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Karazisi C, Dellborg M, Mellgren K, Giang KW, Skoglund K, Eriksson P, Mandalenakis Z. Outcomes after cancer diagnosis in children and adult patients with congenital heart disease in Sweden: a registry-based cohort study. BMJ Open 2024; 14:e083237. [PMID: 38631823 PMCID: PMC11029300 DOI: 10.1136/bmjopen-2023-083237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE Patients with congenital heart disease (CHD) have an increased cancer risk. The aim of this study was to determine cancer-related mortality in CHD patients compared with non-CHD controls, compare ages at cancer diagnosis and death, and explore the most fatal cancer diagnoses. DESIGN Registry-based cohort study. SETTING AND PARTICIPANTS CHD patients born between 1970 and 2017 were identified using Swedish Health Registers. Each was matched by birth year and sex with 10 non-CHD controls. Included were those born in Sweden with a cancer diagnosis. RESULTS Cancer developed in 758 out of 67814 CHD patients (1.1%), with 139 deaths (18.3%)-of which 41 deaths occurred in patients with genetic syndromes. Cancer was the cause of death in 71.9% of cases. Across all CHD patients, cancer accounted for 1.8% of deaths. Excluding patients with genetic syndromes and transplant recipients, mortality risk between CHD patients with cancer and controls showed no significant difference (adjusted HR 1.17; 95% CI 0.93 to 1.49). CHD patients had a lower median age at cancer diagnosis-13.0 years (IQR 2.9-30.0) in CHD versus 24.6 years (IQR 8.6-35.1) in controls. Median age at death was 15.1 years (IQR 3.6-30.7) in CHD patients versus 18.5 years (IQR 6.1-32.7) in controls. The top three fatal cancer diagnoses were ill-defined, secondary and unspecified, eye and central nervous system tumours and haematological malignancies. CONCLUSIONS Cancer-related deaths constituted 1.8% of all mortalities across all CHD patients. Among CHD patients with cancer, 18.3% died, with cancer being the cause in 71.9% of cases. Although CHD patients have an increased cancer risk, their mortality risk post-diagnosis does not significantly differ from non-CHD patients after adjustements and exclusion of patients with genetic syndromes and transplant recipients. However, CHD patients with genetic syndromes and concurrent cancer appear to be a vulnerable group.
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Affiliation(s)
- Christina Karazisi
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
- Adult Congenital Heart Disease Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Mellgren
- Department of Pediatric Oncology, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Kok Wai Giang
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Kristofer Skoglund
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
| | - Peter Eriksson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
- Adult Congenital Heart Disease Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Zacharias Mandalenakis
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
- Adult Congenital Heart Disease Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
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White G, Nonaka D, Chung TT, Oakey RJ, Izatt L. Somatic EPAS1 Variants in Pheochromocytoma and Paraganglioma in Patients With Sickle Cell Disease. J Clin Endocrinol Metab 2023; 108:3302-3310. [PMID: 37285480 PMCID: PMC10655516 DOI: 10.1210/clinem/dgad311] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/09/2023] [Accepted: 05/26/2023] [Indexed: 06/09/2023]
Abstract
CONTEXT Somatic EPAS1 variants account for 5% to 8% of all pheochromocytoma and paragangliomas (PPGL) but are detected in over 90% of PPGL in patients with congenital cyanotic heart disease, where hypoxemia may select for EPAS1 gain-of-function variants. Sickle cell disease (SCD) is an inherited hemoglobinopathy associated with chronic hypoxia and there are isolated reports of PPGL in patients with SCD, but a genetic link between the conditions has yet to be established. OBJECTIVE To determine the phenotype and EPAS1 variant status of patients with PPGL and SCD. METHODS Records of 128 patients with PPGL under follow-up at our center from January 2017 to December 2022 were screened for SCD diagnosis. For identified patients, clinical data and biological specimens were obtained, including tumor, adjacent non-tumor tissue and peripheral blood. Sanger sequencing of exons 9 and 12 of EPAS1, followed by amplicon next-generation sequencing of identified variants was performed on all samples. RESULTS Four patients with both PPGL and SCD were identified. Median age at PPGL diagnosis was 28 years. Three tumors were abdominal paragangliomas and 1 was a pheochromocytoma. No germline pathogenic variants in PPGL-susceptibility genes were identified in the cohort. Genetic testing of tumor tissue detected unique EPAS1 variants in all 4 patients. Variants were not detected in the germline, and 1 variant was detected in lymph node tissue of a patient with metastatic disease. CONCLUSION We propose that somatic EPAS1 variants may be acquired through exposure to chronic hypoxia in SCD and drive PPGL development. Future work is needed to further characterize this association.
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Affiliation(s)
- Gemma White
- Department of Medical and Molecular Genetics, King's College London, London, SE1 9RT, UK
- Department of Clinical Genetics, Guy's and St Thomas’ NHS Foundation Trust, London, SE1 9RT, UK
| | - Daisuke Nonaka
- Department of Pathology, Guy's and St Thomas’ NHS Foundation Trust, London, SE1 7EH, UK
- Department of Cellular Pathology, King's College London, London, SE1 1UL, UK
| | - Teng-Teng Chung
- Department of Endocrinology, University College London Hospital NHS Foundation Trust, London, NW1 2BU, UK
| | - Rebecca J Oakey
- Department of Medical and Molecular Genetics, King's College London, London, SE1 9RT, UK
| | - Louise Izatt
- Department of Medical and Molecular Genetics, King's College London, London, SE1 9RT, UK
- Department of Clinical Genetics, Guy's and St Thomas’ NHS Foundation Trust, London, SE1 9RT, UK
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Jones RB, Cohen DL. Congenital Cyanotic Heart Disease and the Association with Pheochromocytomas and Paragangliomas. Curr Cardiol Rep 2023; 25:1451-1460. [PMID: 37847359 DOI: 10.1007/s11886-023-01974-8] [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] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE OF REVIEW Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors that commonly produce excess catecholamines causing significant morbidity and mortality. Patients with cyanotic congenital heart disease (CCHD) develop PPGLs at a higher frequency than the general population. This review will summarize recent research in the association of PPGL and CCHD. RECENT FINDINGS Advances in molecular genetics have provided new insights into a variety of germline mutations and somatic mutations related to PPGLs. In the CCHD population, mutations can occur in the hypoxia signaling pathway with gain-of-function somatic mutations in EPAS1, which prevent degradation of hypoxia-inducible factor-2 alpha. These mutations are implicated in oncogenesis. PPGLs associated with CCHD develop as early as age 15 years and have predominantly noradrenergic secretion. Surgical removal is considered the first line of therapy, although belzutifan, a HIF-2α inhibitor, is currently being tested as a potential therapy. Early screening with plasma metanephrines may assist in identifying PPGLs in patients with CCHD.
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Affiliation(s)
- Robert Benson Jones
- Division of Endocrinology, Diabetes, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Debbie L Cohen
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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McConnell MM, Kanin MR, Auerbach MS, Yu R. Clinical Progression of a Paraganglioma Over Many Years in a Man With Congenital Heart Disease. AACE Clin Case Rep 2023; 9:193-196. [PMID: 38045797 PMCID: PMC10690415 DOI: 10.1016/j.aace.2023.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 12/05/2023] Open
Abstract
Background Documented symptomatic progression of a paraganglioma (PGL) over many years is unusual. Our objective is to report a young man with such an occurrence. Case Report A 27-year-old male presented with headache, sweating, and palpitation. He had a history of cyanotic congenital heart disease. Five years before presentation, he had 24-hour urine metanephrines 43 mcg/d (25-222), vanillylmandelic acid 3 mg/d (<6), and homovanillic acid 2.4 mg/d (1.6-7.5) levels and a 3.13 cm mass in the upper aortocaval space. Subsequent imaging showed slow growth of the mass. On admission, his blood pressure was 197/134 mm Hg, heart rate was 163 beats per minute, respiratory rate was 25 per minute, and oxygen saturation was 76% on room air. His 24-hour urine normetanephrine level was 2644 mcg/d (81-667) while metanephrine was 405 mcg/d (55-320). Plasma free metanephrine level was 0.92 nmol/L (0-0.49) and normetanephrine was 11.85 nmol/L (0-0.89). DOTATATE positron emission tomography-computed tomography revealed a 4.3 × 3.1 × 4.9 cm mass with activity in the right upper aortocaval space. He was treated with Prazosin. Two months later, he underwent resection of the mass. Pathology diagnosed a 4.9 cm PGL. He had improvement in metanephrine levels. Discussion PGL is diagnosed by documenting excess catecholamines and identifying a lesion on imaging. False negative laboratory testing is rare but can occur. Patients with cyanotic congenital heart disease have a greater risk of developing PGL. Conclusion It is crucial to evaluate a patient for PGL if clinical conditions suggest catecholamine excess, especially if a retroperitoneal tumor has grown or the patient has risk factors.
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Affiliation(s)
- Megan M. McConnell
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Maralee R. Kanin
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Martin S. Auerbach
- Department of Nuclear Medicine and Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Run Yu
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Kadoya T, Fujino M, Nakamura K, Sasaki T, Kawasaki Y, Yoshida Y, Suzuki T, Kanamoto N, Ehara E, Murakami Y. Successful perioperative management of pheochromocytoma in a patient with Fontan circulation. J Cardiol Cases 2023; 28:75-78. [PMID: 37521575 PMCID: PMC10382968 DOI: 10.1016/j.jccase.2023.04.015] [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: 12/10/2022] [Revised: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 08/01/2023] Open
Abstract
Pheochromocytoma (PCC) can adversely affect Fontan circulation. However, there are few reports on its perioperative management before and after PCC resection in Fontan patients. A 24-year-old female patient with congenitally corrected transposition of the great arteries, ventricular septal defect, and pulmonary atresia who had undergone Fontan palliation developed heart failure caused by PCC. The patient was pre-conditioned for PCC resection with heart failure treatment, alpha-blocker titration, and careful infusion, and had a good intraoperative and postoperative course with no complications. Postoperative catheter data showed improvements in systemic vascular resistance, cardiac output, and central venous pressure compared with preoperative data. There is no established preconditioning method for PCC resection in patients with Fontan circulation. Careful perioperative management based on an understanding of the features of the Fontan circulation can lead to better outcomes. Learning objective Pheochromocytoma (PCC) can occur in patients with Fontan circulation. Preoperative management and the PCC itself can adversely affect Fontan circulation, highlighting the importance of suspecting PCCs in Fontan patients based on symptoms such as heart failure, worsening arrhythmias, and headache, and emphasizing careful perioperative management.
