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Turin CG, Crenshaw MM, Fishbein L. Pheochromocytoma and paraganglioma: germline genetics and hereditary syndromes. ENDOCRINE ONCOLOGY (BRISTOL, ENGLAND) 2022; 2:R65-R77. [PMID: 37435466 PMCID: PMC10259326 DOI: 10.1530/eo-22-0044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/28/2022] [Indexed: 07/13/2023]
Abstract
Pheochromocytomas (PCCs) and paragangliomas (PGLs) are neuroendocrine tumors arising from the adrenal medulla and extra-adrenal ganglia, respectively. Approximately 15-25% of PCC/PGL can become metastatic. Up to 30-40% of patients with PCC/PGL have a germline pathogenic variant in a known susceptibility gene for PCC/PGL; therefore, all patients with PCC/PGL should undergo clinical genetic testing. Most of the susceptibility genes are associated with variable penetrance for PCC/PGL and are associated with different syndromes, which include susceptibility for other tumors and conditions. The objective of this review is to provide an overview of the germline susceptibility genes for PCC/PGL, the associated clinical syndromes, and recommended surveillance.
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Affiliation(s)
- Christie G Turin
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Molly M Crenshaw
- Department of Pediatrics, Combined Pediatrics-Medical Genetics Residency Program, University of Colorado, Aurora, Colorado, USA
| | - Lauren Fishbein
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Aurora, Colorado, USA
- Division of Biomedical Informatics and Personalized Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Al-Sharefi A, Javaid U, Perros P, Ealing J, Truran P, Nag S, Kamaruddin S, Abouglila K, Cains F, Lewis L, James RA. Clinical Presentation and Outcomes of Phaeochromocytomas/Paragangliomas in Neurofibromatosis Type 1. EUROPEAN ENDOCRINOLOGY 2019; 15:95-100. [PMID: 31616500 PMCID: PMC6785954 DOI: 10.17925/ee.2019.15.2.95] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 04/25/2019] [Indexed: 12/23/2022]
Abstract
Introduction: Patients with neurofibromatosis type 1 (NF1) are at risk of developing phaeochromocytomas/paragangliomas (PHAEO/PG). Unlike in other familial PHAEO/PG syndromes, there are no published guidelines regarding screening in asymptomatic or normotensive patients with NF1. This strategy may be associated with preventable morbidities in those patients who ultimately present with symptomatic PHAEO/PG. Objective: To describe the mode of presentation and the incidence of adverse clinical outcomes attributed to PHAEO/PG in NF1. Methods: A retrospective study was performed in a tertiary referral centre in collaboration with a national complex NF1 centre. Hospital records and databases between 1998–2018 were searched. Results: Twenty-seven patients with NF1 and PHAEO/PG were identified. In all but one, PHAEO/PG was diagnosed after NF1. The median age at the time of diagnosis of PHAEO/PG was 43 years (range 22–65) and 21/27 (78%) were females. The diagnosis was mostly incidental in 13/27 (48%) while classical PHAEO/PG symptoms were found in 15/27 (56%), and hypertension was found in 14/27 (52%) of NF1 patients prior to PHAEO/PG diagnosis. No patient had undergone biochemical screening for PHAEO/PG. Metastatic disease was evident in 2/27 patients, 8 suffered potentially avoidable complications attributed to PHAEO/PG (including two deaths). Conclusion: The course of PHAEO/PG in NF1 is associated with an unpredictable presentation and potentially avoidable adverse outcomes. We recommend that routine biochemical screening for PHAEO/PG should be part of the care package offered to all patients with NF1 by regular measurements of plasma free or urinary fractionated metanephrines starting from early adolescence and repeated every 3 years.
