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Bowling GC, Maloney TJ, Bui QVV, Pavio M, D'Ambrosio D, Chesnut GT. Adrenal cyst presenting with clinical features of a pheochromocytoma. Radiol Case Rep 2024; 19:3855-3860. [PMID: 39035025 PMCID: PMC11259675 DOI: 10.1016/j.radcr.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 07/23/2024] Open
Abstract
Benign adrenal cysts are relatively uncommon variants of all adrenal incidentalomas. When identified, most benign adrenal cysts are asymptomatic, which differentiates them from other functional adrenal lesions. There are various types of adrenal cysts, although the most common being an endothelial cyst. Ultimately, evaluation and management approaches are aimed at ruling out a functional adrenal mass and management of symptoms if present. We present a unique presentation of an otherwise healthy male with a large incidental adrenal cyst, later identified as a benign endothelial cyst, who presented with classic symptoms of catecholamine excess. The patient had a negative hormonal evaluation, and his episodic symptoms were resolved with surgical removal of the adrenal mass. This case report and brief review provides valuable insight into the evaluation and management of a unique clinical scenario, where a benign cystic mass led to compression-related symptoms of catecholamine excess that were resolved after removal of the nonfunctional, cystic, mass.
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Affiliation(s)
- Gartrell C. Bowling
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
| | - Trevor J. Maloney
- Division of Urology, Department of Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
| | - Quan VV Bui
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
| | - Michael Pavio
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
- Department of Radiology, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
| | - Danielle D'Ambrosio
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
- Department of Pathology and Laboratory Medicine, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
| | - Gregory T. Chesnut
- Uniformed Services University of Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814, USA
- Division of Urology, Department of Surgery, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889, USA
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Serhane Z, Hassane S, Aynaou H, Salhi H, Elouahabi H. Giant Cystic Pheochromocytoma Associated With Neurofibromatosis Type 1: A Case Report. Cureus 2024; 16:e60151. [PMID: 38864044 PMCID: PMC11166379 DOI: 10.7759/cureus.60151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 06/13/2024] Open
Abstract
Pheochromocytomas are tumors that develop from the chromaffin cells of the adrenal medulla. More than 40% of cases of pheochromocytomas are associated with genetic conditions such as neurofibromatosis type 1 (NF1) or von Hippel-Lindau syndrome. Cystic pheochromocytomas are rare, generally asymptomatic, and thus of bigger size at the time of diagnosis. Surgical treatment is necessary to prevent cardiovascular morbidity and malignancy risk. We report the case of a 27-year-old patient admitted for further examination of a left adrenal mass that was discovered by an abdominal CT scan in the context of abdominal pain associated with hypertension evolving for three years. The clinical examination showed the presence of multiple café au lait spots, axillary and inguinal freckling with two dermal neurofibromas diagnosed clinically, as well as Lisch nodules on bilateral ophthalmic examination, thus meeting the clinical criteria for the diagnosis of NF1. The clinical laboratory investigation showed elevated urinary metanephrine and normetanephrine levels. CT scan examination showed a 10 cm left adrenal cystic mass on abdominal CT. This mass uptake of the radioligand in metaiodobenzylguanidine (MIBG) scintigraphy without secondary extra-adrenal localization allowed the diagnosis of a seemingly benign cystic pheochromocytoma to be made. The patient was put on presurgical drug preparation with volume expansion and then underwent left unilateral adrenalectomy. The histopathological study was in favor of a rather aggressive cystic pheochromocytoma with a pheochromocytoma of the adrenal gland scaled (PASS) score of 9. Blood pressure and urine catecholamines at seven days, three months, six months, and one year after surgery were normalized. Cystic pheochromocytoma is a rare tumor with a potentially poor prognosis. It is characterized by a more insidious evolution and a larger volume at diagnosis. It should be considered a diagnosis in patients with a cystic adrenal mass or an extra-adrenal mass with fluctuating blood pressure during surgery. This case illustrates the importance of both presurgical preparation and screening for pheochromocytoma in neurofibromatosis type 1.