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Affiliation(s)
- Takumi Kadoya
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Mitsuhiro Fujino
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Kae Nakamura
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Takeshi Sasaki
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yuki Kawasaki
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yoko Yoshida
- Department of Pediatric Electrophysiology, Osaka City General Hospital, Osaka, Japan
| | - Tsugutoshi Suzuki
- Department of Pediatric Electrophysiology, Osaka City General Hospital, Osaka, Japan
| | - Naotetsu Kanamoto
- Department of Endocrinology, Osaka City General Hospital, Osaka, Japan
| | - Eiji Ehara
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yosuke Murakami
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
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Tanaka Y, Sumie M, Hashimoto T, Osawa S, Karashima Y, Kandabashi T, Yamaura K. Anesthetic management of pheochromocytoma and paraganglioma for patients with Fontan circulation: a case series. JA Clin Rep 2023; 9:13. [PMID: 36897467 PMCID: PMC10006357 DOI: 10.1186/s40981-023-00605-z] [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: 02/17/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Anesthetic management of pheochromocytoma and paraganglioma with Fontan circulation is challenging for physicians, with attention to cardiovascular physiology. CASE PRESENTATION We performed anesthetic management for pheochromocytoma and paraganglioma in three patients with Fontan circulation. We maintained intraoperative central venous pressure at preoperative level under fluid infusion and administrating nitric oxide to decrease pulmonary arterial resistance. We administered noradrenaline or vasopressin if low blood pressure was present despite adequate central venous pressure. Although noradrenaline is prevalent for the case of noradrenaline-secreting tumor especially after resection, we could maintain blood pressure to administrate vasopressin without increasing central venous pressure. Retroperitoneal laparoscopic approach which could avoid intra-abdominal adhesions might be selectable as case 3. CONCLUSIONS Sophisticated management is required for pheochromocytoma and paraganglioma with Fontan circulation.
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Affiliation(s)
- Yuto Tanaka
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.,Department of Anesthesia, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin, Chuo-Ku, Fukuoka, 810-0001, Japan
| | - Makoto Sumie
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan. .,Department of Anesthesia, St. Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka, 830-8543, Japan.
| | - Takuma Hashimoto
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Sayaka Osawa
- Department of Critical Care, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yuji Karashima
- Operating Rooms, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tadashi Kandabashi
- Medical Information Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Toledo RA, Jimenez C, Armaiz-Pena G, Arenillas C, Capdevila J, Dahia PLM. Hypoxia-Inducible Factor 2 Alpha (HIF2α) Inhibitors: Targeting Genetically Driven Tumor Hypoxia. Endocr Rev 2023; 44:312-322. [PMID: 36301191 DOI: 10.1210/endrev/bnac025] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/01/2022] [Indexed: 11/19/2022]
Abstract
Tumors driven by deficiency of the VHL gene product, which is involved in degradation of the hypoxia-inducible factor subunit 2 alpha (HIF2α), are natural candidates for targeted inhibition of this pathway. Belzutifan, a highly specific and well-tolerated HIF2α inhibitor, recently received FDA approval for the treatment of nonmetastatic renal cell carcinomas, pancreatic neuroendocrine tumors, and central nervous system hemangioblastomas from patients with von Hippel-Lindau disease, who carry VHL germline mutations. Such approval is a milestone in oncology; however, the full potential, and limitations, of HIF2α inhibition in the clinic are just starting to be explored. Here we briefly recapitulate the molecular rationale for HIF2α blockade in tumors and review available preclinical and clinical data, elaborating on mutations that might be particularly sensitive to this approach. We also outline some emerging mechanisms of intrinsic and acquired resistance to HIF2α inhibitors, including acquired mutations of the gatekeeper pocket of HIF2α and its interacting partner ARNT. Lastly, we propose that the high efficacy of belzutifan observed in tumors with genetically driven hypoxia caused by VHL mutations suggests that a focus on other mutations that similarly lead to HIF2α stabilization, such as those occurring in neuroendocrine tumors with disruptions in the tricarboxylic acid cycle (SDHA/B/C/D, FH, MDH2, IDH2), HIF hydroxylases (EGLN/PHDs), and the HIF2α-encoding gene, EPAS1, are warranted.
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Affiliation(s)
- Rodrigo A Toledo
- Gastrointestinal and Endocrine Tumors Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Institute of Health Carlos III (ISCIII), 28029 Madrid, Spain
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Gustavo Armaiz-Pena
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA
| | - Carlota Arenillas
- Gastrointestinal and Endocrine Tumors Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Institute of Health Carlos III (ISCIII), 28029 Madrid, Spain
| | - Jaume Capdevila
- Gastrointestinal and Endocrine Tumors Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Medical Oncology Department, Gastrointestinal and Endocrine Tumor Unit, Vall d'Hebron University Hospital, Vall Hebron Institute of Oncology (VHIO), IOB Quiron-Teknon, 08035 Barcelona, Spain
| | - Patricia L M Dahia
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX 78229, USA
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Dubrofsky L, Harvey PJ. Hypertension and an Incidental Neck Mass in a 20-Year-Old Woman. Hypertension 2023; 80:227-230. [PMID: 36475472 DOI: 10.1161/hypertensionaha.122.20315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lisa Dubrofsky
- Division of Nephrology, Department of Medicine, Women's College Hospital and Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Ontario, Canada (L.D.)
| | - Paula J Harvey
- Division of Cardiology, Department of Medicine, University of Toronto and Women's College Hospital, Women's College Research Institute, Women's College Hospital, Ontario, Canada (P.J.H.)
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Lakshmanan S, Gimelli A. Cancer risk in adult congenital heart disease. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2023. [DOI: 10.1016/j.ijcchd.2023.100441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Jensterle M, Podbregar A, Janež A, Rakusa M, Goricar K, Prokšelj K. Comparison of plasma metanephrines in patients with cyanotic and acyanotic congenital heart disease. Endocrine 2022; 78:580-586. [PMID: 36194345 DOI: 10.1007/s12020-022-03205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/17/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The co-occurrence of cyanotic congenital heart disease (CCHD) and PHEO/PGL has been reported, but the role of the hypoxic environment in the pathogenesis of PHEO/PGL remains unclear. Our aim was to compare plasma metanephrine and normetanephrine levels between patients with CCHD and patients with acyanotic congenital heart disease (ACCHD). METHODS We performed a cross-sectional study in a prospective cohort of 44 patients with congenital heart disease (CHD) (31 (70.5%) females) with a median age of 37.5 (31.0-55.6) years at the time of evaluation. Thirty-two (73%) patients had CCHD and 12 (27%) patients had ACCHD. Morning blood samples for plasma determination of metanephrine and normetanephrine were collected. RESULTS Plasma normetanephrine levels were significantly higher in patients with CCHD compared to ACCHD (p = 0.002). Ten (31.3%) patients with CCHD had plasma normetanephrine levels elevated above the reference range, while all ACCHD patients had normal levels. Patients with lower oxygen saturation and higher proBNP had significantly higher normetanephrine levels (ρ = -0.444, p = 0.003 and ρ = 0.449, p = 0.002, respectively). No chromaffin cell tumors were detected. CONCLUSION Increased plasma normetanephrine levels in patients with CCHD can be explained by the effect of hypoxia. Future research is needed to better understand the impact of chronic hypoxia in CCHD on increased sympathetic outflow, hyperplastic response of chromaffin tissue, and the role of somatic mutations in CCHD-PHEO/PGL pathogenesis related to hypoxia.
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Affiliation(s)
- Mojca Jensterle
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia
| | - Ana Podbregar
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- University Rehabilitation Institute Republic of Slovenia, Linhartova cesta 51, 1000, Ljubljana, Slovenia
| | - Andrej Janež
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia
| | - Matej Rakusa
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia
| | - Katja Goricar
- University of Ljubljana, Faculty of Medicine, Institute of Biochemistry and Molecular Genetics, Pharmacogenetics Laboratory, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Katja Prokšelj
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
- Department of Cardiology, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia.
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Ogasawara T, Fujii Y, Kakiuchi N, Shiozawa Y, Sakamoto R, Ogawa Y, Ootani K, Ito E, Tanaka T, Watanabe K, Yoshida Y, Kimura N, Shiraishi Y, Chiba K, Tanaka H, Miyano S, Ogawa S. Genetic Analysis of Pheochromocytoma and Paraganglioma Complicating Cyanotic Congenital Heart Disease. J Clin Endocrinol Metab 2022; 107:2545-2555. [PMID: 35730597 DOI: 10.1210/clinem/dgac362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Pheochromocytoma and paraganglioma (PPGL) may appear as a complication of cyanotic congenital heart disease (CCHD-PPGL) with frequent EPAS1 mutations, suggesting a close link between EPAS1 mutations and tissue hypoxia in CCHD-PPGL pathogenesis. OBJECTIVE Our aim is to further investigate the role of EPAS1 mutations in the hypoxia-driven mechanism of CCHD-PPGL pathogenesis, particularly focusing on metachronous and/or multifocal CCHD-PPGL tumors. METHODS We performed whole-exome sequencing (WES) for somatic and germline mutations in 15 PPGL samples from 7 CCHD patients, including 3 patients with metachronous and/or multifocal tumors, together with an adrenal medullary hyperplasia (AMH) sample. RESULTS We detected EPAS1 mutations in 15 out of 16 PPGL/AMH samples from 7 cases. Conspicuously, all EPAS1 mutations in each of 3 cases with multifocal or metachronous tumors were mutually independent and typical examples of parallel evolution, which is suggestive of strong positive selection of EPAS1-mutated clones. Compared to 165 The Cancer Genome Atlas non-CCHD-PPGL samples, CCHD-PPGL/AMH samples were enriched for 11p deletions (13/16) and 2p amplifications (4/16). Of particular note, the multiple metachronous PPGL tumors with additional copy number abnormalities developed 18 to 23 years after the resolution of hypoxemia, suggesting that CCHD-induced hypoxic environments are critical for positive selection of EPAS1 mutants in early life, but may no longer be required for development of PPGL in later life. CONCLUSION Our results highlight a key role of activated hypoxia-inducible factor 2α due to mutated EPAS1 in positive selection under hypoxic environments, although hypoxemia itself may not necessarily be required for the EPAS1-mutated clones to progress to PPGL.
