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Tarling JA, Kumar R, Ward LJ, Boot C, Wassif WS. Phaeochromocytoma and paraganglioma. J Clin Pathol 2024; 77:507-516. [PMID: 38453430 DOI: 10.1136/jcp-2023-209234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
Phaeochromocytomas and paragangliomas are rare catecholamine-producing neuroendocrine tumours which can potentially cause catastrophic crises with high morbidity and mortality. This best practice article considers the causes and presentation of such tumours, screening and diagnostic tests, management of these patients and consideration of family members at risk.
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Affiliation(s)
- Julie Ann Tarling
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Rajeev Kumar
- Diabetes and Endocrinology, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Louise J Ward
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Christopher Boot
- Blood Sciences, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - W S Wassif
- Clinical Biochemistry, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
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2
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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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Li M, Prodanov T, Meuter L, Kerstens MN, Bechmann N, Prejbisz A, Remde H, Timmers HJLM, Nölting S, Talvacchio S, Berends AMA, Fliedner S, Robledo M, Lenders JWM, Pacak K, Eisenhofer G, Pamporaki C. Recurrent Disease in Patients With Sporadic Pheochromocytoma and Paraganglioma. J Clin Endocrinol Metab 2023; 108:397-404. [PMID: 36190922 PMCID: PMC10091496 DOI: 10.1210/clinem/dgac563] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/26/2022] [Indexed: 01/20/2023]
Abstract
CONTEXT Long-term follow-up has been recommended for patients with pheochromocytoma or paraganglioma (PPGL) due to potential for recurrent disease. However, the need to follow patients with sporadic PPGL has recently become controversial. OBJECTIVE To investigate the prevalence of recurrence among patients with sporadic compared with hereditary PPGL and to identify predictors of recurrence for sporadic disease. METHODS This multicenter study included retrospective data from 1127 patients with PPGL. In addition to sex and age at primary tumor diagnosis, clinical information included location, size, and catecholamine phenotype of primary tumors, genetic test results, and subsequent development of recurrent and/or metastatic disease. Patients with sporadic PPGL were defined as those with negative genetic test results. RESULTS Prevalence of recurrence among patients with sporadic PPGL (14.7%) was lower (P < 0.001) than for patients with pathogenic variants that activate pseudohypoxia pathways (47.5%), but similar to those with variants that activate kinase pathways (14.9%). Among patients with sporadic recurrent PPGL, 29.1% and 17.7% were respectively diagnosed at least 10 and 15 years after first diagnosis. Multivariable regression analysis showed that a noradrenergic/dopaminergic phenotype (HR 2.73; 95% CI, 1.553-4.802; P < 0.001), larger size (HR 1.82; 95% CI, 1.113-2.962; P = 0.017) and extra-adrenal location (HR 1.79; 95% CI, 1.002-3.187; P = 0.049) of primary tumors were independent predictors of recurrence in sporadic PPGL. CONCLUSION Patients with sporadic PPGL require long-term follow-up, as supported by the 14.7% prevalence of recurrent disease, including recurrences at more than 10 years after first diagnosis. The nature of follow-up could be individualized according to tumor size, location, and biochemical phenotype.
