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Fagundes GFC, Almeida MQ. Pitfalls in the Diagnostic Evaluation of Pheochromocytomas. J Endocr Soc 2024; 8:bvae078. [PMID: 38737592 PMCID: PMC11087876 DOI: 10.1210/jendso/bvae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Indexed: 05/14/2024] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs), rare neuroendocrine tumors arising from chromaffin cells, present a significant diagnostic challenge due to their clinical rarity and polymorphic symptomatology. The clinical cases demonstrate the importance of an integrated approach that combines clinical assessment, biochemical testing, and imaging to distinguish PPGLs from mimicking conditions, such as obstructive sleep apnea and interfering medication effects, which can lead to false-positive biochemical results. Although a rare condition, false-negative metanephrine levels can occur in pheochromocytomas, but imaging findings can give some clues and increase suspicion for a pheochromocytoma diagnosis. This expert endocrine consult underscores the critical role of evaluating preanalytical conditions and pretest probability in the biochemical diagnosis of PPGLs. Moreover, a careful differentiation of PPGLs from similar conditions and careful selection and interpretation of diagnostic tests, with focus on understanding and reducing false positives to enhance diagnostic accuracy and patient outcomes, is crucial.
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Affiliation(s)
- Gustavo F C Fagundes
- Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Disciplina de Endocrinologia e Metabologia, Departamento de Medicina Interna, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, 01246-903, São Paulo, SP, Brazil
| | - Madson Q Almeida
- Unidade de Adrenal, Laboratório de Endocrinologia Molecular e Celular LIM/25, Disciplina de Endocrinologia e Metabologia, Departamento de Medicina Interna, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, 01246-903, São Paulo, SP, Brazil
- Unidade de Oncologia Endócrina, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, 01246-903, São Paulo, SP, Brazil
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2
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Kwek KJH, Yeo CP, Ho BCS, Kon YC. Small Incidental Pheochromocytoma Presenting With Normal or Borderline High 24-hour Urine Fractionated Metanephrines. JCEM CASE REPORTS 2024; 2:luae035. [PMID: 38487512 PMCID: PMC10939167 DOI: 10.1210/jcemcr/luae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Indexed: 03/17/2024]
Abstract
A 73-year-old man was found to have a 2-cm lipid-poor right adrenal incidentaloma on computed tomography imaging for hematuria. Twenty-four-hour urine metanephrine was 1.1-fold elevated, then normal on repeat measurement. Paired with the second urine collection, plasma metanephrine measured by liquid chromatography tandem mass spectrometry after a 30-minute supine rest was 3.3-fold elevated. Plasma normetanephrine was 1.2-fold elevated. The 24-hour urine catecholamines and normetanephrine, measured twice, were normal. He received low-dose phenoxybenzamine and underwent successful resection of right pheochromocytoma. Postoperatively, both plasma metanephrine and normetanephrine levels normalized, using an age-appropriate upper reference limit for plasma normetanephrine. Patients who harbor small lipid-poor adrenal incidentalomas have a relatively high risk (>5%) of having pheochromocytoma, indistinguishable from adenomas or carcinomas on computed tomography scan. In such cases when 24-hour urine fractionated metanephrines are normal, plasma free metanephrines measured by liquid chromatography tandem mass spectrometry under optimal sampling conditions that are 2-fold or more elevated confirm the diagnosis of pheochromocytoma. Preoperative alpha blockade followed by surgical resection is then appropriate, rather than continued monitoring with repeat urine measurements.
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Affiliation(s)
| | - Chin Pin Yeo
- Department of Clinical Pathology, Singapore General Hospital, 169608, Singapore
| | | | - Yin Chian Kon
- Department of Endocrinology, Tan Tock Seng Hospital, 308433, Singapore
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3
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Paz-López AJ, Rafael-Pérez CI, Llanos-Salas BA, Castañeda-Anaya PS, Gómez-Arenas SR, Nacud-Bezies YA. Detection and Surgical Approach to Pheochromocytoma: A Case Report. Cureus 2024; 16:e55504. [PMID: 38571831 PMCID: PMC10990478 DOI: 10.7759/cureus.55504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
Pheochromocytomas are neuroendocrine tumors that produce, store, and secrete catecholamines. They are found in the chromaffin tissue of the adrenal medulla and manifest clinical symptoms by producing an excessive amount of one or more catecholamines, such as dopamine, adrenaline, and noradrenaline, as well as their inactive metabolites, such as metanephrine, normetanephrine, and 3-methoxytyramine. This paper is the case report of a 53-year-old male patient with diabetes and hypertension who has been experiencing symptoms such as night sweats, frequent colds, weight loss, reduced appetite, and generalized anxiety. The patient presented with pelvic pain and sought medical attention, leading to an abdominal MRI scan that revealed a right adrenal mass. The patient's plasma metanephrine levels were found to be four-fold higher than the normal range. A contrast CT scan of the abdomen and pelvis revealed a right adrenal gland with increased dimensions and well-defined edges. A diagnosis of right adrenal pheochromocytoma was made. The patient underwent a right laparoscopic adrenalectomy, which resulted in a reduction in metanephrine levels and normal blood pressure readings. The patient presented a favorable clinical evolution in the post-surgical period, for which it was decided to be discharged home.
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Affiliation(s)
- Alexis Jared Paz-López
- Departamento de cirugía digestiva y endocrina, Unidad Médica de Alta Especialidad No. 25, Monterrey, MEX
| | | | - Brenda Aurora Llanos-Salas
- Departamento de cirugía digestiva y endocrina, Unidad Médica de Alta Especialidad No. 25, Monterrey, MEX
| | | | | | - Yamir Ahmed Nacud-Bezies
- Departamento de cirugía digestiva y endocrina, Unidad Médica de Alta Especialidad No. 25, Monterrey, MEX
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4
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King TFJ, Mok Y, Dacay LM, Wong HS, Hsu PP, Tan A, Wong KM, Saffari SE, Lenders JWM, Puar TH. Plasma Metanephrines Yield Fewer False-Positive Results Than Urine Metanephrines in Patients With Obstructive Sleep Apnea. J Clin Endocrinol Metab 2024; 109:844-851. [PMID: 37721483 DOI: 10.1210/clinem/dgad553] [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: 03/15/2023] [Revised: 06/08/2023] [Accepted: 09/16/2023] [Indexed: 09/19/2023]
Abstract
CONTEXT Obstructive sleep apnea (OSA) is associated with increased nocturnal sympathetic activity. In OSA patients, elevations in metanephrines may lead to false-positive tests when evaluating for pheochromocytoma or paraganglioma (PPGL). OBJECTIVE To evaluate whether morning plasma metanephrines would lead to fewer false-positive results than 24-hour urinary metanephrines in OSA patients. METHODS Patients undergoing polysomnography for suspected OSA were recruited. Plasma free and 24-hour urinary metanephrines were measured by HPLC-MS/MS. Patients with elevated levels had repeat measurements, abdominal imaging, and follow-up to diagnose or exclude a PPGL. RESULTS Seventy-six patients completed polysomnography and biochemical testing; 68 (89.5%) patients had OSA, of whom 19 (27.9%) had elevated plasma and/or urinary metanephrines. On follow-up, one patient had a bladder paraganglioma, while PPGL was excluded in the remaining patients. OSA patients had more false-positive urinary metanephrines (17 of 67, 25.4%) than plasma metanephrines (2 of 67, 3.0%), P < .01, and this was more common in severe OSA (13 of 34, 38.2%), compared to moderate/mild OSA (4 of 33, 12.1%), P < .01. Both plasma and urinary metanephrines decreased after treatment with continuous positive airway pressure. On multivariable analysis, severe OSA, obesity, and family history of hypertension were positive predictors for false-positive urinary metanephrines in patients with suspected OSA. CONCLUSION In OSA patients, plasma metanephrines are less likely to yield false-positive results for the diagnosis of PPGL than 24-hour urinary metanephrines. In patients with suspected OSA, obesity, or a family history of hypertension, plasma metanephrines may be the preferred first-line test to avoid unnecessary anxiety or follow-up.
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Affiliation(s)
- Thomas F J King
- Department of Endocrinology, Changi General Hospital, Singapore 529889, Singapore
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore 169547, Singapore
| | - Yingjuan Mok
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore 529889, Singapore
- Department of Sleep Medicine, Surgery and Science, Changi General Hospital, Singapore 529889, Singapore
| | - Lily Mae Dacay
- Department of Endocrinology, Changi General Hospital, Singapore 529889, Singapore
| | - Hang Siang Wong
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore 529889, Singapore
- Department of Sleep Medicine, Surgery and Science, Changi General Hospital, Singapore 529889, Singapore
| | - Pon Poh Hsu
- Department of Otorhinolaryngology, Changi General Hospital, Singapore 529889, Singapore
| | - Alvin Tan
- Department of Otorhinolaryngology, Changi General Hospital, Singapore 529889, Singapore
| | - Kang Min Wong
- Department of Radiology, Changi General Hospital, Singapore 529889, Singapore
| | - Seyed Ehsan Saffari
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore 169547, Singapore
- Department of Neurology, National Neuroscience Institute, Singapore 308433, Singapore
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Troy H Puar
- Department of Endocrinology, Changi General Hospital, Singapore 529889, Singapore
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore 169547, Singapore
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Eisenhofer G, Pamporaki C, Lenders JWM. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev 2023; 44:862-909. [PMID: 36996131 DOI: 10.1210/endrev/bnad011] [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: 09/28/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
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6
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Boot CS. A Laboratory Medicine Perspective on the Investigation of Phaeochromocytoma and Paraganglioma. Diagnostics (Basel) 2023; 13:2940. [PMID: 37761307 PMCID: PMC10529273 DOI: 10.3390/diagnostics13182940] [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: 07/03/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Phaeochromocytomas (PC) and sympathetic paragangliomas (PGL) are potentially malignant tumours arising from the adrenal medulla (PC) or elsewhere in the sympathetic nervous system (PGL). These tumours usually secrete catecholamines and are associated with significant morbidity and mortality, so accurate and timely diagnosis is essential. The initial diagnosis of phaeochromocytoma/paraganglioma (PPGL) is often dependent on biochemical testing. There is a range of pre-analytical, analytical and post-analytical factors influencing the analytical and diagnostic performance of biochemical tests for PPGL. Pre-analytical factors include patient preparation, sample handling and choice of test. Analytical factors include choice of methodology and the potential for analytical interference from medications and other compounds. Important factors in the post-analytical phase include provision of appropriate reference ranges, an understanding of the potential effects of various medications on metanephrine concentrations in urine and plasma and a consideration of PPGL prevalence in the patient population being tested. This article reviews these pre-analytical, analytical and post-analytical factors that must be understood in order to provide effective laboratory services for biochemical testing in the diagnosis of PPGL.