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Affiliation(s)
- Tatsuki Ogasawara
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8315, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Kyoto 606-8501, Japan
| | - Yoichi Fujii
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8315, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Kyoto 606-8501, Japan
| | - Nobuyuki Kakiuchi
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8315, Japan
- The Hakubi Center for Advanced Research, Kyoto University, Kyoto 606-8501, Japan
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Yusuke Shiozawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8315, Japan
| | - Ryuichi Sakamoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Katsuki Ootani
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562,Japan
| | - Etsuro Ito
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki 036-8562,Japan
| | - Tomoaki Tanaka
- Department of Molecular Diagnosis, Graduate School of Medicine, Chiba University, Chiba 260-8670, Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka 420-8660, Japan
| | - Yusaku Yoshida
- Department of Endocrine Surgery, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Noriko Kimura
- Department of Clinical Research Pathology Division, National Hospital Organization Hakodate Hospital, Hakodate 041-8512, Japan
| | - Yuichi Shiraishi
- Division of Genome Analysis Platform Development, National Cancer Center Research Institute, Tokyo 104-0045, Japan
| | - Kenichi Chiba
- Division of Genome Analysis Platform Development, National Cancer Center Research Institute, Tokyo 104-0045, Japan
| | - Hiroko Tanaka
- M&D Data Science Center, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Satoru Miyano
- M&D Data Science Center, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8315, Japan
- Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Kyoto 606-8501, Japan
- Department of Medicine, Center for Hematology and Regenerative Medicine, Karolinska Institute, Stockholm 14157, Sweden
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12
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Thakuria R, Kaur M, Vladimir R, Subramaniam R. Anaesthetic Management of Secretory Paraganglioma With Cyanotic Heart Disease: Double Trouble. Cureus 2022; 14:e25328. [PMID: 35761913 PMCID: PMC9231819 DOI: 10.7759/cureus.25328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 11/05/2022] Open
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13
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Hara M, Hyodo A, Kimura H, Hiraki T. Transfenestration Doppler Assessment During Laparoscopic Pheochromocytoma Resection in a Patient With Fontan Circulation. J Cardiothorac Vasc Anesth 2022; 36:3655-3661. [PMID: 35659830 DOI: 10.1053/j.jvca.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Masato Hara
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan.
| | - Ayako Hyodo
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Hiroko Kimura
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Teruyuki Hiraki
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
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14
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Ferrero P, Piazza I, Giamberti A, Chessa M. Oncogenesis in patients with congenital heart disease: A possible role of the neural crest. Ann Pediatr Cardiol 2022; 15:273-275. [PMID: 36589641 PMCID: PMC9802619 DOI: 10.4103/apc.apc_213_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/31/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022] Open
Abstract
Patients with congenital heart disease (CHD) seem to have a higher risk for specific malignancies. We hypothesize a pathogenetic link between particular congenital heart defects and cancer originating from specific cellular lineages. We report a series of patients, followed in two high-volume referral centers, with CHD involving neural crest-derived structures who developed cancer later in life. Fourteen patients (five female) developed neoplasia with a cellular origin embryologically linked to the neural crest between 2010 and 2020. If confirmed on larger datasets, this observation might support the hypothesis of common embryogenetic pathway suggesting tailored surveillance of a specific subset of patients.
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Affiliation(s)
- Paolo Ferrero
- ACHD UNIT, Pediatric and Adult Congenital Heart Centre, IRCCS – Policlinico San Donato, San Donato Milanese, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart, ERN GUARD-Heart, Milan, Italy
| | - Isabelle Piazza
- EAS, Emergency department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Alessandro Giamberti
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart, ERN GUARD-Heart, Milan, Italy
- Congenital Cardiac Surgery Unit, IRCCS - Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Massimo Chessa
- ACHD UNIT, Pediatric and Adult Congenital Heart Centre, IRCCS – Policlinico San Donato, San Donato Milanese, Italy
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart, ERN GUARD-Heart, Milan, Italy
- Vita Salute San Raffaele University, Milan, Italy
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15
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Kato N, Kimura N. Pheochromocytoma and multiple paragangliomas associated with Eisenmenger syndrome: An autopsy case. Pathol Int 2022; 72:349-351. [PMID: 35394097 DOI: 10.1111/pin.13225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/19/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Noriko Kato
- Department of Anatomic Pathology, Hirosaki University School of Medicine and Hospital, Hirosaki, Japan
| | - Noriko Kimura
- Department of Diagnostic Pathology, Department of Clinical Research, National Hospital Organization, Hakodate Hospital, Hakodate, Japan
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16
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Ritmeester E, Veger VA, van der Ven JPG, van Tussenbroek GMJW, van Capelle CI, Udink ten Cate FEA, Helbing WA. Fontan Circulation Associated Organ Abnormalities Beyond the Heart, Lungs, Liver, and Gut: A Systematic Review. Front Cardiovasc Med 2022; 9:826096. [PMID: 35391839 PMCID: PMC8981209 DOI: 10.3389/fcvm.2022.826096] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/17/2022] [Indexed: 12/22/2022] Open
Abstract
Introduction Patients with a Fontan circulation are at risk for sequelae of Fontan physiology during follow-up. Fontan physiology affects all organ systems and an overview of end-organ damage is needed. Methods We performed a systematic review of abnormalities in multiple organ systems for patients with a longstanding Fontan circulation. We searched online databases for articles describing abnormalities in multiple organ systems. Cardio-pulmonary abnormalities, protein losing enteropathy, and Fontan associated liver disease have already extensively been described and were excluded from this systematic review. Results Our search returned 5,704 unique articles. After screening, we found 111 articles relating to multiple organ systems. We found abnormalities in, among others, the nervous system, pituitary, kidneys, and musculoskeletal system. Pituitary edema—relating to the unique pituitary vasculature- may affect the thyroid axis. Renal dysfunction is common. Creatinine based renal function estimates may be inappropriate due to myopenia. Both lean muscle mass and bone mineral density are decreased. These abnormalities in multiple organ systems may be related to Fontan physiology, cyanosis, iatrogenic factors, or lifestyle. Conclusions Health care providers should be vigilant for hypothyroidism, visual or hearing deficits, and sleep disordered breathing in Fontan patients. We recommend including cystatin C for assessment of renal function. This review may aid health care providers and guide future research. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021232461, PROSPERO, identifier: CRD42021232461.
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Affiliation(s)
- Evi Ritmeester
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Veerle A. Veger
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jelle P. G. van der Ven
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | | | - Carine I. van Capelle
- Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Floris E. A. Udink ten Cate
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem A. Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
- Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- *Correspondence: Willem A. Helbing
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17
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Kimura N, Shiga K, Kaneko KI, Oki Y, Sugisawa C, Saito J, Tawara S, Akahori H, Sogabe S, Yamashita T, Takekoshi K, Naruse M, Katabami T. Immunohistochemical Expression of Choline Acetyltransferase and Catecholamine-Synthesizing Enzymes in Head-and-Neck and Thoracoabdominal Paragangliomas and Pheochromocytomas. Endocr Pathol 2021; 32:442-451. [PMID: 34743284 DOI: 10.1007/s12022-021-09694-x] [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] [Accepted: 10/06/2021] [Indexed: 11/30/2022]
Abstract
Paragangliomas (PGLs) are neural-crest-derived, non-epithelial neuroendocrine tumors distributed along the parasympathetic and sympathetic nerves. Head-and-neck PGLs (HNPGLs) have been recognized as nonchromaffin, nonfunctional, parasympathetic tumors. By contrast, thoracoabdominal paragangliomas and pheochromocytomas (PPGLs) are chromaffin, functional, sympathetic tumors. Although HNPGLs and PPGLs have the same histological structure, the zellballen pattern, composed of chief and sustentacular cells surrounded by abundant capillaries, the pathobiological differences between these types of PGLs remain unclarified. To determine the phenotypic features of these PGLs, we performed an immunohistochemical study using specific antibodies against choline acetyltransferase (ChAT), an enzyme involved in acetylcholine synthesis, and enzymes for the catecholamine-synthesis, tyrosine hydroxylase (TH), and dopamine beta-hydroxylase (DBH), in 34 HNPGLs from 31 patients, 12 thoracoabdominal PGLs from 12 patients, and 26 pheochromocytomas from 22 patients. The expression of ChAT, TH, and DBH was 100%, 23%, and 10% in the HNPGLs; 12%, 100%, and 100% in the pheochromocytomas; and 25%, 67%, and 100% in the thoracoabdominal PGLs, respectively. These results designate HNPGLs as acetylcholine-producing parasympathetic tumors, in contrast to PPGLs being catecholamine-producing tumors. The other most frequently used neuroendocrine markers are synaptophysin and chromogranin A expressed 100% and 80%, respectively, and synaptophysin was superior to chromogranin A in HNPGLs. This is the first report of HNPGLs being acetylcholine-producing tumors. Immunohistochemistry of ChAT could be greatly useful for pathologic diagnosis of HNPGL. Whether measurement of acetylcholine levels in the blood or urine could be a tumor marker of HNPGLs should be investigated soon.
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Affiliation(s)
- Noriko Kimura
- Department of Clinical Research, Department of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Japan.
