Postoperative Management in Patients with Pheochromocytoma and Paraganglioma

Catecholamine-induced hypertensive crises: current insights and management

Phaeochromocytomas and paragangliomas (PPGLs) release catecholamines leading to catecholamine-induced hypertensive (CIH) crises, with blood pressure greater than or equal to 180/120 mm Hg. CIH crises can be complicated by tachyarrhythmias, hypotension, or life-threatening target organ damage while treatment remains undefined, often requiring co-management between endocrinologists and cardiologists. Furthermore, biochemical diagnosis of a PPGL as a cause of a CIH crisis can be difficult to identify or confounded by comorbid conditions, potentially resulting in misdiagnosis. Here, we combine relevant evidence, 60 years of collective clinical experience, insights derived from assessing over 2600 patients with PPGL, and supplementary outcomes from 100 patients (treated at the National Institutes of Health) with a CIH crisis to inform diagnosis and treatment of CIH crises. Recognising that disparities exist between availability, cost, and familiarity of various agents, flexible approaches are delineated allowing for customisation, given institutional availability and provider preference. A CIH crisis and its complications are readily treatable with available drugs, with effective intervention defining an avenue for mitigating consequent morbidity and mortality in patients with PPGL.

Paediatric phaeochromocytoma and paraganglioma: A clinical update

Paediatric phaeochromocytomas and paragangliomas (PPGLs), though rare tumours, are associated with significant disability and death in the most vulnerable of patients early in their lives. However, unlike cryptogenic and insidious disease states, the clinical presentation of paediatric patients with PPGLs can be rather overt, allowing early diagnosis, granted that salient findings are recognized. Additionally, with prompt and effective intervention, prognosis is favourable if timely intervention is implemented. For this reason, this review focuses on four exemplary paediatric cases, succinctly emphasizing the now state-of-the-art concepts in paediatric PPGL management.

Intraoperative difficulty in cardiorespiratory management during anesthesia for retroperitoneal paraganglioma resection

We report the anesthetic management of a case of paraganglioma, which was challenging because of intraoperative circulatory changes and difficult ventilatory management. A 52-year-old man with a history of chronic obstructive pulmonary disease was scheduled for paraganglioma resection under general anesthesia combined with epidural anesthesia. Since a marked increase in blood pressure was observed immediately after administration of rocuronium, antihypertensive agents were administered as necessary. The ventilatory settings were initially adjusted to deliver a tidal volume of 7 mL/kg, and the drive pressure was maintained at 13 cm H₂O or less. However, despite increasing the minute volume, PETCO₂ increased to 60 mmHg and PaCO₂ to 76 mmHg before tumor removal. Blood pressure decreased immediately after tumor removal, and PETCO₂ and PaCO₂ gradually returned to normal. We speculated that the increases in PETCO₂ and PaCO₂ might have been due to both an increase in endogenous catecholamine secretion as well as chronic obstructive pulmonary disease. It is important to preoperatively evaluate the functionality of the tumor and to anticipate perioperative cardiorespiratory instability in the management of paragangliomas.

Deliberate Compensated Vasoplegia-A Novel Pharmaceutical Approach for Controlling Blood Pressure During Surgery for Pheochromocytoma

BACKGROUND

The most dreaded adverse event of pheochromocytoma surgery is operative severe blood pressure fluctuations. Preoperative protocols with alpha-blockade have achieved controversial results. No study to date evaluated the use of operative protocols in pheochromocytoma patients. Deliberated compensated vasoplegia (DCV) is a novel pharmaceutical regimen developed at our institution to decrease severe hypertensive events. The aim of this study is to compare outcomes of pheochromocytoma resection with and without DCV protocol.

METHODS

A retrospective analysis of all pheochromocytoma resections between the years 2012 and 2021 was performed. Resections performed with and without DCV protocol were compared. The primary outcome measured was the incidence of severe hypertension (MAP > 150 mmHg) during surgery. Secondary outcomes included other abnormal blood pressure measurements as well as perioperative data and complications.