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Affiliation(s)
- Minghao Li
- Department of Medicine ΙΙΙ, University Hospital Carl Gustav Carus at the TU Dresden, Dresden 01307, Germany
| | - Tamara Prodanov
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda 20892, USA
| | - Leah Meuter
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda 20892, USA
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen 9700, The Netherlands
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden 01307, Germany
| | | | - Hanna Remde
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg 97080, Germany
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Hospital, Nijmegen 6500, The Netherlands
| | - Svenja Nölting
- Department of Internal Medicine, University Hospital of Munich, Munich 80539, Germany
- Department of Endocrinology, Diabetology, and Clinical Nutrition, University Hospital, Zurich 8091, Switzerland
| | - Sara Talvacchio
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda 20892, USA
| | - Annika M A Berends
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen 9700, The Netherlands
| | - Stephanie Fliedner
- Department of Medicine, University Medical Center Schleswig-Holstein, Luebeck 23538, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Human Cancer Genetics Programme, Spanish National Cancer Research Centre, Madrid 28029, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid 28029, Spain
| | - Jacques W M Lenders
- Department of Medicine ΙΙΙ, University Hospital Carl Gustav Carus at the TU Dresden, Dresden 01307, Germany
- Department of Internal Medicine, Radboud University Hospital, Nijmegen 6500, The Netherlands
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (NIH), Bethesda 20892, USA
| | - Graeme Eisenhofer
- Department of Medicine ΙΙΙ, University Hospital Carl Gustav Carus at the TU Dresden, Dresden 01307, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden 01307, Germany
| | - Christina Pamporaki
- Department of Medicine ΙΙΙ, University Hospital Carl Gustav Carus at the TU Dresden, Dresden 01307, Germany
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Jensterle M, Podbregar A, Janež A, Rakusa M, Goricar K, Prokšelj K. Comparison of plasma metanephrines in patients with cyanotic and acyanotic congenital heart disease. Endocrine 2022; 78:580-586. [PMID: 36194345 DOI: 10.1007/s12020-022-03205-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/17/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The co-occurrence of cyanotic congenital heart disease (CCHD) and PHEO/PGL has been reported, but the role of the hypoxic environment in the pathogenesis of PHEO/PGL remains unclear. Our aim was to compare plasma metanephrine and normetanephrine levels between patients with CCHD and patients with acyanotic congenital heart disease (ACCHD). METHODS We performed a cross-sectional study in a prospective cohort of 44 patients with congenital heart disease (CHD) (31 (70.5%) females) with a median age of 37.5 (31.0-55.6) years at the time of evaluation. Thirty-two (73%) patients had CCHD and 12 (27%) patients had ACCHD. Morning blood samples for plasma determination of metanephrine and normetanephrine were collected. RESULTS Plasma normetanephrine levels were significantly higher in patients with CCHD compared to ACCHD (p = 0.002). Ten (31.3%) patients with CCHD had plasma normetanephrine levels elevated above the reference range, while all ACCHD patients had normal levels. Patients with lower oxygen saturation and higher proBNP had significantly higher normetanephrine levels (ρ = -0.444, p = 0.003 and ρ = 0.449, p = 0.002, respectively). No chromaffin cell tumors were detected. CONCLUSION Increased plasma normetanephrine levels in patients with CCHD can be explained by the effect of hypoxia. Future research is needed to better understand the impact of chronic hypoxia in CCHD on increased sympathetic outflow, hyperplastic response of chromaffin tissue, and the role of somatic mutations in CCHD-PHEO/PGL pathogenesis related to hypoxia.
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Affiliation(s)
- Mojca Jensterle
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia
| | - Ana Podbregar
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- University Rehabilitation Institute Republic of Slovenia, Linhartova cesta 51, 1000, Ljubljana, Slovenia
| | - Andrej Janež
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia
| | - Matej Rakusa
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
- Department of Endocrinology, Diabetes and Metabolic Disease, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia
| | - Katja Goricar
- University of Ljubljana, Faculty of Medicine, Institute of Biochemistry and Molecular Genetics, Pharmacogenetics Laboratory, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Katja Prokšelj
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
- Department of Cardiology, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia.