| | - Kiyoto Shiga
- Department of Head & Neck Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Ken-Ichi Kaneko
- Department of Otolaryngology-Head and Neck Surgery, Nagasaki University Graduate School of Bio-Medical Sciences, Nagasaki, Japan
| | - Yutaka Oki
- Department of Endocrinology and Metabolism, Hamamatsu Medical School, Hama-Matsu-Kita Hospital, Hamamatsu, Japan
| | - Chiho Sugisawa
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama, Japan
| | - Seiich Tawara
- Department of Gastroenterology, Osaka General Medical Center, Osaka, Japan
| | - Hiroshi Akahori
- Department of Endocrinology and Metabolism, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Susumu Sogabe
- Medical Oncology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Takafumi Yamashita
- Kyoto University Graduate School of Medicine, Faculty of Medicine, Department of Diabetes, Endocrinology and Nutrition, Metabolism and Endocrinology, Division of Internal Medicine, Kishiwada City Hospital, Kishiwada, Japan
| | - Kazuhiro Takekoshi
- Division of Sports Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology, Metabolism, and Hypertension, National Hospital Organization, Kyoto Medical Center, and Endocrine Center, Ijinkai Takeda General Hospital Kyoto, Japan
| | - Takayuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
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18
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Eckardt L, Prange-Barczynska M, Hodson EJ, Fielding JW, Cheng X, Lima JDCC, Kurlekar S, Douglas G, Ratcliffe PJ, Bishop T. Developmental role of PHD2 in the pathogenesis of pseudohypoxic pheochromocytoma. Endocr Relat Cancer 2021; 28:757-772. [PMID: 34658364 PMCID: PMC8558849 DOI: 10.1530/erc-21-0211] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/20/2021] [Indexed: 01/03/2023]
Abstract
Despite a general role for the HIF hydroxylase system in cellular oxygen sensing and tumour hypoxia, cancer-associated mutations of genes in this pathway, including PHD2, PHD1, EPAS1 (encoding HIF-2α) are highly tissue-restricted, being observed in pseudohypoxic pheochromocytoma and paraganglioma (PPGL) but rarely, if ever, in other tumours. In an effort to understand that paradox and gain insights into the pathogenesis of pseudohypoxic PPGL, we constructed mice in which the principal HIF prolyl hydroxylase, Phd2, is inactivated in the adrenal medulla using TH-restricted Cre recombinase. Investigation of these animals revealed a gene expression pattern closely mimicking that of pseudohypoxic PPGL. Spatially resolved analyses demonstrated a binary distribution of two contrasting patterns of gene expression among adrenal medullary cells. Phd2 inactivation resulted in a marked shift in this distribution towards a Pnmt-/Hif-2α+/Rgs5+ population. This was associated with morphological abnormalities of adrenal development, including ectopic TH+ cells within the adrenal cortex and external to the adrenal gland. These changes were ablated by combined inactivation of Phd2 with Hif-2α, but not Hif-1α. However, they could not be reproduced by inactivation of Phd2 in adult life, suggesting that they arise from dysregulation of this pathway during adrenal development. Together with the clinical observation that pseudohypoxic PPGL manifests remarkably high heritability, our findings suggest that this type of tumour likely arises from dysregulation of a tissue-restricted action of the PHD2/HIF-2α pathway affecting adrenal development in early life and provides a model for the study of the relevant processes.
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Affiliation(s)
- Luise Eckardt
- Target Discovery Institute, University of Oxford, Oxford, UK
- Institute of Physiology and Pathophysiology, University of Heidelberg, Heidelberg, Germany
| | - Maria Prange-Barczynska
- Target Discovery Institute, University of Oxford, Oxford, UK
- Ludwig Institute for Cancer Research, University of Oxford, Oxford, UK
| | - Emma J Hodson
- The Francis Crick Institute, London, UK
- The Department of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - James W Fielding
- Target Discovery Institute, University of Oxford, Oxford, UK
- Ludwig Institute for Cancer Research, University of Oxford, Oxford, UK
| | - Xiaotong Cheng
- Target Discovery Institute, University of Oxford, Oxford, UK
- Ludwig Institute for Cancer Research, University of Oxford, Oxford, UK
| | | | - Samvid Kurlekar
- Target Discovery Institute, University of Oxford, Oxford, UK
| | - Gillian Douglas
- BHF Centre of Research Excellence, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter J Ratcliffe
- Target Discovery Institute, University of Oxford, Oxford, UK
- Ludwig Institute for Cancer Research, University of Oxford, Oxford, UK
- The Francis Crick Institute, London, UK
- Correspondence should be addressed to P J Ratcliffe or T Bishop: or
| | - Tammie Bishop
- Target Discovery Institute, University of Oxford, Oxford, UK
- Correspondence should be addressed to P J Ratcliffe or T Bishop: or
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19
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Special situations in pheochromocytomas and paragangliomas: pregnancy, metastatic disease, and cyanotic congenital heart diseases. Clin Exp Med 2021; 22:359-370. [PMID: 34591219 DOI: 10.1007/s10238-021-00763-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/18/2021] [Indexed: 01/08/2023]
Abstract
The aim of our study was to describe the epidemiology, diagnosis, and treatment of the most complex pheochromocytoma and paraganglioma (PGL) cases, including pheochromocytoma/PGL during pregnancy, in cyanotic congenital heart diseases (CCHDs), and metastatic pheochromocytoma. The English and Spanish literature was thoroughly evaluated searching for articles reporting clinical studies, case reports, or reviews of pheochromocytoma/PGL in pregnancy and in CCHD and metastatic pheochromocytoma/PGL. Particular settings in the diagnosis and management of pheochromocytoma and PGLs remain challenging. Those special situations include the diagnosis during pregnancy or in the context of CCHD since the typical clinical features of pheochromocytoma may be confounded with preeclampsia during pregnancy and with the complications commonly observed in CCHD. In addition, although some clinical and genetic features have been associated with higher risk of metastatic pheochromocytoma, the detection and prediction of the development of metastatic disease involve another complex situation that may require special hormonal determinations as plasmatic 3-methoxytyramine and nuclear medicine studies including 18FDG PET-CT or 18F-FDOPA PET-CT, among others. Furthermore, the selection of the most appropriate treatment in these situations, as well as the moment to carry it out, requires special care as limited evidence is available. This article reviews the epidemiology, diagnosis, and treatment of the pheochromocytoma/PGL during pregnancy, metastatic pheochromocytoma/PGL, and pheochromocytoma/PGL in CCHD. The diagnosis, and especially the treatment, of metastatic pheochromocytomas and pheochromocytoma/PGL during pregnancy and in CCHD is challenging. Thus, these cases should be management in reference centres by multidisciplinary teams specialized in the pheochromocytoma/PGL treatment.
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20
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Flores SK, Estrada-Zuniga CM, Thallapureddy K, Armaiz-Peña G, Dahia PLM. Insights into Mechanisms of Pheochromocytomas and Paragangliomas Driven by Known or New Genetic Drivers. Cancers (Basel) 2021; 13:cancers13184602. [PMID: 34572828 PMCID: PMC8467373 DOI: 10.3390/cancers13184602] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/12/2021] [Accepted: 09/12/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that are often hereditary. Although research has advanced considerably, significant gaps still persist in understanding risk factors, predicting metastatic potential and treating aggressive tumors. The study of rare mutations can provide new insights into how pheochromocytomas and paragangliomas develop. In this review, we provide examples of such rare events and how they can inform our understanding of the spectrum of mutations that can lead to these tumors and improve our ability to provide a genetic diagnosis. Abstract Pheochromocytomas and paragangliomas are rare tumors of neural crest origin. Their remarkable genetic diversity and high heritability have enabled discoveries of bona fide cancer driver genes with an impact on diagnosis and clinical management and have consistently shed light on new paradigms in cancer. In this review, we explore unique mechanisms of pheochromocytoma and paraganglioma initiation and management by drawing from recent examples involving rare mutations of hypoxia-related genes VHL, EPAS1 and SDHB, and of a poorly known susceptibility gene, TMEM127. These models expand our ability to predict variant pathogenicity, inform new functional domains, recognize environmental-gene connections, and highlight persistent therapeutic challenges for tumors with aggressive behavior.
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Affiliation(s)
- Shahida K. Flores
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA; (S.K.F.); (C.M.E.-Z.); (K.T.); (G.A.-P.)
| | - Cynthia M. Estrada-Zuniga
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA; (S.K.F.); (C.M.E.-Z.); (K.T.); (G.A.-P.)
| | - Keerthi Thallapureddy
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA; (S.K.F.); (C.M.E.-Z.); (K.T.); (G.A.-P.)
| | - Gustavo Armaiz-Peña
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA; (S.K.F.); (C.M.E.-Z.); (K.T.); (G.A.-P.)
| | - Patricia L. M. Dahia
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229, USA; (S.K.F.); (C.M.E.-Z.); (K.T.); (G.A.-P.)
- Mays Cancer Center, University of Texas Health San Antonio, San Antonio, TX 78229, USA
- Correspondence:
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21
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Łoń I, Kunikowska J, Jędrusik P, Góra J, Toutounchi S, Placha G, Gaciong Z. Familial SDHB gene mutation in disseminated non-hypoxia-related malignant paraganglioma treated with [ 90Y]Y/[ 177Lu]Lu- DOTATATE. Intractable Rare Dis Res 2021; 10:207-213. [PMID: 34466344 PMCID: PMC8397825 DOI: 10.5582/irdr.2021.01047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/17/2021] [Accepted: 05/18/2021] [Indexed: 11/05/2022] Open
Abstract
Familial paraganglioma may be related to mutations in succinate dehydrogenase (SDH) enzyme complex genes. Among patients with hereditary paraganglioma, SDH subunit B (SDHB) gene mutations are associated with the highest morbidity and mortality related to a higher malignancy rate. We report a family with the c.689G>A (p.Arg230His) mutation in the SDHB gene identified in two family members, a father and his daughter. While the 14-year-old daughter had no evidence of clinical disease, recurrent and later disseminated [131I]metaiodobenzylguanidine uptake-negative head and neck paraganglioma with multiple bone metastases developed in the father who underwent peptide receptor radionuclide therapy with [90Y]Y/[177Lu]Lu-dodecane tetraacetic acid octreotate (DOTATATE) at the time of the genetic diagnosis. This treatment was repeated 6 years later due to disease progression and the patient, who is currently 49 years old, remains alive and in good overall clinical condition at 8 years of follow-up after the original presentation at our unit. The growing armamentarium of imaging methods available for such patients may inform decision making regarding choice of the optimal treatment approach, potentially contributing to improved outcomes.
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Affiliation(s)
- Izabela Łoń
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Kunikowska
- Department of Nuclear Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Jędrusik
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
- Address correspondence to:P i o t r J ę d r u s i k , D e p a r t m e n t o f I n t e r n a l M e d i c i n e , Hypertension and Vascular Diseases, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland. E-mail:
| | - Jarosław Góra
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Sadegh Toutounchi
- Department of General and Endocrine Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Placha
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
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22
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Doyle C, Bolger J, Conneely JB, Walsh KP. Paraganglioma in an adolescent awaiting a cardiac transplant due to unrepaired congenital cyanotic heart disease and a univentricular heart: the first reported case. BMJ Case Rep 2021; 14:14/5/e241804. [PMID: 34035024 DOI: 10.1136/bcr-2021-241804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a 16-year-old adolescent male born with univentricular congenital cyanotic heart disease (CCHD) who was diagnosed with an incidental paraganglioma while awaiting a cardiac transplant. The coexistence of paraganglioma and univentricular CCHD is very rare, with no previous cases described in the literature of a patient concurrently requiring a cardiac transplant. The complex physiology associated with a common atrium, common ventricle, aortopulmonary lung perfusion and a hypoplastic left lung rendered our patient extremely vulnerable to catecholamine-mediated effects of preload, contractility and afterload. The interactions and interdependence between these systems provided unique difficulties for perioperative management with serious implications for prospective cardiac transplant.
