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Passman JE, Wachtel H. Management of Pheochromocytomas and Paragangliomas. Surg Clin North Am 2024; 104:863-881. [PMID: 38944505 DOI: 10.1016/j.suc.2024.02.014] [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] [Indexed: 07/01/2024]
Abstract
Pheochromocytomas and paragangliomas are distinctive neuroendocrine tumors which frequently produce excess catecholamines with resultant cardiovascular morbidity. These tumors have a strong genetic component, with up to 40% linked to hereditary pathogenic variants; therefore, germline genetic testing is recommended for all patients. Surgical resection offers the only potential cure in the case of localized disease. Given the potential for catecholaminergic crises, appropriate perioperative management is crucial, and all patients should undergo alpha-adrenergic blockade before resection. Therapeutic options for metastatic disease are limited and include surgical debulking, radiopharmaceutical therapies, and conventional chemotherapy.
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Affiliation(s)
- Jesse E Passman
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 4th Floor, Maloney Building, Philadelphia, PA 19104, USA.
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 4th Floor, Maloney Building, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Alzelfawi L, Almajed E, Alhindawi Z, AlDosari L, Alhumaidan A, Alharthi B. Feasibility of laparoscopic adrenalectomy in adrenal masses greater than 5 centimeters: a systematic review and meta-analysis. Gland Surg 2024; 13:952-968. [PMID: 39015701 PMCID: PMC11247588 DOI: 10.21037/gs-24-69] [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: 02/28/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024]
Abstract
Background Laparoscopic adrenalectomy (LA) has emerged as the primary treatment for adrenal masses. This systematic review and meta-analysis assessed LA's feasibility, safety, effectiveness, and complications for adrenal masses exceeding 5 cm. Methods The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023462901. Adults with unilateral adrenal masses >5 cm who underwent unilateral LA were included. Intraoperative and postoperative measurements and complications were assessed. A systematic literature review employed a comprehensive search strategy which was last searched on September 8, 2023, through PubMed, Google Scholar, Web of Science, and ProQuest databases. Meta-analysis was utilized to analyze the outcomes. Risk of bias was assessed using the Newcastle-Ottawa scale. Results This systematic review encompassed 25 studies involving 963 patients who underwent LA. Tumor size varied 7.05 cm [95% confidence interval (CI): 6.24-7.70], with 50% on the right and 45% on the left. The subgroup meta-analysis comparing the transperitoneal and retroperitoneal approaches revealed the transperitoneal approach h was utilized for the largest tumor size with a mean of 12.10 cm (95% CI: 11.30-12.96), compared to the retroperitoneal approach 5.83 cm (95% CI: 5.52-6.14). Notably, the mean operative time across studies was 137.4 minutes (95% CI: 113.36-150.94), bleeding prevalence was 0.02% (95% CI: 0.01-0.03%), and average blood loss was 110.6 mL (95% CI: 78.2-156.3). Postoperative complications such as pulmonary edema, pulmonary embolism, gastric dysfunction, and wound infection were very low, ranging from 0.03% to 0.4%. Out of 963 patients, only 49 were converted to open surgery. Patient hospital stay averaged 3.72 days (95% CI: 2.97-4.66); blood transfusion was required in 1.3% (95% CI: 0.30-8.88%). Conclusions The feasibility and safety of LA for tumors exceeding 5 cm in size have notable implications for intraoperative and postoperative outcomes. Underreporting in the included studies may impact the generalizability of findings.
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Affiliation(s)
- Lama Alzelfawi
- College of Medicine, Princess Noura Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ebtesam Almajed
- College of Medicine, Princess Noura Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Zeena Alhindawi
- College of Medicine, Princess Noura Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Lena AlDosari
- College of Medicine, Princess Noura Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Almaha Alhumaidan
- College of Medicine, Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Bandar Alharthi
- King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
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Konjety P, Chakole V. Esmolol's Role in Hemodynamic Management During Pheochromocytoma Surgery: A Comprehensive Review. Cureus 2024; 16:e61786. [PMID: 38975526 PMCID: PMC11227420 DOI: 10.7759/cureus.61786] [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] [Received: 05/26/2024] [Accepted: 06/06/2024] [Indexed: 07/09/2024] Open
Abstract
Pheochromocytoma (PCC) surgery presents significant challenges due to the hemodynamic instability induced by catecholamine release. Effective perioperative management is essential to minimize complications and ensure optimal outcomes. This comprehensive review examines the role of esmolol, a short-acting beta-blocker, in hemodynamic stabilization during PCC surgery. We provide an overview of the pathophysiology of PCC, highlighting the cardiovascular effects of excessive catecholamines. Challenges in perioperative management and the need for effective hemodynamic control are discussed. The pharmacology and mechanisms of action of esmolol are outlined, along with evidence from clinical studies supporting its use in PCC surgery. Comparative analyses with other hemodynamic agents are presented, along with recommendations for optimizing esmolol administration and monitoring. Key findings include the ability of esmolol to attenuate catecholamine-induced hypertension and tachycardia, thereby promoting hemodynamic stability and reducing the risk of intraoperative cardiovascular crises. Implications for clinical practice include the incorporation of esmolol into perioperative management protocols and the importance of multidisciplinary collaboration. Future research directions include further elucidating optimal dosing regimens, comparative effectiveness studies, and exploring novel therapeutic approaches. Collaboration among clinicians, researchers, and pharmaceutical companies is essential to advance the care of patients undergoing surgery for PCC.