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Affiliation(s)
- Zineb Serhane
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fes, MAR
| | - Sara Hassane
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fes, MAR
| | - Hayat Aynaou
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fes, MAR
| | - Houda Salhi
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fes, MAR
| | - Hanan Elouahabi
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fes, MAR
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Kim BC, Pak SJ, Kwon D, Cho JW, Kim WW, Lee YM, Park KJ, Chung KW, Sung TY. Silent pheochromocytoma in adrenal incidentaloma: unveiling clinical and radiological characteristics. Ann Surg Treat Res 2024; 106:38-44. [PMID: 38205093 PMCID: PMC10774699 DOI: 10.4174/astr.2024.106.1.38] [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: 10/13/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 01/12/2024] Open
Abstract
Purpose Silent pheochromocytoma refers to tumors without signs and symptoms of catecholamine excess. This study aimed to clarify the clinical, radiological characteristics, and perioperative features of silent pheochromocytomas diagnosed after adrenalectomy for adrenal incidentaloma. Methods Medical records of patients who underwent adrenalectomy for adrenal incidentaloma and were subsequently diagnosed with silent pheochromocytoma between January 2000 and December 2020 were retrospectively reviewed for demographic, diagnostic, surgical, and pathological findings. Results Of the 130 patients who underwent adrenalectomy for incidentaloma, 8 (6.1%) were diagnosed with silent pheochromocytoma. Almost all patients had no hypertensive symptoms and their baseline hormonal levels remained within normal ranges. All patients exhibited tumor size >4 cm, precontrast Hounsfield unit >10, and absolute washout <60%. Intraoperative hypertensive events were noted in 2 patients (25.0%) in whom antiadrenergic medications were not administered. All patients in the intraoperative hypertensive event group exhibited atypical features on CT, whereas 83.3% of patients in the non-intraoperative hypertensive event group showed atypical features on CT imaging. Conclusion Silent pheochromocytomas share radiological traits with malignant adrenal tumors. Suspicious features on CT scans warrant surgical consideration for appropriate treatment. Administering alpha-blockers can enhance hemodynamic stability during adrenalectomy in suspected silent pheochromocytoma cases.
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Affiliation(s)
- Byung-Chang Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Jeong Pak
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Douk Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Won Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Woong Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yu-mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kye Jin Park
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Wook Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yon Sung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Giant Pheochromocytoma Diagnosis Confounded by Amphetamine Use. Case Rep Endocrinol 2023; 2023:8799089. [PMID: 36742443 PMCID: PMC9897925 DOI: 10.1155/2023/8799089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/06/2022] [Accepted: 12/24/2022] [Indexed: 01/29/2023] Open
Abstract
Objective Diagnosis of giant pheochromocytoma is difficult; patients often lack the classic triad and presence of gross biochemical positivity. At times, presence of sympathetic stimulant drugs can further complicate the clinical picture. Here, we present a case of giant "functional" pheochromocytoma with a history of amphetamine use. Case Description. 37-year-old female presented with a 1-day history of abdominal pain. CT abdomen identified a 12.5 cm heterogeneously enhancing left adrenal mass. Plasma/urine catecholamine and metanephrine levels were markedly elevated with evidence of elevated serum/urine cortisol. However, the patient's subsequent urine toxicology was found to be positive for amphetamines, which she later admitted to using, 1 week prior to admission. Repeat biochemical workup after 1 week drug washout period showed improvement in both catecholamine and cortisol levels. Given the high degree of suspicion for PCC, an open laparoscopic adrenalectomy was performed with histology confirming SDHB gene mutation positive giant pheochromocytoma. Discussion. Diagnosis of PCC in a patient with a history of amphetamine abuse remains an enigma, to which addition of it being a giant PCC that are rare and typically silent further confounds the clinical picture as seen in this case. Conclusion PCC could be termed a "chameleon" tumor given its varied clinical presentations and lack of standardized biochemical and radiological data (giant, pheochromocytoma, and amphetamine).
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Feng Q, Li H, Qiu G, Cai Z, Li J, Zeng Y, Huang J. Case report: Significant liver atrophy due to giant cystic pheochromocytoma. Front Oncol 2022; 12:987705. [PMID: 36110948 PMCID: PMC9469016 DOI: 10.3389/fonc.2022.987705] [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: 07/06/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Pheochromocytoma is a neuroendocrine tumor originating from chromaffin cells in the adrenal medulla. Giant pheochromocytomas with a maximum diameter of over 20 cm are particularly rare. Case presentation We present a case of giant cystic pheochromocytoma in a 64-year-old woman who was found to have a right abdominal mass during an ultrasound examination, which is the largest pheochromocytoma ever documented in China. Meanwhile, obvious atrophy of the right lobe of the liver was found in preoperative CT and during the operation. Our literature review identified 20 cases with a diameter of over 20 cm. The average age at diagnosis was 51.7 (range 17–85), and 35% of cases did not exhibit classic symptoms. Conclusion Giant pheochromocytoma is an uncommon neoplasm. It can be discovered late due to a lack of clinical manifestations. Diagnosis is dependent on imaging recognition together with catecholamine secretion. Surgical resection is the only curative treatment for such tumors.