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Affiliation(s)
- Conor Doyle
- Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jarlath Bolger
- General Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John B Conneely
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kevin P Walsh
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
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23
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Barradas-Pires A, Constantine A, Dimopoulos K. Preventing disease progression in Eisenmenger syndrome. Expert Rev Cardiovasc Ther 2021; 19:501-518. [PMID: 33853494 DOI: 10.1080/14779072.2021.1917995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Eisenmenger syndrome describes a condition in which a congenital heart defect has caused severe pulmonary vascular disease, resulting in reversed (right-left) or bidirectional shunting and chronic cyanosis.Areas covered: In this paper, the progression of congenital heart defects to Eisenmenger syndrome, including early screening, diagnosis and operability are covered. The mechanisms of disease progression in Eisenmenger syndrome and management strategies to combat this, including the role of pulmonary arterial hypertension therapies, are also discussed.Expert opinion/commentary: Patients with congenital heart disease (CHD) are at increased risk of developing pulmonary arterial hypertension with Eisenmenger syndrome being its extreme manifestation. All CHD patients should be regularly assessed for pulmonary hypertension. Once Eisenmenger syndrome develops, shunt closure should be avoided. The clinical manifestations of Eisenmenger syndrome are driven by the systemic effects of the pulmonary hypertension, congenital defect and long-standing cyanosis. Expert care is essential for avoiding pitfalls and preventing disease progression in this severe chronic condition, which is associated with significant morbidity and mortality. Pulmonary arterial hypertension therapies have been used alongside supportive care to improve the quality of life, exercise tolerance and the outcome of these patients, although the optimal timing for their introduction and escalation remains uncertain.
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Affiliation(s)
- Ana Barradas-Pires
- Department of Cardiology, Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Andrew Constantine
- Department of Cardiology, Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK.,Biomedical Research Unit, National Heart & Lung Institute, Imperial College London, UK
| | - Konstantinos Dimopoulos
- Department of Cardiology, Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK.,Biomedical Research Unit, National Heart & Lung Institute, Imperial College London, UK
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Abdominal Imaging of Children and Young Adults With Fontan Circulation: Pathophysiology and Surveillance. AJR Am J Roentgenol 2021; 217:207-217. [PMID: 33909464 DOI: 10.2214/ajr.20.23404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE. The Fontan procedure has significantly improved the survival in children with a functional single ventricle, but it is associated with chronically elevated systemic venous pressure that leads to multisystemic complications. Imaging plays an important role in assessing these complications and guiding management. The pathophysiology, imaging modalities, and current surveillance recommendations are discussed and illustrated. CONCLUSION. Significant improvement in survival of patients with Fontan circulation is associated with ongoing cardiac and extracardiac comorbidities and multisystemic complications. The liver and intestines are particularly vulnerable to damage. In addition, this patient population has been shown to be at increased risk of certain malignancies such as hepatocellular carcinoma and neuroendocrine tumors. Familiarity with imaging findings of Fontan-associated liver disease and other abdominal complications of the Fontan circulation is essential for radiologists because we are likely to encounter these patients in our general practice.
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Pitsava G, Settas N, Faucz FR, Stratakis CA. Carney Triad, Carney-Stratakis Syndrome, 3PAS and Other Tumors Due to SDH Deficiency. Front Endocrinol (Lausanne) 2021; 12:680609. [PMID: 34012423 PMCID: PMC8126684 DOI: 10.3389/fendo.2021.680609] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/12/2021] [Indexed: 12/20/2022] Open
Abstract
Succinate dehydrogenase (SDH) is a key respiratory enzyme that links Krebs cycle and electron transport chain and is comprised of four subunits SDHA, SDHB, SDHC and SDHD. All SDH-deficient tumors are caused by or secondary to loss of SDH activity. As many as half of the familial cases of paragangliomas (PGLs) and pheochromocytomas (PHEOs) are due to mutations of the SDHx subunits. Gastrointestinal stromal tumors (GISTs) associated with SDH deficiency are negative for KIT/PDGFRA mutations and present with distinctive clinical features such as early onset (usually childhood or adolescence) and almost exclusively gastric location. SDH-deficient GISTs may be part of distinct clinical syndromes, Carney-Stratakis syndrome (CSS) or dyad and Carney triad (CT). CSS is also known as the dyad of GIST and PGL; it affects both genders equally and is inherited in an autosomal dominant manner with incomplete penetrance. CT is a very rare disease; PGL, GIST and pulmonary chondromas constitute CT which shows female predilection and may be a mosaic disorder. Even though there is some overlap between CT and CSS, as both are due to SDH deficiency, CSS is caused by inactivating germline mutations in genes encoding for the SDH subunits, while CT is mostly caused by a specific pattern of methylation of the SDHC gene and may be due to germline mosaicism of the responsible genetic defect.
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Affiliation(s)
- Georgia Pitsava
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institutes of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Nikolaos Settas
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Fabio R. Faucz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Fabio R. Faucz,
| | - Constantine A. Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
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Abstract
Paragangliomas occurring with cyanotic heart disease is a known association. We present a case of an active paraganglioma in a child with unoperated Tetralogy of Fallot, which posed a management challenge considering the pathophysiology of both these conditions.
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Vural C, Skaria P, Dehner LP, Khanna G. Gastrointestinal neuroendocrine tumors in Fontan patients. Radiol Case Rep 2020; 15:2153-2156. [PMID: 32952754 PMCID: PMC7484531 DOI: 10.1016/j.radcr.2020.08.004] [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: 05/27/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/29/2022] Open
Abstract
The Fontan procedure used for palliation of single ventricle physiology is associated with multisystemic morbidity. With improving survival and increased use of surveillance imaging in this patient population, long-term complications associated with Fontan circuits are commonly encountered by radiologists. One interesting observation is the apparent increased risk of paragangliomas and pheochromocytomas in this group of patients and perhaps a pathogenetic role of chronic hypoxia. We report 2 cases of gastrointestinal neuroendocrine tumors (NET) in the setting of Fontan circuit. The first is a 20-year-old female with history of hypoplastic left heart and Fontan palliation who presented with hematochezia and was diagnosed with a jejunal grade 2 NET. The second case is of a 12-year-old boy with history Fontan palliation for single ventricle physiology, incidentally found to have a well-differentiated pancreatic NET during precardiac transplant workup. These cases should alert the radiologists to be aware of the apparent association between Fontan procedure and NET.
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Affiliation(s)
- Corey Vural
- Washington University School of Medicine, Campus Box 8131, 510 S. Kingshighway, St Louis, MO 63110 USA
| | - Priya Skaria
- Department of Pathology, Washington University School of Medicine, St Louis, MO, USA
| | - Louis P Dehner
- Department of Pathology, Washington University School of Medicine, St Louis, MO, USA
| | - Geetika Khanna
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO¸USA
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28
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Opotowsky AR, Webb GD. Small Defects, Small Effects, Big Data, Big Anxiety: Our Evolving Understanding of Low-Risk Congenital Heart Disease. Circ Cardiovasc Interv 2020; 13:e009350. [PMID: 32519888 DOI: 10.1161/circinterventions.120.009350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Alexander R Opotowsky
- Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, OH
| | - Gary D Webb
- Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, OH
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Cummings JJ, Siegrist KK, Deegan RJ, Solórzano CC, Eagle SS. Robotic Adrenalectomy for Pheochromocytoma in a Patient with Fontan Physiology. J Cardiothorac Vasc Anesth 2020; 34:2446-2451. [PMID: 32434722 DOI: 10.1053/j.jvca.2020.02.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/25/2020] [Accepted: 02/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Jared J Cummings
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Kara K Siegrist
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Robert J Deegan
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Carmen C Solórzano
- Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Susan S Eagle
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
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Lan L, Liu P, Tian Y, Zhu B, Shen L, Huang Y. Anaesthetic management of a large paraganglioma resection in a woman with isolated L-looped transposition of the great arteries: a case report. BMC Anesthesiol 2020; 20:79. [PMID: 32252631 PMCID: PMC7132883 DOI: 10.1186/s12871-020-00998-9] [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: 01/27/2020] [Accepted: 03/30/2020] [Indexed: 11/24/2022] Open
Abstract
Background Reports of anaesthetic management of paraganglioma resection in patients with isolated L-transposition of the great arteries (L-TGA) are rare. We focus on the preoperative evaluation, intraoperative management, and postoperative care of a frail patient with “physiologically corrected” L-TGA for paraganglioma resection. Case presentation We performed general anaesthesia for a 46-year-old patient with “physiologically corrected” L-TGA undergoing open large retroperitoneal paraganglioma resection. Although the preoperative medical therapy had attained its goals, the patient went through three periods of severe episodic hypertension and tachycardia as tumour manipulation released catecholamines. Goal-directed fluid therapy based on pulse pressure variation (PPV) and point-of-care transesophageal echocardiography (TEE) imaging enabled anaesthesiologists to make rapid judgments and to regulate blood pressure in a timely manner, thereby reducing the risk of heart failure caused by massive rapid fluid bolus therapy. The patient was transferred to the intensive care unit because of intraoperative hemodynamic changes and significant blood loss. Despite transient myocardial injury (elevated troponin I), no lethal arrhythmia or complications occurred perioperatively, and the patient recovered well and was discharged 1 week later. Conclusions Goal-directed fluid therapy combined with the adoption of TEE could effectively guide fluid administration, which is helpful for anaesthesia management during operation. We recommend the routine use of TEE in such cases.
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Affiliation(s)
- Ling Lan
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, P.R. China
| | - Penghao Liu
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, P.R. China
| | - Yuan Tian
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, P.R. China
| | - Bo Zhu
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, P.R. China
| | - Le Shen
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, P.R. China.
| | - Yuguang Huang
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, P.R. China
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31
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Ng P, Deepak D, Teo L, Low TT. Asymptomatic phaeochromocytoma in a patient with Holt-Oram syndrome: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 3:1-5. [PMID: 32099963 PMCID: PMC7026609 DOI: 10.1093/ehjcr/ytz206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/29/2019] [Accepted: 10/21/2019] [Indexed: 11/19/2022]
Abstract
Background Holt-Oram syndrome (HOS) is a rare congenital disease that affects the heart and upper limbs. Phaeochromocytoma, a catecholamine-secreting tumour, is a rare neuroendocrine disorder. We present an interesting case presentation of these two rare disorders in a patient who was asymptomatic for phaeochromocytoma. Case summary A 28-year-old woman who was diagnosed at birth with HOS, presented to the hospital with heart failure. She has a past medical history of corrected cyanotic congenital heart disease. She presented with dyspnoea but she did not have headaches, tremors, or diaphoresis. Cardiac magnetic resonance scan was done to investigate the cause of her heart failure and revealed right ventricular systolic dysfunction and a suspicious adrenal lesion. Magnetic resonance imaging adrenal confirmed the presence of the adrenal lesion and concerns were raised for a possible phaeochromocytoma. Biochemical tests showed raised plasma free metanephrine levels. Gallium-68 DOTA positron emission tomography scan showed intense right adrenal gland uptake in keeping with diagnosis of phaeochromocytoma. Discussion Phaeochromocytoma appears to be more prevalent in patients who are in a chronic hypoxic state. This hypoxic state has been postulated to cause the proliferation of adrenal tissue and therefore the formation of phaeochromocytomas. The hypoxia-inducing factor, which is increased in patients with phaeochromocytoma, has been identified as one of the key factors driving this process as it modulates genes that regulate angiogenesis and proliferation. Congenital heart defects seen in HOS can progress to cyanotic heart disease if left uncorrected and may have been the driver for the development of phaeochromocytoma in our patient.