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Affiliation(s)
- Ahmed Al-Sharefi
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
| | - Usman Javaid
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
| | - Petros Perros
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
| | - John Ealing
- Manchester Centre for Clinical Neuroscience, Salford Royal NHS Foundation Trust, Manchester, UK.,Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Peter Truran
- Department of Endocrine Surgery, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Sath Nag
- Department of Endocrinology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Shafie Kamaruddin
- Department of Endocrinology, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Kamal Abouglila
- Department of Endocrinology, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Fiona Cains
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Lauren Lewis
- Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Robert Andrew James
- Department of Endocrinology, The Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
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Abstract
Pheochromocytomas and paragangliomas (PCC/PGL) are neuroendocrine tumors of the adrenal medulla and extra-adrenal ganglia which often over-secrete catecholamines leading to cardiovascular morbidity and even mortality. These unique tumors have the highest heritability of all solid tumor types with up to 35-40% of patients with PCC/PGL having a germline predisposition. PURPOSE OF REVIEW: To review the germline susceptibility genes and clinical syndromes associated with PCC/PGL. RECENT FINDINGS: There are over 12 PCC/PGL susceptibility genes identified in a wide range of pathways. Each gene is associated with a clinical syndrome with varying penetrance for both primary and metastatic PCC/PGL and often includes increased risk for additional tumors besides PCC/PGL. Patients with sporadic or hereditary PCC/PGL should be monitored for life given the risk of multiple primary tumors, recurrence, and metastatic disease. All patients with PCC/PGL should be referred for consideration for clinical genetic testing given the high heritability of disease.
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Affiliation(s)
- Lauren Fishbein
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes, Division of Biomedical Informatics and Personalized Medicine, University of Colorado School of Medicine, 12801 E. 17th Ave, MS 8106, Aurora, CO, 80045, USA.
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Wang J, Yuan D, Lu Y, Ma Y, Huang B, Yang Y, Zhao J. A large pheochromocytoma requiring aortic and inferior vena caval reconstruction: A case report. Medicine (Baltimore) 2019; 98:e16494. [PMID: 31335714 PMCID: PMC6709035 DOI: 10.1097/md.0000000000016494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE It is difficult to discriminate malignant pheochromocytoma (PCC) from benign PCC. The requirement of abdominal aortic and inferior vena cava reconstruction is extremely rare. PATIENT CONCERNS We here report a case of a large pheochromocytoma in a 56-year-old woman who complained of only hand trembling and had no hypertension or other symptoms. The operation was difficult because of a tight adhesion to the circumference of great vessels. A replacement of the aortocaval vessels with grafts was necessary to remove the tumor completely. DIAGNOSES Ultrasonography, computed tomography (CT), and catecholamine assay revealed suspecting the retroperitoneal PCC. INTERVENTIONS Tumor excision and reconstruction of the abdominal aorta and inferior vena cava by externally supported polytetrafluoroethylene (ePTFE) vessels were successfully performed. OUTCOMES A follow-up CT angiography showed no recurrence and graft vessels presented good patency after 7years. Catecholamine in urine and serum assay was normal. LESSONS The complete resection of the tumor and infiltrated great vessels were necessary for the long-term survival of patients with a large PCC. The ePTFE graft is a good substitute for vessel reconstruction.
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Affiliation(s)
- Jian Wang
- Department of Vascular Surgery, The West China Medical School of Sichuan University, West China Hospital of Sichuan University, Chengdu, Sichuan
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Ya Lu
- Department of Pathology, The West China Medical School of Sichuan University, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yukui Ma
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province
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Ivanidze J, Roytman M, Sasson A, Skafida M, Fahey TJ, Osborne JR, Dutruel SP. Molecular imaging and therapy of somatostatin receptor positive tumors. Clin Imaging 2019; 56:146-154. [PMID: 31121520 DOI: 10.1016/j.clinimag.2019.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/13/2019] [Indexed: 01/28/2023]
Abstract
Somatostatin receptors (SSTR) are upregulated in the cells of origin that define numerous neuroendocrine neoplasms. PET imaging with 68Ga-DOTATATE allows specific targeting of SSTR2A, a single species of SSTR receptor, which is commonly overexpressed in a variety of gastroenteropancreatic neuroendocrine tumors, as well as pulmonary carcinoid and head and neck tumors. Due to more specific targeting of SSTR2 as well as lower radiation dose, shorter study length, ability to quantify uptake, and lower cost, 68Ga-DOTATATE has demonstrated superior imaging attributes when compared to 111In-pentetreotide. As with any novel imaging modality, dedicated training, increasing experience and staying up-to-date with scientific publications are required to provide optimal patient care. The purpose of this review is to summarize the current state of the art in SSTR-targeted molecular imaging and discuss ongoing and future potential diagnostic and therapeutic applications.