RESULTS

A total of 41 resections were included, 21 performed under DCV protocol, and 20 without the protocol. Analysis demonstrated no significant difference in preoperative parameters including tumor size, catecholamine levels, and preoperative alpha-blockade protocol. The use of DCV protocol resulted in significant decrease in severe hypertension incidence from 1.95 ± 3.6 to 0.03 ± 0.13 events/h, p = 0.008. Application of the DCV protocol was not associated with any other adverse events.

CONCLUSIONS

This study suggests that DCV anesthesia protocol significantly decreases the incidence of severe hypertensive episodes during pheochromocytoma resection. This is the first study that describes a highly effective protocol for controlling hypertension in pheochromocytoma patients.

Management of acute severe hypertension in youth: from the philosophical to the practical

PURPOSE OF REVIEW

Acute severe hypertension remains an uncommon but important source of morbidity and mortality in youth. However, there has been very little progress made in our understanding of how to best manage youth with acute severe hypertension to improve patient outcomes.

RECENT FINDINGS

Our understanding of what is acute severe hypertension is undergoing a philosophical change. Management of patients with acute severe hypertension is evolving towards more of a risk and outcomes-based approach.

SUMMARY

We should be intentional when we consider whether a patient has acute severe hypertension and if they are truly at an increased risk for life-threatening target organ injury. We should consider their specific risk factors to best interpret the risks and benefits of how best to treat a patient with acute severe hypertension, rather than relying on traditional approaches and conventional wisdom. We should always ask 'why' when we are pursuing a given management course. Future studies should clearly define the research questions they are investigating to best advance the field to ultimately improve patient outcomes.

Pathophysiology and Management of Glycemic Alterations before and after Surgery for Pheochromocytoma and Paraganglioma

Glycemic alterations are frequent in patients with pheochromocytoma and paraganglioma (PPGL), but the real incidence of secondary diabetes mellitus (DM) is uncertain, because prospective multicenter studies on this topic are lacking in the literature. The main pathophysiological mechanisms of glucose homeostasis alterations in PPGL, related to catecholamine hypersecretion, are impaired insulin and glucagon-like peptide type 1 (GLP-1) secretion and increased insulin resistance. Moreover, it has been reported that different pathways leading to glucose intolerance may be related to the secretory phenotype of the chromaffin tumor. Predictive factors for the development of glucose intolerance in PPGL patients are a higher age at diagnosis, the need for a higher number of anti-hypertensive drugs, and the presence of secreting neoplasms. Tumor resection is strongly related to the resolution of DM in PPGL patients, with a significant improvement of glycemic control in most cases. We can hypothesize a different personalized therapeutic approach based on the secretory phenotype. The adrenergic phenotype is more closely related to reduced insulin secretion, so insulin therapy may be required. On the other hand, the noradrenergic phenotype mainly acts by increasing insulin resistance and, therefore, insulin-sensitizing antidiabetic agents can find a greater application. Regarding GLP-1 receptor agonists, the data suggest a possible promising therapeutic effect, based on the assumption that GLP-1 secretion is impaired in patients with PPGL. The principal predictors of remission of glycemic alterations after surgery for PPGL are a lower preoperative body mass index (BMI), a larger tumor, higher preoperative catecholamine levels, and a shorter duration of the disease (under three years). Otherwise, after resection of PPGL, hypoglycemia can occur as the result of an excessive rebound of preoperative hyperinsulinemia. It is a rare, but potentially severe complication reported in a lot of case reports and a few small retrospective studies. Higher 24-h urinary metanephrine levels, longer operative times and larger tumors are predictive factors for hypoglycemia in this setting. In conclusion, alterations of carbohydrate metabolism are clinically relevant manifestations of PPGL before and after surgery, but there is the need to conduct multicenter prospective studies to obtain an adequate sample size, and to allow the creation of shared strategies for the clinical management of these potentially severe manifestations of PPGL.