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Affiliation(s)
- Perryn Ng
- National University Health System, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Doddabele Deepak
- National University Health System, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Lynette Teo
- National University Health System, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Ting Ting Low
- National University Health System, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
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Roose LM, Rupp NJ, Röösli C, Valcheva N, Weber A, Beuschlein F, Tschopp O. Tinnitus With Unexpected Spanish Roots: Head and Neck Paragangliomas Caused by SDHAF2 Mutation. J Endocr Soc 2020; 4:bvaa016. [PMID: 32133432 PMCID: PMC7049286 DOI: 10.1210/jendso/bvaa016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Indexed: 12/19/2022] Open
Abstract
It is estimated that up to 40% of all head and neck paragangliomas (HNPGL) have a hereditary background with the most common mutations being found in the succinate dehydrogenase (SDH) genes. SDHAF2 mutation leads to the rare paraganglioma syndrome 2. The authors present the case of a 15-year-old male patient with 2, non-secretory HNPGLs, presenting with left-sided, pulsatile tinnitus, and hearing loss. Imaging led to the suspicion of a jugulotympanic paraganglioma on the left, as well as a carotid body tumor on the right. After resection of the jugulotympanic tumor, histology confirmed the presence of a paraganglioma; immunohistochemistry furthermore suggested a loss of SDHB expression. Genetic testing revealed a rare germline, loss-of-function mutation in the SDHAF2 gene, previously described to cause hereditary paraganglioma syndrome 2. Twenty months after the first operation, the patient underwent a resection of the right carotid body paraganglioma. Plasma-free metanephrines/catecholamines always remained within the reference range; the patient is under regular follow-up, and his relatives will be screened. Our findings emphasize the relevance of genetic testing in patients with HNPGL, also with negative family history, especially when the patients present at a young age and with multiple lesions.
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Affiliation(s)
- Laura Maria Roose
- Clinic for Endocrinology, Diabetology and Clinical Nutrition, Zurich, Switzerland
| | | | - Christof Röösli
- Department of Otorhinolaryngology, University Hospital Zurich, Zurich, Switzerland
| | | | - Achim Weber
- Department of Pathology, Zurich, Switzerland
| | - Felix Beuschlein
- Clinic for Endocrinology, Diabetology and Clinical Nutrition, Zurich, Switzerland
| | - Oliver Tschopp
- Clinic for Endocrinology, Diabetology and Clinical Nutrition, Zurich, Switzerland
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McCracken C, Spector LG, Menk JS, Knight JH, Vinocur JM, Thomas AS, Oster ME, St Louis JD, Moller JH, Kochilas L. Mortality Following Pediatric Congenital Heart Surgery: An Analysis of the Causes of Death Derived From the National Death Index. J Am Heart Assoc 2019; 7:e010624. [PMID: 30571499 PMCID: PMC6404427 DOI: 10.1161/jaha.118.010624] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Prior research has focused on early outcomes after congenital heart surgery, but less is known about later risks. We aimed to determine the late causes of death among children (<21 years of age) surviving their initial congenital heart surgery. Methods and Results This is a retrospective cohort study from the Pediatric Cardiac Care Consortium, a US‐based registry of interventions for congenital heart defects (CHD). Excluding patients with chromosomal anomalies or inadequate identifiers, we matched those surviving their first congenital heart surgery (1982–2003) against the National Death Index through 2014. Causes of death were obtained from the National Death Index to calculate cause‐specific standardized mortality ratios (SMRs). Among 31 132 patients, 2527 deaths (8.1%) occurred over a median follow‐up period of 18 years. Causes of death varied by time after surgery and severity of CHD but, overall, 69.9% of deaths were attributed to the CHD or another cardiovascular disorder, with a SMR for CHD/cardiovascular disorder of 67.7 (95% confidence interval: 64.5–70.8). Adjusted odds ratios revealed increased risk of death from CHD/cardiovascular disorder in females [odds ratio=1.28; 95% confidence interval (1.04–1.58); P=0.018] with leading cardiovascular disorder contributing to death being cardiac arrest (16.8%), heart failure (14.8%), and arrhythmias (9.1%). Other major causes of death included coexisting congenital malformations (4.7%, SMR: 7.0), respiratory diseases (3.6%, SMR: 8.2), infections (3.4%, SMR: 8.2), and neoplasms (2.1%, SMR: 1.9). Conclusions Survivors of congenital heart surgery face long‐term risks of premature mortality mostly related to residual CHD pathology, heart failure, and arrhythmias, but also to other noncardiac conditions. Ongoing monitoring is warranted to identify target factors to address residual morbidities and improve long‐term outcomes.
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Affiliation(s)
| | - Logan G Spector
- 3 Department of Pediatrics University of Minnesota Minneapolis MN
| | - Jeremiah S Menk
- 5 Biostatistical Design and Analysis Center University of Minnesota Minneapolis MN
| | - Jessica H Knight
- 6 Department of Epidemiology and Biostatistics University of Georgia School of Public Health Athens GA
| | - Jeffrey M Vinocur
- 7 Department of Pediatrics School of Medicine and Dentistry University of Rochester NY
| | - Amanda S Thomas
- 1 Department of Pediatrics Emory University School of Medicine Atlanta GA
| | | | - James D St Louis
- 8 Department of Pediatric Surgery University of Missouri-Kansas City School of Medicine Kansas City MO
| | - James H Moller
- 4 Department of Internal Medicine University of Minnesota Minneapolis MN
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Cohen S, Gurvitz MZ, Beauséjour-Ladouceur V, Lawler PR, Therrien J, Marelli AJ. Cancer Risk in Congenital Heart Disease-What Is the Evidence? Can J Cardiol 2019; 35:1750-1761. [PMID: 31813507 DOI: 10.1016/j.cjca.2019.09.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/13/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022] Open
Abstract
As life expectancy in patients with congenital heart disease (CHD) has improved, the risk for developing noncardiac morbidities is increasing in adult patients with CHD (ACHD). Among these noncardiac complications, malignancies significantly contribute to the disease burden of ACHD patients. Epidemiologic studies of cancer risk in CHD patients are challenging because they require large numbers of patients, extended follow-up, detailed and validated clinical data, and appropriate reference populations. However, several observational studies suggest that cancer risks are significantly elevated in patients with CHD compared with the general population. CHD and cancer share genetic and environmental risk factors. An association with exposure to low-dose ionizing radiation secondary to medical therapeutic or diagnostic procedures has been reported. Patients with Down syndrome, as well as, to a lesser extent, deletion of 22q11.2 and renin-angiotensin system pathologies, may manifest both CHD and a predisposition to cancer. Such observations suggest that carcinogenesis and CHD may share a common basis in some cases. Finally, specific conditions, such as Fontan circulation and cyanotic CHD, may lead to multisystem consequences and subsequently to cancer. Nonetheless, there is currently no clear consensus regarding appropriate screening for cancer and surveillance modalities in CHD patients. Physicians caring for patients with CHD should be aware of this potential predisposition and meet screening recommendations for the general population fastidiously. An interdisciplinary and global approach is required to bridge the knowledge gap in this field.
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Affiliation(s)
- Sarah Cohen
- Congenital Heart Diseases Department, Complex Congenital Heart Diseases M3C Network, Hospital Marie Lannelongue, Paris-Sud University, Paris-Saclay University, Le Plessis-Robinson, France
| | - Michelle Z Gurvitz
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada; Heart and Stroke/Richard Lewar Centre for Excellence, University of Toronto, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
| | - Judith Therrien
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada
| | - Ariane J Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence, Montréal, Québec, Canada.
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Agarwal S, Jindal I, Balazs A, Paul D. Catecholamine-Secreting Tumors in Pediatric Patients With Cyanotic Congenital Heart Disease. J Endocr Soc 2019; 3:2135-2150. [PMID: 31687640 PMCID: PMC6821216 DOI: 10.1210/js.2019-00226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/28/2019] [Indexed: 12/15/2022] Open
Abstract
Catecholamine-secreting tumors are rare among the pediatric population but are increasingly being reported in children with sustained hypoxia secondary to cyanotic congenital heart disease (CCHD). With this review, we report the clinical characteristics of these tumors in children with CCHD. The articles included in the present review were identified using PubMed through February 2019. A manual search of the references retrieved from relevant articles was also performed. Pheochromocytomas and paragangliomas (PPGL) in children are commonly associated with high-risk germline or somatic mutations. There is evidently a higher risk of tumorigenesis in children with CCHD as compared with the general pediatric population, even in the absence of susceptible gene mutations. This is due to molecular mechanisms involving the aberrant activation of hypoxia-response elements, likely secondary to sustained hypoxemia, resulting in tumorigenesis. Due to overlapping symptoms with CCHD, the diagnosis of PPGL may be delayed or missed in these patients. We studied all previously reported PPGL cases in children with CCHD and reviewed phenotypic and biochemical features to assess for contributing factors in tumorigenesis. Larger studies are needed to help determine other potential predisposing factors and to establish screening guidelines in this high-risk population. A delay in diagnosis of the PPGL tumors can lead to exacerbation of cardiac failure, and therefore early diagnosis and intervention may provide better outcomes in these patients, necessitating the need for regular surveillance. We recommend routine biochemical screening in patients with sustained hypoxia secondary to CCHD.