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Affiliation(s)
- Christopher S Boot
- Department of Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
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Ceccato F, Correa R, Livhits M, Falhammar H. Editorial: Predictive tools in pheochromocytoma and paraganglioma. Front Endocrinol (Lausanne) 2023; 14:1227543. [PMID: 37383393 PMCID: PMC10298152 DOI: 10.3389/fendo.2023.1227543] [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: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/30/2023] Open
Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padua, Padua, Italy
| | - Ricardo Correa
- Endocrinology, Diabetes and Metabolism, The University of Arizona College of Medicine Phoenix, Phoenix, AZ, United States
| | - Masha Livhits
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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8
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Bradshaw C, Abounasr A, Brunsing RL, Kao CS, Reejhsinghani R, Annes JP, Chung BI, Mihm F, Bhalla V. Rare Presentation of Paroxysmal High B-Pee. Hypertension 2023; 80:679-684. [PMID: 36794582 DOI: 10.1161/hypertensionaha.122.20790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Affiliation(s)
- Christina Bradshaw
- Stanford Hypertension Center (C.B., J.P.A., F.M., V.B.), Stanford University School of Medicine, CA
| | - Aya Abounasr
- Department of Anesthesiology, Perioperative and Pain Medicine (A.A., F.M.), Stanford University School of Medicine, CA
| | - Ryan L Brunsing
- Department of Radiology (R.L.B.), Stanford University School of Medicine, CA
| | - Chia-Sui Kao
- Department of Pathology (C.-S.K.), Stanford University School of Medicine, CA
| | - Risheen Reejhsinghani
- Division of Cardiovascular Medicine, Department of Medicine (R.R.), Stanford University School of Medicine, CA
| | - Justin P Annes
- Stanford Hypertension Center (C.B., J.P.A., F.M., V.B.), Stanford University School of Medicine, CA.,Division of Endocrinology, Department of Medicine (J.P.A.), Stanford University School of Medicine, CA
| | - Benjamin I Chung
- Department of Urology (B.I.C.), Stanford University School of Medicine, CA
| | - Frederick Mihm
- Stanford Hypertension Center (C.B., J.P.A., F.M., V.B.), Stanford University School of Medicine, CA.,Department of Anesthesiology, Perioperative and Pain Medicine (A.A., F.M.), Stanford University School of Medicine, CA
| | - Vivek Bhalla
- Stanford Hypertension Center (C.B., J.P.A., F.M., V.B.), Stanford University School of Medicine, CA.,Division of Nephrology, Department of Medicine (V.B.), Stanford University School of Medicine, CA
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9
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van den Berg MF, Kooistra HS, Grinwis GCM, van Nimwegen SA, van Faassen M, Kema IP, Teske E, Galac S. Reference intervals for plasma, urinary, and salivary concentrations of free metanephrines in dogs: Relevance to the diagnosis of pheochromocytoma. Vet Med (Auckl) 2023; 37:173-183. [PMID: 36637037 PMCID: PMC9889674 DOI: 10.1111/jvim.16624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 12/15/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Measurement of free metanephrines is recommended for screening of pheochromocytoma (PCC) but requires appropriate reference intervals (RIs). HYPOTHESIS/OBJECTIVES To report RIs for plasma, urinary and salivary concentrations of free metanephrines and to determine the diagnostic performance of plasma free normetanephrine (pNMN) and metanephrine (pMN) concentrations in dogs with PCC, hypercortisolism (HC), and nonadrenal illness (NAI). ANIMALS Eighty healthy dogs, 11 PCC dogs, 25 HC dogs, 6 NAI dogs. METHODS Plasma, urine, and saliva were collected prospectively from healthy dogs, and free metanephrine concentrations were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS). In addition, medical records of dogs that had plasma free metanephrine concentrations measured by LC-MS/MS between 2018-2021 were studied retrospectively. RESULTS The RIs for free metanephrines in plasma, urine and saliva are reported. Dogs with PCC had significantly higher pNMN than dogs with HC (P < .001) and NAI (P = .002). The PCC dogs had significantly higher pMN than HC dogs (P < .001), but not higher than NAI dogs (P = .29). Using the upper reference limit, pNMN (>3.56 nmol/L) showed high sensitivity (100%, 95% confidence interval [CI]: 72-100) and specificity (94%, 95% CI: 79-99) for diagnosis of PCC, whereas pMN (>2.49 nmol/L) showed moderate sensitivity (73%, 95% CI: 39-94) and high specificity (94%, 95% CI: 79-99). CONCLUSIONS AND CLINICAL IMPORTANCE With establishment of these RIs, biochemical testing for PCC in dogs can be substantially improved. Measurement of pNMN is superior to pMN in dogs with PCC.
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Affiliation(s)
- Marit F. van den Berg
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Hans S. Kooistra
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Guy C. M. Grinwis
- Department of Biomolecular Health Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | | | - Martijn van Faassen
- Department of Laboratory MedicineUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Ido P. Kema
- Department of Laboratory MedicineUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Erik Teske
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
| | - Sara Galac
- Department of Clinical Sciences, Faculty of Veterinary MedicineUtrecht UniversityUtrechtThe Netherlands
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Tsiomidou S, Pamporaki C, Geroula A, Van Baal L, Weber F, Dralle H, Schmid KW, Führer D, Unger N. Clonidine suppression test for a reliable diagnosis of pheochromocytoma: When to use. Clin Endocrinol (Oxf) 2022; 97:541-550. [PMID: 35274752 DOI: 10.1111/cen.14724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In clinical practice, false-positive results in biochemical testing for suspected pheochromocytoma/paraganglioma (PPGL) are not infrequent and may lead to unnecessary examinations. We aimed to evaluate the role of the clonidine suppression test (CST) in the era of analyses of plasma-free metanephrines for the diagnosis or exclusion of PPGL in patients with adrenal tumours and/or arterial hypertension. DESIGN AND METHODS This single-centre, prospective trial investigated the use of CST in 60 patients with suspected PPGL associated with out-patient elevations of plasma normetanephrine (NMN) and/or metanephrine (MN), in most cases accompanied with hypertension or an adrenal mass. Measurements of plasma catecholamines and free metanephrines were performed by liquid chromatography with electrochemical detection and tandem mass spectrometry, respectively. RESULTS Forty-six patients entered final analysis (n = 20 with PPGL and n = 26 with a nonfunctional adrenal mass and/or hypertension). CST reliably excluded false-positive baseline NMN results with a specificity of 100%. The sensitivity of CST improved from 85% to 94% when tumours with isolated MN increase (n = 3) were not considered. In patients with elevated baseline NMN (n = 24), CST correctly identified all patients without PPGL. Patients with falsely elevated baseline NMN results (n = 7, 26.9%) exhibited increases of baseline NMN up to 1.7-fold above the upper reference limit. CONCLUSION CST qualifies as a useful diagnostic tool for differential diagnosis of borderline elevated plasma-free NMN in patients with suspected PPGL. In this context, CST helps to correctly identify all false-positive NMN screening results.
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Affiliation(s)
- Spyridoula Tsiomidou
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Aikaterini Geroula
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lukas Van Baal
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Frank Weber
- Division of Endocrine Surgery, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Henning Dralle
- Division of Endocrine Surgery, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Kurt W Schmid
- Institute of Pathology, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicole Unger
- Department of Endocrinology, Diabetes and Metabolism, Endocrine Tumour Centre at WTZ and Member of ENDO-ERN, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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11
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Zeng HL, Wang X, Li HJ, Yang Q. Quantitative analysis of catecholamines and their metabolites in 491 patients with adrenal tumors: a retrospective single-center cohort study. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04448-6. [DOI: 10.1007/s00432-022-04448-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
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12
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Noortman WA, Vriens D, de Geus-Oei LF, Slump CH, Aarntzen EH, van Berkel A, Timmers HJLM, van Velden FHP. [ 18F]FDG-PET/CT radiomics for the identification of genetic clusters in pheochromocytomas and paragangliomas. Eur Radiol 2022; 32:7227-7236. [PMID: 36001126 PMCID: PMC9474528 DOI: 10.1007/s00330-022-09034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/15/2022] [Accepted: 07/16/2022] [Indexed: 11/04/2022]
Abstract
Objectives Based on germline and somatic mutation profiles, pheochromocytomas and paragangliomas (PPGLs) can be classified into different clusters. We investigated the use of [18F]FDG-PET/CT radiomics, SUVmax and biochemical profile for the identification of the genetic clusters of PPGLs. Methods In this single-centre cohort, 40 PPGLs (13 cluster 1, 18 cluster 2, 9 sporadic) were delineated using a 41% adaptive threshold of SUVpeak ([18F]FDG-PET) and manually (low-dose CT; ldCT). Using PyRadiomics, 211 radiomic features were extracted. Stratified 5-fold cross-validation for the identification of the genetic cluster was performed using multinomial logistic regression with dimensionality reduction incorporated per fold. Classification performances of biochemistry, SUVmax and PET(/CT) radiomic models were compared and presented as mean (multiclass) test AUCs over the five folds. Results were validated using a sham experiment, randomly shuffling the outcome labels. Results The model with biochemistry only could identify the genetic cluster (multiclass AUC 0.60). The three-factor PET model had the best classification performance (multiclass AUC 0.88). A simplified model with only SUVmax performed almost similarly. Addition of ldCT features and biochemistry decreased the classification performances. All sham AUCs were approximately 0.50. Conclusion PET radiomics achieves a better identification of PPGLs compared to biochemistry, SUVmax, ldCT radiomics and combined approaches, especially for the differentiation of sporadic PPGLs. Nevertheless, a model with SUVmax alone might be preferred clinically, weighing model performances against laborious radiomic analysis. The limited added value of radiomics to the overall classification performance for PPGL should be validated in a larger external cohort. Key Points • Radiomics derived from [18F]FDG-PET/CT has the potential to improve the identification of the genetic clusters of pheochromocytomas and paragangliomas. • A simplified model with SUVmaxonly might be preferred clinically, weighing model performances against the laborious radiomic analysis. • Cluster 1 and 2 PPGLs generally present distinctive characteristics that can be captured using [18F]FDG-PET imaging. Sporadic PPGLs appear more heterogeneous, frequently resembling cluster 2 PPGLs and occasionally resembling cluster 1 PPGLs. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-022-09034-5.
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Affiliation(s)
- Wyanne A Noortman
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands. .,TechMed Centre, University of Twente, Enschede, the Netherlands.
| | - Dennis Vriens
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands.,TechMed Centre, University of Twente, Enschede, the Netherlands.,Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Erik H Aarntzen
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anouk van Berkel
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Henri J L M Timmers
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Floris H P van Velden
- Department of Radiology, Section of Nuclear Medicine, Leiden University Medical Center, Leiden, the Netherlands
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13
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Remde H, Pamporaki C, Quinkler M, Nölting S, Prejbisz A, Timmers HJLM, Masjkur J, Fuss CT, Fassnacht M, Eisenhofer G, Deutschbein T. Improved Diagnostic Accuracy of Clonidine Suppression Testing Using an Age-Related Cutoff for Plasma Normetanephrine. Hypertension 2022; 79:1257-1264. [PMID: 35378989 DOI: 10.1161/hypertensionaha.122.19019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Moderately elevated plasma normetanephrine (NMN) levels are frequent among patients with suspected pheochromocytoma and paraganglioma (PPGL). Clonidine suppression testing (CST) is recommended to distinguish patients with from those without PPGL. We aimed at evaluating the diagnostic outcome of CST in patients with moderate NMN elevations. METHODS Data from patients participating in the PMT study (Prospective Monoamine-Producing Tumor) and the ENSAT (European Network for the Study of Adrenal Tumours) registry in 6 European reference centers were analyzed retrospectively. Eighty-nine patients with suspected PPGL and moderate NMN elevations upon screening were included. During follow-up, PPGL was confirmed in 16 and excluded in 73 cases. Plasma NMN was measured by liquid chromatography tandem mass spectrometry before and 180 minutes after oral clonidine. Receiver operating characteristic analysis was performed to identify optimal cutoffs. RESULTS If published diagnostic criteria for CST (ie, NMN ≥112 ng/L and NMN suppression <40%) were applied, a sensitivity of 88% (CI, 61%-98%) and a specificity of 97% (CI, 90%-100%) were observed. An improved cutoff for plasma NMN 180 minutes after clonidine was established at 80% of the age-related upper limit of normal, resulting in a sensitivity of 94% and a specificity of 97%. False-negative CST results occurred in 2 patients with small PPGL. CONCLUSIONS This study, involving one of the largest cohorts of patients with suspected PPGL and moderately elevated NMN, confirmed the diagnostic accuracy of CST. The application of an adapted cutoff further improved sensitivity.