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Kuhlen M, Pamporaki C, Kunstreich M, Wudy SA, Hartmann MF, Peitzsch M, Vokuhl C, Seitz G, Kreissl MC, Simon T, Hero B, Frühwald MC, Vorwerk P, Redlich A. Adrenocortical Tumors and Pheochromocytoma/Paraganglioma Initially Mistaken as Neuroblastoma-Experiences From the GPOH-MET Registry. Front Endocrinol (Lausanne) 2022; 13:918435. [PMID: 35784570 PMCID: PMC9248437 DOI: 10.3389/fendo.2022.918435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/18/2022] [Indexed: 01/31/2023] Open
Abstract
In children and adolescents, neuroblastoma (NBL), pheochromocytoma (PCC), and adrenocortical tumors (ACT) can arise from the adrenal gland. It may be difficult to distinguish between these three entities including associated extra-adrenal tumors (paraganglioma, PGL). Precise discrimination, however, is of crucial importance for management. Biopsy in ACT or PCC is potentially harmful and should be avoided whenever possible. We herein report data on 10 children and adolescents with ACT and five with PCC/PGL, previously mistaken as NBL. Two patients with adrenocortical carcinoma died due to disease progression. Two (2/9, missing data in one patient) patients with a final diagnosis of ACT clearly presented with obvious clinical signs and symptoms of steroid hormone excess, while seven patients did not. Blood analyses indicated increased levels of steroid hormones in one additional patient; however, urinary steroid metabolome analysis was not performed in any patient. Two (2/10) patients underwent tumor biopsy, and in two others tumor rupture occurred intraoperatively. In 6/10 patients, ACT diagnosis was only established by a reference pediatric pathology laboratory. Four (4/5) patients with a final diagnosis of PCC/PGL presented with clinical signs and symptoms of catecholamine excess. Urine tests indicated possible catecholamine excess in two patients, while no testing was carried out in three patients. Measurements of plasma metanephrines were not performed in any patient. None of the five patients with PCC/PGL received adrenergic blockers before surgery. In four patients, PCC/PGL diagnosis was established by a local pathologist, and in one patient diagnosis was revised to PGL by a pediatric reference pathologist. Genetic testing, performed in three out of five patients with PCC/PGL, indicated pathogenic variants of PCC/PGL susceptibility genes. The differential diagnosis of adrenal neoplasias and associated extra-adrenal tumors in children and adolescents may be challenging, necessitating interdisciplinary and multidisciplinary efforts. In ambiguous and/or hormonally inactive cases through comprehensive biochemical testing, microscopical complete tumor resection by an experienced surgeon is vital to preventing poor outcome in children and adolescents with ACT and/or PCC/PGL. Finally, specimens need to be assessed by an experienced pediatric pathologist to establish diagnosis.
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Affiliation(s)
- Michaela Kuhlen
- Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- *Correspondence: Michaela Kuhlen,
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marina Kunstreich
- Pediatric Oncology Department, Otto von Guericke University Children’s Hospital, Magdeburg, Germany
| | - Stefan A. Wudy
- Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Division of Paediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Michaela F. Hartmann
- Laboratory for Translational Hormone Analytics in Paediatric Endocrinology, Steroid Research & Mass Spectrometry Unit, Division of Paediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Vokuhl
- Section of Pediatric Pathology, University of Bonn, Bonn, Germany
| | - Guido Seitz
- Department of Pediatric Surgery and Urology, University Children’s Hospital Marburg, Marburg, Germany
| | - Michael C. Kreissl
- Division of Nuclear Medicine, Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Otto-von Guericke University, Magdeburg, Germany
| | - Thorsten Simon
- Department of Pediatric Oncology and Hematology, University Hospital, University of Cologne, Cologne, Germany
| | - Barbara Hero
- Department of Pediatric Oncology and Hematology, University Hospital, University of Cologne, Cologne, Germany
| | - Michael C. Frühwald
- Pediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Peter Vorwerk
- Pediatric Oncology Department, Otto von Guericke University Children’s Hospital, Magdeburg, Germany
| | - Antje Redlich
- Pediatric Oncology Department, Otto von Guericke University Children’s Hospital, Magdeburg, Germany