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Affiliation(s)
- Swashti Agarwal
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ishita Jindal
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Andrea Balazs
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - David Paul
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Abstract
Pheochromocytoma/paraganglioma is an exceedingly rare tumour, thought to share an association with cyanotic CHD. This association is thought to be a result of chronic hypoxaemia (Antonio et al, Revista Española de Cardiología (English Edition) 2017; 70: 673-675; Folger et al, Circulation 1964; 29: 750-757; Opotowsky et al, J Clin Endocrinol Metab 2015; 100: 1325-1334) We report two cases of paraganglioma over a 4-year period in patients with hypoplastic left heart syndrome who had undergone Fontan completion by ages 2 and 4. Based on a very small number of reported cases of CHD, the mechanism of tumourigenesis is unclear. It is imperative that cases associated with CHD continue to be reported so that we may learn more about the pathogenesis and epidemiology of this entity.
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Pheochromocytomas and Paragangliomas: Bypassing Cellular Respiration. Cancers (Basel) 2019; 11:cancers11050683. [PMID: 31100940 PMCID: PMC6562521 DOI: 10.3390/cancers11050683] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 12/14/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors that show the highest heritability of all human neoplasms and represent a paradoxical example of genetic heterogeneity. Amongst the elevated number of genes involved in the hereditary predisposition to the disease (at least nineteen) there are eleven tricarboxylic acid (TCA) cycle-related genes, some of which are also involved in the development of congenital recessive neurological disorders and other cancers such as cutaneous and uterine leiomyomas, gastrointestinal tumors and renal cancer. Somatic or germline mutation of genes encoding enzymes catalyzing pivotal steps of the TCA cycle not only disrupts cellular respiration, but also causes severe alterations in mitochondrial metabolite pools. These latter alterations lead to aberrant accumulation of “oncometabolites” that, in the end, may lead to deregulation of the metabolic adaptation of cells to hypoxia, inhibition of the DNA repair processes and overall pathological changes in gene expression. In this review, we will address the TCA cycle mutations leading to the development of PPGL, and we will discuss the relevance of these mutations for the transformation of neural crest-derived cells and potential therapeutic approaches based on the emerging knowledge of underlying molecular alterations.
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O’Toole SM, Watson DS, Novoselova TV, Romano LEL, King PJ, Bradshaw TY, Thompson CL, Knight MM, Sharp TV, Barnes MR, Srirangalingam U, Drake WM, Chapple JP. Oncometabolite induced primary cilia loss in pheochromocytoma. Endocr Relat Cancer 2019; 26:165-180. [PMID: 30345732 PMCID: PMC6215910 DOI: 10.1530/erc-18-0134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/05/2018] [Indexed: 12/24/2022]
Abstract
Primary cilia are sensory organelles involved in regulation of cellular signaling. Cilia loss is frequently observed in tumors; yet, the responsible mechanisms and consequences for tumorigenesis remain unclear. We demonstrate that cilia structure and function is disrupted in human pheochromocytomas - endocrine tumors of the adrenal medulla. This is concomitant with transcriptional changes within cilia-mediated signaling pathways that are associated with tumorigenesis generally and pheochromocytomas specifically. Importantly, cilia loss was most dramatic in patients with germline mutations in the pseudohypoxia-linked genes SDHx and VHL. Using a pheochromocytoma cell line derived from rat, we show that hypoxia and oncometabolite-induced pseudohypoxia are key drivers of cilia loss and identify that this is dependent on activation of an Aurora-A/HDAC6 cilia resorption pathway. We also show cilia loss drives dramatic transcriptional changes associated with proliferation and tumorigenesis. Our data provide evidence for primary cilia dysfunction contributing to pathogenesis of pheochromocytoma by a hypoxic/pseudohypoxic mechanism and implicates oncometabolites as ciliary regulators. This is important as pheochromocytomas can cause mortality by mechanisms including catecholamine production and malignant transformation, while hypoxia is a general feature of solid tumors. Moreover, pseudohypoxia-induced cilia resorption can be pharmacologically inhibited, suggesting potential for therapeutic intervention.
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Affiliation(s)
- Samuel M O’Toole
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
- Department of EndocrinologySt Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - David S Watson
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Tatiana V Novoselova
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Lisa E L Romano
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Peter J King
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Teisha Y Bradshaw
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Clare L Thompson
- Institute of Bioengineering and School of Engineering and Material SciencesQueen Mary University of London, London, UK
| | - Martin M Knight
- Institute of Bioengineering and School of Engineering and Material SciencesQueen Mary University of London, London, UK
| | - Tyson V Sharp
- Barts Cancer InstituteQueen Mary University of London, London, UK
| | - Michael R Barnes
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Umasuthan Srirangalingam
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
- Department of EndocrinologySt Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
- Department of Diabetes and EndocrinologyUniversity College London Hospital, London, UK
| | - William M Drake
- Department of EndocrinologySt Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - J Paul Chapple
- William Harvey Research InstituteBarts and the London School of Medicine, Queen Mary University of London, London, UK
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39
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Martínez-Quintana E, Rodríguez-González F. Neuroendocrine tumors and conotruncal cardiac defects. J Cardiovasc Thorac Res 2018; 10:180-181. [PMID: 30386541 PMCID: PMC6203865 DOI: 10.15171/jcvtr.2018.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/07/2018] [Indexed: 11/09/2022] Open
Affiliation(s)
- Efrén Martínez-Quintana
- Cardiology Service. Insular-Materno Infantil University Hospital, Las Palmas de Gran Canaria, Spain.,Medical and Surgical Sciences Department, Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Fayna Rodríguez-González
- Ophthalmology Service. Dr. Negrín University Hospital of Gran Canaria. Las Palmas de Gran Canaria, Spain
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40
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Anesthetic Management of Staged Bilateral Adrenalectomy for Neuroendocrine Tumors in a Heart-Lung Transplant Patient: A Case Report. A A Pract 2018; 11:253-257. [PMID: 29851693 DOI: 10.1213/xaa.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Neuroendocrine tumors may rarely present after organ transplantation, including cardiac transplant. Treatment is surgical resection with careful perioperative management to optimize blood pressure and intravascular volume. We present the anesthetic management of a patient who was diagnosed with bilateral neuroendocrine tumors soon after heart-lung transplantation and underwent successful staged bilateral adrenalectomy.
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41
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Pheochromocytoma in Congenital Cyanotic Heart Disease. Case Rep Endocrinol 2018; 2018:2091257. [PMID: 30356369 PMCID: PMC6176301 DOI: 10.1155/2018/2091257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/03/2018] [Accepted: 09/11/2018] [Indexed: 11/17/2022] Open
Abstract
Studies on genome-wide transcription patterns have shown that many genetic alterations implicated in pheochromocytoma-paraganglioma (P-PGL) syndromes cluster in a common cellular pathway leading to aberrant activation of molecular response to hypoxia in normoxic conditions (the pseudohypoxia hypothesis). Several cases of P-PGL have been reported in patients with cyanotic congenital heart disease (CCHD). Patients affected with CCHD have an increased likelihood of P-PGL compared to those affected with noncyanotic congenital heart disease. One widely supported hypothesis is that chronic hypoxia represents the determining factor supporting this increased risk. We report the case of a 23-year-old woman affected with congenital tricuspid atresia surgically by the Fontan procedure. The patient was admitted to hospital with hypertensive crisis and dyspnea. Chest computed tomography revealed, incidentally, a 6-cm mass in the left adrenal lodge. Increased levels of noradrenaline (NA) and its metabolites were detected (plasma NA 5003.7 pg/ml, n.v.<480; urinary NA 1059.5 µg/24 h, n.v.<85.5; urinary metanephrine 489 µg/24 h, n.v.<320). The patient did not report any additional symptom related to catecholamine excess. The left adrenal tumor showed abnormal accumulation when 131I-metaiodobenzylguanidine scintigraphy was performed. A 18F-fluorodeoxyglucose positron emission tomography showed no significant metabolic activity in the left adrenal gland but intense uptake in the supra- and subdiaphragmatic brown adipose tissue, probably due to noradrenergic-stimulated glucose uptake. The patient underwent left open adrenalectomy after preconditioning with α- and β-blockers and histopathological examination confirmed the diagnosis of pheochromocytoma (Ki-67<5%). Screening for germline mutations did not show any genes mutation (investigated mutations: RET, TMEM127, MAX, SDHD, SDHC, SDHB, SDHAF2, SDHA, and VHL). Clinicians should consider P-PGL when an unexplained clinical deterioration occurs in CCHD patients, even in the absence of typical paroxysmal symptoms.
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42
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Wcislak SM, King WS, Waller BR, Goins N, Dickson PV. Multifocal pheochromocytoma-paraganglioma in a 29-year-old woman with cyanotic congenital heart disease. Surgery 2018; 165:228-231. [PMID: 30340856 DOI: 10.1016/j.surg.2018.08.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/19/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Multifocal pheochromocytoma/paraganglioma presenting at an early age is commonly associated with a hereditary syndrome. CASE REPORT A 29-year-old woman was referred for evaluation of multifocal pheochromocytoma/paraganglioma. Interestingly, her family history did not include pheochromocytoma/paraganglioma, and comprehensive genetic testing for the well-documented pheochromocytoma/paraganglioma susceptibility genes was negative. Of note, this patient had a history of a complex cardiac defect resulting in cyanotic congenital heart disease and had never undergone operative repair. Thus she lived in a chronic hypoxic state with a baseline oxygen saturation of about 80%. Laboratory evaluation found marked increases in plasma norepinephrine and normetanephrines with normal epinephrine and metanephrines. Imaging revealed 4 aortocaval masses and a right adrenal mass. After appropriate preoperative preparation she underwent successful resection of each of the neoplasms, with pathologic testing revealing multifocal pheochromocytoma/paraganglioma. DISCUSSION This case highlights a growing recognition of the potential development of pheochromocytoma/paraganglioma in patients with cyanotic congenital heart disease. The underlying pathophysiology and phenotypic similarities between pheochromocytoma/paraganglioma in patients with cyanotic congenital heart disease and those with mutations that lead to cellular pseudohypoxia are reviewed.
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Affiliation(s)
- Susan M Wcislak
- University of Tennessee Health Science Center, Department of Surgery, Division of Surgical Oncology, Memphis TN
| | | | - Benjamin R Waller
- University of Tennessee Health Science Center, Department of Pediatrics, Division of Cardiology, Memphis TN
| | - Natasha Goins
- University of Tennessee Health Science Center, Department of Surgery, Division of Surgical Oncology, Memphis TN
| | - Paxton V Dickson
- University of Tennessee Health Science Center, Department of Surgery, Division of Surgical Oncology, Memphis TN.
