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Därr R, Kater J, Sekula P, Bausch B, Krauss T, Bode C, Walz G, Neumann HP, Zschiedrich S. Clinical decision making in small non-functioning VHL-related incidentalomas. Endocr Connect 2020; 9:834-844. [PMID: 32869749 PMCID: PMC7487196 DOI: 10.1530/ec-20-0208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 01/26/2023]
Abstract
The optimal treatment strategy for patients with small non-functioning VHL-related incidentalomas is unclear. We searched the Freiburg VHL registry for patients with radiologic evidence of pheochromocytoma/paraganglioma (PHEO/PGL). In total, 176 patients with single, multiple, and recurrent tumours were identified (1.84 tumours/patient, range 1-8). Mean age at diagnosis was 32 ± 16 years. Seventy-four percent of tumours were localised to the adrenals. Mean tumour diameter was 2.42 ± 2.27 cm, 46% were <1.5 cm. 24% of tumours were biochemically inactive. Inactive tumours were significantly smaller than active PHEO/PGL at diagnosis (4.16 ± 2.80 cm vs 1.43 ± 0.45 cm; P < 0.025) and before surgery (4.89 ± 3.47 cm vs 1.36 ± 0.43 cm; P < 0.02). Disease was stable in 67% of 21 patients with evaluable tumours ≤1.5 cm according to RECIST and progressed in 7. Time till surgery in these patients was 29.5 ± 20.0 months. A total of 155 patients underwent surgery. PHEO/PGL was histologically excluded in 4 and proven in 151. Of these, one had additional metastatic disease, one harboured another tumour of a different type, and in 2 a second surgery for suspected disease recurrence did not confirm PHEO/PGL. Logistic regression analysis revealed 50% probability for a positive/negative biochemical test result at 1.8 cm tumour diameter. Values of a novel symptom score were positively correlated with tumour size (Rs = 0.46, P < 0.0001) and together with a positive biochemistry a linear size predictor (P < 0.01). Results support standardised clinical assessment and measurement of tumour size and metanephrines in VHL patients with non-functioning incidentalomas <1.5 cm at one year following diagnosis and at individualised intervals thereafter depending on evolving growth dynamics, secretory activity and symptomatology.
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Affiliation(s)
- Roland Därr
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Correspondence should be addressed to R Därr:
| | - Jonas Kater
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peggy Sekula
- Institute of Genetic Epidemiology, University Medical Center Freiburg, Freiburg, Germany
| | - Birke Bausch
- Department of Medicine II, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Krauss
- Department of Radiology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerd Walz
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hartmut P Neumann
- Section for Preventive Medicine, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Zschiedrich
- Department of Medicine IV, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Peitzsch M, Kaden D, Pamporaki C, Langton K, Constantinescu G, Conrad C, Fliedner S, Sinnott RO, Prejbisz A, Därr R, Lenders JWM, Bursztyn M, Eisenhofer G. Overnight/first-morning urine free metanephrines and methoxytyramine for diagnosis of pheochromocytoma and paraganglioma: is this an option? Eur J Endocrinol 2020; 182:499-509. [PMID: 32187575 DOI: 10.1530/eje-19-1016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/18/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Sympathoadrenal activity is decreased during overnight rest. This study assessed whether urinary-free normetanephrine, metanephrine and methoxytyramine in overnight/first-morning urine collections might offer an alternative to measurements in 24-h collections or plasma for diagnosis of pheochromocytoma and paraganglioma (PPGL). DESIGN AND METHODS Prospective multicenter cross-sectional diagnostic study involving 706 patients tested for PPGL, in whom tumors were confirmed in 79 and excluded in 627 after follow-up. Another 335 age- and sex-matched volunteers were included for reference purposes. Catecholamines and their free O-methylated metabolites were measured in 24-h collections divided according to waking and sleeping hours and normalized to creatinine. Plasma metabolites from blood sampled after supine rest were measured for comparison. RESULTS Urinary outputs of norepinephrine, normetanephrine, epinephrine and metanephrine in the reference population were respectively 50 (48-52)%, 35 (32-37)%, 76 (74-78)% and 15 (12-17)% lower following overnight than daytime collections. Patients in whom PPGLs were excluded showed 28 (26-30)% and 6 (3-9)% day-to-night falls in normetanephrine and metanephrine, while patients with PPGLs showed no significant day-to-night falls in metabolites. Urinary methoxytyramine was consistently unchanged from day to night. According to receiver-operating characteristic curves, diagnostic accuracy of metabolite measurements in overnight/first-morning urine samples did not differ from measurements in 24-h urine collections, but was lower for both than for plasma. Using optimized reference intervals, diagnostic specificity was higher for overnight than daytime collections at similar sensitivities. CONCLUSIONS Measurements of urinary-free catecholamine metabolites in first-morning/overnight urine collections offer an alternative for diagnosis of PPGL to 24-h collections but remain less accurate than plasma measurements.
