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Memon SS, Srivastava P, Karlekar M, Thakkar H, Bandgar T. Ambulatory blood pressure monitoring in pheochromocytoma - paraganglioma: A single center experience. J Postgrad Med 2024; 70:84-90. [PMID: 37555422 PMCID: PMC11160991 DOI: 10.4103/jpgm.jpgm_208_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/15/2023] [Accepted: 05/02/2023] [Indexed: 08/10/2023] Open
Abstract
CONTEXT/AIMS Pheochromocytoma and paraganglioma (PPGL) are rare tumors, and data on ambulatory blood pressure monitoring (ABPM) in these patients and the effect of blocking on ABPM parameters is limited. We aimed to describe ABPM parameters in a cohort of PPGL at our center in western India. METHODS Retrospective study of patients with PPGL whose ABPM data was available. Demographic details, secretory status, and ABPM data were retrieved. Coefficient of variability (CV) was calculated as standard deviation/mean in percentage. RESULTS In the 39 included patients, mean age at presentation was 39.3 ± 14.2 yr; 20 (51.3%) were males, 25 (64.1%) hypertensive, and mean tumor diameter was 5.3 cm. In 18 patients whose baseline ABPM was done without medications, those with nocturnal blood pressure dipping (6/18, 33%) had higher serum metanephrines (median 313.2 vs. 34.7 pg/ml, P = 0.028). Despite normal office blood pressure (BP), 8.9% of systolic BP readings were >140 mmHg, and 1.2% were >160 mmHg. Among 29 patients with both pre and post-block ABPM, mean BP (systolic 121.6 vs. 132.5 mmHg, P = 0.014; diastolic 68.9 vs. 76.4 mmHg, P = 0.005) and percentage of BP readings above 140 mmHg (median 9.4% vs. 24.4%, P = 0.016) were significantly lowered after the preoperative blockade in hypertensive ( n = 19) patients, whereas CV was similar. The post-blockade ABPM characteristics were similar in patients blocked with amlodipine or prazosin. CONCLUSION ABPM provides additional information about BP characteristics in PPGL. The preoperative blocking decreases the magnitude of BP excursions but does not affect BP variability.
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Affiliation(s)
- SS Memon
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - P Srivastava
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - M Karlekar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - H Thakkar
- Department of Radiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - T Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Schlegel N, Meir M, Reibetanz J, Markus C, Wiegering A, Fassnacht M. [Personalized treatment of pheochromocytoma]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:200-206. [PMID: 37957403 PMCID: PMC10879233 DOI: 10.1007/s00104-023-01988-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Pheochromocytoma is a rare but severe disease of the adrenal glands. The aim of this study is to present and discuss recent developments in the diagnosis and treatment of pheochromocytoma. MATERIAL AND METHODS A narrative review article based on the most recent literature is presented. RESULTS AND DISCUSSION The proportion of pheochromocytomas as tumors of adrenal origin is about 5% of incidentally discovered adrenal tumors. The classical symptomatic triad of headaches, sweating, and palpitations occurs in only about 20% of patients, while almost all patients show at least 1 of these symptoms. To diagnose pheochromocytoma, levels of free plasma metanephrines or alternatively, fractionated metanephrines in a 24‑h urine collection is required in a first step. In the second step an imaging procedure, computed tomography (CT) or magnetic resonance imaging (MRI), is performed to localize the adrenal tumor. Functional imaging is also recommended to preoperatively detect potential metastases. Genetic testing should always be offered during the course of treatment as 30-40% of pheochromocytomas are associated with genetic mutations. The dogma of preoperative alpha blockade is increasingly being questioned and has been controversially discussed in recent years. Minimally invasive removal of the adrenal tumor is the standard surgical procedure to cure patients with pheochromocytoma. The transabdominal and retroperitoneal laparoscopic approaches are considered equivalent. The choice of the minimally invasive procedure depends on the expertise and experience of the surgeon and should be tailored accordingly. Individualized and regular follow-up care is important after surgery.
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Affiliation(s)
- Nicolas Schlegel
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - Michael Meir
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Joachim Reibetanz
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Christian Markus
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Martin Fassnacht
- Medizinische Klinik I, Lehrstuhl für Endokrinologie und Diabetologie, Universitätsklinik Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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Nazari MA, Hasan R, Haigney M, Maghsoudi A, Lenders JWM, Carey RM, Pacak K. Catecholamine-induced hypertensive crises: current insights and management. Lancet Diabetes Endocrinol 2023; 11:942-954. [PMID: 37944546 DOI: 10.1016/s2213-8587(23)00256-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 11/12/2023]
Abstract
Phaeochromocytomas and paragangliomas (PPGLs) release catecholamines leading to catecholamine-induced hypertensive (CIH) crises, with blood pressure greater than or equal to 180/120 mm Hg. CIH crises can be complicated by tachyarrhythmias, hypotension, or life-threatening target organ damage while treatment remains undefined, often requiring co-management between endocrinologists and cardiologists. Furthermore, biochemical diagnosis of a PPGL as a cause of a CIH crisis can be difficult to identify or confounded by comorbid conditions, potentially resulting in misdiagnosis. Here, we combine relevant evidence, 60 years of collective clinical experience, insights derived from assessing over 2600 patients with PPGL, and supplementary outcomes from 100 patients (treated at the National Institutes of Health) with a CIH crisis to inform diagnosis and treatment of CIH crises. Recognising that disparities exist between availability, cost, and familiarity of various agents, flexible approaches are delineated allowing for customisation, given institutional availability and provider preference. A CIH crisis and its complications are readily treatable with available drugs, with effective intervention defining an avenue for mitigating consequent morbidity and mortality in patients with PPGL.