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Affiliation(s)
- Pavithra Konjety
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek Chakole
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Alaswad M, Sabbah BN, Aleem MU, Naguib R, Azzam AZ, Amin TM. Treatment of recurrent malignant pheochromocytoma with a novel approach: A case report and review of literature. Int J Surg Case Rep 2024; 117:109504. [PMID: 38503158 PMCID: PMC10963217 DOI: 10.1016/j.ijscr.2024.109504] [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: 01/22/2024] [Revised: 03/03/2024] [Accepted: 03/07/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION Pheochromocytomas are rare catecholamine-secreting tumors with a high potential for recurrence post-surgery, necessitating prolonged follow-up. This case highlights the diagnostic and therapeutic challenges in managing recurrent pheochromocytoma. CASE PRESENTATION A 25-year-old female, with a history of left pheochromocytoma treated with adrenalectomy a decade earlier, presented with a right adrenal mass. Despite controlled hypertension, elevated urine metanephrines suggested recurrence. Imaging showed a right adrenal mass and suspicious left paraaortic lymph nodes, confirming the diagnosis of recurrent malignant pheochromocytoma in the left adrenal bed and right adrenal gland, with metastasis to the paraaortic lymph nodes. The patient underwent right adrenalectomy coupled with cytoreductive surgery (CRS) in the form of excision of left-sided adrenal bed recurrence and left paraaortic lymph node dissection, intraoperative radiation therapy (IORT), and hyperthermic intraperitoneal chemotherapy (HIPEC). On follow-up six years later, the patient remains free from recurrence. DISCUSSION This case illustrates the importance of continued surveillance in pheochromocytoma patients, even those with a low-risk profile. The recurrence in this case, despite a smaller initial tumor size and no genetic predispositions, underscores the unpredictable nature of pheochromocytomas. The successful management with CRS, IORT, and HIPEC emphasizes the need for a personalized and multifaceted treatment approach. CONCLUSION Pheochromocytoma patients, including those initially considered low risk, require long-term monitoring due to the risk of recurrence. The utilization of CRS, IORT, and HIPEC in this case was pivotal in managing the recurrent and metastatic malignant disease effectively, demonstrating the significance of a comprehensive, multidisciplinary treatment strategy in such complex cases.
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Affiliation(s)
- Marwan Alaswad
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | | | | | - Rania Naguib
- Internal Medicine Department, College of Medicine, Princess NouNrah Bint Abdul Rahman University, Riyadh, Saudi Arabia
| | - Ayman Z Azzam
- Department of Surgery, Surgical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tarek M Amin
- Department of Surgery, Surgical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Wang X, Zhao Y, Liao Z, Zhang Y. Surgical strategies of complicated pheochromocytomas/paragangliomas and literature review. Front Endocrinol (Lausanne) 2023; 14:1129622. [PMID: 37152961 PMCID: PMC10160616 DOI: 10.3389/fendo.2023.1129622] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Pheochromocytomas (PCC)/paragangliomas (PGL) are catecholamine (CA) -secreting neuroendocrine tumors, which are known as PPGL due to their histological and pathophysiological similarities. In addition to the typical triad of paroxysmal headache, palpitation, and sweating, PPGL may also be accompanied by symptoms and signs involving multiple organs and systems such as the cardiovascular system, digestive system, endocrine system, and nervous system. Currently, surgical resection is the first choice for PPGL. Safe and effective surgical management of complicated PPGL is the goal of clinical work. In this paper, we discuss this hot issue based on complicated PPGL cases, aiming to share our experience of the surgical management strategy of PPGL.