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Affiliation(s)
- Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Denise Kaden
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Katharina Langton
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Georgiana Constantinescu
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Catleen Conrad
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stephanie Fliedner
- First Department of Medicine, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Richard O Sinnott
- School of Computing and Information Systems, University of Melbourne, Melbourne, Australia
| | | | - Roland Därr
- Department of Medicine IV, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jacques W M Lenders
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Michael Bursztyn
- Department of Medicine, Hypertension Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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3
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Krauss T, Ferrara AM, Links TP, Wellner U, Bancos I, Kvachenyuk A, Villar Gómez de Las Heras K, Yukina MY, Petrov R, Bullivant G, von Duecker L, Jadhav S, Ploeckinger U, Welin S, Schalin-Jäntti C, Gimm O, Pfeifer M, Ngeow J, Hasse-Lazar K, Sansó G, Qi X, Ugurlu MU, Diaz RE, Wohllk N, Peczkowska M, Aberle J, Lourenço DM, Pereira MAA, Fragoso MCBV, Hoff AO, Almeida MQ, Violante AHD, Quidute ARP, Zhang Z, Recasens M, Díaz LR, Kunavisarut T, Wannachalee T, Sirinvaravong S, Jonasch E, Grozinsky-Glasberg S, Fraenkel M, Beltsevich D, Egorov VI, Bausch D, Schott M, Tiling N, Pennelli G, Zschiedrich S, Därr R, Ruf J, Denecke T, Link KH, Zovato S, von Dobschuetz E, Yaremchuk S, Amthauer H, Makay Ö, Patocs A, Walz MK, Huber TB, Seufert J, Hellman P, Kim RH, Kuchinskaya E, Schiavi F, Malinoc A, Reisch N, Jarzab B, Barontini M, Januszewicz A, Shah N, Young WF, Opocher G, Eng C, Neumann HPH, Bausch B. Preventive medicine of von Hippel-Lindau disease-associated pancreatic neuroendocrine tumors. Endocr Relat Cancer 2018; 25:783-793. [PMID: 29748190 DOI: 10.1530/erc-18-0100] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 05/10/2018] [Indexed: 11/08/2022]
Abstract
Pancreatic neuroendocrine tumors (PanNETs) are rare in von Hippel-Lindau disease (VHL) but cause serious morbidity and mortality. Management guidelines for VHL-PanNETs continue to be based on limited evidence, and survival data to guide surgical management are lacking. We established the European-American-Asian-VHL-PanNET-Registry to assess data for risks for metastases, survival and long-term outcomes to provide best management recommendations. Of 2330 VHL patients, 273 had a total of 484 PanNETs. Median age at diagnosis of PanNET was 35 years (range 10-75). Fifty-five (20%) patients had metastatic PanNETs. Metastatic PanNETs were significantly larger (median size 5 vs 2 cm; P < 0.001) and tumor volume doubling time (TVDT) was faster (22 vs 126 months; P = 0.001). All metastatic tumors were ≥2.8 cm. Codons 161 and 167 were hotspots for VHL germline mutations with enhanced risk for metastatic PanNETs. Multivariate prediction modeling disclosed maximum tumor diameter and TVDT as significant predictors for metastatic disease (positive and negative predictive values of 51% and 100% for diameter cut-off ≥2.8 cm, 44% and 91% for TVDT cut-off of ≤24 months). In 117 of 273 patients, PanNETs >1.5 cm in diameter were operated. Ten-year survival was significantly longer in operated vs non-operated patients, in particular for PanNETs <2.8 cm vs ≥2.8 cm (94% vs 85% by 10 years; P = 0.020; 80% vs 50% at 10 years; P = 0.030). This study demonstrates that patients with PanNET approaching the cut-off diameter of 2.8 cm should be operated. Mutations in exon 3, especially of codons 161/167 are at enhanced risk for metastatic PanNETs. Survival is significantly longer in operated non-metastatic VHL-PanNETs.
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Affiliation(s)
- Tobias Krauss
- Department of RadiologyMedical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Thera P Links
- Department of EndocrinologyUniversity of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ulrich Wellner
- Department of SurgeryUniversity of Luebeck, Luebeck, Germany
| | - Irina Bancos
- Division of EndocrinologyDiabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, USA
| | - Andrey Kvachenyuk
- Institute of Endocrinology and MetabolismNAMS of Ukraine, Kiev, Ukraine
| | | | - Marina Y Yukina
- Department of SurgeryEndocrinology Research Center, Moscow, Russia
| | - Roman Petrov
- Department of SurgeryBakhrushin Brothers Moscow City Hospital, Moscow, Russia
| | - Garrett Bullivant
- Princess Margaret Cancer CenterUniversity Health Network, Toronto, Ontario, Canada
| | - Laura von Duecker
- Department of Medicine IVFaculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
| | - Swati Jadhav
- Department of EndocrinologyKEM Hospital, Mumbai, India
| | - Ursula Ploeckinger
- Interdisciplinary Center of Metabolism: EndocrinologyDiabetes and Metabolism, Charité-University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Staffan Welin
- Department of Endocrine OncologyUppsala University Hospital, Uppsala, Sweden
| | - Camilla Schalin-Jäntti
- EndocrinologyAbdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Oliver Gimm
- Department of Clinical and Experimental MedicineDepartment of Surgery, University of Linköping, Linköping, Sweden
| | - Marija Pfeifer
- Department of EndocrinologyUniversity Medical Center, Ljubljana, Slovenia
| | - Joanne Ngeow
- Cancer Genetics ServiceDivision of Medical Oncology, National Cancer Center Singapore and Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Kornelia Hasse-Lazar
- Department of Endocrine Oncology and Nuclear MedicineCenter of Oncology, MSC Memorial Institute, Gliwice, Poland
| | - Gabriela Sansó
- Centro de Investigaciones Endocrinológicas "Dr Cesar Bergada" (CEDIE)Hospital de Niños Ricardo Gutiérrez, CABA, Buenos Aires, Argentina
| | - Xiaoping Qi
- Department of Oncologic and Urologic Surgerythe 117th PLA Hospital, Wenzhou Medical University, Hangzhou, Peoples Republic of China
| | - M Umit Ugurlu
- Department of General SurgeryBreast and Endocrine Surgery Unit, Marmara University School of Medicine, Istanbul, Turkey
| | - Rene E Diaz
- Endocrine SectionHospital del Salvador, Santiago de Chile, Chile
| | - Nelson Wohllk
- Department of MedicineEndocrine Section, Hospital del Salvador, University of Chile, Santiago de Chile, Chile
| | | | - Jens Aberle
- 3rd Department of MedicineUniversity Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Delmar M Lourenço
- Serviço de EndocrinologiaHospital das Clínicas (HCFMUSP) and Instituto do Cancer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria A A Pereira
- Serviço de EndocrinologiaHospital das Clinicas (HCFMUSP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria C B V Fragoso
- Serviço de EndocrinologiaHospital das Clínicas (HCFMUSP) and Instituto do Cancer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ana O Hoff
- Serviço de EndocrinologiaHospital das Clínicas (HCFMUSP) and Instituto do Cancer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Madson Q Almeida
- Serviço de EndocrinologiaHospital das Clínicas (HCFMUSP) and Instituto do Cancer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Alice H D Violante