Development and validation of a novel nomogram predicting pseudohypoxia type pheochromocytomas and paragangliomas

PURPOSE

Pseudohypoxia type (PHT) pheochromocytomas and paragangliomas (PPGLs) are more likely to metastasize and have a poor prognosis. However, application of genetic tests has many restrictions. The study aims to establish a novel nomogram for predicting the risk of PHT PPGLs.

METHODS

This retrospective cross-sectional study included 242 patients with pathology confirmed PPGLs in one tertiary care center in China in 2010-2021. Clinical and biochemical characteristics were collected. Next-generation sequencing was performed in all PPGLs patients for detection of mutation. Univariate and multivariable logistic regression analyses were used to select risk factors for constructing the nomogram. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the discrimination of the nomogram and the calibration curve was performed.

RESULTS

Four variables including age ≤ 35 years, hypertension, 24 h urinary output of urinary vanillylmandelic acid (VMA) ≥ 100 umol/24 h and urinary 17-ketosteroide (17 KS) ≤ 50 umol/24 h levels were independently associated with PHT PPGLs in the logistic regression analysis and were included in the nomogram. The nomogram showed a good discrimination performance with AUC of 0.829 [95% confidence interval (CI), 0.767-0.891] in the training set and 0.797 (95%CI, 0.659-0.935) in the validation set, respectively. The calibration curve showed a bias-corrected AUC of 0.809 vs. 0.795, and a Hosmer-Lemeshow (H-L) test yielded a p value of 0.801 vs. 0.885, indicating the nomogram's good ability to distinguish PHT PPGLs from non-PHT PPGLs.

CONCLUSION

Our study has proposed a novel nomogram for individualized prediction of the PHT PPGLs, which may make contributions to guide the patients' personalized management, follow-up, and treatment.

Elemental Composition of Pheochromocytoma Resolved on Solid/Adrenal Tissue and Whole Blood Level

Pheochromocytoma (PCC) is an unusual benign adrenal tumor with an unexamined status of the elements. This study delivers the first insight into the levels of microelements (Mn, Co, Cu, Zn, As, Se, Th), toxic elements (Cd, Pb, U), and macroelements (Na, K, Mg, Ca) in both adrenal tissue and whole blood samples collected from PCC patients. The results were strengthened by comparing recorded findings with the patients' healthy adrenal tissue (HAT) and with whole blood samples from the healthy individuals. PCCs had significantly higher levels of Zn, Se, Na, K, and Mg and lower levels of Mn, Co, Pb, and As than that of HATs. Compared to healthy blood samples, the patients' blood exhibited considerably higher levels of Na, K, and Ca but significantly lower levels of Mn, Cu, Zn, Se, and Mg. Females had significantly higher levels of essential Se and toxic Pb and Cd in their PCC tissue samples compared to males. PCC tissue levels of Mn and Cu were significantly elevated in smokers over levels in nonsmokers and in PCC patients with tumor sizes below 5 cm compared to PCC diameters above 5 cm. The data presented in this study provide a new insight into the pathophysiology of PCC. Thus, recorded elements should be considered as initiators/modifiers of PCC and potential inductors of malignant transformation. The findings of this research deepen scientific understanding of this rare adrenal disease, which, in turn, could highlight the pathogenesis of PCC.

The what, why and when of wide awake local anaesthesia no tourniquet surgery

Wide awake local anaesthesia no tourniquet, also known as WALANT, is the practice of performing surgery under local anaesthetic in the absence of a tourniquet. This technique uses the vasoconstrictive effects of adrenaline and the local anaesthetic effects of lignocaine to establish a Bier block with haemostatic control. Permitting active patient participation intraoperatively, wide awake local anaesthesia no tourniquet surgery improves patient compliance with rehabilitation and yields higher patient satisfaction. With reduced cost and equipment requirements, this method improves accessibility for patients and productivity for healthcare institutions. This is of particular benefit within the current COVID-19 climate, as wide awake local anaesthesia no tourniquet technique provides a means of overcoming restrictions to theatre access and anaesthetic support. This review delves into the current uses of wide awake local anaesthesia no tourniquet surgery, outlining the initial conception of the practice by Canadian surgeons. The advantages and disadvantages are considered, and potential future applications of this technique are discussed.

