being >2× URL. For patients over age 50 years, the abnormal rate was 24.9%. When collected supine, interpreted by supine age-adjusted URL, only 5.3% of PNM were mildly elevated. Possible false positives may be even lower when considering PMN or plasma methoxytyramine which were commonly high in true PPGL despite mild PNM elevations. CONCLUSIONS In a general medical population, seated PNM has a high rate of abnormal results, far exceeding expected prevalence. Supine measurement with supine, age-adjusted interpretation is strongly preferred prior to costly or invasive PPGL investigations. SUMMARY Review of 5452 plasma normetanephrine measurements showed 20% to be high, likely false positives for most. Supine, age-adjusted measures were half as likely to be elevated.
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Affiliation(s)
- Jessica Boyd
- Department of Clinical Pathology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Public Laboratory, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hossein Sm Sadrzadeh
- Department of Clinical Pathology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Public Laboratory, Calgary, Alberta, Canada
| | - Christina Pamporaki
- Department of Endocrinology, University Hospital, Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Karel Pacak
- Section of Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Stephanie Fliedner
- Neuroendocrine Oncology and Metabolism, First Department of Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Gregory A Kline
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Gómez R, Hernaiz M, de Miguel V, Aparicio L, Marín M, Lupi S, Barontini M. Enfoque diagnóstico de feocromocitomas y paragangliomas. HIPERTENSION Y RIESGO VASCULAR 2019; 36:34-43. [DOI: 10.1016/j.hipert.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 06/30/2018] [Indexed: 02/09/2023]
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Ferland CE, Teles AR, Ingelmo P, Saran N, Marchand S, Ouellet JA. Blood monoamines as potential biomarkers for conditioned pain modulation efficacy: An exploratory study in paediatrics. Eur J Pain 2018; 23:327-340. [DOI: 10.1002/ejp.1307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/04/2018] [Accepted: 08/12/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Catherine E. Ferland
- McGill Scoliosis and Spine Group; Montreal Québec Canada
- Shriners Hospitals for Children-Canada; Montreal Québec Canada
- McGill University Health Centre; Montreal Québec Canada
- Alan Edwards Centre for Research on Pain; Montreal Québec Canada
- Department of Anesthesia; McGill University; Montreal Québec Canada
| | - Alisson R. Teles
- McGill Scoliosis and Spine Group; Montreal Québec Canada
- Shriners Hospitals for Children-Canada; Montreal Québec Canada
- McGill University Health Centre; Montreal Québec Canada
- Alan Edwards Centre for Research on Pain; Montreal Québec Canada
- Division of Pediatric Orthopaedics; McGill University; Montreal Québec Canada
| | - Pablo Ingelmo
- McGill University Health Centre; Montreal Québec Canada
- Alan Edwards Centre for Research on Pain; Montreal Québec Canada
- Department of Anesthesia; McGill University; Montreal Québec Canada
| | - Neil Saran
- McGill Scoliosis and Spine Group; Montreal Québec Canada
- Shriners Hospitals for Children-Canada; Montreal Québec Canada
- McGill University Health Centre; Montreal Québec Canada
- Division of Pediatric Orthopaedics; McGill University; Montreal Québec Canada
| | - Serge Marchand
- Department of Surgery; Université de Sherbrooke; Sherbrooke Québec Canada
| | - Jean A. Ouellet
- McGill Scoliosis and Spine Group; Montreal Québec Canada
- Shriners Hospitals for Children-Canada; Montreal Québec Canada
- McGill University Health Centre; Montreal Québec Canada
- Alan Edwards Centre for Research on Pain; Montreal Québec Canada
- Division of Pediatric Orthopaedics; McGill University; Montreal Québec Canada
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Vaclavik J, Krenkova A, Kocianova E, Vaclavik T, Kamasova M. Effect of sertraline in paroxysmal hypertension. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:116-120. [DOI: 10.5507/bp.2017.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/06/2017] [Indexed: 11/23/2022] Open