- Department of Internal Medicine-EndocrinologyFaculty of medicine-Hospital Universitario Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana R P Quidute
- Department of Physiology and PharmacologyDrug Research and Development Center (NPDM), Faculty of Medicine, Federal University of Ceará (UFC), Fortaleza, Brazil
| | - Zhewei Zhang
- Department of Urology2nd Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Mònica Recasens
- Hospital Universitari de GironaGerencia Territorial Girona, Institut Català de la Salut, Girona, Spain
| | - Luis Robles Díaz
- Unidad de Tumores DigestivosServicio de Oncología Médica, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Tada Kunavisarut
- Division of Endocrinology and metabolismSiriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Taweesak Wannachalee
- Division of Endocrinology and metabolismSiriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirinart Sirinvaravong
- Division of Endocrinology and metabolismSiriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Eric Jonasch
- Department of Genitourinary Medical OncologyDivision of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor DivisionEndocrinology & Metabolism Service, Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Merav Fraenkel
- Neuroendocrine Tumor DivisionEndocrinology & Metabolism Service, Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Viacheslav I Egorov
- Department of SurgeryBakhrushin Brothers Moscow City Hospital, Moscow, Russia
| | - Dirk Bausch
- Department of SurgeryUniversity of Luebeck, Luebeck, Germany
| | - Matthias Schott
- Department of EndocrinologyHeinrich-Heine-University, Düsseldorf, Germany
| | - Nikolaus Tiling
- Interdisciplinary Center of Metabolism: EndocrinologyDiabetes and Metabolism, Charité-University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Gianmaria Pennelli
- Department of Medicine (DIMED)Surgical Pathology Unit, University of Padua, Padua, Italy
| | - Stefan Zschiedrich
- Department of Medicine IVFaculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
| | - Roland Därr
- Department of Medicine IVFaculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
- Department of Cardiology and Angiology IHeart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juri Ruf
- Department of Nuclear MedicineFaculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
| | - Timm Denecke
- Department of RadiologyCampus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Stefania Zovato
- Familial Cancer Clinic and OncoendocrinologyVeneto Institute of Oncology IOV- IRCCS, Padua, Italy
| | - Ernst von Dobschuetz
- Section of Endocrine SurgeryReinbek Hospital, Academic Teaching Hospital University of Hamburg, Reinbek, Germany
| | | | - Holger Amthauer
- Department of Clinical Nuclear MedicineCharité - Universitätsmedizin Berlin, Berlin, Germany
| | - Özer Makay
- Department of General SurgeryDivision of Endocrine Surgery, Izmir, Turkey
| | - Attila Patocs
- 2nd Department of Medicine and Molecular Medicine Research GroupHungarian Academy of Sciences, Semmelweis-University, Budapest, Hungary
| | - Martin K Walz
- Department of SurgeryHuyssens Foundation Clinics, Essen, Germany
| | - Tobias B Huber
- 3rd Department of MedicineUniversity Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Seufert
- Department of Medicine IIFaculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Per Hellman
- Department of Surgical SciencesUppsala University, University Hospital, Uppsala, Sweden
| | - Raymond H Kim
- Department of MedicineUniversity of Toronto, University Healthy Network & Mount Sinai Hospital, The Fred A Litwin Family Center in Genetic Medicine, Toronto, Ontario, Canada
| | - Ekaterina Kuchinskaya
- Department of Clinical Genetics and Department of Clinical and Experimental MedicineLinköping University, Linköping, Sweden
| | - Francesca Schiavi
- Familial Cancer Clinic and OncoendocrinologyVeneto Institute of Oncology IOV- IRCCS, Padua, Italy
| | - Angelica Malinoc
- Department of Medicine IVFaculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
| | - Nicole Reisch
- Department of EndocrinologyLudwigs-Maximilians-University of Munich, Munich, Germany
| | - Barbara Jarzab
- Department of Endocrine Oncology and Nuclear MedicineCenter of Oncology, MSC Memorial Institute, Gliwice, Poland
| | - Marta Barontini
- Centro de Investigaciones Endocrinológicas "Dr Cesar Bergada" (CEDIE)Hospital de Niños Ricardo Gutiérrez, CABA, Buenos Aires, Argentina
| | | | - Nalini Shah
- Department of EndocrinologyKEM Hospital, Mumbai, India
| | - William F Young
- Division of EndocrinologyDiabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, USA
| | - Giuseppe Opocher
- Scientific DirectionVeneto Institute of Oncology IOV-IRCCS, Padua, Italy
| | - Charis Eng
- Genomic Medicine InstituteLerner Research Institute and Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hartmut P H Neumann
- Section for Preventive MedicineFaculty of Medicine, Albert-Ludwigs-University, Freiburg, Germany
| | - Birke Bausch
- Department of Medicine IIFaculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
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Jawed I, Velarde M, Därr R, Wolf KI, Adams K, Venkatesan AM, Balasubramaniam S, Poruchynsky MS, Reynolds JC, Pacak K, Fojo T. Continued Tumor Reduction of Metastatic Pheochromocytoma/Paraganglioma Harboring Succinate Dehydrogenase Subunit B Mutations with Cyclical Chemotherapy. Cell Mol Neurobiol 2018; 38:1099-1106. [PMID: 29623478 DOI: 10.1007/s10571-018-0579-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/15/2018] [Indexed: 11/27/2022]
Abstract
Patients harboring germline mutations in the succinate dehydrogenase complex subunit B (SDHB) gene present with pheochromocytomas and paragangliomas (PPGL) that are more likely malignant and clinically aggressive. The combination chemotherapy cyclophosphamide, vincristine, and dacarbazine (CVD) was retrospectively evaluated in patients with SDHB-associated metastatic PPGL.Query Twelve metastatic PPGL patients harboring SDHB mutations/polymorphisms with undetectable SDHB immunostaining were treated with CVD. CVD therapy consisted of 750 mg/m2 cyclophosphamide with 1.4 mg/m2 vincristine on day 1 and 600 mg/m2 dacarbazine on days 1 and 2, every 21-28 days. Treatment outcome was determined by RECIST criteria as well as determination of response duration and progression-free and overall survivals. A median of 20.5 cycles (range 4-41) was administered. All patients had tumor reduction (12-100% by RECIST). Complete response was seen in two patients, while partial response was observed in 8. The median number of cycles to response was 5.5. Median duration of response was 478 days, with progression-free and overall survivals of 930 and 1190 days, respectively. Serial [18F]-fluorodeoxyglucose positron emission tomography and computed tomography imaging demonstrated continued incremental reduction in maximal standardized uptake values (SUVmax) values in 26/30 lesions. During treatment administration, the median SUV decreased from > 25 to < 6, indicating the efficacy of chemotherapy over a prolonged period of time. Prolonged therapy results in continued incremental tumor reduction, and is consistent with persistent drug sensitivity. CVD chemotherapy is recommended to be considered part of the initial management in patients with metastatic SDHB-related PPGL.