Intracerebral Haemorrhage: A Rare Presentation of Phaeochromocytoma

Phaeochromocytoma is a rare childhood adrenal medullary catecholamine secreting tumour, arising from the chromaffin cells of the sympathetic origin derived from the neural crest cells. Only a few cases have been reported in the literature so far. We report an uncommon presentation in a 5-year-old boy with intracerebral haemorrhage, hemiplegia, and paroxysmal hypertension. Magnetic resonance imaging of the brain showed chronic and acute hemorrhagic infarcts in the left cerebral hemisphere and no vascular anomaly seen on cerebral venogram. Computed tomography scan abdomen showed a mass in the lesser sac and urinary catecholamines were elevated. The patient underwent exploratory laparotomy and the mass was excised in toto. Histopathological examination (HPE) confirmed the diagnosis. This case illustrates the need for keeping in mind atypical presentations of phaeochromocytoma especially in children; as it is a treatable cause of hypertension and early diagnosis with adequate management can prevent morbidity and fatal outcomes.

Protocol for presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas: a multidisciplinary approach

OBJECTIVE

To offer a practical guide for the presurgical and anesthetic management of pheochromocytomas and sympathetic paragangliomas (PGLs).

METHODS

This protocol was based on a comprehensive review of the literature and on our own multidisciplinary team's experience from managing pheochromocytoma and sympathetic PGLs at a referral center.

RESULTS

Patients with pheochromocytomas and sympathetic paragangliomas (PGLs) may develop potentially life-threatening complications, especially during surgical procedures. A complete biochemical, radiological, genetic, and cardiological assessment is recommended in the preoperative stage as it provides an evaluation of the risk of surgical complications and malignancy, allowing individualization of the presurgical treatment. Treatment with α-blockade and proper volume expansion in the preoperative stage significantly reduces the perioperative morbidity. During surgery, the anesthesiologist should look for a deep anesthetic level that inhibits the cardiovascular effects of catecholamines to minimize the risk of intraoperative complications.

CONCLUSIONS

An optimal presurgical evaluation of pheochromocytomas/ sympathetic PGL requires a multidisciplinary approach, including a complete hormonal, radiological, cardiac, genetic, and functioning evaluation in most cases. A proper preoperative evaluation in combination with strict blood pressure and heart rate control, and blood volume status optimization, will significantly reduce the risk of intraoperative and perioperative complications. In those patients who unfortunately develop intraoperative complications, the role of the anesthesiologist is essential since the selection of the appropriate management has a direct impact on morbimortality reduction.

Common Diagnostic Challenges and Pitfalls in Genitourinary Organs, With Emphasis on Immunohistochemical and Molecular Updates

CONTEXT.—

Lesions in the genitourinary (GU) organs, both benign and malignant, can demonstrate overlapping morphology, and practicing surgical pathologists should be aware of these potential pitfalls and consider a broad differential diagnosis for each specific type of lesion involving the GU organs. The following summary of the contents presented at the 6th Annual Chinese American Pathologists Association (CAPA) Diagnostic Course (October 10-11, 2020), supplemented with relevant literature review, exemplifies the common diagnostic challenges and pitfalls for mass lesions of the GU system of adults, including adrenal gland, with emphasis on immunohistochemical and molecular updates when relevant.

OBJECTIVE.—

To describe the common mass lesions in the GU system of adults, including adrenal gland, with emphasis on the diagnostic challenges and pitfalls that may arise in the pathologic assessment, and to highlight immunohistochemical workups and emerging molecular findings when relevant.

DATA SOURCES.—

The contents presented at the course and literature search comprise our data sources.