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Zuo M, Zhen Q, Zhang X, Zou W, Yang X, Tian G, Shi Z, Li Q, Ding M. High specificity of spot urinary free metanephrines in diagnosis and prognosis of pheochromocytomas and paragangliomas by HPLC with electrochemical detection. Clin Chim Acta 2017; 478:82-89. [PMID: 29273559 DOI: 10.1016/j.cca.2017.12.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/16/2017] [Accepted: 12/18/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The metanephrines (MNs) in plasma and urine were proposed as biomarkers for the diagnosis of pheochromocytomas and paragangliomas (PPGLs). However, plasma free MNs and 24h urinary fractionated MNs were not satisfactory enough in specificity for the diagnosis of PPGLs. Moreover, the collection of 24h urine was inconvenient. This work examined the diagnostic and prognostic efficiency of free MNs in spot urine for PPGLs. METHODS We measured free MNs concentration in spot urine and plasma of 28 PPGLs patients and 155 control subjects by HPLC with electrochemical detection. Postoperative free MNs levels in spot urine and plasma of 14 PPGLs patients were also determined. Creatinine (Cr) concentration was used for the correction of urine volume. RESULTS The specificity of spot urinary free MNs/Cr in the diagnosis of PPGLs was significantly higher than that of plasma free MNs [normetanephrine (NMN), 98.7% (95.4%-99.8%) vs 93.0% (87.4%-96.6%); metanephrine (MN), 93.6% (88.5%-96.9%) vs 84.5% (77.5%-90.0%)]. Meanwhile, the positive likelihood ratios for spot urinary free NMN/Cr and MN/Cr were 69.21 and 13.29, compared with 12.68 and 5.30 for plasma free NMN and MN, respectively. For the PPGLs patients underwent surgery, the plasma free MNs level appeared an abnormal elevation and yielded false-positive results for some patients. Our findings were validated in an independent cohort, resulting in the specificity of 100% for both urinary free NMN/Cr and MN/Cr, and 97.3% and 83.8% for plasma free NMN and MN, respectively. CONCLUSIONS Spot urinary free MNs/Cr, superior to plasma free MNs, presented a promising biomarker for the diagnosis and prognosis of PPGLs.
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Affiliation(s)
- Ming Zuo
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Qianna Zhen
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Xiaoqing Zhang
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Wenbi Zou
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Xiangchun Yang
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Gang Tian
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Zhenghu Shi
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China
| | - Qifu Li
- Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Min Ding
- Key Laboratory of Clinical Laboratory Diagnostics, Ministry of Education, College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, PR China.
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Soleymaninejad M, Joursaraei SG, Feizi F, Jafari Anarkooli I. The Effects of Lycopene and Insulin on Histological Changes and the Expression Level of Bcl-2 Family Genes in the Hippocampus of Streptozotocin-Induced Diabetic Rats. J Diabetes Res 2017; 2017:4650939. [PMID: 28656152 PMCID: PMC5471551 DOI: 10.1155/2017/4650939] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 04/09/2017] [Accepted: 04/19/2017] [Indexed: 01/11/2023] Open
Abstract
The aim of this study was to evaluate the effects of antioxidants lycopene and insulin on histological changes and expression of Bcl-2 family genes in the hippocampus of streptozotocin-induced type 1 diabetic rats. Forty-eight Wistar rats were divided into six groups of control (C), control treated with lycopene (CL), diabetic (D), diabetic treated with insulin (DI), diabetic treated with lycopene (DL), and diabetic treated with insulin and lycopene (DIL). Diabetes was induced by an injection of streptozotocin (60 mg/kg, IP), lycopene (4 mg/kg/day) was given to the lycopene treated groups as gavages, and insulin (Sc, 1-2 U/kg/day) was injected to the groups treated with insulin. The number of hippocampus neurons undergoing cell death in group D had significant differences with groups C and DIL (p < 0.001). Furthermore, insulin and lycopene alone or together reduced the expression of Bax, but increased Bcl-2 and Bcl-xL levels in DI, DL, and DIL rats, especially when compared to group D (p < 0.001). The ratios of Bax/Bcl-2 and Bax/Bcl-xL in DI, DL, and DIL rats were also reduced (p < 0.001). Our results indicate that treatment with insulin and/or lycopene contribute to the prevention of cell death by reducing the expression of proapoptotic genes and increasing the expression of antiapoptotic genes in the hippocampus.