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Affiliation(s)
- Qingbo Feng
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Hancong Li
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Guoteng Qiu
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Zhaolun Cai
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiaxin Li
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Zeng
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Jiwei Huang
- Department of Liver Surgery and Liver Transplantation Centre, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Jiwei Huang,
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Constantinescu G, Preda C, Constantinescu V, Siepmann T, Bornstein SR, Lenders JWM, Eisenhofer G, Pamporaki C. Silent pheochromocytoma and paraganglioma: Systematic review and proposed definitions for standardized terminology. Front Endocrinol (Lausanne) 2022; 13:1021420. [PMID: 36325453 PMCID: PMC9618947 DOI: 10.3389/fendo.2022.1021420] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors with heterogeneous clinical presentations and potential lethal outcomes. The diagnosis is based on clinical suspicion, biochemical testing, imaging and histopathological confirmation. Increasingly widespread use of imaging studies and surveillance of patients at risk of PPGL due to a hereditary background or a previous tumor is leading to the diagnosis of these tumors at an early stage. This has resulted in an increasing use of the term "silent" PPGL. This term and other variants are now commonly found in the literature without any clear or unified definition. Among the various terms, "clinically silent" is often used to describe the lack of signs and symptoms associated with catecholamine excess. Confusion arises when these and other terms are used to define the tumors according to their ability to synthesize and/or release catecholamines in relation to biochemical test results. In such cases the term "silent" and other variants are often inappropriately and misleadingly used. In the present analysis we provide an overview of the literature and propose standardized terminology in an attempt at harmonization to facilitate scientific communication.
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Affiliation(s)
- Georgiana Constantinescu
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
| | - Cristina Preda
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
| | - Victor Constantinescu
- Center of Clinical Neuroscience, University Clinic Carl-Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Timo Siepmann
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan R. Bornstein
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Jacques W. M. Lenders
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Graeme Eisenhofer
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University of Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
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Sathaye S, Parmar KM, Kumar S, Rastogi P. Adrenal pheochromocytoma with involvement of aorta and left renal artery: salvaged with adrenalectomy and nephrectomy. BMJ Case Rep 2021; 14:e244297. [PMID: 34511410 PMCID: PMC8438742 DOI: 10.1136/bcr-2021-244297] [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] [Accepted: 08/24/2021] [Indexed: 11/04/2022] Open
Abstract
Large adrenal pheochromocytomas encasing the renal artery are a rare entity. The management of such challenging cases is surgical resection. The involvement of renal tissue and renal artery may necessitate meticulous dissection and concomitant nephrectomy. Here, we present a case of 41-year-old man diagnosed with left adrenal pheochromocytoma with complete encasement of left renal artery and partial encasement of aorta. Open left adrenalectomy and nephrectomy was performed after adequate preoperative optimisation. The patient is doing well at 6-month follow-up. Large adrenal pheochromocytoma with renal involvement is a rare presentation and requires optimal preoperative imaging, adequate preoperative alpha and beta blockade and meticulous surgical technique.
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8
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Jhala K, Menias C, Hammer M. Paragangliomas Throughout the Body: Hereditary Syndromes and Imaging Features Including 3D Cinematic Rendering. Curr Probl Diagn Radiol 2020; 50:523-531. [PMID: 32980208 DOI: 10.1067/j.cpradiol.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/23/2020] [Accepted: 07/23/2020] [Indexed: 11/22/2022]
Abstract
Paragangliomas are highly vascular neuroendocrine tumors that arise from embryonic neural crest cells. They may either be hormonally active (sympathetic) or silent (parasympathetic). Approximately one-third are hereditary, and patients may develop multiple paragangliomas. Presurgical planning involves medical management as well as interventional and/or surgical techniques that must address vascular supply. Contrast-enhanced CT is the best initial anatomical study and shows the hypervascularity and feeding vessels. 3D cinematic rendering using multiplanar light sources can highlight spatial relationships of a mass to adjacent structures and help in surgical planning. This article will review the clinical presentation of paragangliomas, genetic syndromes, presurgical management, and tumor behavior and imaging appearance by location with a particular emphasis on 3D cinematic rendering.