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Affiliation(s)
- Jana Ivanidze
- New York-Presbyterian Hospital/Weill Cornell Medical Center, United States of America
| | - Michelle Roytman
- New York-Presbyterian Hospital/Weill Cornell Medical Center, United States of America
| | | | - Myrto Skafida
- New York-Presbyterian Hospital/Weill Cornell Medical Center, United States of America
| | - Thomas J Fahey
- New York-Presbyterian Hospital/Weill Cornell Medical Center, United States of America
| | - Joseph R Osborne
- New York-Presbyterian Hospital/Weill Cornell Medical Center, United States of America
| | - Silvina P Dutruel
- New York-Presbyterian Hospital/Weill Cornell Medical Center, United States of America.
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Yadav MP, Ballal S, Bal C. Concomitant 177Lu-DOTATATE and capecitabine therapy in malignant paragangliomas. EJNMMI Res 2019; 9:13. [PMID: 30725219 PMCID: PMC6365580 DOI: 10.1186/s13550-019-0484-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The role of concomitant peptide receptor radionuclide therapy (PRRT) and capecitabine therapy has shown benefit in gastroenteropancreatic neuroendocrine tumors. However, data reporting its role in paraganglioma (PGL) patients is lacking. The aim of this study was to evaluate the role of combined capecitabine and 177Lu-DOTATATE in malignant PGL patients. METHODS In this retrospective, single-institutional, single-arm, observational study, data of consecutive advanced stage PGL patients treated with concomitant 177Lu-DOTATATE-capecitabine therapy, between July 2009 and March 2017, were collected and analyzed. RESULTS Twenty-five PGL patients received an average dose of 22.86 ± 9.54 (14.43-50) GBq 177Lu-DOTATATE and 1250 mg/m2 capecitabine from days 0 to 14, commencing on the morning of PRRT. The median overall survival (OS) was not attained in this patient cohort; however, the median PFS was 32 months. Morphological response according to RECIST 1.1 criteria was achieved in 28% (7/25) patients. Biochemical response with > 50% reduction in chromogranin A levels was observed in 28% of the patients. CONCLUSIONS Our data confirm that 177Lu-DOTATATE-capecitabine therapy is effective in achieving an objective response in 28% and symptomatic response in 43% patients. In comparison to published PRRT monotherapy outcomes in PGL, we did not observe any great advantage of concomitant therapy; however, it could be due to under-powered study. We recommend a large randomized trial to prove or disprove the utility of capecitabine as a radiosensitizer for PRRT in PGL patients.
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Affiliation(s)
- Madhav Prasad Yadav
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sanjana Ballal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Al-Sharefi A, Perros P, James RA. Phaeochromocytoma/paraganglioma and adverse clinical outcomes in patients with neurofibromatosis-1. Endocr Connect 2018; 7:EC-18-0208. [PMID: 30120202 PMCID: PMC6198184 DOI: 10.1530/ec-18-0208] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/08/2018] [Accepted: 08/15/2018] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Phaeochromocytomas/paragangliomas (PHAEO/PG) are linked to hereditary syndromes including neurofibromatosis type 1 (NF-1). Current guidelines do not recommend biochemical screening for PHAEO/PG in asymptomatic or normotensive patients with NF-1. This strategy may miss preventable morbidities in those patients who ultimately present with symptomatic PHAEO/PG. Our aim was to review the literature and extract data on mode of presentation and the incidence of reported adverse outcomes. METHODS PubMed and EMBASE literature search using the keywords "Phaeochromocytoma", "Paraganglioma" and "Neurofibromatosis" was performed looking for reported cases from 2000 to 2018. RESULTS 73 reports of NF-1 patients with PHAEO/PG were found. Patients were predominately women (n=40) with a median age of 46 years (range 16-82). PHAEO/PG was found incidentally in most patients, 36/73 did not present with typical symptoms while 27 patients were normotensive at diagnosis. 31 patients had adverse outcomes including metastases and death. CONCLUSION Given the protean presentation of PHAEO/PG, relying on symptomology and blood pressure status as triggers for screening is associated with adverse outcomes. Further studies are required to ascertain whether biochemical screening in asymptomatic and normotensive patients with NF-1 can reduce the rate of adverse outcomes.