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Affiliation(s)
- Masoume Soleymaninejad
- Department of Anatomy, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | | | - Farideh Feizi
- Department of Anatomy, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Iraj Jafari Anarkooli
- Department of Anatomy, School of Medicine, Zanjan University of Medical Sciences (ZUMS), Zanjan, Iran
- *Iraj Jafari Anarkooli:
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Cho YY, Kim YN, Kim JH, Jeong BC, Lee SY, Kim JH. Different values of urinary fractionated metanephrines after unilateral adrenalectomy for pheochromocytoma according to time intervals after surgery. Ann Clin Biochem 2016; 54:165-169. [DOI: 10.1177/0004563215620822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background After adrenalectomy, urinary fractionated metanephrine concentrations are expected to be reduced. However, there are few studies suggesting cut-offs for adrenalectomy patients. Methods Urinary metanephrine and normetanephrine concentrations in adrenalectomy patients and two controls were compared and hormonal concentrations were evaluated via time intervals after surgery. Results The median urinary metanephrine level after unilateral adrenalectomy was lower than that of the non-pheochromocytoma controls but comparable to healthy controls. Urinary normetanephrine concentrations did not differ between adrenalectomy patients and non-pheochromocytoma controls, although both group had levels higher than those of healthy controls. The median urinary normetanephrine level in the immediate postoperative period was higher than in the later period. Conclusions Urinary metanephrine concentrations were lower after adrenalectomy, but urinary normetanephrine concentrations were not changed compared with the non-pheochromocytoma controls. However, urinary normetanephrine concentrations in the patient group were higher than levels in the heathy controls.
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Affiliation(s)
- Yoon Y Cho
- Division of Endocrinology & Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young N Kim
- Division of Endocrinology & Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Han Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byong C Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae H Kim
- Division of Endocrinology & Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Samsung Biomedical Research Institute, Seoul, Republic of Korea
- Department of Health Sciences & Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
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Abstract
BACKGROUND Pheochromocytomas and paragangliomas (PPGLs) are potentially lethal yet usually surgically curable causes of endocrine hypertension; therefore, once clinical suspicion is aroused it is imperative that clinicians choose the most appropriate laboratory tests to identify the tumors. CONTENT Compelling evidence now indicates that initial screening for PPGLs should include measurements of plasma free metanephrines or urine fractionated metanephrines. LC-MS/MS offers numerous advantages over other analytical methods and is the method of choice when measurements include methoxytyramine, the O-methylated metabolite of dopamine. The plasma test offers advantages over the urine test, although it is rarely implemented correctly, rendering the urine test preferable for mainstream use. To ensure optimum diagnostic sensitivity for the plasma test, reference intervals must be established for blood samples collected after 30 min of supine rest and after an overnight fast when measurements include methoxytyramine. Similarly collected blood samples during screening, together with use of age-adjusted reference intervals, further minimize false-positive results. Extents and patterns of increases in plasma normetanephrine, metanephrine, and methoxytyramine can additionally help predict size and adrenal vs extraadrenal locations of tumors, as well as presence of metastases and underlying germline mutations of tumor susceptibility genes. SUMMARY Carried out correctly at specialist endocrine centers, collection of blood for measurements of plasma normetanephrine, metanephrine, and methoxytyramine not only provides high accuracy for diagnosis of PPGLs, but can also guide clinical decision-making about follow-up imaging strategies, genetic testing, and therapeutic options. At other centers, measurements of urine fractionated metanephrines will identify most PPGLs.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine and Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine and
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Hodin R, Lubitz C, Phitayakorn R, Stephen A. Diagnosis and management of pheochromocytoma. Curr Probl Surg 2014; 51:151-87. [DOI: 10.1067/j.cpsurg.2013.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 12/27/2013] [Indexed: 12/21/2022]
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Abstract
The current work-up of a patient suspected to have a pheochromocytoma starts with the measurement of plasma or urine metanephrines. Notably, up to a quarter of these patients will have a false positive result. When the plasma or urine metanephrines are less than the 4-fold upper limit of normal, clinicians struggle between the fear of missing a potentially fatal condition and ordering costly follow up tests. In many cases, ordering unnecessary imaging studies may only increase the level of patient anxiety. This article will review various physiologic factors, pathologic conditions and medications that may influence the levels of catecholamines and their metabolites yielding false positive or false negative results. Acquiring familiarity with these conditions as well as interfering medications will equip clinicians with better interpretation skills of the biochemical tests.
