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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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Galatola R, Romeo V, Simeoli C, Guadagno E, De Rosa I, Basso L, Mainolfi C, Klain M, Nicolai E, Colao A, Maurea S, Salvatore M. Characterization with hybrid imaging of cystic pheochromocytomas: correlation with pathology. Quant Imaging Med Surg 2021; 11:862-869. [PMID: 33532285 DOI: 10.21037/qims-20-490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Roberta Galatola
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Chiara Simeoli
- Department of Clinical Medicine and Surgery, Division of Endocrinology, University of Naples "Federico II", Naples Italy
| | - Elia Guadagno
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Ilaria De Rosa
- UOC di Anatomia ed Istologia Patologica, Azienda Ospedaliera dei Colli, Naples, Italy
| | | | - Ciro Mainolfi
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Michele Klain
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | | | - Annamaria Colao
- Department of Clinical Medicine and Surgery, Division of Endocrinology, University of Naples "Federico II", Naples Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
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Ren X, Shang J, Ren R, Zhang H, Yao X. Laparoscopic resection of a large clinically silent paraganglioma at the organ of Zuckerkandl: a rare case report and review of the literature. BMC Urol 2020; 20:156. [PMID: 33028271 PMCID: PMC7542907 DOI: 10.1186/s12894-020-00732-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/29/2020] [Indexed: 12/15/2022] Open
Abstract
Background Large paraganglioma of the Zuckerkandl organ (POZ) is extremely rare. The patient can occasionally be paucisymptomatic, further obscuring the diagnosis and carrying high mortality. Recommended treatment for large paraganglioma (PGL) is open surgical removal. We report a case of successful laparoscopic resection of a large POZ with normal blood pressure in a 45-year-old man. Case presentation A 45-year-old man was hospitalized because of hyperglycemia. Computed tomography of the abdomen and the serum and urinary catecholamine levels confirmed the diagnosis of large POZ. But his blood pressure was normal and he underwent laparoscopic tumor excision successfully. During 6 months follow-up after laparoscopy, serum and urinary catecholamines were normal but glycaemia remained high level. DNA analysis of the succinate dehydrogenase complex subunits B (SDHB) and SDHD revealed no mutation. Conclusions POZ is an unusual mass and preoperative diagnosis can be difficult in clinically silent cases. PGL cannot be excluded in patients with normal blood pressure. Even a large POZ can be excised laparoscopically by following proper techniques.
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Affiliation(s)
- Xiang Ren
- Graduate School, Shanxi Medical University, Taiyuan, 030000, China
| | - Jiwen Shang
- Graduate School, Shanxi Medical University, Taiyuan, 030000, China. .,Department of Urology, Shanxi Bethune Hospital, No. 99 Longcheng Street, Taiyuan, 030032, Shanxi, China.
| | - Ruimin Ren
- Department of Urology, Shanxi Bethune Hospital, No. 99 Longcheng Street, Taiyuan, 030032, Shanxi, China
| | - Huajun Zhang
- Department of Urology, Shanxi Bethune Hospital, No. 99 Longcheng Street, Taiyuan, 030032, Shanxi, China
| | - Xue Yao
- Department of Urology, Shanxi Bethune Hospital, No. 99 Longcheng Street, Taiyuan, 030032, Shanxi, China
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Diagnostic and surgical challenges of a giant pheochromocytoma in a resource limited setting-A case report. Int J Surg Case Rep 2018; 50:111-115. [PMID: 30099264 PMCID: PMC6091315 DOI: 10.1016/j.ijscr.2018.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/05/2018] [Accepted: 07/26/2018] [Indexed: 11/21/2022] Open
Abstract
Giant pheochromocytomas are rare. Diagnosis requires a high index of suspicion. Commonly present with a triad of headache, palpitations and hypertension. The surgical and anaesthetic team must be prepared to manage hypertensive crisis.
