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Tullavardhana T. Laparoscopic adrenalectomy performed by a general surgeon on functioning adrenal tumors: Treatment outcomes and risk prediction of persistent hypertension. Qatar Med J 2024; 2024:30. [PMID: 39156635 PMCID: PMC11329866 DOI: 10.5339/qmj.2024.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/09/2024] [Indexed: 08/20/2024] Open
Abstract
Background Functional adrenal tumors may contribute to poor hypertension control and electrolyte abnormalities, thus increasing the risk of cardiovascular mortality. Currently, laparoscopic adrenalectomy is an effective surgical option that contributes to improved treatment outcomes as compared to open surgery. The purpose of this study was to evaluate the outcomes of laparoscopic adrenalectomy performed by a general surgeon at a low-volume center and to identify clinicopathological risk factors for postoperative persistent hypertension. Methods A retrospective study of patients with functional adrenal tumors who underwent laparoscopic adrenalectomy at Srinakharinwirot University, Thailand, between 2014 and 2022. Clinicopathologic and postoperative data were examined. Results This study included twenty-five patients; the indications for laparoscopic adrenalectomy included primary aldosteronism in 19 (76%), pheochromocytoma in 4 (16%), and Cushing's syndrome in 2 (8%). The average time of surgery was 103.5 ± 19.7 min, and intraoperative complications occurred in three patients (12%), with one patient requiring conversion to open surgery (4%). The postoperative systolic (125 ± 15 vs. 158 ± 18 mmHg; p < 0.001) and diastolic (78.5 ± 6.7 vs. 95.3 ± 10 mmHg; p = 0.013) blood pressure significantly decreased compared to prior surgery, but only 19 patients (76%) achieved a cure for hypertension. Multivariate analysis revealed that the patient's physical status, as classified by the American Society of Anesthesiologists (odds ratio (OR) = 0.66, 95% confidence interval (CI) 0.43-1.32, p = 0.001), and the need for at least three antihypertensive medicines (OR = 0.7, 95% CI 0.36-1.2, p = 0.002), were independent predictive factors of persistent hypertension after surgery. Conclusion Laparoscopic adrenalectomy is a safe and effective surgical treatment for functional adrenal tumors, even when performed in a low-volume center. According to the American Society of Anesthesiologists' physical categorization, the patient's physical condition and the necessity for at least three antihypertensive medications are predictors of postoperative hypertension. Trial registration The study was registered with the Thai Clinical Registry Trials: TCTR20230707007.
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Affiliation(s)
- Thawatchai Tullavardhana
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand *
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2
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He X, Dai R, Zhou L, Lv L, Li M, Deng J, Yan D. Pheochromocytoma-induced diffuse alveolar hemorrhage after cholecystectomy: A case report and literature review. Heliyon 2024; 10:e34218. [PMID: 39091938 PMCID: PMC11292511 DOI: 10.1016/j.heliyon.2024.e34218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 07/04/2024] [Accepted: 07/05/2024] [Indexed: 08/04/2024] Open
Abstract
Diffuse alveolar hemorrhage (DAH) can be caused by various conditions, categorized as autoimmune and non-autoimmune. Immunofactor-mediated vasculitis, such as Wegener granulomatosis, microscopic polyangiitis, Goodpasture syndrome, connective tissue disorders, and antiphospholipid antibody syndrome, are common autoimmune causes. Non-autoimmune factors include infectious or toxic exposures and neoplastic conditions. The diagnosis of DAH, resulting from excessive catecholamine release from an adrenal pheochromocytoma or extra-adrenal paraganglioma, can present diagnostic challenges and necessitate prompt treatment. In this report, we present a case of pheochromocytoma that manifested as an adrenal incidentaloma (diagnosed during the management of sudden-onset DAH after cholecystectomy). Case report: A 39-year-old female patient with adrenal incidentaloma developed DAH following a cholecystectomy procedure, presenting with sudden-onset hemoptysis and dyspnea. Administration of glucocorticoids, known to precipitate pheochromocytoma crisis (PCC), was required before the cause was determined. Intubation and mechanical ventilation were necessary due to persistent hypoxemic respiratory failure and acute respiratory distress syndrome (ARDS). The patient in this case experienced two epidoses of PCC while she was on mechanical ventilation. Subsequent work-up revealed a 26 × 25 mm left adrenal adenoma with hormonal confirmation of catecholamine hypersecretion. A laparoscopic adrenalectomy was done eight months later to excise the left adrenal gland. Subsequent examination of the tissue revealed pheochromocytoma, thereby validating the initial diagnosis. Conclusion: Adrenal incidentalomas may be pheochromocytomas (adrenal incidentalomas can manifest as pheochromocytomas), even without adrenergic symptoms. It is recommended that adrenal incidentalomas undergo evaluation for pheochromocytoma before undergoing invasive surgery or receiving corticosteroid treatment. When considering potential causes of DAH without further elucidation, including a pheochromocytoma or paraganglioma (PPGLs) in the differential diagnosis is important.
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Affiliation(s)
- Xinlian He
- Department of Endocrinology, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, Health Science Center of Shenzhen University, Shenzhen Clinical Research Center for Metabolic Diseases, Shenzhen Center for Diabetes Control and Prevention, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, Guangdong Province, China
| | - Ruchun Dai
- Department of Endocrinology and Metabolism, Hunan Provincial Key Laboratory of Metabolic Bone Diseases, National Clinical Research Center for Metabolic Disease, The Second XiangYa Hospital, Central South University, 139 Renmin Middle Road, Changsha, 410011, China
| | - Liming Zhou
- Department of Endocrinology, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, Health Science Center of Shenzhen University, Shenzhen Clinical Research Center for Metabolic Diseases, Shenzhen Center for Diabetes Control and Prevention, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, Guangdong Province, China
| | - Lingbo Lv
- Department of Endocrinology, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, Health Science Center of Shenzhen University, Shenzhen Clinical Research Center for Metabolic Diseases, Shenzhen Center for Diabetes Control and Prevention, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, Guangdong Province, China
| | - Mingzheng Li
- Department of Endocrinology, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, Health Science Center of Shenzhen University, Shenzhen Clinical Research Center for Metabolic Diseases, Shenzhen Center for Diabetes Control and Prevention, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, Guangdong Province, China
| | - Jianxin Deng
- Department of Endocrinology, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, Health Science Center of Shenzhen University, Shenzhen Clinical Research Center for Metabolic Diseases, Shenzhen Center for Diabetes Control and Prevention, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, Guangdong Province, China
| | - Dewen Yan
- Department of Endocrinology, Shenzhen Second People's Hospital, the First Affiliated Hospital of Shenzhen University, Health Science Center of Shenzhen University, Shenzhen Clinical Research Center for Metabolic Diseases, Shenzhen Center for Diabetes Control and Prevention, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, Guangdong Province, China
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3
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Xing Y, Shi H, Guo Q, Wang C, Li C, Hao C. Chromogranin A as a diagnostic marker of pheochromocytoma and paraganglioma: A systematic review and meta-analysis. Int J Urol 2024; 31:637-645. [PMID: 38380475 DOI: 10.1111/iju.15423] [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: 10/30/2023] [Accepted: 01/31/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVES This work aims to assess the diagnostic value of chromogranin A (CgA) in the laboratory diagnosis of neuroendocrine tumors classified as pheochromocytoma and paraganglioma (PPGL). METHODS A comprehensive search was performed in PubMed, Embase, the Cochrane Library, and Web of Science databases to obtain relevant studies reporting the diagnostic accuracy of CgA in patients with PPGL. The search involved studies written in English between the time of library inception and May 1, 2023. We computed the pooled sensitivity, specificity, and diagnostic odds ratio (DOR). Additionally, the receiver operating characteristic curve and area under the curve (AUC) were determined. The heterogeneity was assessed using the Chi-square test and the I2 test. The subgroup analyses were performed to investigate the origins of heterogeneity. Stata 15.1 statistical software was used in all data analyses. RESULTS This meta-analysis included 13 studies involving 1470 patients. CgA had a pooled diagnostic sensitivity of 0.86 (95% CI 0.81-0.91), a specificity of 0.90 (95% CI 0.81-0.95), and a DOR of 57 (95% CI 23-142). CgA had an AUC of 0.93. The studies did not reveal any threshold effect (r = -0.165; p > 0.05). The subgroup analyses revealed that the control group category and the detection method caused the overall heterogeneity. CONCLUSIONS Our study suggests that CgA is a helpful PPGL biomarker. However, relying solely on CgA for diagnosis is not advisable. A comprehensive approach is essential for accurate diagnosis. Future large-scale research is needed to refine CgA's clinical application.
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Affiliation(s)
- Yanbo Xing
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Haoying Shi
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Qiang Guo
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Cong Wang
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Second Clinical Medical College, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Chengyong Li
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Chuan Hao
- Department of Urology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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Kamalanathan S. Glimpses of pheochromocytoma-paraganglioma management through ambulatory blood pressure monitoring window. J Postgrad Med 2024; 70:71-72. [PMID: 38099611 PMCID: PMC11160992 DOI: 10.4103/jpgm.jpgm_642_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/09/2023] [Accepted: 09/11/2023] [Indexed: 04/30/2024] Open
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5
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Louis S, Selma H, Nicolas T. Pheochromocytoma-induced cardiogenic shock. Acta Chir Belg 2023; 123:573-576. [PMID: 35583372 DOI: 10.1080/00015458.2022.2079822] [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: 10/24/2021] [Accepted: 05/16/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pheochromocytoma is a rare catecholamine-secreting tumor of neuroendocrine origin. It has a prevalence of <1% in adults with hypertension. In some cases, hypertension is associated with the classical triad of headache, sweating, and tachycardia. Cardiogenic shock due to stress-induced cardiomyopathy caused by catecholamine excess may rarely be the initial symptom of pheochromocytoma, mimicking Takotsubo Syndrome. METHODS We report the case of a 58-year-old female patient with pheochromocytoma-induced cardiogenic shock (PICS) in the early postoperative period after thyroidectomy. RESULTS PICS is caused by a catecholamine storm, which induces myocardial stress and cardiac dysfunction. In such cases, early management with mechanical circulatory assistance may be promptly considered, given the increased risk of mortality. CONCLUSION PICS is a rare and serious condition. Prompt diagnosis and adequate resuscitation measures are necessary to avoid high mortality.
