Flow cytometric DNA analysis for determination of malignant potential in adrenal pheochromocytoma or paraganglioma: an Indian experience

Development and validation of pheochromocytoma of the adrenal gland scaled score for predicting malignant pheochromocytomas

OBJECTIVES

To evaluate the diagnostic performances of the pheochromocytoma of the adrenal gland scaled score (PASS) proposed in a previous report and that of a logistic model developed in this investigation.

METHODS

In all 130 patients with malignant or assumed benign pheochromocytomas, 15 predictive variables were observed. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic performance of PASS. The logistic model was developed using the 15 predictive variables. Its performance was evaluated by calculating the area under the ROC curve and comparing it with that of the PASS.

RESULTS

The PASS had the area under the ROC curve of 0.899 (95% confidence interval 0.844 to 0.954). Of the 15 variables entered in the logistic regression analysis, 9 were retained in the model. The area under the ROC curve for the logistic model was 0.983 (95% confidence interval 0.967 to 0.998).

CONCLUSIONS

ROC analysis indicated that the PASS could be used for the diagnosis of malignant pheochromocytomas. The logistic model was able to improve the diagnostic performance of the PASS using a different variable weighting method. We emphasize, however, that a clinical prospective evaluation is needed to confirm their actual value.

Long-term outcome of a large series of patients surgically treated for pheochromocytoma

OBJECTIVE

To analyse the morbidity, mortality and long-term outcome in a consecutive series of surgically treated patients with pheochromocytoma (PC), or paraganglioma (PG), from the western region of Sweden between 1950 and 1997.

PATIENTS

All patients (n = 121) who had been hospitalized and treated for PC/PG over 47 years.

DESIGN

Retrospective review of patients with PC/PG regarding presenting symptoms, tumour characteristics, clinical management and long-term outcome after treatment.

SETTING

One referral centre for all patients from the western region of Sweden.

RESULTS

During an observation of 15 +/- 6 years, 42 patients died vs. 23.6 expected in the general population (P < 0.001). There was no intra- or post-operative mortality. Four patients with sporadic disease died of malignant PC and six with hereditary disease of associated neuroectodermal tumours. Five patients died of other malignancies, 20 of cardiovascular disease and seven of other causes. Besides older age at primary surgery, elevated urinary excretion of methoxy-catecholamines was the only observed risk factor for death (P = 0.02). At diagnosis 85% of the patients were hypertensive; one year after surgery more than half were still hypertensive. However, pre- and post-operative hypertension did not influence the risk for death versus controls.

CONCLUSION

Pheochromocytoma/PG can be safely treated by surgery. Death of malignant PC/PG was unusual, but the patients as a group had an increased risk of death. We recommend life-long follow-up of patients treated for PC/PG with screening for recurrent tumour in sporadic cases and for associated tumours in hereditary cases. This strategy would also be helpful in diagnosing cardiovascular disease at an early stage.

Case report: intra-renal paraganglioma masquerading as a renal cyst

A case is reported in which a 46-year-old normotensive male patient presented with large right-sided painless abdominal mass. On sonography there was a large cyst in the lower pole of right kidney. Intravenous urography showed distortion of pelvicollecting system and medial shift of upper right ureter. Exploration revealed a cystic mass (18 x 15 cm) located in lower pole of right kidney. It contained brownish fluid and because of suspicion of malignancy radical nephrectomy was carried out. Histological examination showed the cystic mass to be adrenal tissue infiltrated by neoplastic cells. Characteristic organoid nests of malignant cells ("Zellaballen" were present. Cells stained positively for chromogranin, neurone specific enolase (NSE), neurofilament, and synaptophysin. Sustentacular cells showed positive reaction to S-100 protein. No further treatment was offered. Patient remains well at 30 months follow-up. On medline search there is record of three cases of intra-renal paraganglioma in English literature and the present case appears to be the fourth one.