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43
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Turchini J, Cheung VKY, Tischler AS, De Krijger RR, Gill AJ. Pathology and genetics of phaeochromocytoma and paraganglioma. Histopathology 2018; 72:97-105. [PMID: 29239044 DOI: 10.1111/his.13402] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 12/13/2022]
Abstract
Phaeochromocytoma and paraganglioma (PHEO/PGL) are rare tumours with an estimated annual incidence of 3 per million. Advances in molecular understanding have led to the recognition that at least 30-40% arise in the setting of hereditary disease. Germline mutations in the succinate dehydrogenase genes SDHA, SDHB, SDHC, SDHD and SDHAF2 are the most prevalent of the more than 19 hereditary genetic abnormalities which have been reported. It is therefore recommended that, depending on local resources and availability, at least some degree of genetic testing should be offered to all PHEO/PGL patients, including those with clinically sporadic disease. It is now accepted that that all PHEO/PGL have some metastatic potential; therefore, concepts of benign and malignant PHEO/PGL have no meaning and have been replaced by a risk stratification approach. Although there is broad acceptance that certain features, including high proliferative activity, invasive growth, increased cellularity, large tumour nests and comedonecrosis, are associated with an increased risk of metastasis, it remains difficult to predict the clinical behaviour of individual tumours and no single risk stratification scheme is endorsed or in widespread use. In this review, we provide an update on advances in the pathology and genetics of PHEO/PGL with an emphasis on the changes introduced in the WHO 2017 classification of endocrine neoplasia relevant to practising surgical pathologists.
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Affiliation(s)
- John Turchini
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia.,University of Sydney, Sydney, NSW, Australia.,Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Veronica K Y Cheung
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia.,Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Arthur S Tischler
- Department of Pathology and Laboratory Medicine Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Ronald R De Krijger
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Pathology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Anthony J Gill
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, NSW, Australia.,University of Sydney, Sydney, NSW, Australia.,Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Australia
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44
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Song MK, Kim GB, Bae EJ, Lee YA, Kim HY, Min SK, Kim JH, Won JK. Pheochromocytoma and paraganglioma in Fontan patients: Common more than expected. CONGENIT HEART DIS 2018; 13:608-616. [DOI: 10.1111/chd.12625] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/11/2018] [Accepted: 04/19/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Mi Kyoung Song
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul Republic of Korea
| | - Gi Beom Kim
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul Republic of Korea
| | - Eun Jung Bae
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul Republic of Korea
| | - Young Ah Lee
- Department of Pediatrics; Seoul National University Children's Hospital; Seoul Republic of Korea
| | - Hyun-Young Kim
- Department of Pediatric Surgery; Seoul National University College of Medicine; Seoul Republic of Korea
| | - Seung-Kee Min
- Department of Surgery; Seoul National University Hospital; Seoul Republic of Korea
| | - Jung Hee Kim
- Department of Internal Medicine; Seoul National University College of Medicine; Seoul Republic of Korea
| | - Jae-Kyung Won
- Department of Pathology; Seoul National University College of Medicine; Seoul Republic of Korea
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45
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Deshpande SR, Patel P, Videlefsky N, Soler Rodriguez DM, Romero R, Clifton MS. Retroperitoneal paraganglioma in a patient with Fontan: The hypoxia connection. Ann Pediatr Cardiol 2018; 11:197-200. [PMID: 29922019 PMCID: PMC5963236 DOI: 10.4103/apc.apc_172_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Paragangliomas are rare neuroendocrine tumors where hypoxia-inducible factor plays a critical role in tumorigenesis. It has been suggested that patients with congenital heart disease, in particular, may have cellular environment and relative hypoxia favorable to the development of these neuroendocrine tumors. Here, we present a case of an 11-year-old child with hypoplastic left heart syndrome previously palliated with Fontan procedure, diagnosed with paraganglioma on surveillance imaging. We present the clinical course, intervention, and outcome as well as review the possible contributory mechanisms. As we continue to improve long-term survival for single ventricle patients, awareness of these tumors during surveillance may be warranted as timely intervention may lead to cure.
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Affiliation(s)
- Shriprasad R Deshpande
- Department of Pediatrics, Pediatric Cardiology, Heart Failure and Heart Transplantation, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Neill Videlefsky
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Dellys M Soler Rodriguez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA, USA
| | - Rene Romero
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew S Clifton
- Department of Surgery, Division of Pediatric Surgery, Emory University School of Medicine, Atlanta, GA, USA
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46
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Kim TH, Yang HK, Jang HJ, Yoo SJ, Khalili K, Kim TK. Abdominal imaging findings in adult patients with Fontan circulation. Insights Imaging 2018; 9:357-367. [PMID: 29623675 PMCID: PMC5991003 DOI: 10.1007/s13244-018-0609-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/04/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract The Fontan procedures, designed to treat paediatric patients with functional single ventricles, have markedly improved the patient’s survival into adulthood. The physiology of the Fontan circuit inevitably increases systemic venous pressure, which may lead to multi-system organ failure in the long-term follow-up. Fontan-associated liver disease (FALD) can progress to liver cirrhosis with signs of portal hypertension. Focal nodular hyperplasia-like nodules commonly develop in FALD. Imaging surveillance is often performed to monitor the progression of FALD and to detect hepatocellular carcinoma, which infrequently develops in FALD. Other abdominal abnormalities in post-Fontan patients include protein losing enteropathy and pheochromocytoma/paraganglioma. Given that these abdominal abnormalities are critical for patient management, it is important for radiologists to become familiar with the abdominal abnormalities that are common in post-Fontan patients on cross-sectional imaging. Teaching points • Fontan procedure for functional single ventricle has improved patient survival into adulthood. • Radiologists should be familiar with unique imaging findings of Fontan-associated liver disease. • Focal nodular hyperplasia-like nodules commonly develop in Fontan-associated liver disease. • Hepatocellular carcinoma, protein-losing enteropathy, pheochromocytoma/paraganglioma may develop. Electronic supplementary material The online version of this article (10.1007/s13244-018-0609-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tae-Hyung Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongnogu, Seoul, 03080, South Korea
| | - Hyun Kyung Yang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Hyun-Jung Jang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5J2L4, Canada
| | - Korosh Khalili
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Tae Kyoung Kim
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
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47
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Vaidya A, Flores SK, Cheng ZM, Nicolas M, Deng Y, Opotowsky AR, Lourenço DM, Barletta JA, Rana HQ, Pereira MA, Toledo RA, Dahia PLM. EPAS1 Mutations and Paragangliomas in Cyanotic Congenital Heart Disease. N Engl J Med 2018; 378:1259-1261. [PMID: 29601261 PMCID: PMC5972530 DOI: 10.1056/nejmc1716652] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Shahida K Flores
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Zi-Ming Cheng
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Marlo Nicolas
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Yilun Deng
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | | | | | | | | | | | | | - Patricia L M Dahia
- University of Texas Health Science Center at San Antonio, San Antonio, TX
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48
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Rossitti HM, Söderkvist P, Gimm O. Extent of surgery for phaeochromocytomas in the genomic era. Br J Surg 2018; 105:e84-e98. [DOI: 10.1002/bjs.10744] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/15/2017] [Accepted: 10/01/2017] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Germline mutations are present in 20–30 per cent of patients with phaeochromocytoma. For patients who develop bilateral disease, complete removal of both adrenal glands (total adrenalectomy) will result in lifelong adrenal insufficiency with an increased risk of death from adrenal crisis. Unilateral/bilateral adrenal-sparing surgery (subtotal adrenalectomy) offers preservation of cortical function and independence from steroids, but leaves the adrenal medulla in situ and thus at risk of developing new and possibly malignant disease. Here, present knowledge about how tumour genotype relates to clinical behaviour is reviewed, and application of this knowledge when choosing the extent of adrenalectomy is discussed.
Methods
A literature review was undertaken of the penetrance of the different genotypes in phaeochromocytomas, the frequency of bilateral disease and malignancy, and the underlying pathophysiological mechanisms, with emphasis on explaining the clinical phenotypes of phaeochromocytomas and their associated syndromes.
Results
Patients with bilateral phaeochromocytomas most often have multiple endocrine neoplasia type 2 (MEN2) or von Hippel–Lindau disease (VHL) with high-penetrance mutations for benign disease, whereas patients with mutations in the genes encoding SDHB (succinate dehydrogenase subunit B) or MAX (myelocytomatosis viral proto-oncogene homologue-associated factor X) are at increased risk of malignancy.
Conclusion
Adrenal-sparing surgery should be the standard approach for patients who have already been diagnosed with MEN2 or VHL when operating on the first side, whereas complete removal of the affected adrenal gland(s) is generally recommended for patients with SDHB or MAX germline mutations. Routine assessment of a patient's genotype, even after the first operation, can be crucial for adopting an appropriate strategy for follow-up and future surgery.
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Affiliation(s)
- H M Rossitti
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - P Söderkvist
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - O Gimm
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Surgery, County Council of Östergötland, Linköping, Sweden
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49
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50
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Zhao B, Zhou Y, Zhao Y, Zhao Y, Wu X, Bi Y, Luo Y, Ji Z, Rong S. Co-Occurrence of Pheochromocytoma-Paraganglioma and Cyanotic Congenital Heart Disease: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2018; 9:165. [PMID: 29719528 PMCID: PMC5914282 DOI: 10.3389/fendo.2018.00165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/28/2018] [Indexed: 11/20/2022] Open
Abstract
Pheochromocytoma and paraganglioma (PHEO-PGL) and cyanotic congenital heart disease (CCHD) are both rare diseases. We reported a 30-year-old patient with a right adrenal gland nodule and a retroperitoneal mass and history of functional single atrium and ventricle. 123I-metaiodobenzylguanidine scintigraphy showed intense uptake in both lesions. Laboratory investigation demonstrated elevated urinary norepinephrine. Preoperative α-blockade was initiated. A successful open resection of right adrenal and retroperitoneal masses was performed. Pathological examination confirmed PHEO-PGL. Postoperative urinary norepinephrine returned to normal level. A systematic case review in English publications in PubMed and EMBASE suggested a hypothesis that there may exist a possible link between PHEO-PGL and hypoxia from CCHD, which was also indicated in our case. Due to higher risk for PHEO-PGL, a lower threshold of suspicion should be considered in CCHD patients. Therefore, active screening and early treatment of PHEO-PGL are recommended in CCHD patients and clinicians should keep on a long-term follow-up to monitor PHEO-PGL recurrence if hypoxia is not corrected.
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Affiliation(s)
- Bingbin Zhao
- Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Zhou
- Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Zhao
- Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yumo Zhao
- Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xingcheng Wu
- Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yalan Bi
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yufeng Luo
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhigang Ji
- Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shi Rong
- Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Shi Rong,
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