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Affiliation(s)
- Smits Louis
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Gilly, Belgium
| | - Hameurlaine Selma
- Department of Anesthesiology, Grand Hôpital de Charleroi, Gilly, Belgium
| | - Tinton Nicolas
- Department of Abdominal Surgery, Grand Hôpital de Charleroi, Gilly, Belgium
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6
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Patel T, Singleton LA, Mejia M, Senior A, Millis RM. Pheochromocytoma: A Troublesome Tumor. Cureus 2023; 15:e45490. [PMID: 37727845 PMCID: PMC10506759 DOI: 10.7759/cureus.45490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 09/21/2023] Open
Abstract
This report presents the case of a 45-year-old man with a history of episodic headaches, palpitations, and sweating for the past six months. His blood pressure on admission was 170/100 mmHg. The patient was diagnosed with pheochromocytoma confirmed by elevated levels of plasma catecholamines and metanephrines. CT imaging revealed a 3 cm mass in the left adrenal gland with evidence of local invasion into the surrounding tissues. The patient underwent a laparoscopic adrenalectomy and was discharged on the third postoperative day with normal blood pressure. Histopathological examination confirmed the diagnosis of pheochromocytoma. The patient was followed for six months postoperatively with the resolution of symptoms and no evidence of tumor recurrence on imaging. Recurrence involves complex environment-gene interactions that are poorly understood. The diagnosis of pheochromocytoma could take several weeks to several years mainly because the symptoms are nonspecific and episodic. Although sudden death is rare, the debilitations associated with pheochromocytoma are often multisystemic with cardiovascular, emotional, and metabolic components. This case report highlights the importance of early diagnosis, appropriate management, and follow-up for pheochromocytoma.
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Affiliation(s)
- Tirath Patel
- Department of Pathophysiology, American University of Antigua, St. John's, ATG
| | - Leah A Singleton
- Department of Pathophysiology, American University of Antigua, St. John's, ATG
| | - Michael Mejia
- Department of Pathophysiology, American University of Antigua, St. John's, ATG
| | - Amanda Senior
- Department of Pathophysiology, American University of Antigua, St. John's, ATG
| | - Richard M Millis
- Department of Pathophysiology, American University of Antigua, St. John's, ATG
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7
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Kulandaivel S, Lin CH, Yeh YC. A bioinspired copper-based coordination polymer for the detection of pheochromocytoma biomarkers. Talanta 2023; 255:124206. [PMID: 36563506 DOI: 10.1016/j.talanta.2022.124206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
Oxidase-mimicking (catechol oxidase/laccase) nanozymes provide outstanding specificity in the detection of epinephrine (Epi) for the assessment of pheochromocytoma; however, epinephrine (Epi) and norepinephrine (NE) co-existing in the same systems will reduce the selectivity of the biosensor. In the current study, we synthesized copper-based coordination polymer (Cu-CP) nanozymes capable of accelerating the oxidation of Epi with high specificity. Furthermore, the Cu-CP is able to detect Epi over a wide linear range of 0.5-100 μM with a low detection limit of 0.36 μM while providing excellent stability and recyclability. Furthermore, we employed colorimetric and fluorescence signals for sequential detection of the coexistence of Epi and NE for use in tracking the treatment outcomes of patients with pheochromocytoma. Experiments using artificial urine further confirmed the efficacy of the proposed system.
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Affiliation(s)
| | - Chia-Her Lin
- Department of Chemistry, National Taiwan Normal University, Taipei, 116, Taiwan.
| | - Yi-Chun Yeh
- Department of Chemistry, National Taiwan Normal University, Taipei, 116, Taiwan.
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8
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Bhandarwar AH, Tandur AE, Rachapalli KR, Wagh A, Shah A, Dhimole N. Minimally Invasive Management of Hemorrhagic Pheochromocytoma—A Rare Case Report. Surg J (N Y) 2023; 9:e52-e57. [PMID: 36987408 PMCID: PMC10040260 DOI: 10.1055/s-0043-1762554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 01/02/2023] [Indexed: 03/29/2023] Open
Abstract
Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. The diagnosis is usually suggested by its classic history, presence of a strong family history, or discovery of an incidental mass on imaging in an asymptomatic patient. Hemorrhage into an occult pheochromocytoma is a rare complication with ∼1 to 2 per 100,000 individuals diagnosed annually. We report a case of a 29-year-old woman, who presented with abdominal pain (with no other significant history) due to a right hemorrhagic pheochromocytoma. Computed tomographic imaging and magnetic resonance imaging revealed the source of retroperitoneal hemorrhage as the right adrenal mass. They lacked the typical features of a pheochromocytoma which was eventually proven by the biochemical tests. The patient underwent preoperative stabilization with α and β adrenergic receptor blockers for 7 days following which laparoscopic adrenalectomy was performed successfully with an uneventful postoperative period. This is the eighth reported case in literature managed laparoscopically. Histopathology confirmed it as pheochromocytoma. The treacherous and deceptive nature of pheochromocytomas and its hemorrhage make it crucial to detect and treat it promptly; otherwise, it will almost certainly be fatal from cardiovascular complications or metastasis.
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Affiliation(s)
- Ajay H. Bhandarwar
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Amarjeet E. Tandur
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Keerthika Reddy Rachapalli
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
- Address for correspondence Keerthika Reddy Rachapalli, MBBS 470/D, REDDYS, 15th cross, Idealhomes township, Rajarajeshwari nagar, Bengaluru- 560098, KarnatakaIndia
| | - Amol Wagh
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Abhijit Shah
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
| | - Nikhil Dhimole
- Department of General Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
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9
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Alsayed EF. Undiagnosed Thyrotoxicosis Storm in a Patient Presenting With a Perioperative Sinus Tachycardia and Hypertensive Crisis After Induction of Anesthesia for Emergent Bipolar Hip Hemiarthroplasty After Traumatic Femur Neck Fracture: A Case Report. Cureus 2022; 14:e31145. [DOI: 10.7759/cureus.31145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 11/07/2022] Open
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10
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Odion-Omonhimin LO, Marwizi FM, Chive M, Obasi NB, Akinrinmade AO, Obitulata-Ugwu VO, Victor F, Obijiofor NB. Etiology and Management of Treatment-Resistant Hypertension in African American Adults ≥18 Years: A Literature Review. Cureus 2022; 14:e29566. [PMID: 36312638 PMCID: PMC9595575 DOI: 10.7759/cureus.29566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/25/2022] Open
Abstract
Treatment-resistant hypertension (TRH) is defined as blood pressure levels that remain above the therapeutic goal despite concurrent use of three or more antihypertensive medications taken at maximally tolerated doses, one of which should be a diuretic. Additionally, individuals on four or more antihypertensive agents regardless of blood pressure are also considered to have TRH. Amongst people diagnosed with TRH, African American adults face a huge management gap, resulting in increased cardiovascular disease risk. The primary objective of this review was to identify the commonly encountered etiologies and extensively discuss the current management strategies of TRH with a particular focus on African Americans. Relevant studies were identified by analyzing scientific databases and journals such as PubMed, Cochrane, MEDLINE, Cureus, and American Heart Association (AHA). The studies identified and examined common causes of TRH, describing their pathophysiology and highlighting different treatment options for the respective etiologies. The most prevalent etiologies of TRH amongst African Americans were chronic kidney disease (CKD), renal artery stenosis (RAS), fibromuscular dysplasia, obstructive sleep apnea (OSA), endocrine causes (Conn syndrome, Cushing syndrome, etc.), sympathetic nervous system overactivity, lifestyle factors, inaccurate blood pressure measurement, and inappropriate treatment. Of the etiologies reviewed, OSA, lifestyle factors, and CKD exhibited a striking prevalence among the subpopulation studied. Unfortunately, there was a paucity of articles addressing this topic amongst African Americans, and therefore there was not a substantial appreciation of the prevalence of some of the identified etiologies in the population of interest. Thorough diagnostic testing for associated or underlying conditions provides a basis for successful management. This review brought to the fore the need for doctors and patients to collaborate in order to improve TRH management and help patients lead healthier lives.
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11
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Role of Chromogranin A in the Diagnosis and Follow-up of Neuroendocrine Tumors: Real-World Experience. Pancreas 2022; 51:1007-1010. [PMID: 36607947 DOI: 10.1097/mpa.0000000000002132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of this study was to assess the utility of serum chromogranin A (CgA) along the clinical pathway of patients with neuroendocrine tumors (NETs). METHODS A retrospective review of medical records was conducted of patients with NET who had at least 1 measurement of CgA between January 2015 and April 2021 at a large metropolitan Australian hospital. Chromogranin A was classified as increased or decreased if there was at least a 25% change in sequential levels and was compared with disease response by anatomical or functional imaging if within 6 weeks (considered concurrent). RESULTS Of 102 patients with NETs, 67 had at least 1 serum CgA level: 50 had been ordered during diagnostic workup, of which 33 were elevated (sensitivity: 66%; 95% confidence interval, 51%-79%). Of 129 CgA results concurrent with imaging, the sensitivity for detecting progressive disease was 28% (95% confidence interval, 15%-44%). CONCLUSIONS Our findings support previous concerns that CgA adds little value in clinical decision-making.
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12
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Chee YJ, Teo CHY, Au RTM, Kon YC. Subclinical phaeochromocytoma: a diagnostic and management challenge. BMJ Case Rep 2022; 15:e248571. [PMID: 35428667 PMCID: PMC9014025 DOI: 10.1136/bcr-2021-248571] [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] [Accepted: 03/29/2022] [Indexed: 11/04/2022] Open
Abstract
There is a paradigm shift in the detection of phaeochromocytomas with more being identified as adrenal 'incidentalomas'. While majority of these individuals are asymptomatic, they are nevertheless at risk of subtle cardiovascular dysfunction and phaeochromocytoma crises. Therefore, early resection of phaeochromocytomas, even if subclinical, is recommended. However, the perioperative management can be challenging as the normotension can limit the initiation and titration of alpha-blockade. We present a man in his 60s with a subclinical phaeochromocytoma, discuss the evaluation of an incidentally discovered adrenal nodule, as well as the practical considerations in the perioperative management.
