A case of clinically silent giant right pheochromocytoma and review of literature

Silent pheochromocytoma in adrenal incidentaloma: unveiling clinical and radiological characteristics

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.

Laparoscopic resection of a large clinically silent paraganglioma at the organ of Zuckerkandl: a rare case report and review of the literature

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.

Diagnostic and surgical challenges of a giant pheochromocytoma in a resource limited setting-A case report

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Giant pheochromocytomas are rare.

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Diagnosis requires a high index of suspicion.

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Commonly present with a triad of headache, palpitations and hypertension.

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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.

Giant Cystic Pheochromocytoma with Low Risk of Malignancy: A Case Report and Literature Review

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.

Adrenal giant cystic pheochromocytoma treated by posterior retroperitoneoscopic adrenalectomy

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Giant cystic pheochromocytoma is a rare entity.

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Preoperative diagnosis is very difficult to obtain.

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Open surgery is the gold standard to treat these giant masses, but comparison studies are lacking.

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Posterior retroperitoneoscopic approach has advantages over transperitoneal laparoscopic method.

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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.

Case Report: A giant but silent adrenal pheochromocytoma - a rare entity

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.

Undiagnosed giant cystic pheochromocytoma: A case report

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.

A giant cystic pheochromocytoma mimicking liver abscess an unusual presentation - a case report

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.