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Affiliation(s)
- Khushboo Jhala
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | | | - Mark Hammer
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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9
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Fajardo R, García N, Díaz F. Transperitoneal laparoscopic adrenalectomy for the resection of large size pheochromocytoma: Case report and literature review. Int J Surg Case Rep 2020; 71:353-359. [PMID: 32502952 PMCID: PMC7270531 DOI: 10.1016/j.ijscr.2020.05.027] [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: 01/21/2020] [Revised: 05/15/2020] [Accepted: 05/15/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Pheochromocytomas are rare neuroendocrine tumors that form in chromaffin cells of the neural crest during the embryological period. In the overall population, incidence rate is 0.1%; lack of early diagnosis or adequate treatment can lead to life-threatening complications. The secretion of catecholamines, such as adrenaline or norepinephrine, produces paroxysmal headache, palpitations and arterial hypertension. Secondary, hyperglycemic crises may also appear, thus contributing to misdiagnosis of diabetes mellitus or diabetic ketoacidosis. Surgery prevails as primary treatment; despite its subsequent high mortality rate of up to 50% during the intra and postoperative periods. CASE REPORT We describe the case of a 55-year-old man, diagnosed in 2012 with arterial hypertension and almost uncontrollable labile arterial hypertension, who had been medicated with second and third-line antihypertensive drugs, but, who, nonetheless showed no clinical improvement. Biochemical profile studies showed elevated normetanephrine and metanephrine levels; and an abdominal MRI, a markedly vascularized, 72 × 62 mm diameter solid mass in the right adrenal fossa; thereby leading to its classification as a large, noradrenergic phenotype pheochromocytoma. DISCUSSION In 2018, at the Fundación de Santa Fe de Bogotá Hospital, patient underwent Transperitoneal Laparoscopic Adrenalectomy, which proceeded without complications. In the 6-month postoperative follow-up, patient remained asymptomatic for cardiovascular risk and maintained stable blood pressure within goals; consequently, antihypertensive therapy was suspended. CONCLUSION Despite advances in surgical technique and perioperative management, minimally invasive surgery for resection of large pheochromocytoma is a challenging procedure, due to risk of intraoperative hemodynamic instability.
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Affiliation(s)
- Roosevelt Fajardo
- Fundación Santa Fe de Bogotá Hospital, General Surgery Department, Cra 7 # 117- 15, Bogota, Colombia
| | - Nicole García
- Fundación Santa Fe de Bogotá Hospital, General Surgery Department, Cra 7 # 117- 15, Bogota, Colombia.
| | - Francisco Díaz
- Fundación Santa Fe de Bogotá Hospital, General Surgery Department, Cra 7 # 117- 15, Bogota, Colombia
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10
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Clements HA, Wilson MS, Smith DM. Incidental giant cystic pheochromocytoma: a case report and review of the literature. Scott Med J 2020; 65:64-70. [PMID: 31931648 DOI: 10.1177/0036933019900339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pheochromocytoma is a tumour arising from the adrenal medulla, which secretes catecholamines. Approximately 20% of pheochromocytomas are cystic and more likely to be asymptomatic. They should be surgically resected as all have a malignant potential and pose cardiovascular risk. Case presentation: We report the case of a 61-year-old female patient admitted electively for laparoscopic adrenalectomy for a large cystic pheochromocytoma detected incidentally. Diagnosis was confirmed preoperatively by elevated 24-h urinary metanephrines. The patient was treated preoperatively with alpha and beta blockade. Surgery was without complication; she had an uneventful postoperative recovery and no evidence of recurrence at one-year follow-up. CONCLUSION This case highlights the necessity of investigating for biochemical function in all adrenal lesions by measuring metanephrines, even when entirely cystic on imaging. Given the surgical and anaesthetic risk in resection of pheochromocytoma, attaining a preoperative diagnosis allows for careful preoperative planning and safe surgery.
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Affiliation(s)
| | - Michael Sj Wilson
- Specialty Registrar, Department of General Surgery, Ninewells Hospital, UK
| | - David M Smith
- Consultant Surgeon, Department of General Surgery, Ninewells Hospital, UK
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11
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Kumar S, Parmar KM, Aggarwal D, Jhangra K. Simple adrenal cyst masquerading clinically silent giant cystic pheochromocytoma. BMJ Case Rep 2019; 12:12/9/e230730. [PMID: 31570355 DOI: 10.1136/bcr-2019-230730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pheochromocytoma (PCC) may present as a cystic or solid tumour. Cystic PCCs are difficult to differentiate from simple cysts in the absence of classic symptoms of PCCs. Cystic nature develops due to intralesional bleeding and necrosis. We present a case of young man without any comorbidity who was diagnosed as a simple adrenal cyst and planned for laparoscopic excision but found to be functional PCC during the time of surgery only. The patient was managed with extensive monitoring and use of multiple drugs to control blood pressure. Surgery was completed without any complication laparoscopically and postoperative period was also uneventful. Histopathology confirmed the diagnosis of cystic PCC. Our case also shows the importance of functional imaging like metaiodobenzylguanidine (MIBG) scan in doubtful cases of adrenal cysts when other biochemical markers are unremarkable to diagnosis. We emphasise the importance of meticulous preparation for any intraoperative disasters even for apparently simple adrenal cyst.