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Affiliation(s)
- Hanna Remde
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany (H.R., C.T.F., M.F., T.D.)
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (C.P., J.M., G.E.)
| | | | - Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich and University of Zurich, Switzerland (S.N.).,Department of Medicine IV, University Hospital, LMU Munich, Germany (S.N.)
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland (A.P.)
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands (H.J.L.M.T.)
| | - Jimmy Masjkur
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (C.P., J.M., G.E.)
| | - Carmina T Fuss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany (H.R., C.T.F., M.F., T.D.)
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Germany (H.R., C.T.F., M.F., T.D.)
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (C.P., J.M., G.E.).,Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (G.E.)
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14
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Remde H, Kimpel O, Fassnacht M. [Adrenal incidentaloma - differential diagnosis and management]. Dtsch Med Wochenschr 2022; 147:85-91. [PMID: 35100640 DOI: 10.1055/a-1370-6005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Adrenal masses are common incidental findings on imaging procedures.In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but in up to 20 % they require therapeutic intervention. The aim of this article is to provide essential guidance for clinicians regarding clinical management of patients with adrenal incidentalomas based on the respective current clinical guidelines. The following main questions are addressed: How to distinguish a nonfunctioning incidentaloma from a functioning one and how to assess risk of malignancy? How to define and manage low-level autonomous cortisol secretion, formerly called "subclinical" Cushing's syndrome? Which patients have to be treated surgically and which approach should be used? What follow-up is indicated if the adrenal incidentaloma is not surgically removed?
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15
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Smy L, Kushnir MM, Frank EL. A high sensitivity LC-MS/MS method for measurement of 3-methoxytyramine in plasma and associations between 3-methoxytyramine, metanephrines, and dopamine. J Mass Spectrom Adv Clin Lab 2021; 21:19-26. [PMID: 34820673 PMCID: PMC8601001 DOI: 10.1016/j.jmsacl.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/27/2022] Open
Abstract
3-methoxytyramine (3MT) aids diagnosis of dopamine-producing tumors and metastases. A sensitive and specific LC-MS/MS method was developed to measure 3MT in plasma. 3MT was elevated in 46% of samples with elevated metanephrine and normetanephrine. 3MT concentrations correlated the strongest with normetanephrine concentrations.
Introduction Diagnosis of pheochromocytoma and paraganglioma (PPGL) is aided by the measurement of metanephrine (MN) and normetanephrine (NMN). Research suggests that 3-methoxytyramine (3MT), a dopamine (DA) metabolite, may serve as a biomarker of metastasis in patients with paraganglioma. Considering the very low endogenous plasma 3MT concentrations (<0.1 nM), highly sensitive and specific methods for 3MT are needed. Methods We developed a simple method for measurement of 3MT. Sample preparation was performed using solid phase micro-extraction with the eluates injected directly onto the LC-MS/MS. Data acquisition was performed in multiple reaction monitoring mode with an instrumental analysis time of 3 min per sample. We evaluated the method’s performance and analyzed samples from healthy individuals and pathological specimens. Results The limit of quantitation and upper limit of linearity were 0.03 nM and 20 nM, respectively. The intra-/inter-day imprecision for pooled plasma samples at concentrations of 0.04 nM, 0.2 nM, and 2 nM was 10.7%/18.3%, 4.5%/8.9%, and 3.1%/0.9%, respectively. Among samples with MN, NMN, or both MN and NMN above the reference intervals (RIs), 0%, 16% and 46%, respectively, showed 3MT greater than the proposed upper RI value of 0.1 nM; 12% of samples with DA above the RI had 3MT above 0.1 nM. Conclusions The developed method allowed accurate quantitation of 3MT in patient samples and would provide valuable information to clinicians diagnosing or monitoring patients with PPGL. High 3MT concentrations in patient samples with MN and NMN within the respective RIs may alert clinicians of the possibility of a DA-producing tumor.
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Key Words
- 3-Methoxytryamine
- 3MT, 3-methoxytyramine
- 3MT-d4, deuterated 3-methoxytyramine
- CE, collision energy
- CI, confidence interval
- COMT, catechol-O-methyltransferase
- CV, coefficient of variation
- CXP, collision cell exit potential
- DA, dopamine
- DBH, dopamine-β-hydroxylase
- DP, declustering potential
- Dopamine
- EDTA, ethylenediaminetetraacetic acid
- HCl, hydrochloride
- HPLC, high-performance liquid chromatography
- IQR, interquartile range
- IS, internal standard
- LC-MS/MS, liquid-chromatography tandem mass spectrometry
- LOQ, limit of quantification
- Liquid-chromatography tandem mass spectrometry
- MAO, monoamine oxidase
- MN, metanephrine
- MN-d3, deuterated metanephrine
- NMN, normetanephrine
- NMN-d3, deuterated normetanephrine
- PPGL, pheochromocytoma and paraganglioma
- Paraganglioma
- Pheochromocytoma
- Plasma
- RI, reference interval
- SD, standard deviation
- SDHx, succinate dehydrogenase genes
- SPE, solid phase extraction
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Affiliation(s)
- Laura Smy
- Department of Pathology, University of Utah Health School of Medicine, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Mark M Kushnir
- ARUP Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Elizabeth L Frank
- Department of Pathology, University of Utah Health School of Medicine, 500 Chipeta Way, Salt Lake City, UT 84108, USA
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16
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Eijkelenkamp K, van Geel EH, Kerstens MN, van Faassen M, Kema IP, Links TP, van der Horst-Schrivers ANA. Blood sampling for metanephrines comparing venipuncture vs. indwelling intravenous cannula in healthy subjects. Clin Chem Lab Med 2021; 58:1681-1686. [PMID: 32324153 DOI: 10.1515/cclm-2020-0022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/12/2020] [Indexed: 01/04/2023]
Abstract
Background To diagnose pheochromocytoma or sympathetic paraganglioma, guidelines recommend blood sampling after at least 30 min of supine rest and using an indwelling intravenous cannula is preferred. Although blood sampling by venipuncture is more convenient and cost-effective, it is unknown whether venipuncture affects plasma concentrations of free metanephrines (MNs). We therefore investigated whether there is a difference in plasma concentrations of free MNs collected by venipuncture or by an intravenous cannula. Methods We included 22 healthy participants (12 men and 10 women, median age 26 years). We collected blood using an indwelling cannula and venipuncture to determine plasma concentrations of free MNs and catecholamines, and calculated the median of the individually calculated absolute and relative differences. Results Plasma concentrations of free MN, normetanephrine (NMN) and epinephrine were higher with blood sampling using venipuncture compared to that when using an indwelling cannula. The median (interquartile range [IQR]) difference was MN 0.020 (-0.004 to 0.040) nmol/L, median percentage difference 20.5% (-2.4 to 35.2%), NMN 0.019 (-0.004 to 0.077) nmol/L, median percentage difference 4.6% (-1.1 to 25.4%) and epinephrine 0.022 (0.007-0.079) nmol/L, median percentage difference 24.9% (7.8-83.3%). When the two sampling conditions were compared, plasma-free 3-methoxytyramine (3-MT), norepinephrine and dopamine concentrations did not differ. Conclusions Blood sampling by venipuncture resulted in statistically significant higher concentrations of MN, NMN and epinephrine compared to sampling by means of an indwelling cannula. However, differences were small. For most patients it seems justifiable to collect blood via venipuncture.
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Affiliation(s)
- Karin Eijkelenkamp
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eva H van Geel
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martijn van Faassen
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thera P Links
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anouk N A van der Horst-Schrivers
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Emergency Medicine, Maastricht University Medical Center and Maastricht University, Maastricht, The Netherlands
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17
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Kline GA, Boyd J, Polzin B, Harvey A, Pasieka JL, Sadrzadeh HSM, Leung AA. Properly Collected Plasma Metanephrines Excludes PPGL After False-Positive Screening Tests. J Clin Endocrinol Metab 2021; 106:e2900-e2906. [PMID: 33846745 DOI: 10.1210/clinem/dgab241] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT False-positive results are common for pheochromocytoma/paraganglioma (PPGL) real-world screening. OBJECTIVE Determine the correlation between screening urine and seated plasma metanephrines in outpatients where PPGL was absent, compared to meticulously prepared and supine-collected plasma metanephrines with age-adjusted references. DESIGN Retrospective cohort study. SETTING Databases from a single-provider provincial laboratory (2012-2018), a validated PPGL registry, and a manual chart review from a specialized endocrine testing unit. PATIENTS PPGL registry data excluded known PPGL cases from the laboratory database. Outpatients having both urine and plasma metanephrines <90 days apart. METHODS The correlation between urine and seated plasma measures along with the total positivity rate. All cases of plasma metanephrines drawn in the endocrine unit were reviewed for test indication and test positivity rate. RESULTS There were 810 non-PPGL pairs of urine and plasma metanephrines in the laboratory database; 46.1% of urine metanephrines were reported high. Of seated outpatient plasma metanephrines drawn a median of 5.9 days later, 19.2% were also high (r = 0.33 and 0.50 for normetanephrine and metanephrine, respectively). In contrast, the meticulously prepared and supine collected patients (n = 139, 51% prior high urine metanephrines) had <3% rate of abnormal high results in patients without known PPGL/adrenal mass. CONCLUSIONS There was a poor-to-moderate correlation between urine and seated plasma metanephrines. Up to 20% of those with high urine measures also had high seated plasma metanephrines in the absence of PPGL. Properly prepared and collected supine plasma metanephrines had a false-positive rate of <3% in the absence of known PPGL/adrenal mass.
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Affiliation(s)
- Gregory A Kline
- Cumming School of Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Jessica Boyd
- Department of Clinical Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
- Alberta Precision Laboratories, Calgary, Canada
| | | | - Adrian Harvey
- Cumming School of Medicine, Department of Surgery, University of Calgary, Calgary, Canada
| | - Janice L Pasieka
- Cumming School of Medicine, Department of Surgery, University of Calgary, Calgary, Canada
| | - Hossein S M Sadrzadeh
- Department of Clinical Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
- Alberta Precision Laboratories, Calgary, Canada
| | - Alexander A Leung
- Cumming School of Medicine, Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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18
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Voltan G, Boscaro M, Armanini D, Scaroni C, Ceccato F. A multidisciplinary approach to the management of adrenal incidentaloma. Expert Rev Endocrinol Metab 2021; 16:201-212. [PMID: 34240680 DOI: 10.1080/17446651.2021.1948327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/23/2021] [Indexed: 01/15/2023]
Abstract
An adrenal incidentaloma (AI) is an adrenal neoplasm incidentally discovered during an imaging unrelated to suspected adrenal disease. The aim of the present review is to offer practical guidance on the multidisciplinary approach of AIs.Areas covered:The prevalence of AI is high in the aging population (up to 5-8%); however, hormonally active or malignant conditions are rare. After the discovery of an AI, it is suggested to assess in parallel if the mass is potentially malignant and functionally active. The answer to the former question is mainly based on medical history (extra-adrenal malignancies, new-onset of signs or symptoms) and imaging (conventional radiology and/or nuclear medicine). The answer to the latter question is a complete endocrine evaluation of both cortical (glucocorticoids, mineralocorticoids) and medullary (catecholamines) secretion.Expert opinion:A multidisciplinary discussion is suggested for patients with adrenal disease, after the exclusion of nonfunctioning benign cortical adenoma, in order to plan a close and tailored follow-up for the suspected malignant or functioning forms. Surgery is advised for patients with malignant disease (adrenocortical cancer) or with clinically relevant secreting neoplasm (primary aldosteronism, Cushing's syndrome, and pheochromocytoma).