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Affiliation(s)
- Irfan Jawed
- Medical Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Margarita Velarde
- Medical Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Roland Därr
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Katherine I Wolf
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Karen Adams
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Aradhana M Venkatesan
- Section of Abdominal Imaging, Department of Diagnostic Radiology, MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Sanjeeve Balasubramaniam
- Medical Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Marianne S Poruchynsky
- Medical Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - James C Reynolds
- Nuclear Medicine Division, Department of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA.
| | - Tito Fojo
- Medical Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892, USA
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5
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Gieldon L, Masjkur JR, Richter S, Därr R, Lahera M, Aust D, Zeugner S, Rump A, Hackmann K, Tzschach A, Januszewicz A, Prejbisz A, Eisenhofer G, Schrock E, Robledo M, Klink B. Next-generation panel sequencing identifies NF1 germline mutations in three patients with pheochromocytoma but no clinical diagnosis of neurofibromatosis type 1. Eur J Endocrinol 2018; 178:K1-K9. [PMID: 29158289 DOI: 10.1530/eje-17-0714] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/13/2017] [Accepted: 11/20/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Our objective was to improve molecular diagnostics in patients with hereditary pheochromocytoma and paraganglioma (PPGL) by using next-generation sequencing (NGS) multi-gene panel analysis. Derived from this study, we here present three cases that were diagnosed with NF1 germline mutations but did not have a prior clinical diagnosis of neurofibromatosis type 1 (NF1). DESIGN We performed genetic analysis of known tumor predisposition genes, including NF1, using a multi-gene NGS enrichment-based panel applied to a total of 1029 PPGL patients. We did not exclude genes known to cause clinically defined syndromes such as NF1 based on missing phenotypic expression as is commonly practiced. METHODS Genetic analysis was performed using NGS (TruSight Cancer Panel/customized panel by Illumina) for analyzing patients' blood and tumor samples. Validation was carried out by Sanger sequencing. RESULTS Within our cohort, three patients, who were identified to carry pathogenic NF1 germline mutations, attracted attention, since none of the patients had a clinical suspicion of NF1 and one of them was initially suspected to have MEN2A syndrome due to co-occurrence of a medullary thyroid carcinoma. In these cases, one splice site, one stop and one frameshift mutation in NF1 were identified. CONCLUSIONS Since phenotypical presentation of NF1 is highly variable, we suggest analysis of the NF1 gene also in PPGL patients who do not meet diagnostic NF1 criteria. Co-occurrence of medullary thyroid carcinoma and PPGL was found to be a clinical decoy in NF1 diagnostics. These observations underline the value of multi-gene panel NGS for PPGL patients.
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Affiliation(s)
- Laura Gieldon
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Partner Site Dresden, Dresden, Germany
| | - Jimmy Rusdian Masjkur
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Susan Richter
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Roland Därr
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany
- Department of Medicine IV, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marcos Lahera
- Endocrinology and Nutrition Department, La Princesa University Hospital, Madrid, Spain
| | - Daniela Aust
- German Cancer Consortium (DKTK), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Partner Site Dresden, Dresden, Germany
- Institute for Pathology, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
- Tumor- and Normal Tissuebank of the University Cancer Center/NCT-Standort Dresden, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Silke Zeugner
- Institute for Pathology, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Andreas Rump
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Karl Hackmann
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Partner Site Dresden, Dresden, Germany
| | - Andreas Tzschach
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | | | | | - Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Evelin Schrock
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Partner Site Dresden, Dresden, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Madrid, Spain
| | - Barbara Klink
- Institute for Clinical Genetics, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Partner Site Dresden, Dresden, Germany
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6
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Därr R, Kuhn M, Bode C, Bornstein SR, Pacak K, Lenders JWM, Eisenhofer G. Accuracy of recommended sampling and assay methods for the determination of plasma-free and urinary fractionated metanephrines in the diagnosis of pheochromocytoma and paraganglioma: a systematic review. Endocrine 2017; 56:495-503. [PMID: 28405881 PMCID: PMC6297899 DOI: 10.1007/s12020-017-1300-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/05/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine the accuracy of biochemical tests for the diagnosis of pheochromocytoma and paraganglioma. METHODS A search of the PubMed database was conducted for English-language articles published between October 1958 and December 2016 on the biochemical diagnosis of pheochromocytoma and paraganglioma using immunoassay methods or high-performance liquid chromatography with coulometric/electrochemical or tandem mass spectrometric detection for measurement of fractionated metanephrines in 24-h urine collections or plasma-free metanephrines obtained under seated or supine blood sampling conditions. RESULTS Application of the Standards for Reporting of Diagnostic Studies Accuracy Group criteria yielded 23 suitable articles. Summary receiver operating characteristic analysis revealed sensitivities/specificities of 94/93% and 91/93% for measurement of plasma-free metanephrines and urinary fractionated metanephrines using high-performance liquid chromatography or immunoassay methods, respectively. Partial areas under the curve were 0.947 vs. 0.911. Irrespective of the analytical method, sensitivity was significantly higher for supine compared with seated sampling, 95 vs. 89% (p < 0.02), while specificity was significantly higher for supine sampling compared with 24-h urine, 95 vs. 90% (p < 0.03). Partial areas under the curve were 0.942, 0.913, and 0.932 for supine sampling, seated sampling, and urine. Test accuracy increased linearly from 90 to 93% for 24-h urine at prevalence rates of 0.0-1.0, decreased linearly from 94 to 89% for seated sampling and was constant at 95% for supine conditions. CONCLUSIONS Current tests for the biochemical diagnosis of pheochromocytoma and paraganglioma show excellent diagnostic accuracy. Supine sampling conditions and measurement of plasma-free metanephrines using high-performance liquid chromatography with coulometric/electrochemical or tandem mass spectrometric detection provides the highest accuracy at all prevalence rates.