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Affiliation(s)
- Santosh Kumar
- Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kalpesh Mahesh Parmar
- Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dharmender Aggarwal
- Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jhangra
- Anaesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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12
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Degheili JA, Bustros GD, El-Asmar J, Abou Heidar N, Nasr RW. Adrenal Cystic Lymphangioma: An Unexpected Pathological Finding in a Constellation of Uncontrolled Hypertension and Hypercalcemia. Cureus 2019; 11:e5741. [PMID: 31723502 PMCID: PMC6825453 DOI: 10.7759/cureus.5741] [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] [Indexed: 11/24/2022] Open
Abstract
Adrenal cysts are rarely observed lesions. Adrenal cystic lymphangiomas are asymptomatic benign lesions of the lymphatic vessels with the vast majority occurring in women. We herein present a rare case of a middle-aged gentleman with labile blood pressure associated with an incidental finding of an adrenal mass of 4 x 3 x 3 cm. Following surgical resection, pathology revealed the diagnosis of adrenal cystic lymphangioma.
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Affiliation(s)
- Jad A Degheili
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, LBN
| | - Gerges D Bustros
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, LBN
| | - Jose El-Asmar
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, LBN
| | - Nassib Abou Heidar
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, LBN
| | - Rami W Nasr
- Department of Surgery, Division of Urology, American University of Beirut Medical Center, Beirut, LBN
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13
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Labib M, Ismail A, Elmansy H, Shahrour W, Prowse O, Kotb A. Adrenalectomy for huge solid pheochromocytoma: a challenging surgery or piece of cake? J Surg Case Rep 2019; 2019:rjz255. [PMID: 31462986 PMCID: PMC6705450 DOI: 10.1093/jscr/rjz255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/26/2019] [Accepted: 08/03/2019] [Indexed: 12/17/2022] Open
Abstract
Pheochromocytoma (PCC) is an uncommon adrenal tumor that is occasionally diagnosed during the work up for patients with uncontrolled hypertension. Treatment of PCC is mainly surgical. This case represents the largest PCC reported to date, which was safely removed.
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Affiliation(s)
- Mahmoud Labib
- Anesthesia Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Asmaa Ismail
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Hazem Elmansy
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Walid Shahrour
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Owen Prowse
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Ahmed Kotb
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
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14
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Bouassida M, Samet A, Mseddi MA, Smaoui W, Slimèn MH, Mhiri MN. Laparoscopic treatment of a cystic pheochromocytoma of 6cms: A challenging case. Urol Case Rep 2019; 26:100978. [PMID: 31388495 PMCID: PMC6677886 DOI: 10.1016/j.eucr.2019.100978] [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: 05/25/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 11/17/2022] Open
Abstract
Cystic pheochromocytoma is a very rare entity.Preoperative diagnosis is difficult because clinical, biochemical and radiologic findings are usually not consistent with a pheochromocytoma.Open surgery is traditionally the gold standard to avoid cyst rupture.we present a case of a 6 cm cystic pheochromocytoma treated by laparoscopy.
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Affiliation(s)
- Mehdi Bouassida
- Urology Department, Academic Hospital Habib Bourguiba. Sfax, Tunisia
| | - Ahmed Samet
- Urology Department, Academic Hospital Habib Bourguiba. Sfax, Tunisia
| | | | - Walid Smaoui
- Urology Department, Academic Hospital Habib Bourguiba. Sfax, Tunisia
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[Tumors of the adrenal glands : Update]. DER PATHOLOGE 2019; 40:467-492. [PMID: 31250089 DOI: 10.1007/s00292-019-0618-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Nodular hyperplasias and adenomas are by far the most frequently resected tumors of the adrenal cortex followed by pheochromocytomas, which are either discovered incidentally or become conspicuous due to hormonal hypersecretions. Cortical nodes and adenomas are easy to diagnose using simple staining methods. Uncertain cortical carcinomas, pheochromocytomas and other tumors of the adrenal region require additional immunohistochemical staining methods. Determination of the dignity of tumors of the adrenal cortex necessitates at least the Weiss score (possibly in its modified form), for oncocytic tumors the Bisceglia score and for pediatric tumors the Wieneke score. The Ki-67 index must also be taken into consideration. For pheochromocytomas the PASS and the GAPP systeme are used.