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Affiliation(s)
- Giacomo Voltan
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Decio Armanini
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
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19
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Eijkelenkamp K, Osinga TE, van Faassen M, Kema IP, Kerstens MN, Pacak K, Sluiter WJ, Links TP, van der Horst-Schrivers ANA. Diagnostic Accuracy of Salivary Metanephrines in Pheochromocytomas and Paragangliomas. Clin Chem 2021; 67:1090-1097. [PMID: 34096581 DOI: 10.1093/clinchem/hvab064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/24/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Measurements of plasma free metanephrines are recommended for diagnosing pheochromocytomas and paragangliomas (PPGL). Metanephrines can be detected in saliva with LC-MS/MS with sufficient analytical sensitivity and precision. Because collecting saliva is noninvasive and less cumbersome than plasma or urine sampling, we assessed the diagnostic accuracy of salivary metanephrines in diagnosing PPGL. METHODS This 2-center study included 118 healthy participants (44 men; mean age: 33 years (range: 19--74 years)), 44 patients with PPGL, and 54 patients suspected of PPGL. Metanephrines were quantified in plasma and saliva using LC-MS/MS. Diagnostic accuracy; correlation between plasma and salivary metanephrines; and potential factors influencing salivary metanephrines, including age, sex, and posture during sampling, were assessed. RESULTS Salivary metanephrines were significantly higher in patients with PPGL compared with healthy participants (metanephrine (MN): 0.19 vs 0.09 nmol/L, P < 0.001; normetanephrine (NMN): 2.90 vs 0.49 nmol/L, P < 0.001). The diagnostic sensitivity and specificity of salivary metanephrines were 89% and 87%, respectively. Diagnostic accuracy of salivary metanephrines was 88%, with an area under the ROC curve of 0.880. We found a significant correlation between plasma and salivary metanephrines (Pearson correlation coefficient: MN, 0.86, P < 0.001; NMN, 0.83, P < 0.001). Salivary NMN concentrations were higher when collected in a seated position compared with supine (P < 0.001) and increased with age (P < 0.001). CONCLUSIONS Salivary metanephrines are a promising tool in the biochemical diagnosis of PPGL. Salivary metanephrines correlate with plasma free metanephrines and are increased in patients with PPGL. At this time, however, salivary metanephrines cannot replace measurement of plasma free metanephrines.
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Affiliation(s)
- Karin Eijkelenkamp
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thamara E Osinga
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Martijn van Faassen
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Wim J Sluiter
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thera P Links
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Anouk N A van der Horst-Schrivers
- Department of Endocrinology and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Internal Medicine, Division of Endocrinology, Maastricht University Medical Center, Maastricht, the Netherlands
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20
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Peitzsch M, Novos T, Kaden D, Kurlbaum M, van Herwaarden AE, Müller D, Adaway J, Grouzmann E, McWhinney B, Hoad K, Woollard G, Kema I, Boot C, Fassnacht M, Sweep F, Loh TP, Horvath AR, Eisenhofer G. Harmonization of LC-MS/MS Measurements of Plasma Free Normetanephrine, Metanephrine, and 3-Methoxytyramine. Clin Chem 2021; 67:1098-1112. [PMID: 33993248 DOI: 10.1093/clinchem/hvab060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/19/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Plasma-free normetanephrine and metanephrine (metanephrines) are the recommended biomarkers for testing of pheochromocytoma and paraganglioma (PPGL). This study evaluated the status of harmonization of liquid chromatography-tandem mass spectrometry-based measurements of plasma metanephrines and methoxytyramine and clinical interpretation of test results. METHODS 125 plasma samples from patients tested for PPGLs were analyzed in 12 laboratories. Analytical performance was also assessed from results of a proficiency-testing program. Agreement of test results from different laboratories was assessed by Passing-Bablok regression and Bland-Altman analysis. Agreement in clinical test interpretation based on laboratory specific reference intervals was also examined. RESULTS Comparisons of analytical test results by regression analysis revealed strong correlations for normetanephrine and metanephrine (R ≥ 0.95) with mean slopes of 1.013 (range 0.975-1.078), and 1.019 (range 0.963-1.081), and intercepts of -0.584 (-53.736 to 54.790) and -3.194 (-17.152 to 5.933), respectively. The mean bias between methods was 1.2% (-11.6% to 16.0%) for metanephrine and 0.1% (-18.0% to 9.5%) for normetanephrine. Measurements of 3-methoxytyramine revealed suboptimal agreement between laboratories with biases ranging from -32.2% to 64.0%. Interrater agreement in test interpretation was >94% for metanephrine and >84% for normetanephrine; improvements in interrater agreement were observed with use of harmonized reference intervals, including age-specific cut-offs for normetanephrine. CONCLUSIONS Analytical methods for metanephrines are well harmonized between laboratories. However, the 16% disagreement in test interpretation for normetanephrine suggests use of suboptimal method-dependent reference intervals for clinical decision-making for this metabolite. Improved analytical methods and reference interval harmonization are particularly required for 3-methoxytyramine.
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Affiliation(s)
- Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Talia Novos
- Department of Clinical Chemistry, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, Australia
| | - Denise Kaden
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Max Kurlbaum
- Department of Endocrinology and Diabetology, Julius-Maximilians-Universität Wuerzburg, Wuerzburg, Germany
| | | | - Daniel Müller
- Institute for Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland
| | - Jo Adaway
- Department of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Eric Grouzmann
- Département Médecine de Laboratoire et Pathologie, Laboratoire des Catécholamines et Peptides, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Brett McWhinney
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Kirsten Hoad
- PathWest Laboratory, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Gerald Woollard
- Department of Pathology and Laboratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ido Kema
- Department of Laboratory Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Christopher Boot
- Department of Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Martin Fassnacht
- Department of Endocrinology and Diabetology, Julius-Maximilians-Universität Wuerzburg, Wuerzburg, Germany
| | - Fred Sweep
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tze P Loh
- Department of Laboratory Medicine, National University Hospital Singapore, Singapore
| | - Andrea R Horvath
- Department of Clinical Chemistry, New South Wales Health Pathology, Prince of Wales Hospital, Sydney, Australia
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Internal Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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21
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Fowler D, Irving H, Borzi P, Trnka P, Huynh T. A Rare and Unusual Cause of Unilateral Ureteric Obstruction in a Child. Clin Chem 2021; 66:1006-1009. [PMID: 32746464 DOI: 10.1093/clinchem/hvaa059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 10/18/2019] [Indexed: 11/14/2022]
Affiliation(s)
- Dallas Fowler
- Department of Endocrinology and Diabetes, Queensland Children's Hospital, South Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Helen Irving
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Oncology, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Peter Borzi
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Surgery, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Peter Trnka
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Nephrology, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Tony Huynh
- Department of Endocrinology and Diabetes, Queensland Children's Hospital, South Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Chemical Pathology, Mater Pathology, South Brisbane, QLD, Australia
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22
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Sherlock M, Scarsbrook A, Abbas A, Fraser S, Limumpornpetch P, Dineen R, Stewart PM. Adrenal Incidentaloma. Endocr Rev 2020; 41:bnaa008. [PMID: 32266384 PMCID: PMC7431180 DOI: 10.1210/endrev/bnaa008] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
An adrenal incidentaloma is now established as a common endocrine diagnosis that requires a multidisciplinary approach for effective management. The majority of patients can be reassured and discharged, but a personalized approach based upon image analysis, endocrine workup, and clinical symptoms and signs are required in every case. Adrenocortical carcinoma remains a real concern but is restricted to <2% of all cases. Functional adrenal incidentaloma lesions are commoner (but still probably <10% of total) and the greatest challenge remains the diagnosis and optimum management of autonomous cortisol secretion. Modern-day surgery has improved outcomes and novel radiological and urinary biomarkers will improve early detection and patient stratification in future years to come.
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Affiliation(s)
- Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrew Scarsbrook
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Afroze Abbas
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Sheila Fraser
- Department of Endocrine Surgery, Leeds Teaching Hospitals NHS Trust, St James University Hospital, Leeds, UK
| | - Padiporn Limumpornpetch
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Rosemary Dineen
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Faculty of Medicine & Health, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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Raber W, Kotal H, Marculescu R, Scheuba C, Niederle MB, Kautzky-Willer A, Krebs M. Measurements of Plasma-Free Metanephrines by Immunoassay Versus Urinary Metanephrines and Catecholamines by Liquid Chromatography with Amperometric Detection for the Diagnosis of Pheochromocytoma/Paraganglioma. J Clin Med 2020; 9:jcm9103108. [PMID: 32993074 PMCID: PMC7600173 DOI: 10.3390/jcm9103108] [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: 08/20/2020] [Revised: 09/14/2020] [Accepted: 09/24/2020] [Indexed: 01/03/2023] Open
Abstract
Studies conflict concerning the use of enzyme immunoassays (EIA) for plasma free metanephrines (P-MNs) vs. other methods for pheochromocytoma/paraganglioma (PPGL) diagnosis. We compared commercially available EIAs for P-MNs with high-pressure liquid chromatography (HPLC) for 24 h-urinary MNs (U-MNs) and -catecholamines (U-CATs). 943 (565 female, 378 male) patients (54 PPGL, 889 Non-PPGL) were studied. Simultaneous measurements of all parameters analyzed at the central lab of our university hospital was mandatory for inclusion. Sensitivity of P-MNs (94.4%) was similar to that of U-MNs (100%), and both were higher than of U-CATs (77.8%), specificity of P-MNs (100%) higher than of U-MNs (73.6%), and similar to U-CATs (99.8%). With the recently proposed downward adjusted ULN of P-MNs to correct for the reported negative bias of the EIAs sensitivity (98.1%) raised non-significantly, but specificity decreased significantly (94.8%). Areas under receiver-operating characteristic curves indicated comparable diagnostic performance of P-MNs (0.989) vs. U-MNs (0.995), both better than U-CATs (0.956). In summary, the EIAs to measure P-MNs performed similarly to U-MNs by HPLC, and both better than U-CATs by HPLC. The post-test probability of PPGL given a positive test result was best for P-MNs, and higher than for the other pairs of analytes. Downward corrections of ULN of P-MNs did not improve test performances.
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Affiliation(s)
- Wolfgang Raber
- Division of Endocrinology & Metabolism, Department of Medicine III, Medical University of Vienna, 1090 Vienna, Austria; (H.K.); (A.K.-W.); (M.K.)
- Correspondence: ; Tel.: +43-1-40400-43120
| | - Hans Kotal
- Division of Endocrinology & Metabolism, Department of Medicine III, Medical University of Vienna, 1090 Vienna, Austria; (H.K.); (A.K.-W.); (M.K.)