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Affiliation(s)
- Roland Därr
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Freiburg, Germany.
| | - Matthias Kuhn
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Freiburg, Germany
| | - Stefan R Bornstein
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Jacques W M Lenders
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Graeme Eisenhofer
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
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7
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Därr R, Nambuba J, Del Rivero J, Janssen I, Merino M, Todorovic M, Balint B, Jochmanova I, Prchal JT, Lechan RM, Tischler AS, Popovic V, Miljic D, Adams KT, Prall FR, Ling A, Golomb MR, Ferguson M, Nilubol N, Chen CC, Chew E, Taïeb D, Stratakis CA, Fojo T, Yang C, Kebebew E, Zhuang Z, Pacak K. Novel insights into the polycythemia-paraganglioma-somatostatinoma syndrome. Endocr Relat Cancer 2016; 23:899-908. [PMID: 27679736 PMCID: PMC5096964 DOI: 10.1530/erc-16-0231] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 09/27/2016] [Indexed: 12/14/2022]
Abstract
Worldwide, the syndromes of paraganglioma (PGL), somatostatinoma (SOM) and early childhood polycythemia are described in only a few patients with somatic mutations in the hypoxia-inducible factor 2 alpha (HIF2A). This study provides detailed information about the clinical aspects and course of 7 patients with this syndrome and brings into perspective these experiences with the pertinent literature. Six females and one male presented at a median age of 28 years (range 11-46). Two were found to have HIF2A somatic mosaicism. No relatives were affected. All patients were diagnosed with polycythemia before age 8 and before PGL/SOM developed. PGLs were found at a median age of 17 years (range 8-38) and SOMs at 29 years (range 22-38). PGLs were multiple, recurrent and metastatic in 100, 100 and 29% of all cases, and SOMs in 40, 40 and 60%, respectively. All PGLs were primarily norepinephrine-producing. All patients had abnormal ophthalmologic findings and those with SOMs had gallbladder disease. Computed tomography (CT) and magnetic resonance imaging revealed cystic lesions at multiple sites and hemangiomas in 4 patients (57%), previously thought to be pathognomonic for von Hippel-Lindau disease. The most accurate radiopharmaceutical to detect PGL appeared to be [18F]-fluorodihydroxyphenylalanine ([18F]-FDOPA). Therefore, [18F]-FDOPA PET/CT, not [68Ga]-(DOTA)-[Tyr3]-octreotate ([68Ga]-DOTATATE) PET/CT is recommended for tumor localization and aftercare in this syndrome. The long-term prognosis of the syndrome is unknown. However, to date no deaths occurred after 6 years follow-up. Physicians should be aware of this unique syndrome and its diagnostic and therapeutic challenges.
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Affiliation(s)
- Roland Därr
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Joan Nambuba
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Jaydira Del Rivero
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Ingo Janssen
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Maria Merino
- Laboratory of PathologyNational Institutes of Health, Bethesda, Maryland, USA
| | - Milena Todorovic
- Institute of HematologyClinical Center of Serbia and Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Bela Balint
- Institute of Transfusiology and Hemobiology of Military Medical Academy and Institute for Medical ResearchUniversity of Belgrade, Belgrade, Serbia
| | - Ivana Jochmanova
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
- 1st Department of Internal MedicineFaculty of Medicine, Pavol Jozef Safarik University in Kosice, Kosice, Slovakia
| | - Josef T Prchal
- Division of HematologyUniversity of Utah, Salt Lake City, Utah, USA
| | - Ronald M Lechan
- Tupper Research Institute and Department of MedicineDivision of Endocrinology, Diabetes and Metabolism, Tufts Medical Center, Boston, Massachusetts, USA
| | - Arthur S Tischler
- Department of Pathology and Laboratory MedicineTufts Medical Center, Boston, Massachusetts, USA
| | - Vera Popovic
- Institute of EndocrinologyClinical Center of Serbia, Medical Faculty, University Belgrade, Belgrade, Serbia
| | - Dragana Miljic
- Institute of EndocrinologyClinical Center of Serbia, Medical Faculty, University Belgrade, Belgrade, Serbia
| | - Karen T Adams
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - F Ryan Prall
- Department of OphthalmologyEugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexander Ling
- Department of Radiology and Imaging SciencesClinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Meredith R Golomb
- Division of Child NeurologyDepartment of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael Ferguson
- Riley Hospital for Children at Indiana University HealthIndianapolis, Indiana, USA
| | - Naris Nilubol
- Endocrine Oncology BranchNational Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Clara C Chen
- Division of Nuclear MedicineDepartment of Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Emily Chew
- Division of Epidemiology and Clinical ApplicationsNational Eye Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - David Taïeb
- Department of Nuclear MedicineLa Timone University Hospital & CERIMED & Inserm UMR1068 Marseille Cancerology Research Center, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
| | - Constantine A Stratakis
- Division of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Tito Fojo
- Medical Oncology BranchNational Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Chunzhang Yang
- Neuro-Oncology BranchCenter for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Electron Kebebew