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Giant Cystic Pheochromocytoma with Low Risk of Malignancy: A Case Report and Literature Review. Case Rep Oncol Med 2017; 2017:4638608. [PMID: 28396811 PMCID: PMC5370478 DOI: 10.1155/2017/4638608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/10/2017] [Indexed: 12/14/2022] Open
Abstract
Giant pheochromocytomas are rare silent entities that do not present with the classical symptoms commonly seen in catecholamine-secreting tumors. In many cases they are accidentally discovered. The algorithm to diagnose a pheochromocytoma consists of biochemical evaluation and imaging of a retroperitoneal mass. The female patient in this case report presented with a palpable abdominal mass and was cured with surgical resection. She suffered no recurrence or complications on follow-up. The left retroperitoneal mass measured 27 × 18 × 12 cm and weighed 3,315 grams. Biochemical, radiological, and pathological examinations confirmed the diagnosis of a pheochromocytoma. In this paper, we report on our experience treating this patient and provide a summary of all giant pheochromocytomas greater than 10 cm reported to date in English language medical journals. Our patient's giant cystic pheochromocytoma was the fourth heaviest and fifth largest maximal diameter identified using our literature search criteria. Additionally, this tumor had the largest maximal diameter of all histologically confirmed benign/low metastatic risk pheochromocytomas. Giant cystic pheochromocytomas are rare entities requiring clinical suspicion coupled with strategic diagnostic evaluation to confirm the diagnosis.
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Costa Almeida CE, Silva M, Carvalho L, Costa Almeida CM. Adrenal giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy. Int J Surg Case Rep 2016; 30:201-204. [PMID: 28081522 PMCID: PMC5226667 DOI: 10.1016/j.ijscr.2016.12.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/23/2016] [Indexed: 12/02/2022] Open
Abstract
Giant cystic pheochromocytoma is a rare entity. Preoperative diagnosis is very difficult to obtain. Open surgery is the gold standard to treat these giant masses, but comparison studies are lacking. Posterior retroperitoneoscopic approach has advantages over transperitoneal laparoscopic method. This is the first report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy.
Introduction Giant cystic pheochromocytoma (>10 cm) is rare with only a few cases described in the literature. Preoperative diagnosis is very difficult because clinical, biochemical and radiologic finds are usually not consistent with a pheochromocytoma. Open surgery is traditionally the gold standard. Case presentation A 51 year-old male patient resorted to surgery department with an adrenal cystic incidentaloma. He was asymptomatic, mild hypertension easily controlled, with increased plasma fractionated metanephrines. MRI and MIBG scans confirmed the presence of a right adrenal giant cystic pheochromocytoma (14 cm). A right posterior retroperitoneoscopic adrenalectomy was performed, complicated with an unintended disruption. At follow-up he was asymptomatic and with plasma fractionated metanephrines normalized. Discussion Although laparoscopic surgery is effective and safe, traditional open surgery is the gold standard in the presence of adrenal tumours with suspicion of malignancy, like masses larger than 8 cm (including giant cystic pheochromocytomas). Minimal invasive techniques have the advantages of less postoperative pain and ileus, less morbidity, improved cosmetics, and faster recovery, but with the negative impact in R0 resection and probably a higher risk of cystic rupture. However comparisons between open and minimally invasive surgery are lacking. Additionally posterior retroperitoneoscopic approach has several advantages over laparoscopic transperitoneal method. Conclusion This is the first case report of a giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy, but the occurrence of the unintended rupture may be a factor against this approach. More studies are needed to compare open and minimally invasive techniques in terms of resectability and cystic rupture rate.
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Affiliation(s)
- Carlos E Costa Almeida
- Surgery C, Centro Hospitalar e Universitário de Coimbra, Hospital Geral (Covões), Portugal.
| | - Marta Silva
- Surgery C, Centro Hospitalar e Universitário de Coimbra, Hospital Geral (Covões), Portugal.
| | - Luis Carvalho
- Surgery C, Centro Hospitalar e Universitário de Coimbra, Hospital Geral (Covões), Portugal.
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