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Kuo MJM, Nazari MA, Jha A, Pacak K. Pediatric Metastatic Pheochromocytoma and Paraganglioma: Clinical Presentation and Diagnosis, Genetics, and Therapeutic Approaches. Front Endocrinol (Lausanne) 2022; 13:936178. [PMID: 35903274 PMCID: PMC9314859 DOI: 10.3389/fendo.2022.936178] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/13/2022] [Indexed: 12/18/2022] Open
Abstract
Although pediatric pheochromocytomas and paragangliomas (PPGLs) are rare, they have important differences compared to those in adults. Unfortunately, without timely diagnosis and management, these tumors have a potentially devastating impact on pediatric patients. Pediatric PPGLs are more often extra-adrenal, multifocal/metastatic, and recurrent, likely due to these tumors being more commonly due to a genetic predisposition than in adults. This genetic risk results in disease manifestations at an earlier age giving these tumors time to advance before detection. In spite of these problematic features, advances in the molecular and biochemical characterization of PPGLs have heralded an age of increasingly personalized medicine. An understanding of the genetic basis for an individual patient's tumor provides insight into its natural history and can guide clinicians in management of this challenging disease. In pediatric PPGLs, mutations in genes related to pseudohypoxia are most commonly seen, including the von Hippel-Lindau gene (VHL) and succinate dehydrogenase subunit (SDHx) genes, with the highest risk for metastatic disease associated with variants in SDHB and SDHA. Such pathogenic variants are associated with a noradrenergic biochemical phenotype with resultant sustained catecholamine release and therefore persistent symptoms. This is in contrast to paroxysmal symptoms (e.g., episodic hypertension, palpitations, and diaphoresis/flushing) as seen in the adrenergic, or epinephrine-predominant, biochemical phenotype (due to episodic catecholamine release) that is commonly observed in adults. Additionally, PPGLs in children more often present with signs and symptoms of catecholamine excess. Therefore, children, adolescents, and young adults present differently from older adults (e.g., the prototypical presentation of palpitations, perspiration, and pounding headaches in the setting of an isolated adrenal mass). These presentations are a direct result of genetic determinants and highlight the need for pediatricians to recognize these differences in order to expedite appropriate evaluations, including genetic testing. Identification and familiarity with causative genes inform surveillance and treatment strategies to improve outcomes in pediatric patients with PPGL.
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Affiliation(s)
- Mickey J. M. Kuo
- Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, United States
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Matthew A. Nazari
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Abhishek Jha
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
- *Correspondence: Karel Pacak,
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Eisenhofer G, Peitzsch M, Bechmann N, Huebner A. Biochemical Diagnosis of Catecholamine-Producing Tumors of Childhood: Neuroblastoma, Pheochromocytoma and Paraganglioma. Front Endocrinol (Lausanne) 2022; 13:901760. [PMID: 35957826 PMCID: PMC9360409 DOI: 10.3389/fendo.2022.901760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Catecholamine-producing tumors of childhood include most notably neuroblastoma, but also pheochromocytoma and paraganglioma (PPGL). Diagnosis of the former depends largely on biopsy-dependent histopathology, but this is contraindicated in PPGL where diagnosis depends crucially on biochemical tests of catecholamine excess. Such tests retain some importance in neuroblastoma though continue to largely rely on measurements of homovanillic acid (HVA) and vanillylmandelic acid (VMA), which are no longer recommended for PPGL. For PPGL, urinary or plasma metanephrines are the recommended most accurate tests. Addition of methoxytyramine to the plasma panel is particularly useful to identify dopamine-producing tumors and combined with normetanephrine also shows superior diagnostic performance over HVA and VMA for neuroblastoma. While use of metanephrines and methoxytyramine for diagnosis of PPGL in adults is established, there are numerous pitfalls for use of these tests in children. The establishment of pediatric reference intervals is particularly difficult and complicated by dynamic changes in metabolites during childhood, especially in infants for both plasma and urinary measurements, and extending to adolescence for urinary measurements. Interpretation of test results is further complicated in children by difficulties in following recommended preanalytical precautions. Due to this, the slow growing nature of PPGL and neglected consideration of the tumors in childhood the true pediatric prevalence of PPGL is likely underappreciated. Earlier identification of disease, as facilitated by surveillance programs, may uncover the true prevalence and improve therapeutic outcomes of childhood PPGL. For neuroblastoma there remain considerable obstacles in moving from entrenched to more accurate tests of catecholamine excess.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine III, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Graeme Eisenhofer,