CONCLUSIONS.—

The diagnostic challenges and pitfalls that arise in the pathologic assessment of the mass lesions in the GU system of adults, including adrenal gland, are common. We summarize the contents presented at the course, supplemented with relevant literature review, and hope to provide a diagnostic framework to evaluate these lesions in routine clinical practice.

Is laparoscopic adrenalectomy for pheochromocytoma safe and effective in geriatric patients?

OBJECTIVES

The study aimed to assess the haemodynamic changes of laparoscopic adrenalectomy (LA) in geriatric patients with pheochromocytoma (PHEO). To the best of our knowledge, this is the first study to evaluate the haemodynamic outcomes of LA in this patient population.

METHODS

Data of 350 patients who underwent single-side transperitoneal LA between 2000 and 2020 were reviewed retrospectively. Patients with a histopathological diagnosis of PHEO were included in the study and classified into two groups according to their ages at the date of surgery. Patients older than 65 years were accepted as elderly according to the World Health Organisation (WHO) recommendations.

RESULTS

A total of 54 patients underwent LA for PHEO. Fifteen patients were enrolled in the elderly and 39 in the young groups. There were no significant differences in terms of the operation site (0.564), tumour size (0.878), perioperative results such as mean anaesthesia; operation times, blood loss and haemodynamic changes. There were no significant differences in mean hospitalisation and intensive care unit times. One patient in both groups had grade 1 complication according to Clavien Dindo classification (prolonged ileus, managed with medical treatment and transfusion during surgery, respectively).

CONCLUSION

Young and elderly patients had similar outcomes in terms of haemodynamic changes that occurred with LA. LA in elderly patients with PHEO is as safe and effective as in younger patients.

Endocrine hypertension secondary to adrenal tumors: clinical course and predictive factors of clinical remission

PURPOSE

Endocrinopathies constitute ~ 10% of secondary hypertension (SH) etiologies. Primary aldosteronism, pheochromocytoma (PHEO), and Cushing's syndrome are common causes. Early identification and treatment result in resolution/improvement of SH. The aim of this study was to characterize the clinical course, outcomes, and remission-associated prognostic factors of SH related to adrenal tumors.

METHODS

Retrospective cohort study including patients with SH who underwent adrenalectomy from 2000 to 2019. Postoperative outcomes were analyzed. Remission was defined as normalization of blood pressure without drug use.

RESULTS

Eighty-three patients with SH were included. Mean ± SD age was 38.8 ± 14.2 years and 75.9% were women. Diagnosis was PHEO in 35 patients (42.2%), aldosteronoma (APA) in 28 (33.7%), cortisol producing adenoma (CPA) in 16 (19.3%), and ACTH-dependent Cushing's in 4 (4.8%). Laparoscopic adrenalectomy was performed in 81 (97.6%) patients. Mean ± SD follow-up was 57.4 ± 49.6 months (range 1-232). Surgical morbidity occurred in 7.2% of patients and there was no mortality. Remission of SH occurred in 61(73.5%): 100% of ACTH-dependent Cushing's, 85.7% of PHEO, 68.8% of CPA, and 57.1% of APA. Biochemical phenotype and the combination of larger tumor size, number of antihypertensive drugs, male gender, older age, obesity, and preoperative SH for more than 5 years were associated with less likely clinical remission in patients with APA (p = 0.004), CPA (p < 0.0001), and PHEO (p < 0.0001).

CONCLUSION

SH remission rates are 57-100% after adrenalectomy. Several prognostic factors could be used to predict SH control. Adrenalectomy provides good clinical outcome and must be considered a treatment option in all surgical candidates.

Outcomes of malignant pheochromocytoma based on operative approach: A National Cancer Database analysis

BACKGROUND

Malignant pheochromocytoma is often managed with adrenalectomy. Most literature focusing on postoperative outcomes are from single institutions. This study aimed to describe outcomes of adrenalectomy for malignant pheochromocytoma using a national database. We hypothesized that minimally invasive approaches might be associated with improved short-term outcomes but potentially inferior oncologic efficacy.