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria;
| | - Christian Scheuba
- Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Martin B. Niederle
- Department of Anesthesia, General Intensive Care and Pain Therapy, Medical University of Vienna, 1090 Vienna, Austria;
| | - Alexandra Kautzky-Willer
- Division of Endocrinology & Metabolism, Department of Medicine III, Medical University of Vienna, 1090 Vienna, Austria; (H.K.); (A.K.-W.); (M.K.)
| | - Michael Krebs
- Division of Endocrinology & Metabolism, Department of Medicine III, Medical University of Vienna, 1090 Vienna, Austria; (H.K.); (A.K.-W.); (M.K.)
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Kline GA, Boyd J, Leung AA, Tang A, Sadrzadeh HM. Moderate renal impairment does not preclude the accuracy of 24-hour urine normetanephrine measurements for suspected pheochromoctyoma. Clin Endocrinol (Oxf) 2020; 92:518-524. [PMID: 32133686 DOI: 10.1111/cen.14180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/19/2020] [Accepted: 02/26/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE A 24-hour urine nor/metanephrine (urine NM-MN) measurements are a recommended first step in pheochromocytoma diagnosis. We hypothesized the presence of renal impairment (CKD) significantly confounds the results obtained in a urine NM-MN collection, giving artificially lower measurements. DESIGN Retrospective review of a comprehensive laboratory database with all urine NM-MN results from Southern Alberta from 2010 to 2018 (n = 15 505). After excluding high probability pheochromocytoma cases, results from patients with three levels of CKD (n = 796) were compared to those without CKD to determine the potential CKD effect. PATIENTS All patients having urine NM-MN collection during the time period, irrespective of ordering physician or test indication. MEASUREMENTS Urine NM-MN was measured by liquid chromatography-tandem mass spectrometry and glomerular filtration rate determined within a median of 1.9 days, as estimated by CKD-EPI equation. RESULTS In subjects with mild-to-moderate renal impairment, there was no continuous gradient between subnormal renal function and urine NM-MN measures. When the estimated GFR was < 15 mL/min/m2 , the hypothesized effect on lowered urine NM-MN became apparent. CONCLUSIONS A 24-hour urine NM-MN measurement is unlikely to be affected by mild-to-moderate renal impairment and may be used as a reliable diagnostic test. With more advanced renal impairment, CKD-specific reference ranges or an alternative test may be needed.
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Affiliation(s)
- Gregory A Kline
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jessica Boyd
- Department of Clinical Pathology and Lab Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Public Laboratories, Calgary, AB, Canada
| | - Alex A Leung
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew Tang
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hossein M Sadrzadeh
- Department of Clinical Pathology and Lab Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Public Laboratories, Calgary, AB, Canada
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Affiliation(s)
- James K Moon
- Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Peter Mattei
- General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia.
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Abstract
Pheochromocytomas are rare neuroendocrine chromaffin-derived tumors that arise within the adrenal medulla. They are usually benign, but if not diagnosed or if left untreated, they can have devastating consequences. Clinical consideration of the diagnosis is paramount, as they may have protean manifestations, and a high index of suspicion is essential if serious consequences are to be avoided. An accurate biochemical diagnosis is crucial for the management of these patients: either plasma or urinary metanephrines are both highly sensitive and specific if correctly employed, but knowledge of pre- and post-analytic interference is essential. Diagnostic imaging with cross-sectional CT and/or MRI offers high sensitivity in their detection, but lack specificity. The introduction of PET/CT/MR has led to a dramatic improvement in the localization of both pheochromocytomas and paragangliomas, together with the increasing availability of new functional imaging radionuclides. Optimal investigation and accurate diagnosis is best achieved at 'centers of excellence' with expert multidisciplinary teams.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK; Centre for Endocrinology, Barts and the London School of Medicine, London, EC1M 6BQ, UK; ENETS Centre of Excellence, Royal Free Hospital, London, NW3 2QG, UK
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Kline GA, Boyd J, Leung AA, Tang A, Sadrzadeh HM. Very high rate of false positive biochemical results when screening for pheochromocytoma in a large, undifferentiated population with variable indications for testing. Clin Biochem 2020; 77:26-31. [PMID: 31978379 DOI: 10.1016/j.clinbiochem.2020.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Pheochromocytoma/Paraganglioma (PPGL) is a rare tumor with non-specific presentations overlapping common entities like anxiety, hypertension, acute illness and episodic "spells." Assessment of urine normetanephrine or metanephrine (UNM-UMN) in real-life, where PPGL is very rare and PPGL mimics extremely common, may show overlap in results with loss of specificity depending on the reference range. We determined the extent to which UNM-UMN are high in people undergoing screening for PPGL. DESIGN AND METHODS Retrospective review of all UNM-UMN performed in a central lab serving Southern Alberta over 8 years. RESULTS After excluding pediatric ages and patients with CKD, there were 12,572 unique patients with 14,383 measures of UNM-UMN. 85 patients (0.7%) had markedly high UNM-UMN compatible with likely PPGL. Depending on the age category (in decades), 10-22% of all UNM results were above the upper reference limit(URL), particularly between ages of 40-60. Less than 3% had elevations in both UNM and UMN. Of those with high UNM, 99% were less than 3-fold the URL. Based on the population data, a potential new reference range for UNM is suggested, which may be more appropriate to the types of patient who undergo this form of testing. CONCLUSIONS There is an extraordinarily high prevalence of high UNM seen in real-life use of the test. However, the vast majority of high UNM are unlikely to be PPGL given the disease rarity and the massive number of tests ordered. This suggests the current laboratory URL may be too low (poor specificity) and/or the reference range may not be appropriate to the type of patient being screened for PPGL. Depending on the frequency of use of any screening test in a population, if the disease is rare and the specificity of the test is poor, a high rate of false positive results will be expected.
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Affiliation(s)
- G A Kline
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Canada.
| | - J Boyd
- Department of Clinical Pathology and Lab Medicine, Cumming School of Medicine, University of Calgary, Canada; Alberta Public Laboratories, Canada
| | - A A Leung
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Canada
| | - A Tang
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Canada
| | - H M Sadrzadeh
- Department of Clinical Pathology and Lab Medicine, Cumming School of Medicine, University of Calgary, Canada; Alberta Public Laboratories, Canada
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Aporowicz M, Domosławski P, Kaliszewski K, Sutkowski K, Kubicka E, Bolanowski M. The level of accordance between preoperative and postoperative diagnosis in patients undergoing adrenalectomy - a study of 230 consecutive cases. Arch Med Sci 2020; 20:485-493. [PMID: 38757020 PMCID: PMC11094816 DOI: 10.5114/aoms.2020.92343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/14/2019] [Indexed: 05/18/2024] Open
Abstract
Introduction Patients are qualified for an adrenalectomy due to endocrine or oncologic reasons. Final histopathological diagnoses include a wide spectrum of more than a dozen entities. The aim of this study was to compare preoperative and postoperative diagnoses of patients undergoing adrenalectomy to determine the level of diagnostic accuracy, as well as sex and age of patients. Material and methods A group of 214 patients (230 specimens in total) operated on in a single center was studied and their demographic and pathological data were investigated. Results The majority of diagnoses were characterized by both high positive predictive value and sensitivity, excluding pheochromocytoma (60.0% and 67.7%, respectively) and adrenal cyst (100% and 37.5%, respectively). Patients operated on due to Cushing's syndrome were statistically significantly more often females (p = 0.009), while those with metastases (diagnosed both pre- and postoperatively) were more often males (both p = 0.001). Patients qualified due to non-functioning tumors were older than those with Cushing's or Conn's syndrome (p = 0.044 and p = 0.002, respectively). Conclusions The lowest diagnostic accuracy is observed in cases of pheochromocytoma and adrenal cyst. Meticulous preparation of the patient for hormonal tests, including discontinuation of certain medications, is essential for obtaining accurate results. The diagnosis of Cushing's syndrome is more prevalent in females, while metastasis syndrome is more prevalent in males. Adrenocortical carcinoma may initially be diagnosed as a non-functioning tumor (1.6% of such cases) or a recurrence of a previously resected tumor, which should always raise a suspicion of a malignant neoplasm.
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Affiliation(s)
- Michał Aporowicz
- Department and Division of Surgical Didactics, Wroclaw Medical University, Wroclaw, Poland
| | - Paweł Domosławski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kaliszewski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Sutkowski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Eliza Kubicka
- Department and Clinic of Endocrinology, Diabetology and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Bolanowski
- Department and Clinic of Endocrinology, Diabetology and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
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Boyd J, Leung AA, Sadrzadeh HS, Pamporaki C, Pacak K, Deutschbein T, Fliedner S, Kline GA. A high rate of modestly elevated plasma normetanephrine in a population referred for suspected PPGL when measured in a seated position. Eur J Endocrinol 2019; 181:301-309. [PMID: 31370003 PMCID: PMC7446766 DOI: 10.1530/eje-19-0176] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/10/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine rate of high plasma normetanephrine or metanephrine (PNM-PMN) in a large sample of patients according to PNM-PMN posture and age-adjusted references. DESIGN Retrospective re-analysis of PNM-PMN from a Canadian reference laboratory (n = 5452), 2011-2015; most were in seated position (n = 5112) rather than supine (n = 340). An international PPGL database demonstrated expected distribution of supine PNM-PMN in PPGL patients. METHODS All PNM-PMN from a tertiary referral laboratory were reviewed. Any PNM-PMN result greater than 2× upper reference limit (URL) was considered likely true PPGL. Results 1-2× URL were uncertain, requiring additional testing/follow-up despite most being false positive given the rarity of PPGL. The rate of results in the 1-2× URL category were calculated for each group according to collection posture and differing published URL: seated, supine or supine age adjusted. RESULTS When collected and interpreted by seated URL, 19.6% of PNM required additional testing; only 4.6% being >2× URL. For patients over age 50 years, the abnormal rate was 24.9%. When collected supine, interpreted by supine age-adjusted URL, only 5.3% of PNM were mildly elevated. Possible false positives may be even lower when considering PMN or plasma methoxytyramine which were commonly high in true PPGL despite mild PNM elevations. CONCLUSIONS In a general medical population, seated PNM has a high rate of abnormal results, far exceeding expected prevalence. Supine measurement with supine, age-adjusted interpretation is strongly preferred prior to costly or invasive PPGL investigations. SUMMARY Review of 5452 plasma normetanephrine measurements showed 20% to be high, likely false positives for most. Supine, age-adjusted measures were half as likely to be elevated.