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Affiliation(s)
- Ahmed Al-Sharefi
- A Al-Sharefi, Department of Endocrinology , Royal Victoria Infirmary , Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Petros Perros
- P Perros, Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Robert Andrew James
- R James, Department of Endocrinology , Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
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Pheochromocytoma Crisis in the ICU: A French Multicenter Cohort Study With Emphasis on Rescue Extracorporeal Membrane Oxygenation. Crit Care Med 2017; 45:e657-e665. [PMID: 28403121 DOI: 10.1097/ccm.0000000000002333] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To describe the characteristics, management, and outcome of patients admitted to ICUs for pheochromocytoma crisis. DESIGN A 16-year multicenter retrospective study. SETTING Fifteen university and nonuniversity ICUs in France. PATIENTS Patients admitted in ICU for pheochromocytoma crisis. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS We included 34 patients with a median age of 46 years (40-54 yr); 65% were males. At admission, the median Sequential Organ Failure Assessment score was 8 (4-12) and median Simplified Acute Physiology Score II 49.5 (27-70). The left ventricular ejection fraction was consistently decreased with a median value of 30% (15-40%). Mechanical ventilation was required in 23 patients, mainly because of congestive heart failure. Vasoactive drugs were used in 23 patients (68%) and renal replacement therapy in eight patients (24%). Extracorporeal membrane oxygenation was used as a rescue therapy in 14 patients (41%). Pheochromocytoma was diagnosed by CT in 33 of 34 patients. When assayed, urinary metanephrine and catecholamine levels were consistently elevated. Five patients underwent urgent surgery, including two during extracorporeal membrane oxygenation. Overall ICU mortality was 24% (8/34), and overall 90-day mortality was 27% (9/34). Crude 90-day mortality was not significantly different between patients managed with versus without extracorporeal membrane oxygenation (22% vs 30%) (p = 0.7) despite higher severity scores at admission in the extracorporeal membrane oxygenation group. CONCLUSIONS Mortality is high in pheochromocytoma crisis. Routinely considering this diagnosis and performing abdominal CT in patients with unexplained cardiogenic shock may allow an earlier diagnosis. Extracorporeal membrane oxygenation and adrenalectomy should be considered as a therapeutic in most severe cases.
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Riester A, Weismann D, Quinkler M, Lichtenauer UD, Sommerey S, Halbritter R, Penning R, Spitzweg C, Schopohl J, Beuschlein F, Reincke M. Life-threatening events in patients with pheochromocytoma. Eur J Endocrinol 2015; 173:757-64. [PMID: 26346138 DOI: 10.1530/eje-15-0483] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/07/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Pheochromocytomas are rare chromaffin cell-derived tumors causing paroxysmal episodes of headache, palpitation, sweating and hypertension. Life-threatening complications have been described in case reports and small series. Systematic analyses are not available. We took an opportunity of a large series to make a survey. DESIGN AND METHODS We analyzed records of patients diagnosed with pheochromocytomas in three geographically spread German referral centers between 2003 and 2012 (n=135). RESULTS Eleven percent of the patients (ten women, five men) required in-hospital treatment on intensive care units (ICUs) due to complications caused by unsuspected pheochromocytomas. The main reasons for ICU admission were acute catecholamine induced Tako-Tsubo cardiomyopathy (n=4), myocardial infarction (n=2), acute pulmonary edema (n=2), cerebrovascular stroke (n=2), ischemic ileus (n=1), acute renal failure (n=2), and multi organ failure (n=1). One patient required extracorporeal membrane oxygenation due to a hypertensive crisis with lung edema occurring during delivery (n=1). Two patients died of refractory shock and pheochromocytomas were found postmortem. Two patients were treated by emergency surgery. Compared to pheochromocytoma patients without life-threatening events (n=120), patients with complications had a significant larger maximal tumor diameter (7.0 vs 4.5 cm, P<0.01), higher levels of catecholamines (20- vs ninefold upper limit of normal, P<0.01), and tended to be younger (42 vs 51 years, P=0.05). CONCLUSION Although pheochromocytomas are rare, they are likely to be associated with a life-threatening situation. Clinicians have to be aware of these situations and perform a timely diagnosis.