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Affiliation(s)
- Georgiana A Dobri
- a Department of Endocrinology and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Emmanuel Bravo
- b Department of Hypertension and Nephrology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Amir H Hamrahian
- a Department of Endocrinology and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
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Brossaud J, Gosse P, Gatta B, Tabarin A, Simonnet G, Corcuff JB. Phasing-in plasma metanephrines determination. Eur J Endocrinol 2013; 169:163-70. [PMID: 23689041 DOI: 10.1530/eje-13-0044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES We set up plasma normetanephrine (pNMA) and metanephrine (pMA) assays as they demonstrated their usefulness for diagnosing phaeochromocytomas. Our scope is to describe some practical laboratory aspects and the clinical relevance of these assays in our endocrinological or cardiological departments. METHODS We retrospectively reviewed the results of MA from a population of in- and outpatients over a 7-year period. Subjects (n=2536) from endocrinological or cardiological departments were investigated (66 phaeochromocytomas). Urinary NMA (uNMA) and pNMA, and urinary MA (uMA) and pMA were assayed by HPLC with electrochemical detection. RESULTS pNMA and pMA assays are now more frequently requested than uNMA and uMA. This changed our laboratory work load with improved delivery, sensitivity and reliability of plasma assays as well as reduced apparatus maintenance time. The pNMA and pMA upper reference limits (URLs) of subjects with no phaeochromocytoma were 1040 and 430 pmol/l respectively. Sensitivity and specificity based on receiver operating characteristic curves optimal points were 83 and 93% for pNMA at 972 pmol/l and 67 and 98% for pMA at 638 pmol/l. Sensitivity and specificity of paired tests of pMA (positive test: at least one analyte above its URLs) were 100 and 91% respectively. CONCLUSION The very low concentration of analytes requires a sustained very good apparatus analytical sensitivity. This can be obtained in an up-to-date laboratory. In terms of clinical performances, assays in plasma or urine are equivalent. Depending on local preferences, populations, strategies or departments, requests for one or the other assay may sustain the need for specifically defined reference ranges.
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Affiliation(s)
- Julie Brossaud
- Department of Nuclear Medicine, CHU de Bordeaux, F-33604 Pessac, France
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Eisenhofer G, Brown S, Peitzsch M, Pelzel D, Lattke P, Glöckner S, Stell A, Prejbisz A, Fassnacht M, Beuschlein F, Januszewicz A, Siegert G, Reichmann H. Levodopa therapy in Parkinson's disease: influence on liquid chromatographic tandem mass spectrometric-based measurements of plasma and urinary normetanephrine, metanephrine and methoxytyramine. Ann Clin Biochem 2013; 51:38-46. [PMID: 23873873 DOI: 10.1177/0004563213487894] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medication-related interferences with measurements of catecholamines and their metabolites represent important causes of false-positive results during diagnosis of phaeochromocytomas and paragangliomas (PPGLs). Such interferences are less troublesome with measurements by liquid chromatography with tandem mass-spectrometry (LC-MS/MS) than by other methods, but can still present problems for some drugs. Levodopa, the precursor for dopamine used in the treatment of Parkinson's disease, represents one potentially interfering medication. METHODS Plasma and urine samples, obtained from 20 Parkinsonian patients receiving levodopa, were analysed for concentrations of catecholamines and their O-methylated metabolites by LC-MS/MS. Results were compared with those from a group of 120 age-matched subjects and 18 patients with PPGLs. RESULTS Plasma and urinary free and deconjugated (free + conjugated) methoxytyramine, as well as urinary dopamine, showed 22- to 148-fold higher (P < 0.0001) concentrations in patients receiving levodopa than in the reference group. In contrast, plasma normetanephrine, urinary noradrenaline and urinary free and deconjugated normetanephrine concentrations were unaffected. Plasma free metanephrine, urinary adrenaline and urinary free and deconjugated metanephrine all showed higher (P < 0.05) concentrations in Parkinsonian patients than the reference group, but this was only a problem for adrenaline. Similar to normetanephrine, plasma and urinary metanephrine remained below the 97.5 percentiles of the reference group in almost all Parkinsonian patients. CONCLUSIONS These data establish that although levodopa treatment confounds identification of PPGLs that produce dopamine, the therapy is not a problem for use of LC-MS/MS measurements of plasma and urinary normetanephrine and metanephrine to diagnose more commonly encountered PPGLs that produce noradrenaline or adrenaline.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University of Dresden, Dresden, Germany
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[Subclinical adrenal diseases: silent pheochromocytoma and subclinical Addison's disease]. ANNALES D'ENDOCRINOLOGIE 2012; 73 Suppl 1:S45-54. [PMID: 23089381 DOI: 10.1016/s0003-4266(12)70014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The silent pheochromocytoma, a hidden form of pheochromocytoma, exposes the patient to an increased risk of mortality if the diagnosis is not established on time. Biological diagnosis of pheochromocytoma can be difficult. Catecholamine secretion is dependent on tumor size and a large number of physiological, pharmacological, lifestyle modifications and sampling conditions influence the measurement of urinary and plasma metanephrines. The prevalence of pheochromocytoma is 2% among adrenal incidentaloma smaller than 3 cm (2/3 of tumors). Recent studies suggest the almost zero risk of pheochromocytoma among these tumors if they are hypodense (<10 housefield units) on adrenal tomography. Addison's disease is a pathology affecting about 1 in 8000. Immunopathology is still unknown, but some elements advocated the hypothesis of a predominant cell-mediated immunity in particular Interferon-gamma production by CD4 T lymphocytes in the presence of an epitope from the 21-hydroxylase, as well as IgG1 subtype produced by activated B lymphocytes, autoantibodies do appear to be a simple marker of the disease. Subclinical Addison's disease is defined by the presence of anti-21-hydroxylase autoantibodies, without clinical symptoms. It evolves faster to the clinical phase in young subjects, male, having high levels of autoantibodies and with an initially impaired adrenal function. Dosage of ACTH, plasma renin active, and basal cortisol and after Synacthen allow to discriminate the subjects with low or high risk of evolution and establish an appropriate monitoring.