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Angela Huebner
- Department of Pediatrics, Universitätsklinikum Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
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9
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Garcia-Carbonero R, Matute Teresa F, Mercader-Cidoncha E, Mitjavila-Casanovas M, Robledo M, Tena I, Alvarez-Escola C, Arístegui M, Bella-Cueto MR, Ferrer-Albiach C, Hanzu FA. Multidisciplinary practice guidelines for the diagnosis, genetic counseling and treatment of pheochromocytomas and paragangliomas. Clin Transl Oncol 2021; 23:1995-2019. [PMID: 33959901 PMCID: PMC8390422 DOI: 10.1007/s12094-021-02622-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/07/2021] [Indexed: 12/20/2022]
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors that arise from chromaffin cells of the adrenal medulla and the sympathetic/parasympathetic neural ganglia, respectively. The heterogeneity in its etiology makes PPGL diagnosis and treatment very complex. The aim of this article was to provide practical clinical guidelines for the diagnosis and treatment of PPGLs from a multidisciplinary perspective, with the involvement of the Spanish Societies of Endocrinology and Nutrition (SEEN), Medical Oncology (SEOM), Medical Radiology (SERAM), Nuclear Medicine and Molecular Imaging (SEMNIM), Otorhinolaryngology (SEORL), Pathology (SEAP), Radiation Oncology (SEOR), Surgery (AEC) and the Spanish National Cancer Research Center (CNIO). We will review the following topics: epidemiology; anatomy, pathology and molecular pathways; clinical presentation; hereditary predisposition syndromes and genetic counseling and testing; diagnostic procedures, including biochemical testing and imaging studies; treatment including catecholamine blockade, surgery, radiotherapy and radiometabolic therapy, systemic therapy, local ablative therapy and supportive care. Finally, we will provide follow-up recommendations.
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Affiliation(s)
- R Garcia-Carbonero
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), UCM, CNIO, CIBERONC, Avda Cordoba km 5.4, 28041, Madrid, Spain.
| | - F Matute Teresa
- Radiology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - E Mercader-Cidoncha
- Endocrine and Metabolic Surgery Unit, General and Digestive Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Mitjavila-Casanovas
- Nuclear Medicine Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain.,Grupo de Trabajo de Endocrino de la SEMNIM, Madrid, Spain
| | - M Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Center, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - I Tena
- Scientific Department, Medica Scientia Innovation Research (MedSIR CORP), Ridgewood, NJ, USA.,Medical Oncology Department, Hospital Provincial, Castellon, Spain
| | - C Alvarez-Escola
- Neuroendocrinology Unit, Endocrinology and Nutrition Department, Hospital Universitario la Paz, Madrid, Spain
| | - M Arístegui
- ENT Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M R Bella-Cueto
- Pathology Department, Hospital Universitario Parc Taulí, Sabadell, Institut D'Investigació I Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - C Ferrer-Albiach
- Radiation Oncology Department, Hospital Provincial Castellón, Castellón, Spain
| | - F A Hanzu
- Endocrinology and Nutrition Department, Hospital Clinic Barcelona, University of Barcelona, IDIBAPS, Barcelona, Spain
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10
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Constantinescu G, Leike S, Gruber M, Langton K, Kunath C, Peitzsch M, Deinum J, Eisenhofer G, Lenders J. Pheochromocytoma Concealed By Chronic Methamphetamine Abuse. AACE Clin Case Rep 2020; 6:e212-e216. [DOI: 10.4158/accr-2019-0601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/15/2020] [Indexed: 11/15/2022] Open
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11