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Affiliation(s)
- Ying Jie Chee
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
| | | | | | - Yin Chian Kon
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
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13
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Kong J, Zheng J, Wu J, Wu S, Cai J, Diao X, Xie W, Chen X, Yu H, Huang L, Fang H, Fan X, Qin H, Li Y, Wu Z, Huang J, Lin T. Development of a radiomics model to diagnose pheochromocytoma preoperatively: a multicenter study with prospective validation. J Transl Med 2022; 20:31. [PMID: 35033104 PMCID: PMC8760711 DOI: 10.1186/s12967-022-03233-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/05/2022] [Indexed: 12/17/2022] Open
Abstract
Background Preoperative diagnosis of pheochromocytoma (PHEO) accurately impacts preoperative preparation and surgical outcome in PHEO patients. Highly reliable model to diagnose PHEO is lacking. We aimed to develop a magnetic resonance imaging (MRI)-based radiomic-clinical model to distinguish PHEO from adrenal lesions. Methods In total, 305 patients with 309 adrenal lesions were included and divided into different sets. The least absolute shrinkage and selection operator (LASSO) regression model was used for data dimension reduction, feature selection, and radiomics signature building. In addition, a nomogram incorporating the obtained radiomics signature and selected clinical predictors was developed by using multivariable logistic regression analysis. The performance of the radiomic-clinical model was assessed with respect to its discrimination, calibration, and clinical usefulness. Results Seven radiomics features were selected among the 1301 features obtained as they could differentiate PHEOs from other adrenal lesions in the training (area under the curve [AUC], 0.887), internal validation (AUC, 0.880), and external validation cohorts (AUC, 0.807). Predictors contained in the individualized prediction nomogram included the radiomics signature and symptom number (symptoms include headache, palpitation, and diaphoresis). The training set yielded an AUC of 0.893 for the nomogram, which was confirmed in the internal and external validation sets with AUCs of 0.906 and 0.844, respectively. Decision curve analyses indicated the nomogram was clinically useful. In addition, 25 patients with 25 lesions were recruited for prospective validation, which yielded an AUC of 0.917 for the nomogram. Conclusion We propose a radiomic-based nomogram incorporating clinically useful signatures as an easy-to-use, predictive and individualized tool for PHEO diagnosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03233-w.
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Affiliation(s)
- Jianqiu Kong
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Junjiong Zheng
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Jieying Wu
- Department of Urology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Shaoxu Wu
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Jinhua Cai
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Xiayao Diao
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Weibin Xie
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Xiong Chen
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Hao Yu
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Lifang Huang
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Hongpeng Fang
- Department of Urology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510630, Guangdong, People's Republic of China
| | - Xinxiang Fan
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Haide Qin
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Yong Li
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Zhuo Wu
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Jian Huang
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China. .,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China. .,State Key Laboratory of Oncology in South China, Guangzhou, 510120, Guangdong, People's Republic of China.
| | - Tianxin Lin
- Department of Urology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China. .,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, Guangdong, People's Republic of China. .,State Key Laboratory of Oncology in South China, Guangzhou, 510120, Guangdong, People's Republic of China.
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14
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De Filpo G, Cantini G, Rastrelli G, Vannini G, Ercolino T, Luconi M, Mannelli M, Maggi M, Canu L. Management and outcome of metastatic pheochromocytomas/paragangliomas: a monocentric experience. J Endocrinol Invest 2022; 45:149-157. [PMID: 34227051 PMCID: PMC8741659 DOI: 10.1007/s40618-021-01629-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/28/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors releasing catecholamines. Metastatic pheochromocytomas/paragangliomas (PPGLs) occur in about 5-26% of cases. To date, the management of patients affected by metastatic disease is a challenge in the absence of guidelines. AIM The aim of this study was to evaluate the overall survival (OS) and the progression-free survival (PFS) in metastatic PPGLs. METHODS Clinical data of 20 patients referred to the Careggi University Hospital (Florence, Italy) were retrospectively collected. Follow-up ranged from 1989 to 2019. Site and size of primary tumor, biochemical activity, genetic analysis and employed therapies were considered. Data were analyzed with SPSS version 27. RESULTS Nine PHEOs (45%) and 11 PGLs (55%) were enrolled. Median age at diagnosis was 43.5 years [30-55]. Mean follow-up was 104.6 ± 89.3 months. Catecholamines were released in 70% of cases. An inherited disease was reported in 50% of patients. OS from the initial diagnosis (OSpt) and from the metastatic appearance (OSmtx) were lower in older patients (OSpt p = 0.028; OSmtx p < 0.001), abdominal PGLs (OSpt p = 0.007; OSmtx p = 0.041), larger tumors (OSpt p = 0.008; OSmtx p = 0.025) and sporadic disease (OSpt p = 0.013; OSmtx p = 0.008). CONCLUSION Our data showed that older age at the initial diagnosis, sympathetic extra-adrenal localization, larger tumors and wild-type neoplasms are related to worse prognosis. Notably, the employed therapies do not seem to influence the survival of our patients. At present, effective treatments for metastatic PPGLs are missing and a multidisciplinary approach is indispensably required.
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Affiliation(s)
- G De Filpo
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy.
| | - G Cantini
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - G Rastrelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - G Vannini
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - T Ercolino
- Endocrinology Unit, Careggi University Hospital, Florence, Italy
| | - M Luconi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - M Mannelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - M Maggi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - L Canu
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
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15
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Buragohain S, Das D, Bhattacharjee H, Kuri G, Ghosh R. Pheochromocytoma-induced hypertensive retinopathy. TNOA JOURNAL OF OPHTHALMIC SCIENCE AND RESEARCH 2022. [DOI: 10.4103/tjosr.tjosr_108_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Sathaye S, Parmar KM, Kumar S, Rastogi P. Adrenal pheochromocytoma with involvement of aorta and left renal artery: salvaged with adrenalectomy and nephrectomy. BMJ Case Rep 2021; 14:e244297. [PMID: 34511410 PMCID: PMC8438742 DOI: 10.1136/bcr-2021-244297] [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] [Accepted: 08/24/2021] [Indexed: 11/04/2022] Open
Abstract
Large adrenal pheochromocytomas encasing the renal artery are a rare entity. The management of such challenging cases is surgical resection. The involvement of renal tissue and renal artery may necessitate meticulous dissection and concomitant nephrectomy. Here, we present a case of 41-year-old man diagnosed with left adrenal pheochromocytoma with complete encasement of left renal artery and partial encasement of aorta. Open left adrenalectomy and nephrectomy was performed after adequate preoperative optimisation. The patient is doing well at 6-month follow-up. Large adrenal pheochromocytoma with renal involvement is a rare presentation and requires optimal preoperative imaging, adequate preoperative alpha and beta blockade and meticulous surgical technique.
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17
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Li SJ, Lee J, Hall J, Sutherland TR. The inferior vena cava: anatomical variants and acquired pathologies. Insights Imaging 2021; 12:123. [PMID: 34460015 PMCID: PMC8405820 DOI: 10.1186/s13244-021-01066-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/07/2021] [Indexed: 01/05/2023] Open
Abstract
The inferior vena cava (IVC) is the largest vein in the body, draining blood from the abdomen, pelvis and lower extremities. This pictorial review summarises normal anatomy and embryological development of the IVC. In addition, we highlight a wide range of anatomical variants, acquired pathologies and a common pitfall in imaging of the IVC. This information is essential for clinical decision making and to reduce misdiagnosis.
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Affiliation(s)
- Simon J Li
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
| | - Jean Lee
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jonathan Hall
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Tom R Sutherland
- Medical Imaging Department, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC, Australia
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18
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Hallin Thompson L, Makay Ö, Brunaud L, Raffaelli M, Bergenfelz A. Adrenalectomy for incidental and symptomatic phaeochromocytoma: retrospective multicentre study based on the Eurocrine® database. Br J Surg 2021; 108:1199-1206. [PMID: 34270711 PMCID: PMC10364866 DOI: 10.1093/bjs/znab199] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/05/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative α-blockade. METHODS This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in Eurocrine®, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed. RESULTS Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative α-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P = 0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative α-blockade or not. CONCLUSION Subclinical phaeochromocytoma detected incidentally is common. A significantproportion of patients with phaeochromocytoma did not have α-blockade before surgery, without an apparent effect on complications.
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Affiliation(s)
- L Hallin Thompson
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Ö Makay
- Department of General Surgery, Division of Endocrine Surgery, Ege University Hospital, Izmir, Turkey
| | - L Brunaud
- Department of Gastrointestinal, Metabolic and Surgical Oncology, Université de Lorraine, CHU Nancy, Hospital Brabois Adultes, Vandoevre les Nancy, France
| | - M Raffaelli
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Dipatimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Bergenfelz
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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19
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Lau ES, Scirica B, Schaefer IM, Miller AL, Loscalzo J. Hypertensive Heartbreak. N Engl J Med 2021; 384:2145-2152. [PMID: 34077647 DOI: 10.1056/nejmcps2018493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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20
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Jandou I, Moataz A, Dakir M, Debbagh A, Aboutaieb R. Malignant pheochromocytoma: A diagnostic and therapeutic dilemma. Int J Surg Case Rep 2021; 83:106009. [PMID: 34052712 PMCID: PMC8175409 DOI: 10.1016/j.ijscr.2021.106009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Malignant pheochromocytomas are rare endocrine tumors that develop within chromaffin tissue. The diagnosis of malignancy is based on neoplastic recurrence or the presence of metastasis in organs that lack chromaffin tissue. We report a series of four cases because of their diagnostic and therapeutic particularities. Presentation of case we describe four clinical cases of patients with malignant pheochromocytoma whose Menard triad “headache-palpitations-sweating” was present in three out of four patients, the methoxylated derivatives were measured in 4 patients, 3 of which had high values, all of our patients carried out a CT scan which objectified signs of malignancy, MRI was performed on a single patient; presenting with a neoplastic recurrence; looking for a locoregional invasion. Discussion Pheochromocytoma (PC) is a rare neuroendocrine tumor derived from the chromaffin cells of the adrenal medulla. Its annual incidence is 2 to 8 per million adults. A peak frequency is observed between 30 and 40 years of age. Approximately 10% of pheochromocytomas are malignant and in 10% of cases, bilateral localization is observed. Criteria for malignancy include the invasion of neighboring organs, a large tumor, the presence of lymphadenopathy on imaging, or fixation on scintigraphy. Surgery for MAP is not always curative. In the case of multiple liver metastases, treatment is based on adrenalectomy, which can be effectively combined with chemoembolization, cryoablation, or radiofrequency techniques. Conclusion The main prognostic factors of the malignant pheochromocytomas are a large tumor volume, the existence or number of visceral metastases, and the presence of a mutation in the SDHB (Succinate dehydrogenase B) gene. Malignant pheochromocytomas are rare endocrine tumors that develop within chromaffin tissue. A very large part of pheochromocytomas are of genetic origin which can be part of hereditary syndromes. Criteria for malignancy include the invasion of neighboring organs, a large tumor, the presence of lymphadenopathy on imaging, or fixation on scintigraphy. Adequate management of this pathology requires a multidisciplinary consultation meeting
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Affiliation(s)
- Issam Jandou
- Ibn Rochd University Hospital Casablanca, Morocco; Faculty of Medicine and Pharmacy of Casablanca, Morocco.