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Eisenhofer G, Lattke P, Herberg M, Siegert G, Qin N, Därr R, Hoyer J, Villringer A, Prejbisz A, Januszewicz A, Remaley A, Martucci V, Pacak K, Ross HA, Sweep FCGJ, Lenders JWM. Reference intervals for plasma free metanephrines with an age adjustment for normetanephrine for optimized laboratory testing of phaeochromocytoma. Ann Clin Biochem 2012; 50:62-9. [PMID: 23065528 DOI: 10.1258/acb.2012.012066] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Measurements of plasma normetanephrine and metanephrine provide a useful diagnostic test for phaeochromocytoma, but this depends on appropriate reference intervals. Upper cut-offs set too high compromise diagnostic sensitivity, whereas set too low, false-positives are a problem. This study aimed to establish optimal reference intervals for plasma normetanephrine and metanephrine. METHODS Blood samples were collected in the supine position from 1226 subjects, aged 5-84 y, including 116 children, 575 normotensive and hypertensive adults and 535 patients in whom phaeochromocytoma was ruled out. Reference intervals were examined according to age and gender. Various models were examined to optimize upper cut-offs according to estimates of diagnostic sensitivity and specificity in a separate validation group of 3888 patients tested for phaeochromocytoma, including 558 with confirmed disease. RESULTS Plasma metanephrine, but not normetanephrine, was higher (P < 0.001) in men than in women, but reference intervals did not differ. Age showed a positive relationship (P < 0.0001) with plasma normetanephrine and a weaker relationship (P = 0.021) with metanephrine. Upper cut-offs of reference intervals for normetanephrine increased from 0.47 nmol/L in children to 1.05 nmol/L in subjects over 60 y. A curvilinear model for age-adjusted compared with fixed upper cut-offs for normetanephrine, together with a higher cut-off for metanephrine (0.45 versus 0.32 nmol/L), resulted in a substantial gain in diagnostic specificity from 88.3% to 96.0% with minimal loss in diagnostic sensitivity from 93.9% to 93.6%. CONCLUSIONS These data establish age-adjusted cut-offs of reference intervals for plasma normetanephrine and optimized cut-offs for metanephrine useful for minimizing false-positive results.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital of Dresden, 01307 Dresden, Germany.
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Eagle K. Toxicological effects of red wine, orange juice, and other dietary SULT1A inhibitors via excess catecholamines. Food Chem Toxicol 2012; 50:2243-9. [DOI: 10.1016/j.fct.2012.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 03/01/2012] [Accepted: 03/03/2012] [Indexed: 02/05/2023]
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van Duinen N, Kema IP, Romijn JA, Corssmit EPM. Plasma chromogranin A levels are increased in a small portion of patients with hereditary head and neck paragangliomas. Clin Endocrinol (Oxf) 2011; 74:160-5. [PMID: 21044118 DOI: 10.1111/j.1365-2265.2010.03914.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CONTEXT The majority of patients with head and neck paragangliomas (HNPGL) have biochemically silent tumours. Chromogranin A (CgA) is a tumour marker for neuroendocrine tumours. OBJECTIVE To assess the role of CgA as a tumour marker in patients with hereditary HNPGL. PATIENTS AND METHODS We included 95 consecutive patients with hereditary HNPGL for screening of plasma CgA levels and catecholamine excess by measurement of 24-h urinary excretion of (nor)metanephrine, (nor)adrenaline, VMA, dopamine and 3-methoxytyramine. In all patients with catecholamine excess, abdominal/intrathoracic paragangliomas were excluded by (123) I-MIBG scintigraphy, MRI and/or CT. RESULTS Plasma CgA levels were increased in only 15 of 95 patients (16%). Thirty-three of the 95 patients (35%) had increased urinary excretion rates of catecholamines. Six of these 33 patients (18%) had increased plasma CgA levels. Nine of the 62 patients (15%) with a biochemically silent tumour, i.e. no increased urinary excretion of catecholamines or their metabolites, had increased CgA levels. Increased plasma CgA levels were positively correlated with urinary excretion rates of noradrenaline (r = 0·68, P = 0·005) and normetanephrine (r = 0·68, P = 0·005). There was a positive correlation between maximal HNPGL diameter and plasma CgA levels in the 57 patients with a single HNPGL (r = 0·57, P = 0·001). CONCLUSIONS Plasma CgA levels are increased in only a small portion of patients with hereditary HNPGL and have limited additional value to the combination of radiological and routine biochemical assessment of patients with HNPGL. Increased plasma CgA levels are associated with increased noradrenergic activity and tumour size in patients with a single HNPGL.