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Nölting S, Ullrich M, Pietzsch J, Ziegler CG, Eisenhofer G, Grossman A, Pacak K. Current Management of Pheochromocytoma/Paraganglioma: A Guide for the Practicing Clinician in the Era of Precision Medicine. Cancers (Basel) 2019; 11:cancers11101505. [PMID: 31597347 PMCID: PMC6827093 DOI: 10.3390/cancers11101505] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/18/2019] [Accepted: 09/24/2019] [Indexed: 12/13/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PCC/PGLs) are rare, mostly catecholamine-producing neuroendocrine tumors of the adrenal gland (PCCs) or the extra-adrenal paraganglia (PGL). They can be separated into three different molecular clusters depending on their underlying gene mutations in any of the at least 20 known susceptibility genes: The pseudohypoxia-associated cluster 1, the kinase signaling-associated cluster 2, and the Wnt signaling-associated cluster 3. In addition to tumor size, location (adrenal vs. extra-adrenal), multiplicity, age of first diagnosis, and presence of metastatic disease (including tumor burden), other decisive factors for best clinical management of PCC/PGL include the underlying germline mutation. The above factors can impact the choice of different biomarkers and imaging modalities for PCC/PGL diagnosis, as well as screening for other neoplasms, staging, follow-up, and therapy options. This review provides a guide for practicing clinicians summarizing current management of PCC/PGL according to tumor size, location, age of first diagnosis, presence of metastases, and especially underlying mutations in the era of precision medicine.
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Affiliation(s)
- Svenja Nölting
- Department of Medicine IV, University Hospital, LMU Munich, Ziemssenstraße 1, 80336 München, Germany.
| | - Martin Ullrich
- Department of Radiopharmaceutical and Chemical Biology, Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf, Bautzner Landstrasse 400, 01328 Dresden, Germany.
| | - Jens Pietzsch
- Department of Radiopharmaceutical and Chemical Biology, Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf, Bautzner Landstrasse 400, 01328 Dresden, Germany.
- Department of Chemistry and Food Chemistry, School of Science, Technische Universität Dresden, Mommsenstrasse 9, 01062 Dresden, Germany.
| | - Christian G Ziegler
- Department of Medicine III, University Hospital Carl Gustav Carus Dresden, Fetscherstraße 74, 01307 Dresden, Germany.
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus Dresden, Fetscherstraße 74, 01307 Dresden, Germany.
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany.
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford Ox3 7LJ, UK.
- Department of Gastroenterology, Royal Free Hospital ENETS Centre of Excellence, London NW3 2QG, UK.
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20814, USA.
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12
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Leng OM, Madathil AC. REMISSION OF LONGSTANDING INSULIN-TREATED DIABETES MELLITUS FOLLOWING SURGICAL RESECTION OF PHEOCHROMOCYTOMA. AACE Clin Case Rep 2019; 5:e62-e65. [PMID: 31967003 DOI: 10.4158/accr-2018-0091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/12/2018] [Indexed: 11/15/2022] Open
Abstract
Objective To describe the case of a woman with a longstanding misdiagnosis of type 1 diabetes mellitus (T1DM), in whom diabetes remission was achieved following surgical resection of adrenal pheochromocytoma. Methods We present a case report with accompanying biochemical, histologic, and genetic investigation results. Results We report the case of a 57-year-old woman with a 13-year history of apparent T1DM, and her presentation with intermittent exertional nausea. An abdominal ultrasound scan identified a rounded heterogeneous mass measuring 120 × 110 × 104 mm superior to her left kidney. Plasma metanephrine levels were markedly elevated with normetaneprhine at 17,856 pmol/L (reference range is 120 to 1,180 pmol/L), metanephrine >25,000 pmol/L (reference range is 80 to 510 pmol/L), 3-methoxytyramine at 1,393 pmol/L (reference range is 0 to 180 pmol/L). The mass demonstrated marked uptake on an iodine-123-meta-iodobenzylguanidine scan. The patient's hypertension was managed with phenoxybenzamine, and she underwent adrenalectomy. Following surgery, she was able to discontinue all diabetes medications and has maintained a hemoglobin A1c value <48 mmol/mol for over 12 months. Conclusion The case illustrates that remission of T1DM is possible even after prolonged insulin treatment upon surgical resection of pheochromocytoma. It highlights the potential benefits of reevaluating the diagnostic classification of T1DM in the light of new clinical information.