- Endocrine Oncology BranchNational Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Zhengping Zhuang
- Neuro-Oncology BranchCenter for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Karel Pacak
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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8
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Därr R, Bursztyn M, Pamporaki C, Peitzsch M, Siegert G, Bornstein SR, Eisenhofer G. Dipping in Ambulatory Blood Pressure Monitoring Correlates With Overnight Urinary Excretion of Catecholamines and Sodium. J Clin Hypertens (Greenwich) 2016; 18:921-6. [DOI: 10.1111/jch.12791] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/05/2015] [Accepted: 12/10/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Roland Därr
- Department of Medicine III; University Hospital Carl Gustav Carus at the Technische Universität Dresden; Dresden Germany
| | - Michael Bursztyn
- Department of Medicine; Hypertension Unit; Hadassah-Hebrew University Medical Center; Jerusalem Israel
| | - Christina Pamporaki
- Department of Medicine III; University Hospital Carl Gustav Carus at the Technische Universität Dresden; Dresden Germany
| | - Mirko Peitzsch
- Institute of Clinical Chemistry and Laboratory Medicine; University Hospital Carl Gustav Carus at the Technische Universität Dresden; Dresden Germany
| | - Gabriele Siegert
- Institute of Clinical Chemistry and Laboratory Medicine; University Hospital Carl Gustav Carus at the Technische Universität Dresden; Dresden Germany
| | - Stefan R. Bornstein
- Department of Medicine III; University Hospital Carl Gustav Carus at the Technische Universität Dresden; Dresden Germany
| | - Graeme Eisenhofer
- Department of Medicine III; University Hospital Carl Gustav Carus at the Technische Universität Dresden; Dresden Germany
- Institute of Clinical Chemistry and Laboratory Medicine; University Hospital Carl Gustav Carus at the Technische Universität Dresden; Dresden Germany
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9
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Nambuba J, Därr R, Janssen I, Bullova P, Adams KT, Millo C, Bourdeau I, Kassai A, Yang C, Kebebew E, Zhuang Z, Pacak K. Functional Imaging Experience in a Germline Fumarate Hydratase Mutation–Positive Patient With Pheochromocytoma and Paraganglioma. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15759.cr] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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10
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Peitzsch M, Bursztyn M, Pamporaki C, Därr R, Fliedner S, Timmers H, Lenders J, Prejbisz A, Eisenhofer G. Biochemical diagnosis of pheochromocytoma by measurements of overnight excretion levels of catecholamines and metabolites as a simplified alternative to 24-hour collections. Exp Clin Endocrinol Diabetes 2015. [DOI: 10.1055/s-0035-1547715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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11
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Eisenhofer G, Därr R, Pamporaki C, Peitzsch M, Bornstein S, Lenders JWM. Supine or Sitting? Economic and other considerations for use of plasma metanephrines for diagnosis of phaeochromocytoma. Clin Endocrinol (Oxf) 2015; 82:463-4. [PMID: 25186957 DOI: 10.1111/cen.12602] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry & Laboratory Medicine, Dresden; Department of Medicine III, Technische Universität Dresden, Dresden.
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12
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Weismann D, Peitzsch M, Raida A, Prejbisz A, Gosk M, Riester A, Willenberg HS, Klemm R, Manz G, Deutschbein T, Kroiss M, Därr R, Bidlingmaier M, Januszewicz A, Eisenhofer G, Fassnacht M. Measurements of plasma metanephrines by immunoassay vs liquid chromatography with tandem mass spectrometry for diagnosis of pheochromocytoma. Eur J Endocrinol 2015; 172:251-60. [PMID: 25452465 DOI: 10.1530/eje-14-0730] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Reports conflict concerning measurements of plasma metanephrines (MNs) for diagnosis of pheochromocytomas/paragangliomas (PPGLs) by immunoassays compared with other methods. We aimed to compare the performance of a commercially available enzyme-linked immunoassay (EIA) kit with liquid chromatography-tandem mass spectrometric (LC-MS/MS) measurements of MNs to diagnose PPGLs. METHODS In a substudy of a prospective, multicenter trial to study the biochemical profiles of monoamine-producing tumors, we included 341 patients (174 males and 167 females) with suspected PPGLs (median age 54 years), of whom 54 had confirmed PPGLs. Plasma MNs were measured by EIA and LC-MS/MS, each in a specialized laboratory. RESULTS Plasma normetanephrine (NMN) and MN were measured 60 and 39% lower by EIA than by LC-MS/MS. Using upper cut-offs stipulated for the EIA, diagnostic sensitivity was only 74.1% at a specificity of 99.3%. In contrast, use of similar cut-offs for MN and overall lower age-adjusted cut-offs for NMN measured by LC-MS/MS returned a diagnostic sensitivity and specificity of 98.1 and 99.7%. Areas under receiver-operating characteristic curves, nevertheless, indicated comparable diagnostic performance of the EIA (0.993) and LC-MS/MS (0.985). Diagnostic sensitivity for the EIA increased to 96.2% with a minimal loss in specificity (95.1%) following use of cut-offs for the EIA adapted to correct for the negative bias. CONCLUSIONS The EIA underestimates plasma MNs and diagnostic sensitivity is poor using commonly stipulated cut-offs, resulting in a high risk for missing patients with PPGLs. Correction of this shortcoming can be achieved by appropriately determined cut-offs resulting in comparable diagnostic performance of EIA and LC-MS/MS assays.