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Affiliation(s)
- Nicolette van Duinen
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands.
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Roberts NB, Higgins G, Sargazi M. A study on the stability of urinary free catecholamines and free methyl-derivatives at different pH, temperature and time of storage. Clin Chem Lab Med 2010; 48:81-7. [DOI: 10.1515/cclm.2010.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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d'Herbomez M, Rouaix N, Bauters C, Wémeau JL. [Biological diagnosis of pheochromocytomas and paragangliomas]. Presse Med 2009; 38:927-34. [PMID: 19135846 DOI: 10.1016/j.lpm.2008.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 08/04/2008] [Accepted: 08/26/2008] [Indexed: 11/25/2022] Open
Abstract
Pheochromocytomas and/or paragangliomas are rare, heterogeneous tumors of the chromaffin cells. Thirty percent of the patients presented with these diseases in a hereditary context. The biological diagnosis relies on the identification of excessive secretion of the metanephrines which are more sensitive and specific than those of catecholamines The published recommendations give the opportunity to choose between the free metanephrines and the fractionated metanephrines in sera or urines. The concentrations of the free plasmatic metanephrines reflect the ongoing production of tumor. They are little sensitive to the renal failure. The assay of the vanillylmandelic acid should be dropped because of its inefficiency. The assay of the chromogranin A in serum should be used in association with those of metanephrines in the diagnosis but also in the follow-up. Its role still has to be precised.
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Yu R, Nissen NN, Chopra P, Dhall D, Phillips E, Wei M. Diagnosis and treatment of pheochromocytoma in an academic hospital from 1997 to 2007. Am J Med 2009; 122:85-95. [PMID: 19114176 DOI: 10.1016/j.amjmed.2008.08.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Revised: 08/04/2008] [Accepted: 08/09/2008] [Indexed: 12/26/2022]
Abstract
BACKGROUND The diagnosis and treatment of pheochromocytoma pose a challenge to physicians. Several trends in the presentation, diagnosis, and surgical treatment of pheochromocytoma have emerged in the last 10 years. The diagnostic accuracy and consequences of misdiagnosis of pheochromocytoma are not well known. We aimed to systemically study the diagnostic accuracy and treatment outcomes of pheochromocytoma and to reveal the causes and consequences of misdiagnosis (including both overdiagnosis and underdiagnosis). METHODS We reviewed the electronic and paper charts of 49 patients who underwent adrenalectomy or adrenal biopsy with either preoperative or pathologic diagnosis of pheochromocytoma in a large academic hospital from 1997 to 2007. Three groups of patients (overdiagnosed, correctly diagnosed, and underdiagnosed) were compared on clinical courses, biochemical tests, imaging studies, and surgical outcomes. RESULTS Pheochromocytoma was overdiagnosed in 9 patients, correctly diagnosed in 30 patients, and underdiagnosed in 10 patients. The overdiagnosis rate was 23% (9/39), and the underdiagnosis rate was 25% (10/40). The 3 distinct groups of patients exhibited significant differences in clinical presentation, biochemical tests, and imaging characteristics. The most common causes of overdiagnosis were misinterpretation of borderline biochemical test results and overzealous imaging. Overdiagnosis subjected patients to unnecessary adrenalectomy and its complications. The most common cause of underdiagnosis was failure to consider and test for pheochromocytoma. Underdiagnosis resulted in dangerous adrenal biopsy or adrenalectomy with hypertensive crisis and nearly doubled the length of stay in hospital. Surgical resection of correctly diagnosed pheochromocytoma was largely effective and safe, but intraoperative and postoperative complications occurred in some patients. CONCLUSION We conclude that misdiagnosis of pheochromocytoma is not uncommon and causes serious adverse effects. Correct interpretation of biochemical tests and imaging is crucial to a correct diagnosis, and pheochromocytoma should always be included in the differential diagnosis of any adrenal mass. Our data suggest that physician education is needed to improve the diagnosis and treatment of pheochromocytoma.