| | - Amine Moataz
- Ibn Rochd University Hospital Casablanca, Morocco; Faculty of Medicine and Pharmacy of Casablanca, Morocco
| | - Mohammed Dakir
- Ibn Rochd University Hospital Casablanca, Morocco; Faculty of Medicine and Pharmacy of Casablanca, Morocco
| | - Adil Debbagh
- Ibn Rochd University Hospital Casablanca, Morocco; Faculty of Medicine and Pharmacy of Casablanca, Morocco
| | - Rachid Aboutaieb
- Ibn Rochd University Hospital Casablanca, Morocco; Faculty of Medicine and Pharmacy of Casablanca, Morocco
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21
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De Filpo G, Maggi M, Mannelli M, Canu L. Management and outcome of metastatic pheochromocytomas/paragangliomas: an overview. J Endocrinol Invest 2021; 44:15-25. [PMID: 32602077 DOI: 10.1007/s40618-020-01344-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/23/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Metastatic pheochromocytomas and paragangliomas (PPGLs) occur in about 5-26% of cases and are characterized by a heterogeneous prognosis. Metastases can be synchronous at the initial diagnosis, but they can occur also many years after surgery for the primary tumor. To date, the treatment of patients affected by metastatic PPGLs represents a clinical challenge because of the lack of guidelines. AIM The aim of this article is to review the available management options and their impact on the outcomes of patients with metastatic PPGLs. RESULTS Generally, treatments are not curative. Surgery, when possible, can be used to reduce hormonal symptoms and cardiovascular morbidity. Chemotherapy plays a role in patients with high burden tumor and rapid disease progression. Tyrosine kinases inhibitors (TKIs) might be considered for their ability to block the angiogenesis and cell growth. Radiation therapy and interventional radiology techniques can help in the management of local metastases to control symptoms and avoid tumor progression. On the other hand, peptide receptor radionuclide therapy (PRRT), using 90Y or 177Lu-DOTATATE, could be a promising therapy. In addition, high specific 131I-MIBG was approved by the Food and Drug Administration (FDA) in the US for the treatment of patients affected by metastatic and unresectable 131I-MIBG positive PPGLs. Considering the different pathways involved in the pathogenesis of PPGLs, several target therapies have been proposed and are under evaluation in clinical trials. CONCLUSIONS The choice of the appropriate treatment should be based on multidisciplinary and personalized approach taking into account the rarity and the variability of these tumors.
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Affiliation(s)
- G De Filpo
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy.
| | - M Maggi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - M Mannelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - L Canu
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
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22
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Emran MY, Shenashen MA, El-Safty SA, Selim MM, Minowa T, Elmarakbi A. Three-Dimensional Circular Surface Curvature of a Spherule-Based Electrode for Selective Signaling and Dynamic Mobility of Norepinephrine in Living Cells. ACS APPLIED BIO MATERIALS 2020; 3:8496-8506. [DOI: 10.1021/acsabm.0c00882] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Mohammed Y. Emran
- Research Center for Functional Materials, National Institute for Materials Science (NIMS), 1-2-1 Sengen, Tsukuba-shi, Ibaraki-ken 305-0047, Japan
| | - Mohamed A. Shenashen
- Research Center for Functional Materials, National Institute for Materials Science (NIMS), 1-2-1 Sengen, Tsukuba-shi, Ibaraki-ken 305-0047, Japan
| | - Sherif A. El-Safty
- Research Center for Functional Materials, National Institute for Materials Science (NIMS), 1-2-1 Sengen, Tsukuba-shi, Ibaraki-ken 305-0047, Japan
| | - Mahmoud M. Selim
- Department of Mathematics, Al-Aflaj College of Science and Human Studies, Prince Sattam Bin Abdulaziz University, Al-Aflaj 710-11912, Saudi Arabia
| | - Takashi Minowa
- Nanotechnology Innovation Station, National Institute for Materials Science (NIMS), 1-2-1 Sengen, Tsukuba 305-0047, Japan
| | - Ahmed Elmarakbi
- Department of Mechanical & Construction Engineering, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne NE1 8ST, UK
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23
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Lenders JWM, Kerstens MN, Amar L, Prejbisz A, Robledo M, Taieb D, Pacak K, Crona J, Zelinka T, Mannelli M, Deutschbein T, Timmers HJLM, Castinetti F, Dralle H, Widimský J, Gimenez-Roqueplo AP, Eisenhofer G. Genetics, diagnosis, management and future directions of research of phaeochromocytoma and paraganglioma: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension. J Hypertens 2020; 38:1443-1456. [PMID: 32412940 PMCID: PMC7486815 DOI: 10.1097/hjh.0000000000002438] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
: Phaeochromocytoma and paraganglioma (PPGL) are chromaffin cell tumours that require timely diagnosis because of their potentially serious cardiovascular and sometimes life- threatening sequelae. Tremendous progress in biochemical testing, imaging, genetics and pathophysiological understanding of the tumours has far-reaching implications for physicians dealing with hypertension and more importantly affected patients. Because hypertension is a classical clinical clue for PPGL, physicians involved in hypertension care are those who are often the first to consider this diagnosis. However, there have been profound changes in how PPGLs are discovered; this is often now based on incidental findings of adrenal or other masses during imaging and increasingly during surveillance based on rapidly emerging new hereditary causes of PPGL. We therefore address the relevant genetic causes of PPGLs and outline how genetic testing can be incorporated within clinical care. In addition to conventional imaging (computed tomography, MRI), new functional imaging approaches are evaluated. The novel knowledge of genotype-phenotype relationships, linking distinct genetic causes of disease to clinical behaviour and biochemical phenotype, provides the rationale for patient-tailored strategies for diagnosis, follow-up and surveillance. Most appropriate preoperative evaluation and preparation of patients are reviewed, as is minimally invasive surgery. Finally, we discuss risk factors for developing metastatic disease and how they may facilitate personalised follow-up. Experts from the European Society of Hypertension have prepared this position document that summarizes the current knowledge in epidemiology, genetics, diagnosis, treatment and surveillance of PPGL.
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Affiliation(s)
- Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medicine III, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Laurence Amar
- Unité d'Hypertension Artérielle, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université de Paris-PARCC, INSERM, Paris, France
| | | | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Human Cancer Genetics Program, Spanish National Cancer Research Centre (CNIO), and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, European Center for Research in Medical Imaging, Aix-Marseille University, Marseille, France
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Joakim Crona
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Tomáš Zelinka
- Center for Hypertension, 3rd Department of Medicine, Division of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Massimo Mannelli
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital, University of Würzburg, Würzburg, Germany
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frederic Castinetti
- Aix-Marseille Université, Department of Endocrinology, Institut National de la Santé et de la Recherche Médicale (INSERM), Marseille Medical Genetics (MMG), et Assistance Publique-Hôpitaux de Marseille (AP-HM), Marseille, France
| | - Henning Dralle
- Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany
| | - Jřri Widimský
- Center for Hypertension, 3rd Department of Medicine, Division of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Anne-Paule Gimenez-Roqueplo
- Assistance Publique-Hôpitaux de Paris, AP-HP, Hôpital Européen Georges Pompidou, Service de Génétique, Université de Paris, PARCC, INSERM, Paris, France
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
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24
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Hantson P, Hubert C, Dieu A, Castanares-Zapatero D, Lelotte J, Laterre PF. Refractory shock during the anesthetic and surgical management of an intrahepatic tumor arising from the adrenal cortex: A case report. Int J Surg Case Rep 2020; 73:109-111. [PMID: 32673783 PMCID: PMC7363625 DOI: 10.1016/j.ijscr.2020.06.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/18/2020] [Accepted: 06/25/2020] [Indexed: 11/28/2022] Open
Abstract
With adrenocortical carcinoma, tumoral secretion is present in 25 to 75% of the cases. In the absence of excessive hormonal production, the diagnosis is often delayed. Isolated liver metastatic lesion may develop after several years of follow-up. Resection of a large intrahepatic malignant lesion may be complicated by a secondary capillary leak syndrome.
Introduction Adrenocortical carcinoma is a rare type of malignant adrenal tumor with a possibility of delayed metastases. Diagnosis may be delayed with a non-secreting tumor or metastasis, and even in this case, surgical management may be complicate. Presentation of case A 55-year-old man underwent elective surgery for the resection of a large intra-hepatic mass from an undetermined type according to a recent liver biopsy. He had a previous history of a non-secreting adrenal tumor that was operated ten years before. Pre-operatively, he was poorly symptomatic, with a normal arterial blood pressure. Anesthesia induction was uneventful, but at the time of tumor resection and removal, he developed extreme vasoplegia and shock with anuric renal failure, lactic acidosis, four-limb and abdominal compartment syndrome. The patient died on day 9 from delayed septic complications. According to the pathological findings, the tumor was a non-secreting adrenocortical carcinoma. Discussion Adrenocortical carcinoma (ACC) is rare condition with diverse clinical manifestations due to excessive hormonal production when the tumor is secreting and mimicking pheochromocytoma. Our patient underwent the resection a large intrahepatic non-secreting metastasis more than ten years after the initial lesion. Peri-operative and post-operative management was complicated by a refractory shock with the characteristics of a secondary systemic capillary leak syndrome. The role of endothelial lesions may be discussed. Conclusion Surgery of metastatic adrenocortical carcinoma may be complicated by severe hemodynamic complications, even in the absence of hormonal secretion.