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Araujo-Castro M, Pascual-Corrales E, Lorca Álvaro J, Mínguez Ojeda C, Pian H, Ruz-Caracuel I, Sanjuanbenito Dehesa A, Serrano Romero A, Alonso-Gordoa T, Molina-Cerrillo J, Gómez Dos Santos V. Manejo quirúrgico y posquirúrgico de paragangliomas abdominales y feocromocitomas. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Bernardi S, Calabrò V, Cavallaro M, Lovriha S, Eramo R, Fabris B, de Manzini N, Dobrinja C. Is the Adrenal Incidentaloma Functionally Active? An Approach-To-The-Patient-Based Review. J Clin Med 2022; 11:jcm11144064. [PMID: 35887828 PMCID: PMC9323753 DOI: 10.3390/jcm11144064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/01/2022] [Accepted: 07/10/2022] [Indexed: 02/01/2023] Open
Abstract
Adrenal incidentalomas are a common occurrence. Most of them are adrenocortical adenomas that do not cause harm and do not require surgery, but a non-negligible proportion of incidentalomas is represented by functionally active masses, including cortisol-secreting adenomas (12%), pheochromocytomas (3–6%), aldosterone-secreting adenomas (2–3%), as well as malignant nodules, such as adrenocortical carcinomas (2–5%), which can be either functioning or non-functioning. All patients with an adrenal incidentaloma should undergo a few biochemical screening and confirmatory tests to exclude the presence of a functionally active mass. In this approach-to-the-patient-based review, we will summarize current recommendations on biochemical evaluation and management of functionally active adrenal incidentalomas. For this purpose, we will present four case vignettes, whereby we will describe how patients were managed, then we will review and discuss additional considerations tied to the diagnostic approach, and conclude with practical aspects of patient perioperative management. To improve the perioperative management of patients with functional adrenal incidentalomas, multidisciplinary meetings are advocated.
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Affiliation(s)
- Stella Bernardi
- Department of Medical, Surgical and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy; (S.L.); (B.F.); (N.d.M.); or (C.D.)
- SS Endocrinologia, UCO Medicina Clinica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
- Correspondence: ; Tel.: +39-(0)403994318
| | - Veronica Calabrò
- SS Endocrinologia, UCO Medicina Clinica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Marco Cavallaro
- UCO Radiologia, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Sara Lovriha
- Department of Medical, Surgical and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy; (S.L.); (B.F.); (N.d.M.); or (C.D.)
- SS Endocrinologia, UCO Medicina Clinica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Rita Eramo
- UCO Clinica Chirurgica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Bruno Fabris
- Department of Medical, Surgical and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy; (S.L.); (B.F.); (N.d.M.); or (C.D.)
- SS Endocrinologia, UCO Medicina Clinica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Nicolò de Manzini
- Department of Medical, Surgical and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy; (S.L.); (B.F.); (N.d.M.); or (C.D.)
- UCO Clinica Chirurgica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Chiara Dobrinja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy; (S.L.); (B.F.); (N.d.M.); or (C.D.)
- UCO Clinica Chirurgica, ASUGI (Azienda Sanitaria Universitaria Giuliano Isontina), Cattinara Teaching Hospital, Strada di Fiume 447, 34149 Trieste, Italy;
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Luo S, Cui Q, Wang D. Case Report: Surgical Intervention Under Pheochromocytoma Multisystem Crisis: Timing and Approach. Front Oncol 2022; 12:908039. [PMID: 35795034 PMCID: PMC9252594 DOI: 10.3389/fonc.2022.908039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/19/2022] [Indexed: 12/19/2022] Open
Abstract
Background Progressive multiple organ failures still occur in some patients with pheochromocytoma multisystem crisis (PMC) despite α- and β-blockade being used, and emergency adrenalectomy may lead to rapid hemodynamic stabilization and recovery. Therefore, the optimal timing and surgical approach under PMC remain controversial. Case Presentation A 50-year-old man presented with persistent chest pain accompanied by vomiting and headache. CT showed a right adrenal mass, and plasma catecholamine levels were significantly elevated. Phenoxybenzamine was used, but his symptoms were aggravated. He progressed to acute respiratory distress syndrome (ARDS) and received mechanical ventilation. Reexamination of CT showed pheochromocytoma rupture. Emergency pheochromocytoma resection was performed on the 5th day, and he was discharged on the 21st day. A 46-year-old woman was admitted for intrauterine device removal and received hysteroscopy under intravenous anesthesia. She presented with dyspnea, fluctuating blood pressure, and loss of consciousness 9 h after hysteroscopy surgery. CT showed a left adrenal mass, and plasma catecholamine levels were significantly elevated. Her condition fluctuated and could not meet the preoperative preparation criteria for pheochromocytoma despite adequate doses of α-blockade and β-blockade were taken. Furthermore, her lung condition worsened due to recurrent crises and pulmonary edema. After multidisciplinary discussions, laparoscopic left adrenalectomy with venoarterial extracorporeal membrane oxygenation (VA-ECMO) support was performed on the 28th day, and she was discharged on the 69th day. Conclusion Elective surgical resection is the essential therapy for PMC with adequate preoperative medical management. Emergency surgery is recommended for patients who fail to achieve medical stabilization or progressive organ dysfunction within 1 week, especially those with tumor rupture and uncontrolled bleeding. The laparoscopic approach may represent an option even under PMC.