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Affiliation(s)
- Dirk Weismann
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresd
| | - Mirko Peitzsch
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anna Raida
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Aleksander Prejbisz
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maria Gosk
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Anna Riester
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Holger S Willenberg
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Reiner Klemm
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Georg Manz
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timo Deutschbein
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Matthias Kroiss
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Roland Därr
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Bidlingmaier
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Andrzej Januszewicz
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Graeme Eisenhofer
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresd
| | - Martin Fassnacht
- Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany Endocrine and Diabetes UnitDepartment of Internal Medicine I, University Hospital, University of Würzburg, Oberdürrbacher Str. 6, 97080 Würzburg, GermanyComprehensive Heart Failure CenterUniversity of Würzburg, Würzburg, GermanyInstitute of Clinical Chemistry and Laboratory MedicineUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, GermanyDepartment of HypertensionInstitute of Cardiology, Warsaw, PolandMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Munich, GermanyDivision for Specific EndocrinologyDepartment of Endocrinology and Diabetology, Medical Faculty, University Dusseldorf, Dusseldorf, GermanyLDN Labor Diagnostika Nord GmbH und Co. KGNordhorn, GermanyCentral Laboratory of the University Hospital of WuerzburgWürzburg, GermanyComprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, GermanyDepartment of Medicine IIIUniversity Hospital Carl Gustav Carus, Technische Universität Dresden, Dresd
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Därr R, Pamporaki C, Peitzsch M, Miehle K, Prejbisz A, Peczkowska M, Weismann D, Beuschlein F, Sinnott R, Bornstein SR, Neumann HP, Januszewicz A, Lenders J, Eisenhofer G. Biochemical diagnosis of phaeochromocytoma using plasma-free normetanephrine, metanephrine and methoxytyramine: importance of supine sampling under fasting conditions. Clin Endocrinol (Oxf) 2014; 80:478-86. [PMID: 24102244 DOI: 10.1111/cen.12327] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/05/2013] [Accepted: 09/10/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To document the influences of blood sampling under supine fasting versus seated nonfasting conditions on diagnosis of phaeochromocytomas and paragangliomas (PPGL) using plasma concentrations of normetanephrine, metanephrine and methoxytyramine. DESIGN AND METHODS Biochemical testing for PPGL was performed on 762 patients at six centres, two of which complied with requirements for supine sampling after an overnight fast and four of which did not. Phaeochromocytomas and paragangliomas were found in 129 patients (67 noncompliant, 62 compliant) and not in 633 patients (195 noncompliant, 438 compliant). RESULTS Plasma concentrations of normetanephrine and methoxytyramine did not differ between compliant and noncompliant sampling conditions in patients with PPGL but were 49-51% higher in patients without PPGL sampled under noncompliant compared with compliant conditions. The 97·5 percentiles of distributions were also higher under noncompliant compared with compliant conditions for normetanephrine (1·29 vs 0·79 nmol/l), metanephrine (0·49 vs 0·41 nmol/l) and methoxytyramine (0·42 vs 0·18 nmol/l). Use of upper cut-offs established from seated nonfasting sampling conditions resulted in substantially decreased diagnostic sensitivity (98% vs 85%). In contrast, use of upper cut-offs established from supine fasting conditions resulted in decreased diagnostic specificity for testing under noncompliant compared with compliant conditions (71% vs 95%). CONCLUSIONS High diagnostic sensitivity of plasma normetanephrine, metanephrine and methoxytyramine for the detection of PPGL can only be guaranteed using upper cut-offs of reference intervals established with blood sampling under supine fasting conditions. With such cut-offs, sampling under seated nonfasting conditions can lead to a 5·7-fold increase in false-positive results necessitating repeat sampling under supine fasting conditions.
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Affiliation(s)
- Roland Därr
- Department of Medicine III, University Hospital Dresden at the TU Dresden, Dresden, Germany
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14
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Weismann D, Raida A, Deutschbein T, Prejbisz A, Januszewicz A, Willenberg HS, Peitzsch M, Därr R, Klemm R, Manz G, Bidlingmaier M, Eisenhofer G, Fassnacht M. Measurements of plasma metanephrines by immunoassay versus LC-MS/MS for diagnosis of pheochromocytoma. Exp Clin Endocrinol Diabetes 2014. [DOI: 10.1055/s-0034-1371996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
Pheochromocytomas (P) are rare catecholamine producing neuroendocrine tumors originating from the chromaffin cells of the adrenal medulla or in 15 % of cases from extra adrenal chromaffin tissue and termed paragangliomas (PGL). Because of secretion of the catecholamines - adrenaline, noradrenaline and dopamine - the tumors are dangerous with a risk of life threating hypertensive crises. Measurements of plasma metanephrine, normetanephrine and methoxytyramine by liquid chromatography with tandem mass spectrometry provides the most accurate and precise method for biochemical diagnosis. Approximately 30-40 % of the tumors have a hereditary background due to mutations of 11 known susceptibility genes, with identification facilitated by targeted genetic testing according to clinical presentation. Apart from syndrome-dependent clinical stigmata, other hints to an underlying mutation can be provided by biochemical profiles of the catecholamine metabolites, tumor location, patient age and presence of metastatic disease. Surgery with minimal invasive procedures is the recommended therapeutic way after pretreatment with an alpha receptor blocking medication.
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Affiliation(s)
- M Gruber
- Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
| | - R Därr
- Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
| | - G Eisenhofer
- Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
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16
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Pamporaki C, Därr R, Bursztyn M, Glöckner S, Bornstein SR, Lenders JWM, Pacak K, Krinner A, Eisenhofer G. Plasma-free vs deconjugated metanephrines for diagnosis of phaeochromocytoma. Clin Endocrinol (Oxf) 2013; 79:476-83. [PMID: 23461656 PMCID: PMC3762922 DOI: 10.1111/cen.12191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/13/2013] [Accepted: 02/09/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnosis of phaeochromocytoma is commonly performed by the measurements of plasma-free normetanephrine and metanephrine. Plasma-deconjugated normetanephrine and metanephrine have been proposed as alternative, equivalent, but easier to measure biomarkers. OBJECTIVE The aim of this study was to compare the diagnostic performance of plasma-free vs deconjugated normetanephrine and metanephrine in patients tested for phaeochromocytoma. METHODS The study population included a reference group of 262 normotensive and hypertensive volunteers, 198 patients with phaeochromocytoma and 528 patients initially suspected of having the tumour, but with negative investigations after at least 2 years of follow-up. Measurements were performed using liquid chromatography with electrochemical detection. RESULTS Plasma concentrations of free normetanephrine were 17-fold higher in patients with phaeochromocytoma than in the reference population, a 72% larger (P < 0·001) difference than that for the 10-fold higher levels of plasma-deconjugated normetanephrine. In contrast, relative increases in plasma concentrations of free and deconjugated metanephrine were similar. Using upper cut-offs established in the reference population, measurements of plasma-free metabolites provided superior diagnostic performance than deconjugated metabolites according to measures of both sensitivity (97% vs 92%, P = 0·002) and specificity (93% vs 89%, P = 0·012). The area under the receiver operating characteristic curve for the free metabolites was larger than that for the deconjugated metabolites (0·986 vs 0·965, P < 0·001). CONCLUSION Measurements of plasma-free normetanephrine and metanephrine are superior to the deconjugated metabolites for diagnosis of phaeochromocytoma.
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Affiliation(s)
- Christina Pamporaki
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstrasse 74, Dresden, Germany.