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Affiliation(s)
- Philippe Hantson
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium; Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Université catholique de Louvain, 1200 Brussels, Belgium.
| | - Catherine Hubert
- Department of Abdominal Surgery and Transplantation, Unit of Hepato-biliary and Pancreatic Surgery, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
| | - Audrey Dieu
- Department of Anesthesiology, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
| | - Diego Castanares-Zapatero
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
| | - Julie Lelotte
- Department of Pathology, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, 1200 Brussels, Belgium
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Conzo G, Musella M, Corcione F, Depalma M, Stanzione F, Della-Pietra C, Palazzo A, Napolitano S, Pasquali D, Milone M, Agostino-Sinisi A, Ferraro F, Santini L. Role of Preoperative Adrenergic Blockade with Doxazosin on Hemodynamic Control during the Surgical Treatment of Pheochromocytoma: A Retrospective Study of 48 Cases. Am Surg 2020. [DOI: 10.1177/000313481307901125] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Authors evaluated the effects of selective adrenergic blockade by means of doxazosin on blood pressure in 48 patients operated on for pheochromocytoma by a multicenter retrospective study. Age, tumor size, surgical approach, and operative time were analyzed as predictive factors of intraoperative hypertensive crises. Forty-eight patients underwent adrenalectomy—four open surgery and 44 laparoscopic surgery—for pheochromocytoma of adrenal glands from 1998 to 2008 after preoperative administration of doxazosin. Perioperative cardiovascular status modifications and surgical medium- and long-term outcomes were analyzed. There was no mortality, conversion rate was 4.5 per cent, and morbidity rate was 8.3 per cent. Intraoperative hypertensive crises (180/ 90 mmHg or higher) were observed in 14.5 per cent (seven of 48) of patients and were treated pharmacologically with no aftermath. None of the examined variables influenced the occurrence of intraoperative hypertensive episodes. Postoperative hypotension (lower than 90/60 mmHg) was observed in four of 48 patients (8.3%) and was treated by crystalloids and hydrocortisone. In the surgical treatment of pheochromocytoma, the preoperative adrenergic blockade by doxazosin does not prevent intraoperative hypertensive crises. Nevertheless, in our series, they were of short duration and were not associated with major cardiovascular complications. Perioperative hemodynamic instability was managed bypreoperative pharmacological treatment, allowing low morbidity.
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Affiliation(s)
- Giovanni Conzo
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Mario Musella
- Department of Surgery, Orthopedics, Trauma and Emergency, University of Naples “Federico II,” Naples, Italy; the
| | - Francesco Corcione
- Department of General and Laparoscopic Surgery, Monaldi Hospital, Naples, Italy; the
| | - Maurizio Depalma
- Department of General and Specialistic Surgery, Cardarelli Hospital, Naples, Italy; the
| | - Francesco Stanzione
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Cristina Della-Pietra
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Antonietta Palazzo
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Salvatore Napolitano
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Daniela Pasquali
- Division of Endocrinology, Second University of Naples, Naples, Italy
| | - Marco Milone
- Department of Surgery, Orthopedics, Trauma and Emergency, University of Naples “Federico II,” Naples, Italy; the
| | | | - Fausto Ferraro
- Anesthesiology and Intensive Care, Second University of Naples, Naples, Italy
| | - Luigi Santini
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
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Mbouché LO, Epoupa Ngallé FG, Sando Z, Choukem SP, Angwafo FF. The case series of functional adrenal tumors: Experience of two tertiary hospitals in Yaoundé, Cameroon. Int J Surg Case Rep 2020; 72:577-583. [PMID: 32698292 PMCID: PMC7327872 DOI: 10.1016/j.ijscr.2020.05.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 11/24/2022] Open
Abstract
This is a case series of functional adrenal tumors and treatment outcomes. A diversity of cases is presented with clinical, medical imaging, macroscopic and microscopic features included. Successful management of two cases of adrenal insufficiency following classic adrenalectomy in a low resource community is reported.
Introduction Adrenal tumors are often found incidentally during abdominal imaging. Functioning adrenal tumors are less frequent than these incidentalomas discovered unexpectedly. We report treatment outcomes (major complications) of 7 cases of symptomatic adrenal masses from 2009 to 2019. Presentation of the cases Seven cases of functioning adrenal tumors: four adenomas presenting with Cushing’s syndrome, two adrenal carcinomas, and one pheochromocytoma are described. The preoperative diagnoses were made through clinical manifestations, an increase in urinary free cortisol with normal ACTH, elevated metanephrine and enlarged masses on CT. The diagnoses were established on histopathology of adrenalectomy specimens. Adrenal insufficiency in two patients following surgery was corrected with corticoid replacement therapy. One patient died of hypovolemia the day of surgery and another from anaphylactic shock (allergy) late in the post-operative period. Discussion Pre, intra and post-operative complications from vascular instability often complicate surgery in functioning adrenal tumors. Adrenal adenomas manifest as Cushing’s syndrome in 10–15 % of patients. They are the most common adrenal tumor although the diagnosis is most often coincidental to abdominal imaging. The incidence of adrenal adenoma increases with age, up to 7 % in the seventh decade. Laparoscopic adrenalectomy, which was not available in our hospitals then, is standard treatment for most tumors. It is alleged to have better outcomes in trained and tested hands. Conclusion Surgery of functioning adrenal tumors demands close collaboration of multiple clinical disciplines to manage vascular instability and adrenal insufficiency, especially in resource strapped communities.
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Affiliation(s)
- L O Mbouché
- Department of Surgery, Yaoundé Gynaeco-Obstetric and Pediatric Hospital, University of Yaoundé I, Cameroon.
| | - F G Epoupa Ngallé
- Department of Surgery, Yaoundé Gynaeco-Obstetric and Pediatric Hospital, University of Yaoundé I, Cameroon
| | - Z Sando
- Department of Pathology, Yaoundé Gynaeco-Obstetric and Pediatric Hospital, University of Yaoundé I, Cameroon
| | - S P Choukem
- Department of Internal Medicine, Douala General Hospital, University of Dschang, Cameroon
| | - F F Angwafo
- Department of Surgery, Yaoundé Gynaeco-Obstetric and Pediatric Hospital, University of Yaoundé I, Cameroon
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Abstract
Pheochromocytomas are rare neuroendocrine chromaffin-derived tumors that arise within the adrenal medulla. They are usually benign, but if not diagnosed or if left untreated, they can have devastating consequences. Clinical consideration of the diagnosis is paramount, as they may have protean manifestations, and a high index of suspicion is essential if serious consequences are to be avoided. An accurate biochemical diagnosis is crucial for the management of these patients: either plasma or urinary metanephrines are both highly sensitive and specific if correctly employed, but knowledge of pre- and post-analytic interference is essential. Diagnostic imaging with cross-sectional CT and/or MRI offers high sensitivity in their detection, but lack specificity. The introduction of PET/CT/MR has led to a dramatic improvement in the localization of both pheochromocytomas and paragangliomas, together with the increasing availability of new functional imaging radionuclides. Optimal investigation and accurate diagnosis is best achieved at 'centers of excellence' with expert multidisciplinary teams.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK; Centre for Endocrinology, Barts and the London School of Medicine, London, EC1M 6BQ, UK; ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK
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28
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Heider EC, Davis BG, Frank EL. Nonparametric Determination of Reference Intervals for Plasma Metanephrine and Normetanephrine. Clin Chem 2020; 50:2381-4. [PMID: 15563487 DOI: 10.1373/clinchem.2004.035089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Emily C Heider
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT 84108, USA
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Cvasciuc IT, Gull S, Oprean R, Lim KH, Eatock F. Changing pattern of pheochromocytoma and paraganglioma in a stable UK population. ACTA ENDOCRINOLOGICA-BUCHAREST 2020; 16:78-85. [PMID: 32685043 DOI: 10.4183/aeb.2020.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Context Pheochromocytomas and paragangliomas (PCC/PGLs) are diagnosed variously with increasing incidence and changing clinical and pathology pattern. Objective The aim was to further characterize PCC/PGLs in a stable population. Methods A retrospective, single institution study analysed adrenalectomies for PCC/PGLs between January 2010 - January 2019. Demographics, symptoms, blood pressure, preoperative hormones, imaging, histology, hospital stay, complications and three subgroups [based on the modality of diagnosis - incidentaloma group (IG), genetic group (GG) and symptomatic group (SG)] were noted. Results 86 patients included IG 51 (59.3%), GG 10 (11.62%) and SG 25 patients (29.06%). Incidence was 5.30 cases/1 million population. 33.34% of the IG had a delayed diagnosis with a mean interval of 22.95 months (4-120 months). Females presented more often with paroxysmal symptoms (PS) (p=0.011). Patients with PS and classic symptoms were younger (p=0.0087, p=0.0004) and those with PS required more inotropes postoperatively (p=0.014). SG had higher preoperative hormone levels (p=0.0048), larger tumors (p=0.0169) and more likely females. GG are younger compared with those from the IG (p=0.0001) or SG (p= 0.178). Conclusion Majority of patients had an incidental and delayed diagnosis. If symptomatic, patients are more likely to be young females with higher hormone levels and larger tumors.
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Affiliation(s)
- I T Cvasciuc
- Royal Victoria Hospital, United Kingdom of Great Britain and Northern Ireland
| | - S Gull
- Royal Victoria Hospital, United Kingdom of Great Britain and Northern Ireland
| | - R Oprean
- Ulster Hospital, Dundonald, Belfast, United Kingdom of Great Britain and Northern Ireland
| | - K H Lim
- Altnagelvin Area Hospital, Londonderry, United Kingdom of Great Britain and Northern Ireland
| | - F Eatock
- Royal Victoria Hospital, United Kingdom of Great Britain and Northern Ireland
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Fang F, Ding L, He Q, Liu M. Preoperative Management of Pheochromocytoma and Paraganglioma. Front Endocrinol (Lausanne) 2020; 11:586795. [PMID: 33117294 PMCID: PMC7551102 DOI: 10.3389/fendo.2020.586795] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/14/2020] [Indexed: 01/10/2023] Open
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, characterized by excessive release of catecholamines (CAs), and manifested as the classic triad of headaches, palpitations, profuse sweating, and a variety of other signs and symptoms. The diagnosis of PPGL requires both evidence of excessive release of CAs and anatomical localization of CA-secreting tumor. Surgery is the mainstay of treatment for all patients with PPGL unless contraindicated. However, without proper preparation, the release of excessive CAs, especially during surgery, can result in lethal cardiovascular complications. Herein, we briefly reviewed the pathogenesis of this disease, discussed the current approaches and evidence available for preoperative management, summarizing the results of the latest studies which compared the efficacies of preoperative management with or without α adrenergic-receptor antagonists, aiming to facilitate better understanding of the preoperative management of PPGL for the physicians.