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Affiliation(s)
- Run Yu
- Division of Endocrinology and Carcinoid and Neuroendocrine Tumor Center, Cedars-Sinai Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif 90084, USA.
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Oleaga A, Goñi F. Pheochromocytoma: diagnostic and therapeutic update. ACTA ACUST UNITED AC 2008; 55:202-16. [PMID: 22967914 DOI: 10.1016/s1575-0922(08)70669-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 02/04/2008] [Indexed: 01/24/2023]
Abstract
Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the sympathetic nervous system. In 80-85% of cases, these tumors are located in the adrenal medulla while the remainder is located in extra-adrenal chromaffin tissues (paragangliomas). Pheochromocytomas account for 6.5% of incidentally discovered adrenal tumors. These tumors may be sporadic or the result of several genetic diseases: multiple endocrine neoplasia type 2, von Hippel-Lindau syndrome, neurofibromatosis type 1, and familial paraganglioma associated with mutations in succinate dehydrogenase subunits. Diagnosis of pheochromocytoma should first be established biochemically by measuring plasma free metanephrines and urinary fractionated metanephrines. The radiological imaging tests of choice are computed tomography (CT) or magnetic resonance imaging (MRI). The first-line specific functional imaging test is scintigraphy with (123)I-metaiodobenzylguanidine (MIBG); if this test is unavailable, scintigraphy with (131)I-MIBG is the second choice. Positron emission tomography (PET) with (18)F-F-fluorodopamine (F-DA) is useful in metastatic disease. The treatment of choice is laparoscopic surgery after adequate alpha adrenergic blockade. Approximately 10% of tumors are malignant. Chemotherapy is used for inoperable disease. Prognosis is good except in malignant disease, in which 5-year survival is less than 50%. The identification of the genes causing hereditary pheochromocytoma has led to changes in the recommendation for genetic testing.
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Affiliation(s)
- Amelia Oleaga
- Servicio de Endocrinología. Hospital de Basurto. Bilbao. Vizcaya. España
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Algeciras-Schimnich A, Preissner CM, Young WF, Singh RJ, Grebe SKG. Plasma chromogranin A or urine fractionated metanephrines follow-up testing improves the diagnostic accuracy of plasma fractionated metanephrines for pheochromocytoma. J Clin Endocrinol Metab 2008; 93:91-5. [PMID: 17940110 PMCID: PMC2729153 DOI: 10.1210/jc.2007-1354] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The initial diagnosis of pheochromocytoma relies on plasma fractionated metanephrines levels. Normal levels exclude pheochromocytoma, but positive tests have a low positive predictive value due to the disease's rarity. OBJECTIVES The objective of the study was to evaluate three approaches to distinguish between true-positive and false-positive tests: 1) increased cutoff for plasma fractionated metanephrines, 2) measurement of serum/plasma chromogranin A (CGA), and 3) urine fractionated metanephrine testing. DESIGN We studied retrospectively all Mayo Clinic patients with positive plasma fractionated metanephrine tests over a 15-month period and determined their final diagnosis based on histology, imaging, additional biochemical tests, and more than 1 yr follow-up. For a subgroup, urine fractionated metanephrine results were available. All original plasma samples were retested for CGA. RESULTS Of 140 patients, 40 had a chromaffin tumor confirmed and 100 excluded, indicating a positive predictive value of plasma fractionated metanephrines of 28.6%. Increasing the threshold for a positive test improved specificity to 98% but missed eight cases (20%). Incorporation of urine fractionated metanephrine testing as follow-up test achieved 80% specificity and 91% sensitivity. The corresponding figures for CGA were 71 and 87% for all patients and 89 and 87% when patients taking proton pump inhibitors were excluded. CONCLUSIONS Unless plasma fractionated metanephrines levels are elevated more than 4-fold above the upper limit of normal, patients with a positive plasma fractionated metanephrines test should be evaluated with urine fractionated metanephrines and serum/plasma CGA assays before being subjected to imaging or invasive diagnostic tests.