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Affiliation(s)
- Anna Riester
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Dirk Weismann
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Marcus Quinkler
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Urs D Lichtenauer
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Sandra Sommerey
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Roland Halbritter
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Randolph Penning
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Christine Spitzweg
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IVKlinikum der Universität München, Ludwig-Maximilians-Universität, Ziemssenstr. 1, D-80336 Munich, GermanyMedizinische Klinik und Poliklinik IUniversitätsklinikum Würzburg, Würzburg, GermanyEndokrinologie in CharlottenburgBerlin, GermanyHelios Klinik SchwerinSchwerin, GermanyChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, GermanyFacharztpraxisPfaffenhofen, GermanyInstitut für RechtsmedizinMedizinische Klinik und Poliklinik IIKlinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany
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Abstract
Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare but unique neuroendocrine tumors. The hypersecretion of catecholamines from the tumors can be associated with high morbidity and mortality, even when tumors are benign. Up to 40% of PCCs/PGLs are associated with germline mutations in susceptibility genes. About one-quarter are malignant, defined by the presence of distant metastases. Treatment options for unresectable metastatic disease, including chemotherapy, (131)I-MIBG, and radiation, can offer limited tumor and hormone control, although none are curative. This article reviews the inherited genetics, diagnosis, and treatment of PCCs and PGLs.
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Affiliation(s)
- Lauren Fishbein
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 351 BRB II/III, 421 Curie Boulevard, Philadelphia, PA 19104, USA.
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11
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Garcha AS, Cohen DL. Catecholamine excess: pseudopheochromocytoma and beyond. Adv Chronic Kidney Dis 2015; 22:218-23. [PMID: 25908471 DOI: 10.1053/j.ackd.2014.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 12/21/2022]
Abstract
Symptoms of catecholamine excess or pseudopheochromocytoma can be clinically indistinguishable from pheochromocytoma. Patients usually present with paroxysmal or episodic hypertension and have a negative evaluation for pheochromocytoma. It is important to exclude other causes of catecholamine excess that can be induced by stress, autonomic dysfunction due to baroreflex failure, medications, and drugs. Patients with pseudopheochromocytoma appear to have an amplified cardiovascular responsiveness to catecholamines with enhanced sympathetic nervous stimulation. The exact mechanism is not well understood and increased secretion of dopamine, epinephrine, and norepinephrine, and their metabolites have been identified as potentiating this clinical scenario leading to differing hemodynamic presentations depending on which catecholamine is elevated. Management of this condition is often difficult and frustrating for both the physician and the patient. Most patients respond reasonably well to medications that reduce sympathetic nervous system activity. Anxiolytics, antidepressants, and psychotherapy also play an important role in managing these patients' symptoms.
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12
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Costa MHS, Ortiga-Carvalho TM, Violante AD, Vaisman M. Pheochromocytomas and Paragangliomas: Clinical and Genetic Approaches. Front Endocrinol (Lausanne) 2015; 6:126. [PMID: 26347711 PMCID: PMC4538298 DOI: 10.3389/fendo.2015.00126] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/27/2015] [Indexed: 12/27/2022] Open
Abstract
Pheochromocytomas (PCCs) and paragangliomas (PGLs) are neuroendocrine tumors derived from the chromaffin tissue. Diagnosis of these tumors is extremely important as they are linked to the hypertension syndrome with great cardiovascular morbidity and mortality. A great majority of PCCs and PGLs are sporadic and benign tumors; however, the classic idea of 10% exception of these features is changing. The description of new genes linked to familial forms of PCC/PGLs, such as succinate dehydrogenase (SDH) complex subunits, KIF1Bβ, EGLN1, TMEM127, and MAX, added to the well-known PCC familial syndrome (MEN2, VHL, and neurofibromatosis type 1) presents new challenges for diagnosis. In this review, we discuss the diversity of clinical and genetic approaches to this syndrome as well the diverse criteria that should guide genetic investigation.
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Affiliation(s)
| | - Tania M. Ortiga-Carvalho
- Laboratory of Translational Endocrinology, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alice Dutra Violante
- Division of Endocrinology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mario Vaisman
- Division of Endocrinology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- *Correspondence: Mario Vaisman, Serviço de Endocrinologia, HUCFF, Rua Rodolpho Paulo Rocco, 255 Cidade Universitária, Rio de Janeiro, RJ CEP 21941-913, Brazil,
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13
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Fishbein L, Orlowski R, Cohen D. Pheochromocytoma/Paraganglioma: Review of perioperative management of blood pressure and update on genetic mutations associated with pheochromocytoma. J Clin Hypertens (Greenwich) 2013; 15:428-34. [PMID: 23730992 PMCID: PMC4581847 DOI: 10.1111/jch.12084] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 02/04/2023]
Abstract
Pheochromocytomas and paragangliomas are rare tumors with high morbidity rates caused by excessive catecholamine secretion, even though the majority of tumors are benign. The use of perioperative blockade regimens, together with improved surgical techniques, has greatly impacted the perioperative morbidity associated with these tumors. The old dogma of the "tumor of tens" no longer holds true. For example, at least one third of all pheochromocytomas and paragangliomas are hereditary, with mutations in 1 of 10 well-characterized susceptibility genes, and one quarter of all tumors are malignant. This review focuses on the perioperative management of pheochromocytoma and paragangliomas and the clinical implications of the associated genetic mutations.