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31
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Pozza C, Sesti F, Di Dato C, Sbardella E, Pofi R, Schiavi F, Bonifacio V, Isidori AM, Faggiano A, Lenzi A, Giannetta E. A Novel MAX Gene Mutation Variant in a Patient With Multiple and "Composite" Neuroendocrine-Neuroblastic Tumors. Front Endocrinol (Lausanne) 2020; 11:234. [PMID: 32508744 PMCID: PMC7249266 DOI: 10.3389/fendo.2020.00234] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/31/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction: Pheochromocytomas (PCCs), paragangliomas (PGLs), ganglioneuroblastomas (GNBs), and ganglioneuromas (GNs) are neuroendocrine neoplasms (NENs) that were thought to share a common embryologic origin from neural crest cells. However, they rarely occur concurrently and recurrently. We describe the case of a 40-years-old woman with "composite PCC-GN" and multiple NENs and neuroblastic tumors. Case presentation: The patient was first referred to our department at the age of 15 years for paroxysmal hypertension, headache, sweating, and watery diarrhea. Her personal history included the diagnosis of a pelvic GNB with lumbar-aortic lymph node metastases at 11 months. Her family history was positive for cerebral glioblastoma multiforme (father). An abdominal ultrasound showed a right adrenal mass that histologically was a "composite adrenal PCC-GN." The symptoms disappeared after surgery. At the age of 20 years, the symptoms returned: computed tomography (CT) and 131I-metaiodobenzylguanidine (MIBG) scintigraphy showed an inter-aortocaval mass, found histologically to be an inter-aortocaval PGL. Her symptoms reappeared again at 28 years: CT and magnetic resonance imaging revealed four left adrenal gland nodules, found histologically to be multifocal PCCs with some atypia. Genetic screening for VHL, RET, NF1, Tp53, SDHD, SDHB, SDHC, SDHAF2, SDHAF3, SDHA, and TMEM127 was negative. Mutational analysis of the MAX gene revealed the presence of a novel heterozygous variant, c299G>C (p.Arg100Pro, NM_002382.5) that the bioinformatics prediction programs defined as noxious and causative of pathology. Conclusion: This report represents the first description of a co-occurrence of multiple composite PCC-GN and neuroblastic tumors. The long timeline of the presentation of the NENs/neuroblastic tumors from infancy to adulthood requires a lifelong follow-up for this patient. Moreover, the importance of this case lies in the presence of a novel MAX gene variant deleterious, harmful, and causative of pathology, confirmed by Sanger sequencing and never been associated before with multiple composite PCC-GN. The present case underlines the importance of precision medicine and molecular diagnoses for hereditary pheochromocytomas and paragangliomas, suggesting that when they occur in early childhood, it is necessary to perform an extensive genetic investigation and a lifelong follow-up.
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Affiliation(s)
- Carlotta Pozza
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Franz Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Carla Di Dato
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Riccardo Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Schiavi
- Familial Cancer Clinic and Oncoendocrinology, Veneto Institute of Oncology, IRCCS, Padua, Italy
| | - Vincenzo Bonifacio
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M. Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Elisa Giannetta
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- *Correspondence: Elisa Giannetta
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32
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Kumar RM, Violette PD, Tran C, Tomiak E, Izard J, Bathini V, Rowe NE. Canadian Urological Association Best Practice Report: Long-term surveillance following resection of pheochromocytoma. Can Urol Assoc J 2019; 13:372-376. [PMID: 31799918 DOI: 10.5489/cuaj.6254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ravi M Kumar
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Philippe D Violette
- Departments of Health Research Methods Evidence and Impact, and Surgery, McMaster, Hamilton, ON, Canada
| | - Christopher Tran
- Division of Endocrinology and Metabolism, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Eva Tomiak
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Jason Izard
- Department of Urology, Kingston Health Sciences Centre, Queen's University, Kingston, ON Canada
| | - Varun Bathini
- Division of Urology, Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada
| | - Neal E Rowe
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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33
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Abstract
Pheochromocytomas are rare neuroendocrine tumors. Extra-adrenal lesions arising from the autonomic neural ganglia are termed paraganglioma. Clinical symptoms are common between the adrenal and extra-adrenal forms and are determined by excess secretion of catecholamines. Hypertension is a critical and often dramatic feature of pheochromocytoma/paraganglioma, and its most prevalent reported symptom. However, given the rare occurrence of this cancer, in patients undergoing screening for hypertension, the prevalence ranges from 0.1% to 0.6%. Still, patients frequently come to the attention of endocrinologist when pheochromocytoma/paraganglioma is suspected as a secondary cause of hypertension. This article summarizes current clinical approaches in patients with pheochromocytoma/paraganglioma.
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Affiliation(s)
- Sergei G Tevosian
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, 1600 Southwest Archer Road, Suite H-2, Gainesville, FL 32608, USA
| | - Hans K Ghayee
- Department of Medicine, Division of Endocrinology, University of Florida, Malcom Randall VA Medical Center, Gainesville, FL 32610, USA.
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Carbone E, Borges R, Eiden LE, García AG, Hernández‐Cruz A. Chromaffin Cells of the Adrenal Medulla: Physiology, Pharmacology, and Disease. Compr Physiol 2019; 9:1443-1502. [DOI: 10.1002/cphy.c190003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Schreuder N, Koopman D, Jager PL, Kosterink JGW, van Puijenbroek E. Adverse Events of Diagnostic Radiopharmaceuticals: A Systematic Review. Semin Nucl Med 2019; 49:382-410. [PMID: 31470933 DOI: 10.1053/j.semnuclmed.2019.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Diagnostic radiopharmaceuticals used in nuclear medicine can cause adverse events. Information on these adverse events is available in case reports and databases but may not be readily accessible to healthcare professionals. This systematic review provides an overview of adverse events of diagnostical radiopharmaceuticals and their characteristics. A median frequency for adverse events in diagnostical radiopharmaceuticals of 1.63 (interquartile range: 1.09-2.29) per 100,000 is reported. Most common are skin and subcutaneous tissue disorders, and general disorders and administration site conditions. Many adverse events reported are minor in severity, although 6.7% can be classified as important. In rare cases, adverse events are serious and potentially life-threatening. With the introduction of new radiopharmaceuticals and the increasing use of positron emission tomography-computed tomography, previously unknown adverse events may be detected in daily practice. Future work should cover the experience of the patient with adverse events from diagnostic radiopharmaceuticals.
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Affiliation(s)
- Nanno Schreuder
- Groningen Research Institute of Pharmacy, Pharmacotherapy, Epidemiology & Economics, University of Groningen, Groningen, the Netherlands; GE Healthcare Radiopharmacy Zwolle, Zwolle, the Netherlands.
| | - Daniëlle Koopman
- Department of Nuclear Medicine, Isala Hospital, Zwolle, the Netherlands; MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Pieter L Jager
- Department of Nuclear Medicine, Isala Hospital, Zwolle, the Netherlands
| | - Jos G W Kosterink
- Groningen Research Institute of Pharmacy, Pharmacotherapy, Epidemiology & Economics, University of Groningen, Groningen, the Netherlands; Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Eugène van Puijenbroek
- Groningen Research Institute of Pharmacy, Pharmacotherapy, Epidemiology & Economics, University of Groningen, Groningen, the Netherlands; Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, the Netherlands
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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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Abstract
Takotsubo syndrome (TS), also known as neurogenic stunned myocardium or broken heart syndrome, is a recognized acute cardiac syndrome. In about 70% of cases, the syndrome is preceded by an emotional or a physical stressor. Among the innumerable physical trigger factors that may induce TS are pheochromocytomas and paragangliomas (PPGLs). PPGL-associated cardiovascular complications as "myocarditis", "myocardial infarction", "reversible cardiomyopathies", and "transient repolarization electrocardiographic changes" have been described since more than 70 years. During the last two decades, dozens of cases of PPGL-induced TS have been reported. PPGLs display increased catecholamine levels, sometimes massively elevated, which may trigger TS, most likely through hyperactivation of sympathetic nervous system including the cardiac sympathetic nerve terminal disruption with norepinephrine seethe and spillover. PPGL-induced TS is characterized by a dramatic clinical presentation with hemodynamic compromise and high complication rates. The prevalence of global and apical sparing pattern of TS in PPGL-induced TS is significantly higher than in other TS populations. In this report, the associations of PPGL-induced cardiovascular complications are analyzed, and clinical features, complications, outcome and treatment of PPGL-induced TS are reviewed.
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Affiliation(s)
- Shams Y-Hassan
- Coronary Artery Disease Area, Heart and Vascular Theme, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
- Departement of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Manoharan M, Sinha P, Sibtain S. Adrenal disorders in pregnancy, labour and postpartum - an overview. J OBSTET GYNAECOL 2019; 40:749-758. [PMID: 31469031 DOI: 10.1080/01443615.2019.1648395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Adrenal disorders may manifest during pregnancy for the first time, or present from before pregnancy as either undiagnosed or diagnosed and treated. They may present as hormonal hypofunction or hyperfunction, or with mass effects or other non-endocrine effects. Adrenal disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyper-aldosteronism and adreno-cortical carcinoma are rare in pregnancy. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal and renin-angiotensin-aldosterone axis as these undergoe major changes during pregnancy. Diagnosis is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. A timely diagnosis and treatment is critical as these disorders can cause maternal and foetal morbidity and mortality. A high index of suspicion must be maintained as they can go unrecognised and untreated. An early diagnosis and treatment often improves outcomes. The aim of this article is to review the patho-physiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.
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Affiliation(s)
| | - Prabha Sinha
- Department of Obstetrics and Gynaecology, Oman Medical College, Muscat, Oman
| | - Shabnum Sibtain
- Department of Obstetrics and Gynaecology, Azra Naheed Medical College, Lahore, Pakistan
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39
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Shen Y, Luo X, Li H, Guan Q, Cheng L. A simple and robust liquid chromatography tandem mass spectrometry assay for determination of plasma free metanephrines and its application to routine clinical testing for diagnosis of pheochromocytoma. Biomed Chromatogr 2019; 33:e4622. [PMID: 31215053 DOI: 10.1002/bmc.4622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/30/2019] [Accepted: 06/06/2019] [Indexed: 11/07/2022]
Abstract
Plasma free metanephrines (PFMs) have high sensitivity for detecting pheochromocytoma (PCC). Herein, we developed a simple and reliable liquid chromatography tandem mass spectrometry assay for PFMs determination in Chinese population. PFMs were enriched by SPE without requiring extract evaporation or the use of buffers containing nonvolatile salts. The analytes were analyzed in multiple reaction monitoring mode. Inter- and intra-assay precisions were ≤4.3% and ≤ 6.3%. The lower limits of quantification were 0.07 nmol/L for metanephrine and 0.06 nmol/L for normetanephrine. Recoveries of PFMs were in the range of 89.3-113%. The method was free from significant matrix effect, carryover and interference. Owing to its fast analysis time, more than 150 samples/day could be easily performed by a single operator. With the established reference intervals of PFMs in the Chinese population, this simple and robust LC-MS/MS method could be valuable for use in routine clinical laboratories. It is noted that the combined tests of PFMs with urinary catecholamines or urinary vanillylmandelic acid could improve specificity.