Introduction Pheochromocytomas are catecholamine producing tumours which arise from chromaffin cells within the adrenal medulla. Patients with these tumours commonly present with a triad of headache, palpitations and hypertension. Case presentation We present a case of a 37-year-old male patient who presented with dull left sided abdominal pain and discomfort for 6 weeks. A preoperative Computed tomography (CT) scan showed a huge left suprarenal tumour but urinary vanillylmandelic acid (VMA) were negative. The patient underwent an open surgical resection via an extraperitoneal approach without untoward intraoperative and postoperative events. Histopathological evaluation of the specimen showed a pheochromocytoma with a PASS score of 9. The successful management of the patient highlights the good results of team work despite the limitations of preoperative diagnosis. Discussion Giant pheochromocytomas by definition are tumours more than 7 cm in size and are rare. They rarely secrete catecholamines and commonly present with vague abdominal symptoms. A computerized tomogram helps suggest the diagnosis whilst the biochemical workup for pheochromocytoma may be diagnostic. If the tumours are biochemically active, preoperative alpha-blockade is necessary and care must be taken at operation in handling the tumour. The surgical and anaesthetic team must be prepared to manage hypertensive crisis should it occur. Conclusion This case brings to the attention of clinicians the need to have a high index of suspicion of a giant pheochromocytoma in a patient presenting with vague abdominal symptoms whose CT scan shows a large retroperitoneal tumour, even in the absence of clinical symptoms and negative or absent biochemical workup.
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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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Munakomi S, Rajbanshi S, Adhikary PS. Case Report: A giant but silent adrenal pheochromocytoma - a rare entity. F1000Res 2016; 5:290. [PMID: 27785358 PMCID: PMC5022706 DOI: 10.12688/f1000research.8168.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2016] [Indexed: 01/30/2023] Open
Abstract
Herein we report a rare entity of a giant adrenal pheochromocytoma in a fifty-year-old male presenting with a vague abdominal pain. A computerised tomogram of the abdomen revealed a well-defined left supraadrenal giant lesion with no evidence of invasion to surrounding structures.The patient underwent surgical excision without any untoward postoperative events. Histopathological study revealed a benign pheochromocytoma. This report highlights the importance of acknowledging the fact that sometimes a giant adrenal pheochromocytoma can present with paucity of clinical signs and symptoms.Thorough investigations and a multidisciplinary team approach may lead to a better outcome in these patients.
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Affiliation(s)
- Sunil Munakomi
- Department of General Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Saroj Rajbanshi
- Department of General Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
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Wang HL, Sun BZ, Xu ZJ, Lei WF, Wang XS. Undiagnosed giant cystic pheochromocytoma: A case report. Oncol Lett 2015; 10:1444-1446. [PMID: 26622687 DOI: 10.3892/ol.2015.3484] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 06/25/2015] [Indexed: 11/06/2022] Open
Abstract
Giant cystic pheochromocytomas (GPCCs) are rare adrenal tumors and the majority of them present as asymptomatic. As a result GPCCs often remain undiagnosed until surgery and therefore the surgical team face a greater challenge in perioperative management. The present study describes the case of a 36 year-old woman with an undiagnosed GPCC, which was successfully resected despite the occurrence of perioperative cardiovascular events, including hypertension, hypotension, ventricular arrhythmias, acute heart failure, acute myocardial infarction, and the patient was discharged home without any recurrence. It should be considered in retroperitoneal tumour of patients with nonspecific symptoms and given adequate treatment to promote the perioperative safety.
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Affiliation(s)
- Huan-Liang Wang
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Bao-Zhu Sun
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Zhi-Jie Xu
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Wei-Fu Lei
- Department of Anesthesiology, Qilu Hospital, Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiao-Shuang Wang
- College of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250012, P.R. China
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Sarveswaran V, Kumar S, Kumar A, Vamseedharan M. A giant cystic pheochromocytoma mimicking liver abscess an unusual presentation - a case report. Clin Case Rep 2014; 3:64-8. [PMID: 25678978 PMCID: PMC4317216 DOI: 10.1002/ccr3.149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 07/18/2014] [Accepted: 08/23/2014] [Indexed: 11/30/2022] Open
Abstract
Giant cystic pheochromocytoma is a rare neuroendocrine tumor. The possibility of cystic pheochromocytoma should be considered for any peri-adrenal mass even in absence of characteristic symptoms and negative biochemical analysis. The key in the management of a case of cystic pheochromocytoma is the preoperative suspicion and the intraoperative crisis management.
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Affiliation(s)
- Venugopal Sarveswaran
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
| | - Surees Kumar
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
| | - Amit Kumar
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
| | - Muthukumar Vamseedharan
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
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