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Affiliation(s)
- Jessica Boyd
- Department of Clinical Pathology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Public Laboratory, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hossein Sm Sadrzadeh
- Department of Clinical Pathology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Public Laboratory, Calgary, Alberta, Canada
| | - Christina Pamporaki
- Department of Endocrinology, University Hospital, Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Karel Pacak
- Section of Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Timo Deutschbein
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Stephanie Fliedner
- Neuroendocrine Oncology and Metabolism, First Department of Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Gregory A Kline
- Department of Medicine/Endocrinology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Davies S, Davison A. Liquid chromatography tandem mass spectrometry for plasma metadrenalines. Clin Chim Acta 2019; 495:512-521. [DOI: 10.1016/j.cca.2019.05.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 01/07/2023]
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Al Alwi SAS, Al-Assari F, Al-Kindi M, Mula-Abed WA, Hassan N. Effect of dietary status on plasma-fractionated metanephrines in healthy individuals measured by Elisa. J Immunoassay Immunochem 2019; 40:448-457. [PMID: 31211630 DOI: 10.1080/15321819.2019.1629591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Pheochromocytoma is a rare tumor that typically originates in the adrenal glands, often causing the over-production of catecholamines. The aim of this study was to determine whether dietary status could affect the concentration of plasma-fractionated metanephrines. This study was conducted at the Chemical Pathology Laboratory, Royal Hospital, Oman. Three plasma samples were collected from each participant (16 male and 16 female) over three consecutive days (day one: dietary restriction,day two: excess intake of restricted foods, day three: random sample following the typical diet for each participant). Samples were collected and centrifuged to obtain the plasma, which was then stored at -20°C prior to analysis. Metanephrine and normetanephrine concentrations were measured by comparative ELISA. Plasma metanephrine and normetanephrine measured under the three different dietary conditions for each individual were not significantly different and within normal range. Pearson correlation coefficient analysis of plasma concentration of metanephrines within individual patients under the three dietary conditions revealed positive correlation. We found no significant effect of dietary status on plasma metanephrine or normetanephrine concentration. Therefore, samples taken under any dietary condition may be used to determine plasma MN and NMN concentration. However, dietary restrictions in the diagnosis of Pheochromocytoma need further investigations.
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Affiliation(s)
| | - Fatma Al-Assari
- a Chemical Pathology Laboratory , Royal Hospital , Muscat , Oman
| | - Manal Al-Kindi
- a Chemical Pathology Laboratory , Royal Hospital , Muscat , Oman
| | | | - Nurudeen Hassan
- b Faculty of Health Sport and Science , University of South Wales , Pontypridd , UK
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Plenis A, Olędzka I, Kowalski P, Miękus N, Bączek T. Recent Trends in the Quantification of Biogenic Amines in Biofluids as Biomarkers of Various Disorders: A Review. J Clin Med 2019; 8:E640. [PMID: 31075927 PMCID: PMC6572256 DOI: 10.3390/jcm8050640] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 01/10/2023] Open
Abstract
Biogenic amines (BAs) are bioactive endogenous compounds which play a significant physiological role in many cell processes like cell proliferation and differentiation, signal transduction and membrane stability. Likewise, they are important in the regulation of body temperature, the increase/decrease of blood pressure or intake of nutrition, as well as in the synthesis of nucleic acids and proteins, hormones and alkaloids. Additionally, it was confirmed that these compounds can be considered as useful biomarkers for the diagnosis, therapy and prognosis of several neuroendocrine and cardiovascular disorders, including neuroendocrine tumours (NET), schizophrenia and Parkinson's Disease. Due to the fact that BAs are chemically unstable, light-sensitive and possess a high tendency for spontaneous oxidation and decomposition at high pH values, their determination is a real challenge. Moreover, their concentrations in biological matrices are extremely low. These issues make the measurement of BA levels in biological matrices problematic and the application of reliable bioanalytical methods for the extraction and determination of these molecules is needed. This article presents an overview of the most recent trends in the quantification of BAs in human samples with a special focus on liquid chromatography (LC), gas chromatography (GC) and capillary electrophoresis (CE) techniques. Thus, new approaches and technical possibilities applied in these methodologies for the assessment of BA profiles in human samples and the priorities for future research are reported and critically discussed. Moreover, the most important applications of LC, GC and CE in pharmacology, psychology, oncology and clinical endocrinology in the area of the analysis of BAs for the diagnosis, follow-up and monitoring of the therapy of various health disorders are presented and critically evaluated.
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Affiliation(s)
- Alina Plenis
- Department of Pharmaceutical Chemistry, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland.
| | - Ilona Olędzka
- Department of Pharmaceutical Chemistry, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland.
| | - Piotr Kowalski
- Department of Pharmaceutical Chemistry, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland.
| | - Natalia Miękus
- Department of Pharmaceutical Chemistry, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland.
- Department of Animal and Human Physiology, Faculty of Biology, University of Gdańsk, Wita Stwosza 59, 80-308 Gdańsk, Poland.
| | - Tomasz Bączek
- Department of Pharmaceutical Chemistry, Medical University of Gdańsk, Hallera 107, 80-416 Gdańsk, Poland.
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Performance of plasma free metanephrines in diagnosis of pheochromocytomas and paragangliomas in the population of Asturias. ENDOCRINOLOGÍA, DIABETES Y NUTRICIÓN (ENGLISH ED.) 2019. [DOI: 10.1016/j.endien.2018.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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Martínez-Morillo E, Valdés Gallego N, Eguia Ángeles E, Fernández Fernández JC, Prieto García B, Álvarez FV. Rendimiento de las metanefrinas libres plasmáticas en el diagnóstico de los feocromocitomas y paragangliomas en la población asturiana. ENDOCRINOL DIAB NUTR 2019; 66:312-319. [DOI: 10.1016/j.endinu.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/14/2018] [Accepted: 08/18/2018] [Indexed: 11/30/2022]
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Peitzsch M, Mangelis A, Eisenhofer G, Huebner A. Age-specific pediatric reference intervals for plasma free normetanephrine, metanephrine, 3-methoxytyramine and 3-O-methyldopa: Particular importance for early infancy. Clin Chim Acta 2019; 494:100-105. [PMID: 30904545 DOI: 10.1016/j.cca.2019.03.1620] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/06/2019] [Accepted: 03/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Availability of appropriately established reference intervals for biochemical tests can be troublesome in pediatrics. Here we establish age-specific continuous reference intervals for catecholamine O-methylated metabolites in children evaluated for catecholamine producing tumors, particularly younger children with suspected neuroblastoma. METHODS Plasma concentrations of 3-methoxytyramine, normetanephrine, metanephrine, and 3-O-methyldopa were analyzed by liquid chromatography tandem mass spectrometry in 533 children aged 2 days to 18 years. RESULTS Concentrations of plasma free normetanephrine, 3-methoxytyramine and 3-O-methyldopa were higher in neonates up until six months of age, but thereafter declined steeply to levels after one year that were <38% those of neonatal concentrations and to further lower concentrations in teenagers that were <23% those in neonates. In contrast, concentrations of plasma free metanephrine showed a reciprocal pattern with 50% lower concentrations in infants below one year compared to later in childhood. CONCLUSION The dynamic reciprocal changes in plasma concentrations of normetanephrine, 3-methoxytyramine and 3-O-methyldopa compared to metanephrine during early childhood suggest underlying developmental changes in extra-adrenal and adrenal chromaffin tissue that must be considered for pediatric reference intervals, particularly in infants. With such reference intervals at hand, biochemical testing for catecholamine producing tumors in young children is substantially improved.
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Affiliation(s)
- Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Anastasios Mangelis
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Angela Huebner
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Medical Faculty Carl Gustav Carus, Dresden, Germany
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Shen Y, Li H, Lu J, Luo X, Guan Q, Cheng L. Analytical validation and clinical application of urinary vanillylmandelic acid and homovanillic acid by LC-MS/MS for diagnosis of neuroblastoma. Biomed Chromatogr 2019; 33:e4484. [PMID: 30632178 DOI: 10.1002/bmc.4484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 12/10/2018] [Accepted: 01/05/2019] [Indexed: 11/10/2022]
Abstract
Vanillylmandelic acid (VMA) and homovanillic acid (HVA) are clinical biomarkers for diagnosis of neuroblastoma (NB), which commonly occurs in the childhood. Development and application of a robust LC-MS/MS method for fast determination of these biomarkers for optimal laboratory testing of NB is essential in clinical laboratories. In present study, we developed and validated a simple liquid chromatography tandem mass spectrometry (LC-MS/MS) method for quick clinical testing of VMA and HVA for diagnosis of NB. The method was validated according to the current CLSI C62-A and FDA guidelines. The age-adjusted pediatric reference intervals and diagnostic performance were evaluated in both 24 h urine and random urine. Injection-to-injection time was 3.5 min. Inter- and intra-assay coefficients of variation (CVs) were ≤3.88%. The lower limit of quantification and the limit of detection were 0.50 and 0.25 μmol/L for both VMA and HVA. Recoveries of VMA and HVA were in the ranges of 85-109% and 86-100% with CVs ≤5.76%. This method was free from significant matrix effect, carryover and interference. The establishment of age-adjusted pediatric reference intervals by this LC-MS/MS method was favorable for the improvement in diagnostic performance, which was crucial for correct interpretation of test results from children in both 24 h and random urine.
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Affiliation(s)
- Ying Shen
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huijun Li
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Lu
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Luo
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qing Guan
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liming Cheng
- Department of Laboratory Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Eisenhofer G, Peitzsch M, Kaden D, Langton K, Mangelis A, Pamporaki C, Masjkur J, Geroula A, Kurlbaum M, Deutschbein T, Beuschlein F, Prejbisz A, Bornstein SR, Lenders JWM. Reference intervals for LC-MS/MS measurements of plasma free, urinary free and urinary acid-hydrolyzed deconjugated normetanephrine, metanephrine and methoxytyramine. Clin Chim Acta 2018; 490:46-54. [PMID: 30571948 DOI: 10.1016/j.cca.2018.12.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/09/2018] [Accepted: 12/16/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Plasma or urinary metanephrines are recommended for screening of pheochromocytomas and paragangliomas (PPGLs). Measurements of urinary free rather than deconjugated metanephrines and additional measurements of methoxytyramine represent other developments. For all measurements there is need for reference intervals. METHODS Plasma free, urinary free and urinary deconjugated O-methylated catecholamine metabolites were measured by LC-MS/MS in specimens from 590 hypertensives and normotensives. Reference intervals were optimized using data from 2,056 patients tested for PPGLs. RESULTS Multivariate analyses, correcting for age and body surface area, indicated higher plasma and urinary metanephrine in males than females and sex differences in urinary normetanephrine and free methoxytyramine that largely reflected body size variation. There were positive associations of age with plasma metabolites, but negative relationships with urinary free metanephrine and methoxytyramine. Plasma and urinary normetanephrine were higher in hypertensives than normotensives, but differences were small. Optimization of reference intervals using the data from patients tested for PPGLs indicated that age was the most important consideration for plasma normetanephrine and sex most practical for urinary metabolites. CONCLUSION This study clarifies impacts of demographic and anthropometric variables on catecholamine metabolites, verifies use of age-specific reference intervals for plasma normetanephrine and establishes sex-specific reference intervals for urinary metabolites.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany.