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Affiliation(s)
- Ying Shen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Luo
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huijun Li
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Guan
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liming Cheng
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Levin G, Elchalal U, Rottenstreich A. The adrenal cortex: Physiology and diseases in human pregnancy. Eur J Obstet Gynecol Reprod Biol 2019; 240:139-143. [PMID: 31284087 DOI: 10.1016/j.ejogrb.2019.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/18/2019] [Accepted: 06/28/2019] [Indexed: 11/28/2022]
Abstract
Pregnancy is characterized by marked alterations in the hypothalamic-pituitary-adrenal axis and in the function of the adrenal gland. Some of those alterations have clinical characteristics that are similar to those of adrenal gland disorders. While adrenal disorders are rare among pregnant women, they harbor the potential for significant morbidity if they remain unrecognized and untreated. As the majority of patients with adrenal disorders present with clinical features that are typical of normal pregnancy - diagnosis during pregnancy is not uncommonly delayed. A high index of suspicion must be practiced for these disorders as they might carry severe obstetrical negative outcomes. In this review we will survey the normal function of adrenal glands in pregnancy and the role of adrenal hormones in pregnancy. We will outline the adrenal disorders that commonly present during pregnancy and review the literature on treatment modalities.
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Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel.
| | - Uriel Elchalal
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel
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Agarwal G, Rajan S, Valiveru RC, Tulsyan S, Agrawal V, Mittal B, Zaidi G, Mayilvaganan S, Mishra A, Agarwal A, Mishra SK, Bhatia E. Genetic Profile of Indian Pheochromocytoma and Paraganglioma Patients - A Single Institutional Study. Indian J Endocrinol Metab 2019; 23:486-490. [PMID: 31741911 PMCID: PMC6844179 DOI: 10.4103/ijem.ijem_163_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND AIMS Pheochromocytomas (PCCs) and Paragangliomas (PGL) are rare catecholamine producing tumors that may present in sporadic or familial settings. Despite vast strides in understanding of PCC/PGL genetics in the last two decades, there is a dearth of information from India. The aim here is to study the prevalence of genetic mutations in Indian PCC/PGL patients. SETTINGS AND DESIGN Tertiary care academic hospital; prospective study. METHODS 50 histopathologically diagnosed PCC/PGL patients formed the study group. Clinical, biochemical, pathological attributes and outcomes were documented and the phenotype was compared to the genotype. Succinyl dehydrogenase (SDH), Re-Arranged during Transfection (RET), Von-Hippel-Lindau (VHL) and NeuroFibromatosis-1 (NF1) mutations were studied. Additionally, immunohistochemisty for SDHB was also done, and the results compared to mutational analysis of SDH by MLPA (Multiplex Ligation-dependent Probe Activation). STATISTICAL ANALYSIS Independent samples t-test and Fisher's exact test were used as appropriate. P values ≤0.05 were considered statistically significant. RESULTS The mean age was 34.3 years. Of the 50 patients, 27 were males and 23 females. 10 patients (20%) in all were detected to have a genetic mutation. 6 patients possessed a RET mutation, while two had VHL mutations. No patient presented with a NF1 mutation. 2 patients had a SDH mutation, and Immunohistochemistry for SDHB correlated with mutational analysis for these patients. CONCLUSIONS The proportion of patients with a familial variant of PCC/PGL is more than what the historic "Rule of Ten" suggests. Our study found that one in five patients have a genetic mutation. PCC/PGL patients with genetic mutations not only require more stringent follow-up, but also screening of family members.
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Affiliation(s)
- Gaurav Agarwal
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sendhil Rajan
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
- Department of Surgery, St. John's Medical College, Bengaluru, Karnataka, India
| | - Ramya C. Valiveru
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sonam Tulsyan
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vinita Agrawal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Balraj Mittal
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ghazala Zaidi
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sabaretnam Mayilvaganan
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anjali Mishra
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amit Agarwal
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Saroj Kanta Mishra
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Eesh Bhatia
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Nieto AJ, Trochez L, Ramírez D, Arguello P, Guzman G, Pachajoa H, Escobar Vidarte MF. Paraganglioma in pregnancy: interdisciplinary management during pregnancy. Gynecol Endocrinol 2019; 35:567-570. [PMID: 30786782 DOI: 10.1080/09513590.2019.1576619] [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] [Indexed: 10/27/2022] Open
Abstract
Paragangliomas are tumors that originate from the extra-adrenal neural crest, the incidence of which during pregnancy is not more than two to eight cases per million people per year and are known to be highly morbid. The purpose of this report is to describe the experience and results obtained during management of a primigravida diagnosed with paraganglioma on week 21.2 and received both medical and surgical management with good maternal and perinatal outcomes. This case report evidences the importance of practicing interdisciplinary management of patients with clinical suspicion of paragangliomas or pheochromocytomas during pregnancy at high-complexity centers even in a medium-income country.
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Affiliation(s)
- Albaro J Nieto
- a High Complexity Obstetric Unit, Department of Gynecology and Obstetrics , Fundación Valle del Lili , Santiago de Cali , Colombia
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
| | - Lizette Trochez
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
| | - Daniela Ramírez
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
| | - Pedro Arguello
- c Department of Surgery , Fundación Valle del Lili , Santiago de Cali , Colombia
| | - Guillermo Guzman
- d Department of Endocrinology , Fundación Valle del Lili , Santiago de Cali , Colombia
| | - Harry Pachajoa
- e Department of Genetics , Fundación Valle del Lili , Santiago de Cali , Colombia
| | - María Fernanda Escobar Vidarte
- a High Complexity Obstetric Unit, Department of Gynecology and Obstetrics , Fundación Valle del Lili , Santiago de Cali , Colombia
- b Department of Health Sciences, Faculty of Medicine , ICESI University , Santiago de Cali , Colombia
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Angelousi A, Peppa M, Chrisoulidou A, Alexandraki K, Berthon A, Faucz FR, Kassi E, Kaltsas G. Malignant Pheochromocytomas/Paragangliomas and Ectopic Hormonal Secretion: A Case Series and Review of the Literature. Cancers (Basel) 2019; 11:E724. [PMID: 31137729 PMCID: PMC6563134 DOI: 10.3390/cancers11050724] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/02/2019] [Accepted: 05/17/2019] [Indexed: 12/16/2022] Open
Abstract
Malignant pheochromocytomas (PCs) and paragangliomas (PGLs) are rare neuroendocrine neoplasms defined by the presence of distant metastases. There is currently a relatively paucity of data regarding the natural history of PCs/PGLs and the optimal approach to their treatment. We retrospectively analyzed the clinical, biochemical, imaging, genetic and histopathological characteristics of fourteen patients with metastatic PCs/PGLs diagnosed over 15 years, along with their response to treatment. Patients were followed-up for a median of six years (range: 1-14 years). Six patients had synchronous metastases and the remaining developed metastases after a median of four years (range 2-10 years). Genetic analysis of seven patients revealed that three harbored succinate dehydrogenase subunit B/D gene (SDHB/D) mutations. Hormonal hypersecretion occurred in 70% of patients; normetanephrine, either alone or with other concomitant hormones, was the most frequent secretory component. Patients were administered multiple first and subsequent treatments including surgery (n = 12), chemotherapy (n = 7), radionuclide therapy (n = 2) and radiopeptides (n = 5). Seven patients had stable disease, four had progressive disease and three died. Ectopic hormonal secretion is rare and commonly encountered in benign PCs. Ectopic secretion of interleukin-6 in one of our patients, prompted a literature review of ectopic hormonal secretion, particularly from metastatic PCs/PGLs. Only four cases of metastatic PC/PGLs with confirmed ectopic secretion of hormones or peptides have been described so far.
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Affiliation(s)
- Anna Angelousi
- Department of Internal Medicine, Unit of Endocrinology, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Greece.
| | - Melpomeni Peppa
- Endocrine Unit, 2nd Department of Internal Medicine Propaedeutic, Research Institute and Diabetes Center, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Haidari, Greece.
| | - Alexandra Chrisoulidou
- Unit of Endocrinology, Theagenio Cancer Hospital, 2 Al Simeonidi Str., 54007 Thessaloniki, Greece.
| | - Krystallenia Alexandraki
- st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Athens, Greece.
| | - Annabel Berthon
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Fabio Rueda Faucz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Eva Kassi
- Department of Internal Medicine, Unit of Endocrinology, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Greece.
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 11527 Goudi, Athens, Greece.
| | - Gregory Kaltsas
- st Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens, Laiko hospital, 11527 Goudi, Athens, Greece.
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Bisogni V, Petramala L, Oliviero G, Bonvicini M, Mezzadri M, Olmati F, Concistrè A, Saracino V, Celi M, Tonnarini G, Iannucci G, De Toma G, Ciardi A, La Torre G, Letizia C. Analysis of Short-term Blood Pressure Variability in Pheochromocytoma/Paraganglioma Patients. Cancers (Basel) 2019; 11:E658. [PMID: 31083609 PMCID: PMC6562701 DOI: 10.3390/cancers11050658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/06/2019] [Accepted: 05/10/2019] [Indexed: 12/24/2022] Open
Abstract
Data on short-term blood pressure variability (BPV), which is a well-established cardiovascular prognostic tool, in pheochromocytoma and paraganglioma (PPGL) patients is still lack and conflicting. We retrospectively evaluated 23 PPGL patients referred to our unit from 2010 to 2019 to analyze 24 h ambulatory blood pressure monitoring (24-h ABPM)-derived markers of short-term BPV, before and after surgical treatment. PPGL diagnosis was assessed according to guidelines and confirmed by histologic examination. The 24-h ABPM-derived markers of short-term BPV included: circadian pressure rhythm; standard deviation (SD) and weighted SD (wSD) of 24-h, daytime, and night-time systolic and diastolic blood pressure (BP); average real variability (ARV) of 24-h, daytime, and night-time systolic and diastolic BP. 7 males and 16 females of 53 ± 18 years old were evaluated. After surgical resection of PPGL we found a significant decrease in 24-h systolic BP ARV (8.8 ± 1.6 vs. 7.6 ± 1.3 mmHg, p < 0.001), in 24-h diastolic BP ARV (7.5 ± 1.6 vs. 6.9 ± 1.4 mmHg, p = 0.031), and in wSD of 24-h diastolic BP (9.7 ± 2.0 vs 8.8 ± 2.1 mmHg, p = 0.050) comparing to baseline measurements. Moreover, baseline 24-h urinary metanephrines significantly correlated with wSD of both 24-h systolic and diastolic BP. Our study highlights as PPGL patients, after proper treatment, show a significant decrease in some short-term BPV markers, which might represent a further cardiovascular risk factor.