METHODS

Patients who underwent adrenalectomy for malignant pheochromocytoma were identified in the National Cancer Database (2010-2016). Patients were categorized as minimally invasive adrenalectomy or open adrenalectomy. Short- and long-term outcomes were compared.

RESULTS

A total of 276 patients underwent adrenalectomy for malignant pheochromocytoma: 50.7% open adrenalectomy and 49.3% minimally invasive adrenalectomy. Demographics were similar, except those who underwent open adrenalectomy had larger tumors compared to minimally invasive adrenalectomy (8.2 cm vs 4.7 cm; P < .001). Tumor size ≥6 cm was associated with a reduced likelihood of minimally invasive adrenalectomy (relative to open adrenalectomy) on multivariable regression (odds ratio = 0.23; P < .001). Open adrenalectomy was associated with longer duration of stay relative to minimally invasive adrenalectomy (6 vs 3 days; P < .001). Rates of positive margins, unplanned readmissions, or 30-/90-day mortalities were similar based on operative approach. Five-year survival rates were similar (open adrenalectomy 74.3%, minimally invasive adrenalectomy 79.1%). There was no association between overall survival and operative approach on multivariable Cox analysis when controlling for tumor size, laterality, and clinicodemographic variables.

CONCLUSION

Patients with larger malignant pheochromocytomas were more likely to undergo an open adrenalectomy. With the exception of an increased duration of stay, there was no difference in short- or long-term postoperative outcomes. These data suggest that minimally invasive adrenalectomy appears safe among tumors <6 cm.

Pheochromocytoma Presenting as Testicular Pain: An Unusual Case Report

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.

Management of Adrenal Tumors in Pediatric Patients

Pediatric adrenal tumors are uncommon entities that are frequently occult and identified incidentally or by recognizing symptoms related to hormone overproduction. They often have a genetic underpinning, arise from the medulla or cortex, can be malignant or benign, and require precise diagnostic algorithms. However, pseudotumors must also be a diagnostic consideration. Therapeutic interventions and plans are tumor dependent, but surgery is a cornerstone of treatment. Ongoing surveillance after treatment, regardless of malignant determination, is of utmost importance as well.

A case of an unexpected posterior mediastinal functional paraganglioma: case report and literature review

Background

Paraganglioma can be found in a wide range of locations. However, paraganglioma in the posterior mediastinum is rare. An unexpected paraganglioma located in the posterior mediastinum was found during surgery. The anesthesia management of this patient was challenging.

Case presentation

A 65-year-old male with a posterior mediastinal tumor was scheduled for thoracoscopic mediastinal tumor resection. Severe hemodynamic changes during the operation and postoperative pathological diagnosis showed that the patient had a rare case of posterior mediastinal functional paraganglioma, which was not found before the operation. Although the patient did not experience side effects after surgery, he did experience a dangerous surgical process.

Conclusions

The correct diagnosis of paraganglioma, intensive preoperative screening, adequate preoperative preparation, and accurate intraoperative anesthesia management could provide better anesthesia for paraganglioma patients.

Preoperative Management of Pheochromocytoma and Paraganglioma

Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, characterized by excessive release of catecholamines (CAs), and manifested as the classic triad of headaches, palpitations, profuse sweating, and a variety of other signs and symptoms. The diagnosis of PPGL requires both evidence of excessive release of CAs and anatomical localization of CA-secreting tumor. Surgery is the mainstay of treatment for all patients with PPGL unless contraindicated. However, without proper preparation, the release of excessive CAs, especially during surgery, can result in lethal cardiovascular complications. Herein, we briefly reviewed the pathogenesis of this disease, discussed the current approaches and evidence available for preoperative management, summarizing the results of the latest studies which compared the efficacies of preoperative management with or without α adrenergic-receptor antagonists, aiming to facilitate better understanding of the preoperative management of PPGL for the physicians.

Pheochromocytoma (PHEO) and Paraganglioma (PGL)

This series of 23 articles (17 original articles, six reviews) is presented by international leaders in pheochromocytoma and paraganglioma (PPGL) [...].