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13
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Effect of continuous positive airway pressure in hypertensive patients with obstructive sleep apnea and high urinary metanephrines. J Hypertens 2018; 36:199-204. [DOI: 10.1097/hjh.0000000000001507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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14
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Pamporaki C, Hamplova B, Peitzsch M, Prejbisz A, Beuschlein F, Timmers HJ, Fassnacht M, Klink B, Lodish M, Stratakis CA, Huebner A, Fliedner S, Robledo M, Sinnott RO, Januszewicz A, Pacak K, Eisenhofer G. Characteristics of Pediatric vs Adult Pheochromocytomas and Paragangliomas. J Clin Endocrinol Metab 2017; 102:1122-1132. [PMID: 28324046 PMCID: PMC5460722 DOI: 10.1210/jc.2016-3829] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/26/2017] [Indexed: 12/22/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGLs) in children are often hereditary and may present with different characteristics compared with adults. Hereditary PPGLs can be separated into cluster 1 and cluster 2 tumors due to mutations impacting hypoxia and kinase receptor signaling pathways, respectively. OBJECTIVE To identify differences in presentation of PPGLs between children and adults. DESIGN A retrospective cross-sectional clinical study. SETTING Seven tertiary medical centers. PATIENTS The study included 748 patients with PPGLs, including 95 with a first presentation during childhood. Genetic testing was available in 611 patients. Other data included locations of primary tumors, presence of recurrent or metastatic disease, and plasma concentrations of metanephrines and 3-methoxytyramine. RESULTS Children showed higher (P < 0.0001) prevalence than adults of hereditary (80.4% vs 52.6%), extra-adrenal (66.3% vs 35.1%), multifocal (32.6% vs 13.5%), metastatic (49.5% vs 29.1%), and recurrent (29.5% vs 14.2%) PPGLs. Tumors due to cluster 1 mutations were more prevalent among children than adults (76.1% vs 39.3%; P < 0.0001), and this paralleled a higher prevalence of noradrenergic tumors, characterized by relative lack of increased plasma metanephrine, in children than in adults (93.2% vs 57.3%; P < 0.0001). CONCLUSIONS The higher prevalence of hereditary, extra-adrenal, multifocal, and metastatic PPGLs in children than adults represents interrelated features that, in part, reflect the lower age of disease presentation of noradrenergic cluster 1 than adrenergic cluster 2 tumors. The differences in disease presentation are important to consider in children at risk for PPGLs due to a known mutation or previous history of tumor.