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Denise Kaden
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Katharina Langton
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Anastasios Mangelis
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Jimmy Masjkur
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Aikaterini Geroula
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Max Kurlbaum
- Department of Internal Medicine, Division of Endocrinology, University Hospital, University of Würzburg, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine, Division of Endocrinology, University Hospital, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany; Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | | | - Stefan R Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
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Bílek R, Zelinka T, Vlček P, Dušková J, Michalský D, Novák K, Václavíková E, Widimský J. Radioimmunoassay of chromogranin A and free metanephrines in diagnosis of pheochromocytoma. Physiol Res 2018; 66:S397-S408. [PMID: 28948824 DOI: 10.33549/physiolres.933719] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This work discusses the clinical performance of chromogranin A, free metanephrine and normetanephrine determination in plasma using a radioimmunoanalytical methods for the diagnosis of pheochromocytoma and paraganglioma. Blood samples were collected from 55 patients (46 pheochromocytomas, 9 paragangliomas). A sampling of biological materials was performed preoperatively and about one week, six months and one year after adrenal gland surgery. The comparative group without a diagnosis of pheochromocytoma/paraganglioma consisted of 36 pheochromocytoma/paraganglioma patients more than 4 months after adrenal gland surgery, and of 87 patients, 16 of them with multiple endocrine neoplasia, 9 with medullary and 5 with parafolicullar carcinoma of the thyroid gland. The rest were patients with various adrenal gland disorders. Chromogranin A, metanephrine and normetanephrine were determined in the EDTA-plasma using a radioimmunoassay kits Cisbio Bioassays, France and IBL International GmbH, Germany. Clinical sensitivity was 96 % for the combination of metanephrine and normetanephrine, and 93 % for chromogranin A. Clinical specificity was 100 % for the combination metanephrine and normetanephrine, and 96 % for chromogranin A. Falsely elevated levels of chromogranin A were observed in 1 patient with chronic renal insufficiency and 9 analyses were influenced by the administration of proton pump inhibitors. These results were excluded of CGA specificity. Both the combination of plasma free metanephrine, normetanephrine and chromogranin A as determined by radioimmunoassays, which are simple without the necessity of special laboratory material, are effective markers of pheochromocytoma or paraganglioma. Chromogranin A exerts association to malignity and all markers are associated with tumor mass.
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Affiliation(s)
- R Bílek
- Institute of Endocrinology, Prague, Czech Republic.
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Samsudin I, Page MM, Hoad K, Chubb P, Gillett M, Glendenning P, Vasikaran S. The challenge of improving the diagnostic yield from metanephrine testing in suspected phaeochromocytoma and paraganglioma. Ann Clin Biochem 2018; 55:679-684. [DOI: 10.1177/0004563218774590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Plasma-free metanephrines (PFM) or urinary fractionated metanephrines (UFM) are the preferred biochemical tests for the diagnosis of phaeochromocytoma and paraganglioma (PPGL). Borderline increased results should be followed up to either exclude or confirm diagnosis. Methods We extracted all PFM and UFM results reported by our laboratory over a six-month period from the laboratory information system. We categorized patients with borderline increased results according to whether follow-up testing had been performed as suggested in the initial laboratory report. Questionnaires were then sent to all requesting doctors and medical notes reviewed where available. Results Two hundred and four patients with borderline increased PFM or UFM were identified. Sixty-five (38.5%) of 169 patients with borderline increased PFM had a repeat test out of which 36 were normal and 29 did not normalize. Of 35 patients with borderline increased UFM, 17 (48.6%) had subsequent PFM measurement, out of which 15 were normal. Questionnaires were returned to 106 (52%) patients. Of these, the most frequent indication for testing was hypertension ( n = 50); 15 patients had an incidental adrenal mass and two of these patients were diagnosed with a phaeochromocytoma. Conclusion Only 38% of patients with borderline increased PFM had a repeat PFM measurement. This was not significantly higher when compared with the 28% in a previous audit that we reported in 2010 ( P = 0.10). Forty-nine per cent of patients with a borderline increased UFM had a repeat UFM or PFM measurement. There remains a substantial possibility of missed detection of PPGL.
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Affiliation(s)
- Intan Samsudin
- Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Michael M Page
- Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
| | - Kirsten Hoad
- Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
| | - Paul Chubb
- Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Melissa Gillett
- Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
| | - Paul Glendenning
- Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Samuel Vasikaran
- Department of Clinical Biochemistry, PathWest Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
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Rednam SP, Erez A, Druker H, Janeway KA, Kamihara J, Kohlmann WK, Nathanson KL, States LJ, Tomlinson GE, Villani A, Voss SD, Schiffman JD, Wasserman JD. Von Hippel-Lindau and Hereditary Pheochromocytoma/Paraganglioma Syndromes: Clinical Features, Genetics, and Surveillance Recommendations in Childhood. Clin Cancer Res 2018; 23:e68-e75. [PMID: 28620007 DOI: 10.1158/1078-0432.ccr-17-0547] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 11/16/2022]
Abstract
Von Hippel-Lindau disease (vHL) is a hereditary tumor predisposition syndrome that places affected individuals at risk for multiple tumors, which are predominantly benign and generally occur in the central nervous system or abdomen. Although the majority of tumors occur in adults, children and adolescents with the condition develop a significant proportion of vHL manifestations and are vulnerable to delayed tumor detection and their sequelae. Although multiple tumor screening paradigms are currently being utilized for patients with vHL, surveillance should be reassessed as the available relevant clinical information continues to expand. We propose a new vHL screening paradigm similar to existing approaches, with important modifications for some tumor types, placing an emphasis on risks in childhood. This includes advancement in the timing of surveillance initiation and increased frequency of screening evaluations. Another neuroendocrine-related familial condition is the rapidly expanding hereditary paraganglioma and pheochromocytoma syndrome (HPP). The tumor spectrum for patients with HPP syndrome includes paragangliomas, pheochromocytomas, renal cancer, and gastrointestinal stromal tumors. The majority of patients with HPP syndrome harbor an underlying variant in one of the SHDx genes (SDHA, SDHB, SDHC, SDHD, SDHA, and SDHAF2), although other genes also have been described (MAX and TMEM127). Annual screening for elevated plasma or urine markers along with complete blood count and biennial whole-body MRI accompanied by focal neck MRI is recommended for older children and adults with HPP syndrome to detect tumors early and to decrease morbidity and mortality from HPP-related tumors. Clin Cancer Res; 23(12); e68-e75. ©2017 AACRSee all articles in the online-only CCR Pediatric Oncology Series.
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Affiliation(s)
- Surya P Rednam
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas
| | - Ayelet Erez
- Department of Biological Regulation, Weizmann Institute of Science, Rehovot, Israel
| | - Harriet Druker
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine A Janeway
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts
| | - Junne Kamihara
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Children's Hospital, Boston, Massachusetts
| | - Wendy K Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Katherine L Nathanson
- Department of Medicine, Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lisa J States
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gail E Tomlinson
- Department of Pediatrics, Division of Hematology and Oncology and Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Anita Villani
- Division of Haematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Stephan D Voss
- Department of Radiology, Children's Hospital, Boston, Massachusetts
| | - Joshua D Schiffman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.,Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jonathan D Wasserman
- Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Shores DR, Everett AD. Children as Biomarker Orphans: Progress in the Field of Pediatric Biomarkers. J Pediatr 2018; 193:14-20.e31. [PMID: 29031860 PMCID: PMC5794519 DOI: 10.1016/j.jpeds.2017.08.077] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/04/2017] [Accepted: 08/30/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Darla R Shores
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD.
| | - Allen D Everett
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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Rao D, Peitzsch M, Prejbisz A, Hanus K, Fassnacht M, Beuschlein F, Brugger C, Fliedner S, Langton K, Pamporaki C, Gudziol V, Stell A, Januszewicz A, Timmers HJLM, Lenders JWM, Eisenhofer G. Plasma methoxytyramine: clinical utility with metanephrines for diagnosis of pheochromocytoma and paraganglioma. Eur J Endocrinol 2017; 177:103-113. [PMID: 28476870 PMCID: PMC5488393 DOI: 10.1530/eje-17-0077] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/25/2017] [Accepted: 05/05/2017] [Indexed: 11/08/2022]
Abstract
CONTEXT Measurements of plasma methoxytyramine, the O-methylated dopamine metabolite, are useful for detecting rare dopamine-producing pheochromocytomas and paragangliomas (PPGLs) and head and neck paragangliomas (HNPGLs), but utility for screening beyond that achieved using standard measurements of normetanephrine and metanephrine is unclear. OBJECTIVE Evaluation of the additional utility of methoxytyramine compared to plasma normetanephrine and metanephrine for diagnosis of PPGLs and HNPGLs. DESIGN Comparative prospective study. METHODS Comparison of mass spectrometric-based measurements of plasma methoxytyramine, normetanephrine and metanephrine in 1963 patients tested for PPGLs at six tertiary medical centers according to reference intervals verified in 423 normotensive and hypertensive volunteers. RESULTS Of the screened patients, 213 had PPGLs and 38 HNPGLs. Using an upper cut-off of 0.10 nmol/L for methoxytyramine, 0.45 nmol/L for metanephrine and age-specific upper cut-offs for normetanephrine, diagnostic sensitivity with the addition of methoxytyramine increased from 97.2% to 98.6% for patients with PPGLs and from 22.1% to 50.0% for patients with HNPGLs, with a small decrease in specificity from 95.9% to 95.1%. Addition of methoxytyramine did not significantly alter areas under receiver operating characteristic curves for patients with PPGLs (0.984 vs 0.991), but did increase (P < 0.05) areas for patients with HNPGLs (0.627 vs 0.801). Addition of methoxytyramine also increased the proportion of patients with PPGLs who showed highly positive predictive elevations of multiple metabolites (70.9% vs 49.3%). CONCLUSIONS While the benefit of additional measurements of plasma methoxytyramine for the detection of PPGLs is modest, the measurements do assist with positive confirmation of disease and are useful for the detection of HNPGLs.
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Affiliation(s)
- Dipti Rao
- Department of Internal MedicineRadboud University Medical Centre, Nijmegen, The Netherlands
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Katarzyna Hanus
- Department of HypertensionInstitute of Cardiology, Warsaw, Poland
| | - Martin Fassnacht
- Department of EndocrinologyUniversity Hospital Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Department of EndocrinologyUniversity Hospital München, München, Germany
| | - Christina Brugger
- Department of EndocrinologyUniversity Hospital München, München, Germany
| | - Stephanie Fliedner
- First Department of MedicineUniversity Medical Center Schleswig-Holstein, Lübeck, Germany
| | | | | | - Volker Gudziol
- Departments of OtorhinolaryngologyUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anthony Stell
- Melboune eResearch GroupUniversity of Melbourne, Melbourne, Australia
| | | | - Henri J L M Timmers
- Department of Internal MedicineRadboud University Medical Centre, Nijmegen, The Netherlands
| | - Jacques W M Lenders
- Department of Internal MedicineRadboud University Medical Centre, Nijmegen, The Netherlands
- Departments of Medicine III
- Correspondence should be addressed to J W M Lenders;
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Departments of Medicine III
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Chen Y, Xiao H, Zhou X, Huang X, Li Y, Xiao H, Cao X. ACCURACY OF PLASMA FREE METANEPHRINES IN THE DIAGNOSIS OF PHEOCHROMOCYTOMA AND PARAGANGLIOMA: A SYSTEMATIC REVIEW AND META-ANALYSIS. Endocr Pract 2017; 23:1169-1177. [PMID: 28704098 DOI: 10.4158/ep171877.or] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Various studies have validated plasma free metanephrines (MNs) as biomarkers for pheochromocytoma and paraganglioma (PPGL). This meta-analysis aimed to estimate the overall diagnostic accuracy of this biochemical test for PPGL. METHODS We searched the PubMed, the Cochrane Library, Web of Science, Embase, Scopus, OvidSP, and ProQuest Dissertations & Theses databases from January 1, 1995 to December 2, 2016 and selected studies written in English that assessed plasma free MNs in the diagnosis of PPGL. Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) was used to evaluate the quality of the included studies. We calculated pooled sensitivities, specificities, positive and negative likelihood ratios, diagnostic odds ratios (DORs) and areas under curve (AUCs) with their 95% confidence intervals (95% CIs). Heterogeneity was assessed by I2. To identify the source of heterogeneity, we evaluated the threshold effect and performed a meta-regression. Deeks' funnel plot was selected for investigating any potential publication bias. RESULTS Although the combination of metanephrine (MN) and normetanephrine (NMN) carried lower specificity (0.94, 95% CI 0.90-0.97) than NMN (0.97, 95% CI 0.92-0.99), NMN was generally more accurate than individual tests, with the highest AUC (0.99, 95% CI 0.97-0.99), DOR (443.35, 95% CI 216.9-906.23), and pooled sensitivity (0.97, 95% CI 0.94-0.98) values. Threshold effect and meta-regression analyses showed that different cut-offs, blood sampling positions, study types and test methods contributed to heterogeneity. CONCLUSION This meta-analysis suggested an effective value for combined plasma free MNs for the diagnosis of PPGL, but testing for MNs requires more standardization using tightly regulated studies. ABBREVIATIONS AUC = area under curve; CI = confidence interval; DOR = diagnostic odds ratio; EIA = enzyme immunoassay; LC-ECD = liquid chromatography-electrochemical detection; LC-MS/MS = liquid chromatography-tandem mass spectrometry; MN = metanephrine; NMN = normetaneprhine; PPGL = pheochromocytoma and paraganglioma; QUADAS-2 = Quality Assessment of Diagnostic Accuracy Studies 2.