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Affiliation(s)
- Lauren Fishbein
- Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
- Division of Endocrinology, Diabetes and MetabolismUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Robert Orlowski
- Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Debbie Cohen
- Department of MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
- Renal and Hypertension DivisionUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
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14
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Lowery AJ, Walsh S, McDermott EW, Prichard RS. Molecular and therapeutic advances in the diagnosis and management of malignant pheochromocytomas and paragangliomas. Oncologist 2013; 18:391-407. [PMID: 23576482 DOI: 10.1634/theoncologist.2012-0410] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare catecholamine-secreting tumors derived from chromaffin cells originating in the neural crest. These tumors represent a significant diagnostic and therapeutic challenge because the diagnosis of malignancy is frequently made in retrospect by the development of metastatic or recurrent disease. Complete surgical resection offers the only potential for cure; however, recurrence can occur even after apparently successful resection of the primary tumor. The prognosis for malignant disease is poor because traditional treatment modalities have been limited. The last decade has witnessed exciting discoveries in the study of PCCs and PGLs; advances in molecular genetics have uncovered hereditary and germline mutations of at least 10 genes that contribute to the development of these tumors, and increasing knowledge of genotype-phenotype interactions has facilitated more accurate determination of malignant potential. Elucidating the molecular mechanisms responsible for malignant transformation in these tumors has opened avenues of investigation into targeted therapeutics that show promising results. There have also been significant advances in functional and radiological imaging and in the surgical approach to adrenalectomy, which remains the mainstay of treatment for PCC. In this review, we discuss the currently available diagnostic and therapeutic options for patients with malignant PCCs and PGLs and detail the molecular rationale and clinical evidence for novel and emerging diagnostic and therapeutic strategies.
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Affiliation(s)
- Aoife J Lowery
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
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15
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Badri M, Gibbons AV, Popii V, Yih D, Cohen-Stein DL, Patel SM. Perioperative management of a patient with a nonresectable pheochromocytoma. Endocr Pract 2013; 19:e74-6. [PMID: 23425647 DOI: 10.4158/ep12343.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the clinical course of a patient with a nonresectable pheochromocytoma during urgent hip surgery. METHODS To describe the clinical management and postoperative outcome of the patient and review the relevant literature. RESULTS An 85-year-old male with a nonresectable pheochromocytoma required urgent hip surgery following a traumatic hip fracture. He was perioperatively managed with phenoxybenzamine, metyrosine, and metoprolol to avoid potential pheochromocytoma-related complications. He remained hemodynamically stable and recovered from the surgery without complications. CONCLUSIONS This case illustrates the successful management of a patient requiring urgent surgery in the setting of a nonresectable pheochromocytoma, which is rarely described in the literature.
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Affiliation(s)
- Marwan Badri
- Department of Internal Medicine, Lankenau Medical Center, Wynnewood, Pennsylvania 19096, USA.
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16
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Siegelman ES. Adrenal MRI: Techniques and clinical applications. J Magn Reson Imaging 2012; 36:272-85. [DOI: 10.1002/jmri.23601] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Fishbein L, Nathanson KL. Pheochromocytoma and paraganglioma: understanding the complexities of the genetic background. Cancer Genet 2012; 205:1-11. [PMID: 22429592 DOI: 10.1016/j.cancergen.2012.01.009] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 01/17/2012] [Accepted: 01/19/2012] [Indexed: 12/29/2022]
Abstract
Pheochromocytomas and paragangliomas (PCC/PGL) are tumors derived from the adrenal medulla or extra-adrenal ganglia, respectively. They are rare and often benign tumors that are associated with high morbidity and mortality due to mass effect and high circulating catecholamines. Although most PCCs and PGLs are thought to be sporadic, over one third are associated with 10 known susceptibility genes. Mutations in three genes causing well characterized tumor syndromes are associated with an increased risk of developing PCCs and PGLs, including VHL (von Hippel-Lindau disease), NF1 (Neurofibromatosis Type 1), and RET (Multiple Endocrine Neoplasia Type 2). Mutations in any of the succinate dehydrogenase (SDH) complex subunit genes (SDHA, SDHB, SDHC, SDHD) can lead to PCCs and PGLs with variable penetrance, as can mutations in the subunit cofactor, SDHAF2. Recently, two additional genes have been identified, TMEM127 and MAX. Although these tumors are rare in the general population, occurring in two to eight per million people, they are more commonly associated with an inherited mutation than any other cancer type. This review summarizes the known germline and somatic mutations leading to the development of PCC and PGL, as well as biochemical profiling for PCCs/PGLs and screening of mutation carriers.