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Affiliation(s)
- Alicia Algeciras-Schimnich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905, USA
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Václavík J, Stejskal D, Lacnák B, Lazárová M, Jedelský L, Kadalová L, Janosová M, Frysák Z, Vlcek P. Free plasma metanephrines as a screening test for pheochromocytoma in low-risk patients. J Hypertens 2007; 25:1427-31. [PMID: 17563565 DOI: 10.1097/hjh.0b013e32813aeb5a] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Detection of free plasma metanephrines seems to be the most exact method for biochemical diagnosis of pheochromocytoma, but their diagnostic efficacy in the common low-risk clinical settings is debated. METHODS A cross-sectional multicentre study including 1260 subjects assessed the diagnostic efficacy of free plasma metanephrine and normetanephrine in low-risk patients screened for resistant or markedly accelerated hypertension, paroxysmal hypertension, 'flushes' and, in a small proportion, for adrenal incidentaloma or genetic predisposition to pheochromocytoma. RESULTS Pheochromocytoma was identified and verified by histology in 25 subjects (2%), with the diagnosis not confirmed by long-term follow-up or use of imaging techniques in the remaining 1235 individuals. The combined assay of free plasma metanephrines was a highly sensitive (100%) and specific (96.7%) measure, yielding a negative predictive value of 100%. CONCLUSION The satisfactory diagnostic efficacy of free plasma metanephrines allows their use as a single screening test in cases of suspected pheochromocytoma in the population with a low pretest probability.
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Affiliation(s)
- Jan Václavík
- Department of Internal Medicine, Sternberk Hospital, Sternberk, Czech Republic.
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26
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Young WF. Secondary Hypertension: Pheochromocytoma. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50016-0] [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]
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Chidakel AR, Pacak K, Eisenhofer G, Lawrence JE, Ayala AR. Utility of plasma free metanephrines in diagnosis of factitious pheochromocytoma. Endocr Pract 2006; 12:568-71. [PMID: 17002933 DOI: 10.4158/ep.12.5.568] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To report a case of epinephrine-induced factitious pheochromocytoma in a young woman with a past medical history of Conn's syndrome. METHODS We present a case report with clinical and laboratory details, review related reports in the literature, and demonstrate the usefulness of plasma free metanephrine levels in facilitating the diagnosis of factitious pheochromocytoma. RESULTS A 34-year-old woman was admitted to our hospital for confirmation and localization of an occult pheochromocytoma. After thorough investigation, we discovered that the patient was surreptitiously injecting epinephrine in order to induce symptoms and signs consistent with a pheochromocytoma. Analysis of the patient's biochemical profile during and between her catecholaminergic crises revealed plasma epinephrine and free metanephrine levels that would be highly unusual for a patient with a pheochromocytoma. CONCLUSION This case illustrates the utility of implementing the ratio of plasma epinephrine to free metanephrine levels in distinguishing factitious from organic pheochromocytoma.
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Affiliation(s)
- Aaron R Chidakel
- Division of Intramural Research, National Institute of Diabetes and Digestive and Kidney Diseases, W. G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland 20892, USA
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Using free plasma metanephrines in the diagnosis of pheochromocytoma. COR ET VASA 2006. [DOI: 10.33678/cor.2006.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Grossman A, Pacak K, Sawka A, Lenders JWM, Harlander D, Peaston RT, Reznek R, Sisson J, Eisenhofer G. Biochemical Diagnosis and Localization of Pheochromocytoma: Can We Reach a Consensus? Ann N Y Acad Sci 2006; 1073:332-47. [PMID: 17102103 DOI: 10.1196/annals.1353.038] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pheochromocytomas can have a highly variable presentation, making diagnosis challenging. To think of the tumor represents the crucial initial step, but establishing the diagnosis requires biochemical evidence of excessive catecholamine production and imaging studies to localize the source. Currently, however, there exist no generally agreed upon guidelines based on which tests and testing algorithms should be used to confirm and locate or exclude a suspected pheochromocytoma. Choice of biochemical tests and imaging studies instead usually depends on institutional experience. At the First International Symposium on Pheochromocytoma (ISP2005), held in Bethesda in October 2005, a panel of experts and patient representatives discussed current problems and available options for tumor diagnosis and localization and formulated recommendations, which were subsequently agreed upon by those in attendance at the meeting. This article summarizes the discussion and recommendations derived from that session.
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Affiliation(s)
- Ashley Grossman
- Department of Endocrinology, St. Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK, and Department of Medicine, University of Toronto, Ontario, Canada.
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