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Affiliation(s)
- Matthew A Nazari
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Rockyb Hasan
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Mark Haigney
- Division of Cardiology, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Division of Cardiology, Department of Medicine, Walter Reed National Military Medical Center and Herbert School of Medicine, Bethesda, MD, USA
| | - Alireza Maghsoudi
- Department of Cardiovascular Disease, INOVA Heart and Vascular Institute, Fairfax, VA, USA
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Department of Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Robert M Carey
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
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Pang Y, Li M, Jiang J, Chen X, Fu Y, Wang C, He Y, Zhao Y, Wang Y, Guan X, Zhang L, Xu X, Gan Y, Liu Y, Xie Y, Tang T, Wang J, Xie B, Liang Z, Chen D, Liu H, Chen C, Eisenhofer G, Liu L, Yi X, Chen BT. Impact of body composition and genotype on haemodynamics during surgery for pheochromocytoma and paraganglioma. J Cachexia Sarcopenia Muscle 2022; 13:2843-2853. [PMID: 36068986 PMCID: PMC9745493 DOI: 10.1002/jcsm.13071] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 07/05/2022] [Accepted: 07/24/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Maintaining intraoperative haemodynamic stability can reduce cardiovascular complications during surgery for pheochromocytoma and paraganglioma (PPGL). Risk factors such as tumour size and catecholamine levels are reported to predict haemodynamic responses during surgery for PPGL. We hypothesized that additional factors including body composition and genetic information could further improve prediction. METHODS Consecutive patients with PPGL confirmed by surgical pathology between June 2010 and June 2019 were retrospectively included. Cross-sectional computed tomography images at the L3 level were used to assess body composition parameters including skeletal muscle area and visceral fat area. Next-generation sequencing was performed using a panel containing susceptibility genes of PPGL. Differences in clinical-genetic characteristics and body composition parameters were analysed and compared in patients with and without intraoperative haemodynamic instability (HDI). RESULTS We included 221 patients with PPGL (median age 47 [38-56] years, and 52% male). Among them, 49.8% had Cluster 2 mutations (related to kinase signalling pathways), 44.8% had sarcopenia, and 52.9% experienced intraoperative HDI. Compared with patients without HDI, more patients with HDI had Cluster 2 mutations (59.8% vs. 38.5%, P = 0.002) and less had sarcopenia (35.9% vs. 54.8%, P = 0.005). Multivariate analysis showed that urine vanillylmandelic acid ≥ 58 μmol/day (adjusted odds ratio [OR] = 1.840, 95% confidence interval [CI] = 1.012-3.347, P = 0.046), tumour size ≥ 4 cm (adjusted OR = 2.278, 95% CI = 1.242-4.180, P = 0.008), and Cluster 2 mutations (adjusted OR = 2.199, 95% CI = 1.128-4.285, P = 0.021) were independent risk factors for intraoperative HDI, while sarcopenia (adjusted OR = 0.475, 95% CI = 0.266-0.846, P = 0.012) decreased the risk. CONCLUSIONS Body composition and genotype were associated with intraoperative haemodynamics in patients with PPGL. Our results indicated that inclusion of body composition and genotype in the overall assessment of patients with PPGL helped to predict HDI during surgery, which could assist in implementing preoperative and intraoperative measures to reduce perioperative complications.
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Affiliation(s)
- Yingxian Pang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Minghao Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jingjing Jiang
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P. R. China
| | - Xiang Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yan Fu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Cikui Wang
- Department of Urology, Hubei Armed Police Corps Hospital, Wuchang, P. R. China
| | - Yao He
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yuanzhe Zhao
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yong Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiao Guan
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Liang Zhang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiaowen Xu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yu Gan
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Yalin Liu
- Xiangya School of Medicine, Central South University, Changsha, Hunan, P. R. China
| | - Yaoling Xie
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Tingyuan Tang
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Jing Wang
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Bin Xie
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Zhihao Liang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Danlei Chen
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Haipeng Liu
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Changyong Chen
- Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Institute of Clinical Chemistry and Laboratory Medicine, Technische Universität Dresden, Dresden, Germany
| | - Longfei Liu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China
| | - Xiaoping Yi
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Department of Radiology, Xiangya Hospital, Central South University, Changsha, Hunan, P. R. China.,Hunan Key Laboratory of Skin Cancer and Psoriasis, Changsha, Hunan, P. R. China.,Hunan Engineering Research Center of Skin Health and Disease, Changsha, Hunan, P. R. China.,National Engineering Research Center of Personalized Diagnostic and Therapeutic Technology, Central South University, Changsha, Hunan, P. R. China
| | - Bihong T Chen
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA, USA
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