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Affiliation(s)
- Lauren Fishbein
- Division of Endocrinology, Department of Medicine, Diabetes and Metabolism, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Weingarten TN, Cata JP, O'Hara JF, Prybilla DJ, Pike TL, Thompson GB, Grant CS, Warner DO, Bravo E, Sprung J. Comparison of two preoperative medical management strategies for laparoscopic resection of pheochromocytoma. Urology 2010; 76:508.e6-11. [PMID: 20546874 DOI: 10.1016/j.urology.2010.03.032] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 03/09/2010] [Accepted: 03/12/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To compare the intraoperative and postoperative course of patients undergoing laparoscopic pheochromocytoma resection at 2 institutions (Mayo Clinic and Cleveland Clinic) with differing approaches to preoperative preparation. Patients undergoing adrenalectomy for pheochromocytoma typically undergo a preoperative preparation to normalize their blood pressure and intravascular volume. However, no consensus has been reached regarding the best preoperative preparation regimen. METHODS A retrospective chart review was performed of 50 Mayo Clinic patients and 37 Cleveland Clinic patients who had undergone laparoscopic pheochromocytoma resection. Mayo Clinic predominantly used the long-lasting nonselective alpha(1,2) antagonist phenoxybenzamine, and Cleveland Clinic predominately used selective alpha(1) blockade. Data regarding the intraoperative hemodynamics and postoperative complications were collected. RESULTS Almost all patients at Mayo Clinic received phenoxybenzamine (98%). At Cleveland Clinic, the predominant treatment (65%) was selective alpha(1) blockade (doxazosin, terazosin, or prazosin). Intraoperatively, patients at Cleveland Clinic had a greater maximal systolic blood pressure (209 +/- 44 mm Hg versus 187 +/- 30 mm Hg, P = .011) and had received a greater amount of intravenous crystalloid (median 5000, interquartile range 3400-6400, versus median 2977, interquartile range 2000-3139; P <.010) and colloid (median 1000, interquartile range 500-1000, versus median 0, interquartile range 0-0; P <.001). At Mayo Clinic, more patients had received phenylephrine (56.0% versus 27.0%, P = .009). No differences were found in the postoperative surgical outcomes, and the hospital stay was comparable between the 2 groups. CONCLUSIONS Differences in the preoperative preparation and intraoperative management were associated with differences in intraoperative hemodynamics but not with clinically significant outcomes in patients undergoing laparoscopic adrenalectomy for pheochromocytoma at 2 large tertiary care centers.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Abstract
Pheochromocytomas are rare neuroendocrine tumors with a highly variable clinical presentation, but they most commonly present as spells of headaches, sweating, palpitations, and hypertension. Patients with pheochromocytoma may develop complicated and potentially lethal cardiovascular and other complications, especially in the setting of diagnostic or interventional procedures (e.g. upon induction of anesthesia or during surgery). The serious and potentially lethal nature of such complications is due to the potent effect of paroxysmal release of catecholamines. Because this warrants prompt diagnosis and treatment, the physician should be aware of the clinical manifestations and complications of catecholamine excess and be able to provide proper preoperative management to minimize catecholamine-related pre-, intra-, and postoperative adverse events. The following clinical scenario and discussion aim to enhance the knowledge of the physician regarding the behavior of pheochromocytoma and to outline current approaches to comprehensive preoperative management of patients suffering from this tumor.
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Affiliation(s)
- Karel Pacak
- Section on Medical Neuroendocrinology, National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive MSC-1109, Bethesda, Maryland 20892-1109, USA.
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