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Bholah R, Bunchman TE. Review of Pediatric Pheochromocytoma and Paraganglioma. Front Pediatr 2017; 5:155. [PMID: 28752085 PMCID: PMC5508015 DOI: 10.3389/fped.2017.00155] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/26/2017] [Indexed: 01/01/2023] Open
Abstract
Pheochromocytoma (PCC) and paraganglioma (PGL) are rare chromaffin cell tumors which secrete catecholamines and form part of the family of neuroendocrine tumors. Although a rare cause of secondary hypertension in pediatrics, the presentation of hypertension in these patients is characteristic, and treatment is definitive. The gold standard for diagnosis is via measurement of plasma free metanephrines, with imaging studies performed for localization, identification of metastatic lesions and for surgical resection. Preoperative therapy with alpha-blocking agents, beta blockers, and potentially tyrosine hydroxylase inhibitors aid in a safe pre-, intra- and postoperative course. PCC and PGL are inherited in as much as 80% of pediatric cases, and all patients with mutations should be followed closely given the risk of recurrence and malignancy. While the presentation of chromaffin cell tumors has been well described with multiple endocrine neoplasia, NF1, and Von Hippel-Lindau syndromes, the identification of new gene mutations leading to chromaffin cell tumors at a young age is changing the landscape of how clinicians approach such cases. The paraganglioma-pheochromocytoma syndromes (SDHx) comprise familial gene mutations, of which the SDHB gene mutation carries a high rate of malignancy. Since the inheritance rate of such tumors is higher than previously described, genetic screening is recommended in all patients, and lifelong follow-up for recurrent tumors is a must. A multidisciplinary team approach allows for optimal health-care delivery in such children. This review serves to provide an overview of pediatric PCC and PGL, including updates on the preferred methods of imaging, guidelines on gene testing as well as management of hypertension in such patients.
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Affiliation(s)
- Reshma Bholah
- Pediatric Nephrology, Virginia Commonwealth University, Richmond, VA, United States
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Eisenhofer G, Peitzsch M, McWhinney BC. Impact of LC-MS/MS on the laboratory diagnosis of catecholamine-producing tumors. Trends Analyt Chem 2016. [DOI: 10.1016/j.trac.2016.01.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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47
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Boot C, Toole B, Johnson SJ, Ball S, Neely D. Single-centre study of the diagnostic performance of plasma metanephrines with seated sampling for the diagnosis of phaeochromocytoma/paraganglioma. Ann Clin Biochem 2016; 54:143-148. [DOI: 10.1177/0004563216650463] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Measurement of plasma metanephrines is regarded as one of the best screening tests for phaeochromocytoma/paraganglioma. Current guidelines recommend that samples are ideally collected in the supine position after 30 min rest and interpreted using supine reference ranges, in order to optimize the diagnostic performance of the test. Current practice in our centre is to collect samples for plasma metanephrines from seated patients. The aim of the study was to determine, if seated sampling for plasma metanephrines provides acceptable diagnostic performance in our centre. Methods Clinical and laboratory data of 113 patients, gathered over a four-year period 2010–2014, were reviewed. All had undergone preoperative plasma metanephrines measurement and had postoperative histopathology confirmation or exclusion of phaeochromocytoma/paraganglioma. Results Of 113 patients included in the study, 40 had a histological diagnosis of phaeochromocytoma/paraganglioma. The remaining 73 patients had an alternative adrenal pathology. The diagnostic sensitivity of normetanephrine or metanephrine above the upper limit of our in-house seated reference range was 93%. However, excluding three cases of paraganglioma determined clinically and biochemically to be non-functional raised the sensitivity to 100%. Diagnostic specificity was 90%. Applying published supine reference ranges made no difference to diagnostic sensitivity in this group of patients but decreased diagnostic specificity to 75%. Conclusions While these data are derived from a relatively small study population, they demonstrate acceptable diagnostic performance for seated plasma metanephrines as a screening test for phaeochromocytoma/paraganglioma. These data highlight a high diagnostic sensitivity for plasma metanephrines with seated sampling in our centre.
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Affiliation(s)
- Christopher Boot
- Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Barry Toole
- Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sarah J Johnson
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen Ball
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Dermot Neely
- Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Cho YY, Kim YN, Kim JH, Jeong BC, Lee SY, Kim JH. Different values of urinary fractionated metanephrines after unilateral adrenalectomy for pheochromocytoma according to time intervals after surgery. Ann Clin Biochem 2016; 54:165-169. [DOI: 10.1177/0004563215620822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background After adrenalectomy, urinary fractionated metanephrine concentrations are expected to be reduced. However, there are few studies suggesting cut-offs for adrenalectomy patients. Methods Urinary metanephrine and normetanephrine concentrations in adrenalectomy patients and two controls were compared and hormonal concentrations were evaluated via time intervals after surgery. Results The median urinary metanephrine level after unilateral adrenalectomy was lower than that of the non-pheochromocytoma controls but comparable to healthy controls. Urinary normetanephrine concentrations did not differ between adrenalectomy patients and non-pheochromocytoma controls, although both group had levels higher than those of healthy controls. The median urinary normetanephrine level in the immediate postoperative period was higher than in the later period. Conclusions Urinary metanephrine concentrations were lower after adrenalectomy, but urinary normetanephrine concentrations were not changed compared with the non-pheochromocytoma controls. However, urinary normetanephrine concentrations in the patient group were higher than levels in the heathy controls.
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Affiliation(s)
- Yoon Y Cho
- Division of Endocrinology & Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young N Kim
- Division of Endocrinology & Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Han Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byong C Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae H Kim
- Division of Endocrinology & Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Samsung Biomedical Research Institute, Seoul, Republic of Korea
- Department of Health Sciences & Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
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Osinga TE, Kema IP, Kerstens MN, de Jong WHA, van Faassen M, Dullaart RPF, Links TP, van der Horst-Schrivers ANA. No influence of antihypertensive agents on plasma free metanephrines. Clin Biochem 2016; 49:1368-1371. [PMID: 27291837 DOI: 10.1016/j.clinbiochem.2016.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 05/29/2016] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hypertension can be the predominant sign of pheochromocytoma (PCC) and sympathetic paraganglioma (sPGL) and screening for PCC/sPGL is often performed in patients who are already being treated with antihypertensive agents. There is very little information about the influence of antihypertensive drugs on plasma free metanephrines. The aim of this study was to determine whether commonly prescribed antihypertensive drugs can falsely elevate plasma free metanephrines concentrations measured by LC-MS/MS analysis. METHODS In a prospective study we included patients with newly diagnosed hypertension, who started monotherapy with an antihypertensive agent (i.e. β-blocker, thiazide diuretic or angiotensin-converting enzyme (ACE) inhibitor). Plasma free metanephrine (MN) and normetanephrine (NMN) levels were measured before and one month after the start of the medication quantified by LC-MS/MS. RESULTS Between 2009 and 2014, 39 patients were included (β-blocker n=13, thiazide diuretic n=14 and ACE inhibitor n=12). In the whole group, the median plasma free MN and NMN concentrations at baseline were 0.19 [0.17-0.26] nmol/L and 0.56 [0.38-0.95] nmol/L. One month after the start of antihypertensive treatment, the median plasma free MN and NMN concentrations were comparable; 0.20 [0-16-0.24] nmol/L and 0.63 [0.39-0.75] nmol/L, respectively (P=0.43 and P=0.39). Separate analysis for each of the three antihypertensive agents examined did not reveal any significant changes in the median plasma free MN and NMN concentrations. CONCLUSIONS The measurement of plasma free MN and NMN with LC-MS/MS is not affected by use of β-blockers, diuretics and ACE inhibitors. Withdrawal of these drugs prior to the quantification of plasma metanephrines is therefore not necessary.
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Affiliation(s)
- Thamara E Osinga
- Department of Endocrinology (AA31), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
| | - Ido P Kema
- Department of Laboratory Medicine (EA61), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
| | - Michiel N Kerstens
- Department of Endocrinology (AA31), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
| | - Wilhelmina H A de Jong
- Department of Laboratory Medicine (EA61), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
| | - Martijn van Faassen
- Department of Laboratory Medicine (EA61), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
| | - Robin P F Dullaart
- Department of Endocrinology (AA31), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
| | - Thera P Links
- Department of Endocrinology (AA31), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
| | - Anouk N A van der Horst-Schrivers
- Department of Endocrinology (AA31), University of Groningen, University Medical Center Groningen, PO-box 30.001, 9700 RB Groningen, The Netherlands.
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50
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Evaluating the optimum rest period prior to blood collection for fractionated plasma free metanephrines analysis. Pract Lab Med 2016; 5:39-46. [PMID: 28856203 PMCID: PMC5574516 DOI: 10.1016/j.plabm.2016.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/05/2016] [Accepted: 05/06/2016] [Indexed: 12/25/2022] Open
Abstract
Introduction The high diagnostic accuracy of plasma metanephrines (PMets) in the diagnosis of Phaeochromocytoma/Paraganglioma (PPGL) is well established. Considerable controversy exists regarding optimum sampling conditions for PMets. The use of reference intervals that do not compromise diagnostic sensitivity is recommended. However, the optimum rest period prior to sampling has yet to be clearly established. The aim of this study was to evaluate PMets concentrations in paired blood samples collected following 30 and 40 min seated-rest prior to sampling, in patients in whom it was clinically reasonable to suspect that PPGL may be present. Design and Methods A retrospective cross-sectional study design was used. PMets results from paired blood samples collected after 30 and 40 min seated-rest between January 2009 and June 2015 were recorded. Results were interpreted using reference intervals established in subjects seated and supine. Results A total of 410 patient results were eligible for analysis. There was no statistical difference between plasma normetanephrine (NMN) or metanephrine (MN) concentrations in samples collected following 30 and 40 min seated-rest in subjects with PPGL (n=11), post-resection of PPGL (n=20) or in whom PPGL was excluded (n=379). Using reference intervals established in the seated position, diagnostic sensitivity was 100% at 30 min and 90.9% at 40 min. Diagnostic specificity was approximately 95% at both time points. When supine reference intervals were used, diagnostic sensitivity was 100% and diagnostic specificity was reduced by ≈22% at both time points. Conclusion Based on these data, we recommend at most 30 min continuous rest prior to sampling for PMets measurement.
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