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Cerebral hemorrhage as the initial symptom of delayed diagnosis of childhood pheochromocytoma. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Al-Thani H, Al-Thani N, Al-Sulaiti M, Tabeb A, Asim M, El-Menyar A. A Descriptive Comparative Analysis of the Surgical Management of Adrenal Tumors: The Open, Robotic, and Laparoscopic Approaches. Front Surg 2022; 9:848565. [PMID: 35310427 PMCID: PMC8927071 DOI: 10.3389/fsurg.2022.848565] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/27/2022] [Indexed: 02/03/2023] Open
Abstract
BackgroundCurrently, adrenalectomies are trending toward minimally invasive approach including robotic and laparoscopic surgery. We aimed to describe the clinical presentation and outcomes associated with the 3 different surgical approaches in patients who underwent adrenalectomy for adrenal mass at a single tertiary center.MethodsA retrospective descriptive observational study was conducted to include all patients who underwent surgical interventions for adrenal gland mass between 2004 and 2019. Patients were categorized into three groups according to the interventional approach (open, robotic vs. laparoscopic adrenalectomy) and data were analyzed and compared.ResultsA total of 124 patients underwent adrenalectomies (61.3% robotic, 22.6% open, and 16.1% laparoscopic approach). Incidentally discovered adrenal mass was reported in 67% of patients, and hypertension was the most prevalent comorbidity (53%). The tendency for malignancy increased with increasing tumor size while the functioning tumors were more in the smaller tumor size. Larger tumors were more common in younger patients. The robotic approach showed shorter surgical intensive care and hospital length of stay. Patients in the open adrenalectomy group frequently presented with abdominal pain (p = 0.001), had more nonfunctional adrenal mass (p = 0.04), larger mean tumor size (p = 0.001), and were frequently operated on the right side (p = 0.03). There was no post-operative mortality; however, during follow-up, 8 patients died (3 open, 3 laparoscopic and, 2 robotic approach). The median follow-up was 746 days (range 7–5,840).ConclusionsThe study explored the three surgical adrenalectomy approaches in a dedicated center for patients with adrenal pathology. It showed that robotic adrenalectomy could be safe and effective surgical approach for patients with benign functioning adrenal tumors of a diameter <6 cm. However, the choice of a surgical approach varies according to the adrenal mass presentation, patient fitness for surgery, type and sizes of the tumor, surgeon's experience, and hospital resources. Open surgery is considered the first choice for larger, ruptured adrenal tumor or malignancy. However, the recent restructuring of the surgical department resulted in selection bias in favor of the robotic surgery. Further studies are required to address the risk factors, selection criteria for appropriate management, cost, and quality of life.
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Affiliation(s)
| | - Noora Al-Thani
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | | | | | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
- *Correspondence: Ayman El-Menyar
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Pheochromocytoma Presenting as Testicular Pain: An Unusual Case Report. Case Rep Endocrinol 2021; 2021:6699409. [PMID: 33953991 PMCID: PMC8062206 DOI: 10.1155/2021/6699409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/07/2021] [Accepted: 03/29/2021] [Indexed: 11/18/2022] Open
Abstract
Pheochromocytoma (PCC) is a rare catecholamine-secreting tumor that arises from chromaffin cells of the adrenal medulla which are derived from the neural crest. This report illustrates a 51-year-old Caucasian male with a history of hypertension diagnosed two years ago who presented to the hospital due to acute onset of right testicular pain of 3-day duration. Laboratory results and imaging revealed a presumptive diagnosis of PCC. The patient had undergone robot-assisted laparoscopic right adrenalectomy 14 days after being diagnosed with PCC due to perioperative management with phenoxybenzamine. The final pathology report revealed a PCC. At follow-up two weeks after discharge, the patient reported complete resolution of his testicular pain.