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Affiliation(s)
| | - Barbora Hamplova
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, D-01307 Dresden, Germany
| | | | - Felix Beuschlein
- Department of Medicine IV, University Hospital of Munich, 80539 Munich, Germany
| | - Henri J.L.M. Timmers
- Department of Internal Medicine, Radboud University Medical Centre, 6525 HP Nijmegen, The Netherlands
| | - Martin Fassnacht
- Department of Internal Medicine, Division of Endocrinology, University Hospital, University of Wuerzburg, 97070 Wuerzburg, Germany
| | - Barbara Klink
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus at the TU Dresden, D-01307 Dresden, Germany
- German Cancer Consortium, D-01307 Dresden, Germany
- German Cancer Research Center, 69120 Heidelberg, Germany
- National Center for Tumor Diseases, D-01307 Dresden, Germany
| | - Maya Lodish
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | - Constantine A. Stratakis
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | | | - Stephanie Fliedner
- Department of Medicine, University Medical Center Schleswig-Holstein, 23562 Luebeck, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Human Cancer Genetics Programme, Spanish National Cancer Research Centre, 28029 Madrid, Spain
| | - Richard O. Sinnott
- Department of Computing and Information, University of Melbourne, 3010 Melbourne, Australia
| | | | - Karel Pacak
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2425
| | - Graeme Eisenhofer
- Medicine ΙΙI and
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, D-01307 Dresden, Germany
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15
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Pęczkowska M, Cwikla J, Kidd M, Lewczuk A, Kolasinska-Ćwikła A, Niec D, Michałowska I, Prejbisz A, Januszewicz A, Chiarelli J, Bodei L, Modlin I. The clinical utility of circulating neuroendocrine gene transcript analysis in well-differentiated paragangliomas and pheochromocytomas. Eur J Endocrinol 2017; 176:143-157. [PMID: 27913608 DOI: 10.1530/eje-16-0727] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/18/2016] [Accepted: 11/08/2016] [Indexed: 12/18/2022]
Abstract
CONTEXT Paragangliomas and pheochromocytomas (PPGLs) exhibit variable malignancy, which is difficult to determine by histopathology, amine measurements or tissue genetic analyses. OBJECTIVE To evaluate whether a 51-neuroendocrine gene blood analysis has clinical utility as a diagnostic and prognostic marker. DESIGN Prospective cohort study. Well-differentiated PPGLs (n = 32), metastatic (n = 4); SDHx mutation (n = 25); 12 biochemically active, Lanreotide treated (n = 4). Nine patients had multiple sampling. Age- and gender-matched controls and GEP-NETs (comparators). METHODS Circulating neuroendocrine tumor mRNA measured (qPCR) with multianalyte algorithmic analysis. Metabolic, epigenomic and proliferative genes as well as somatostatin receptor expression were assessed (averaged, normalized gene expression: mean ± s.e.m.). Amines were measured by HPLC and chromogranin A by ELISA. Analyses (2-tailed): Fisher's test, non-parametric (Mann-Whitney), receiver-operator curve (ROC) and multivariate analysis (MVA). All data are presented as mean ± s.e.m. RESULTS PPGL were NETest positive (100%). All exhibited higher scores than controls (55 ± 5% vs 8 ± 1%, P = 0.0001), similar to GEP-NETs (47 ± 5%). ROC analysis area under curve was 0.98 for differentiating PPGLs/controls (cut-off for normal: 26.7%). Mutation status was not directly linked to NETest. Genetic and molecular clustering was associated (P < 0.04) with NETest scores. Metastatic (80 ± 9%) and multicentric (64 ± 9%) disease had significantly (P < 0.04) higher scores than localized disease (43 ± 7%). Progressive disease (PD) had the highest scores (86 ± 2%) vs stable (SD, 41 ± 2%) (P < 0.0001). The area under the curve for PD from SD was 0.93 (cut-off for PD: 53%). Proliferation, epigenetic and somatostatin receptor gene expression was elevated (P < 0.03) in PD. Metabolic gene expression was decreased in SDHx mutations. Repeat NETest measurements defined clinical status in the 9 patients (6 SD and 3 PD). Amine measurement was non-informative. Multivariate analysis identified NETest >53% as an independent prognostic factor. CONCLUSION Circulating NET transcript analysis is positive (100% diagnostic) in well-differentiated PCC/PGL, scores were elevated in progressive disease irrespective of mutation or biochemical activity and elevated levels were prognostic.
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Affiliation(s)
| | - J Cwikla
- University of Warmia and MazuryThe Faculty of Medical Sciences, Olsztyn, Poland
| | - M Kidd
- Wren LaboratoriesBranford, Connecticut, USA
| | - A Lewczuk
- Medical University of GdanskGdansk, Poland
| | | | - D Niec
- Institute of CardiologyWarsaw, Poland
| | | | | | | | | | - L Bodei
- Memorial Sloan Kettering Cancer CenterNew York, USA
| | - I Modlin
- Yale University School of MedicineNew Haven, Connecticut, USA
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