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Affiliation(s)
- Valeria Bisogni
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Luigi Petramala
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Gaia Oliviero
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Maria Bonvicini
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Martina Mezzadri
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Federica Olmati
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Antonio Concistrè
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Vincenza Saracino
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Monia Celi
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Gianfranco Tonnarini
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Gino Iannucci
- Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Giorgio De Toma
- "Pietro Valdoni" Surgery Department, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Antonio Ciardi
- Department of Radiological, Oncological and Anatomy-Pathological Sciences, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Giuseppe La Torre
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
| | - Claudio Letizia
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Viale del Policlinico 155, 00165 Rome, Italy.
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Liu XP, Miao Q, Liu XR, Zhang CJ, Ma GT, Liu JZ. Outcomes of surgery for functional cardiac paragangliomas: A single-center experience of 17 patients. J Thorac Cardiovasc Surg 2019; 157:1556-1564. [DOI: 10.1016/j.jtcvs.2018.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 11/26/2022]
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Prakash P, Ramachandran R, Tandon N, Kumar R. Changes in blood pressure, blood sugar, and quality of life in patients undergoing pheochromocytoma surgery: a prospective cohort study. INDIAN JOURNAL OF UROLOGY : IJU : JOURNAL OF THE UROLOGICAL SOCIETY OF INDIA 2019; 35:34-40. [PMID: 30692722 PMCID: PMC6334590 DOI: 10.4103/iju.iju_190_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Pheochromocytoma surgery is associated with significant hemodynamic and metabolic changes that require post-operative monitoring. We prospectively evaluated the trends of blood pressure, blood sugar, body mass index (BMI), and quality of life (QoL) changes in a cohort of patients undergoing pheochromocytoma surgery to determine the minimum duration of monitoring and assess factors that could predict these changes. Materials and Methods: Consecutive patients undergoing surgery for pheochromocytoma over a 20-month period were included in this ethics review board-approved, prospective cohort study. Blood pressure and sugar levels were serially monitored using a fixed protocol in the perioperative period and subsequently at 3 months after surgery. BMI and QoL (using World Health Organization Quality of Life [WHOQOL-BREF] questionnaire) were recorded at baseline and 3 months. Changes were compared and assessed for the predictive factors. Results: Twenty-six patients undergoing 31 procedures were included in the study of whom 8 (30%) developed hypotension and 4 (15%) developed hypoglycemia after surgery. All hypotension episodes occurred within 6 hours of surgery. However, while 3 of the 4 patients who developed hypoglycemia manifest in the first 4 h after surgery, one occurred after 12 h. Occurrence of hypotension correlated with preoperative 24-h urinary vanillylmandelic acid (VMA) levels (P = 0.02) and the total daily dose of prazosin (P = 0.04). Out of 21 hypertensive patients, 7 (33%) had persistent hypertension (HTN) at 3 months and this was associated with age (P = 0.04) and diabetes mellitus (DM) at presentation (P = 0.04). Among six diabetic patients, 1 (16%) had persistent DM. There was significant increase in the BMI (P < 0.0001) and in WHOQOL-BREF scores postoperatively. Conclusions: Hypotension occurs in 30% patients and hypoglycemia in 15% after pheochromocytoma surgery. Hypotension occurs immediately but hypoglycemia may manifest upto 12h after surgery. Older, diabetic patients are more likely to have persistent HTN. Surgery results in increase in BMI and improvement in QoL.
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Affiliation(s)
- Pradeep Prakash
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
| | - Rashmi Ramachandran
- Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeev Kumar
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India
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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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Suh YJ, Park JH, Bilegsaikhan SE, Lee DJ. Transcriptome Analysis Reveals Significant Differences in Gene Expression of Malignant Pheochromocytoma or Paraganglioma. Int J Endocrinol 2019; 2019:7014240. [PMID: 31205467 PMCID: PMC6530119 DOI: 10.1155/2019/7014240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/13/2019] [Accepted: 04/18/2019] [Indexed: 12/18/2022] Open
Abstract
Prediction of malignant behavior of pheochromocytoma (PC) or paraganglioma (PG) is of limited value. The Cancer Genome Atlas (TCGA) and the French 'Cortico et Médullosurrénale: les Tumeurs Endocrines' (COMETE) network in Paris (France) facilitate accurate differentiation of malignant PC/PG based on genetic information. Therefore, the objective of this transcriptome analysis is to identify the prognostic genes underlying the differentiation of malignant PC/PG in the TCGA and COMETE databases. TCGA carries data pertaining to multigenomic analysis of 173 PC/PG surgical resection samples while the COMETE cohort contains data involving 188 PC/PG surgical resection samples. Clinical information and mRNA expression datasets were downloaded from TCGA and COMETE databases. Based on eligibility criteria, 58 of 173 PC/PG samples in TCGA and 171 of 188 PC/PG samples collected by the COMETE network were selected. Using Ingenuity Pathway Analysis, the mRNA expression of malignant and benign PC/PG was compared. The 58 samples in TCGA included 11 malignant and 47 benign cases. Among the 171 samples obtained from the COMETE cohort, 19 were malignant and 152 were benign. A comparative analysis of the mRNA expression data of the two databases revealed that 11 up/downregulated pathways involved in malignant PC/PG were related to cancer signaling, metabolic alteration, and prominent mitosis, whereas 6 upregulated genes and 1 downregulated gene were significantly enriched in the functional annotation pathways. The TCGA and COMETE databases showed differences in mRNA expression associated with malignant and benign PC/PG. Improved recognition of prognostic genes facilitates the diagnosis and treatment of PC/PG.
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Affiliation(s)
- Yong Joon Suh
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Jung Ho Park
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Sanchir-Erdene Bilegsaikhan
- Department of Breast and Endocrine Surgery, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea
| | - Dong Jin Lee
- Department of Otolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul 07441, Republic of Korea
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Parmar K, Chandna A, Kumar S. Retroperitoneal paraganglioma: a chameleon masquerading as an adrenal pheochromocytoma. Ann R Coll Surg Engl 2018; 101:e62-e65. [PMID: 30371110 DOI: 10.1308/rcsann.2018.0193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Retroperitoneal paragangliomas are rare tumours arising from neural crest cells located near or in the autonomic nervous system; right from the skull bass to the pelvic floor. Often called the great masqueraders, their diagnosis and treatment is often difficult and fraught with danger, considering the close proximity of these tumours to important retroperitoneal organs. A 29-year-old woman presented to the outpatient department with complaints of paroxysms of headache, sweating and palpitations for one year. She was found to have elevated urinary metadrenalines (metanephrines) and a suprarenal mass on contrast-enhanced computed tomography of the abdomen, which demonstrated increased tracer activity on I-131 iodine-123 meta-iodobenzylguanidine scintigraphy. Adrenal pheochromocytoma was diagnosed and she underwent laparoscopic adrenalectomy after stabilisation of her blood pressure. Laparoscopy revealed a large suprarenal mass with dense adhesions to the inferior vena cava that was carefully separated from the vein and surrounding structures. The cut section revealed a heterogeneous mass encasing a normal adrenal gland and histopathology confirmed the same, confirming the final diagnosis of retroperitoneal paraganglioma.
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Affiliation(s)
- K Parmar
- Post Graduate Institute of Medical Education and Research, Advanced Urology Centre Nehru Hospital, Pgimer , Chandigarh , India
| | - A Chandna
- Post Graduate Institute of Medical Education and Research, Advanced Urology Centre Nehru Hospital, Pgimer , Chandigarh , India
| | - S Kumar
- Post Graduate Institute of Medical Education and Research, Advanced Urology Centre Nehru Hospital, Pgimer , Chandigarh , India
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Babinska A, Kaszubowski M, Sworczak K. Adipokine and cytokine levels in non-functioning adrenal incidentalomas (NFAI). Endocr J 2018; 65:849-858. [PMID: 29877205 DOI: 10.1507/endocrj.ej18-0066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Due to the fact that overweight or obesity is accompanied by hormonally active adrenal tumors: Cushing Syndrome-(CS) and Subclinical Cushing Syndrome (SCS), it is of high interest the correlation between different adipokines and cytokines secreted by adipose tissue, with metabolic disorders and hormonal activity in this group. Even in non-functioning adrenal incidentalomas (NFAI) elevated risk for cardiovascular disease and metabolic syndrome was demonstrated. The aim of the study was to investigate plasma adiponectin, leptin, resistin, tumor necrosis factor α (TNFα), interleukin 6 (IL6) and monocyte chemoattractant protein 1 (MCP1) levels in patients with NFAIs and healthy subjects. The study included 18 NFAI patients and 18 healthy subjects. The groups were homogeneous in terms of age, sex and body mass index (BMI). Patients with NFAI showed significantly higher circulating levels of pro-inflammatory cytokines compared to healthy controls (MCP 1: p < 0.001; TNFα p = 0.021; IL6 p = 0.012). On the other hand, adiponectin concentration was significantly lower in the NFAI group (p = 0.034). The serum leptin and resistin concentrations did not differ significantly between the two groups. Acquired results were not dependent on glucocorticoid and catecholamine secretion in NFAI patients. Also, there were no clear correlations between BMI and cytokine levels. It is possible that increased risk for cardiovascular and metabolic diseases reported in NFAI patients is at least partially dependent on adipose tissue activity.
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Affiliation(s)
- Anna Babinska
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Mariusz Kaszubowski
- Institute of Statistics, Department of Economic Sciences, Faculty of Management and Economics, Gdansk University of Technology, Gdansk, Poland
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
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