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Dominedò C, D’Avino E, Martinotti A, Cingolani E. A rare pheochromocytoma complicated by cardiogenic shock and posterior reversible encephalopathy syndrome: case report. Eur Heart J Case Rep 2021; 5:ytaa513. [PMID: 33598609 PMCID: PMC7873792 DOI: 10.1093/ehjcr/ytaa513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/21/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022]
Abstract
Background Pheochromocytoma is a rare catecholamine-producing tumour that classically displays clinical manifestations related to alpha-adrenergic stimulation, including paroxysmal or sustained hypertension. However, it may occasionally be complicated by life-threatening crisis, leading to refractory acute heart dysfunction in the most severe cases. Case summary A 28-year-old woman was admitted to intensive care unit due to hypertensive crisis causing pulmonary oedema, Takotsubo cardiomyopathy, and metabolic acidosis. Due to cardiogenic shock, she required venoarterial extracorporeal membrane oxygenation and IMPELLA implantation. A computed tomography scan revealed a 5 cm tumour of the left adrenal gland compatible with pheochromocytoma The clinical course was complicated by acute kidney injury requiring renal replacement therapy and posterior reversible encephalopathy syndrome (PRES). Pharmacological treatment with alpha lityc agents (including urapidil, dexmedetomidine, and doxazosin at maximum daily dose) and beta blockers, together with left videolaparoscopic adrenalectomy, led to progressive blood pressure control and resolution of the neurological symptoms. Discussion Pheochromocytoma crisis turned into a potential catastrophic scenario, characterized by refractory cardiogenic shock requiring circulatory supportive devices and PRES. Alpha-antagonists and beta-blockers were the gold standard pharmacological treatment. A multidisciplinary decision-algorithm was necessary to successfully manage this complex clinical setting.
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Affiliation(s)
- Cristina Dominedò
- Department of Shock and Trauma, San Camillo Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
- Corresponding author. Tel: +39 0658703146,
| | - Emilio D’Avino
- Cardiovascular Anesthesia and Intensive Care Unit and Department of Cardiovascular Diseases and Heart Transplantation, San Camillo Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
| | - Alessandra Martinotti
- Department of Shock and Trauma, San Camillo Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
| | - Emiliano Cingolani
- Department of Shock and Trauma, San Camillo Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
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Aygun N, Uludag M. Pheochromocytoma and Paraganglioma: From Treatment to Follow-up. SISLI ETFAL HASTANESI TIP BULTENI 2020; 54:391-398. [PMID: 33364876 PMCID: PMC7751245 DOI: 10.14744/semb.2020.58998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022]
Abstract
Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors arising from chromaffin cells in the adrenal medulla, sympathetic or parasympathetic ganglia. Currently, the only curative treatment option of pheochromocytomas/paraganglioma (PPGL) is surgical resection. Surgery aims to eliminate both risks of hypersecretion and tumor growth. The consequences of hypersecretion should be carefully controlled with medical therapy before and during the surgery. Postoperative major complications are hypotension and rebound hypoglycemia, and patients should be followed closely for 24-48 hours. The choice of surgical approach is determined based on multiple factors, including germline genetic test results, the size of the tumor, body mass index, surgeon's experience, and the likelihood of malignancy. Primary tumor resection does not completely eliminate the risk of tumor persistence and recurrence. Therefore, all patients with PPGL who are surgically treated should be followed for at least 10 years for recurrent disease and new tumor formation. Although surgical resection is the only curative treatment for PPGLs, surgical treatment is palliative except for resectable locoregional metastases in metastatic disease or for isolated distant metastases. The purpose of palliative treatment is to reduce hormone secretion and prevent metastasis-related complications in a critical anatomical location Combined and alfa;- and beta- adrenergic blockade is usually applied in patients with PPGL preoperatively. Some patients may present with pheochromocytoma multisystem crisis, which is a life-threatening condition that can involve cardiovascular, pulmonary, neurological, gastrointestinal, renal, hepatic and metabolic systems. Pheochromocytoma crisis may be spontaneous or may present with the tumor manipulation, trauma, corticosteroids, beta-blockers, anesthetic drugs, and the stimulation of non-adrenal surgical stress. These patients should be considered as medical emergencies rather than surgical emergencies. In this review, it was aimed to evaluate the pre-, per and post-operative management, curative and palliative surgical management, and postoperative outcomes and follow-up of the patients with PPGLs.
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Affiliation(s)
- Nurcihan Aygun
- Department of General Surgery, University of Health Sciences Turkey, Sisli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, University of Health Sciences Turkey, Sisli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Turkey
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