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Tsourdi E, Därr R, Wieczorek K, Röcken C, Ehehalt F, Conrad K, Platzbecker U, Hofbauer LC. Macroglossia as the only presenting feature of amyloidosis due to MGUS. Eur J Haematol 2013; 92:88-9. [PMID: 23799910 DOI: 10.1111/ejh.12163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Elena Tsourdi
- Department of Medicine III, Dresden Technical University Medical Center, Dresden
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18
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Pamporaki C, Därr R, Bursztyn M, Krinner A, Glökner S, Bornstein S, Pacak K, Lenders JWM, Eisenhofer G. Plasma free versus deconjugated metanephrines for diagnosis of pheochromocytoma. Exp Clin Endocrinol Diabetes 2013. [DOI: 10.1055/s-0033-1336621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Därr R, Lenders JW, Stange K, Kindel B, Hofbauer LC, Bornstein SR, Eisenhofer G. [Diagnosis of pheochromocytoma and paraganglioma: the clonidine suppression test in patients with borderline elevations of plasma free normetanephrine]. Dtsch Med Wochenschr 2013; 138:76-81. [PMID: 23299341 DOI: 10.1055/s-0032-1327395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Measurements of plasma free metanephrines provide a sensitive test for the diagnosis of pheochromocytoma/paraganglioma (P/PGL), with highly elevated levels diagnostic of the disease. However, there is less diagnostic certainty in patients with mild elevations of these catecholamine metabolites. PATIENTS AND METHODS Here we report use of the clonidine suppression test (CST) as a second-tier diagnostic test in 24 patients with mild elevations of plasma free metanephrines and/or catecholamines. Blood samples before and 3 hours after clonidine were analyzed for plasma concentrations of metanephrines and catecholamines with a negative test result defined as either a clonidine-induced fall in normetanephrine or noradrenaline by more than 40 % and 50 % respectively or to below the upper cut-offs of reference intervals. RESULTS P/PGLs were confirmed in 9 patients and excluded in 15 by independent criteria. More than half of the patients without P/PGL showed normalized plasma concentrations of normetanephrine at baseline before clonidine compared to initial screening; all showed appropriate clonidine-induced falls in normetanephrine and noradrenaline or levels after the drug below upper cut-offs, indicating a diagnostic specificity of 100 % (CI 78-100 %). However, similar responses for noradrenaline were noted in 7 patients with P/PGL, indicating a diagnostic sensitivity of only 22 % (CI 2,8-60 %) compared to 100 % (CI 66-100 %) for normetanephrine. CONCLUSION These results support use of the CST in combination with measurements of normetanephrine for confirming or excluding P/PGL in patients with borderline elevated test results, which should, however, first be confirmed by sampling blood under standardized resting conditions.
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Affiliation(s)
- R Därr
- Medizinische Klinik III, UniversitätsklinikumCarl Gustav Carus der Technischen Universität Dresden
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Eisenhofer G, Lattke P, Herberg M, Siegert G, Qin N, Därr R, Hoyer J, Villringer A, Prejbisz A, Januszewicz A, Remaley A, Martucci V, Pacak K, Ross HA, Sweep FCGJ, Lenders JWM. Reference intervals for plasma free metanephrines with an age adjustment for normetanephrine for optimized laboratory testing of phaeochromocytoma. Ann Clin Biochem 2012; 50:62-9. [PMID: 23065528 DOI: 10.1258/acb.2012.012066] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Measurements of plasma normetanephrine and metanephrine provide a useful diagnostic test for phaeochromocytoma, but this depends on appropriate reference intervals. Upper cut-offs set too high compromise diagnostic sensitivity, whereas set too low, false-positives are a problem. This study aimed to establish optimal reference intervals for plasma normetanephrine and metanephrine. METHODS Blood samples were collected in the supine position from 1226 subjects, aged 5-84 y, including 116 children, 575 normotensive and hypertensive adults and 535 patients in whom phaeochromocytoma was ruled out. Reference intervals were examined according to age and gender. Various models were examined to optimize upper cut-offs according to estimates of diagnostic sensitivity and specificity in a separate validation group of 3888 patients tested for phaeochromocytoma, including 558 with confirmed disease. RESULTS Plasma metanephrine, but not normetanephrine, was higher (P < 0.001) in men than in women, but reference intervals did not differ. Age showed a positive relationship (P < 0.0001) with plasma normetanephrine and a weaker relationship (P = 0.021) with metanephrine. Upper cut-offs of reference intervals for normetanephrine increased from 0.47 nmol/L in children to 1.05 nmol/L in subjects over 60 y. A curvilinear model for age-adjusted compared with fixed upper cut-offs for normetanephrine, together with a higher cut-off for metanephrine (0.45 versus 0.32 nmol/L), resulted in a substantial gain in diagnostic specificity from 88.3% to 96.0% with minimal loss in diagnostic sensitivity from 93.9% to 93.6%. CONCLUSIONS These data establish age-adjusted cut-offs of reference intervals for plasma normetanephrine and optimized cut-offs for metanephrine useful for minimizing false-positive results.
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Affiliation(s)
- Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital of Dresden, 01307 Dresden, Germany.
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Därr R, Zöphel K, Eisenhofer G, Abolmaali N, Gastmeier J, Wieczorek K, Jelinek V, Kamvissi V, Bornstein SR, Hofbauer LC. Combined use of 68Ga-DOTATATE and 18F-FDG PET/CT to localize a bronchial carcinoid associated with ectopic ACTH syndrome. J Clin Endocrinol Metab 2012; 97:2207-8. [PMID: 22529105 DOI: 10.1210/jc.2012-1402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Roland Därr
- Division of Endocrinology, Department of Medicine III, Dresden Technical University Medical Center, Fetscherstrasse 74, 01307 Dresden, Germany
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Abstract
Pheochromocytomas are rare endocrine tumors that can present insidiously and remain undiagnosed until death or onset of clear manifestations of catecholamine excess. They are often referred to as one of the 'great mimics' in medicine. These tumors can no longer be regarded as a uniform disease entity, but rather as a highly heterogeneous group of chromaffin cell neoplasms with different ages of onset, secretory profiles, locations, and potential for malignancy according to underlying genetic mutations. These aspects all have to be considered when the tumor is encountered, thereby enabling optimal management for the patient. Referral to a center of specialized expertise for the disease should be considered wherever possible. This is not only important for surgical management of patients, but also for post-surgical follow up and screening of disease in patients with a hereditary predisposition to the tumor. While preoperative management has changed little over the last 20 years, surgical procedures have evolved so that laparoscopic resection is the standard of care and partial adrenalectomy should be considered in all patients with a hereditary condition. Follow-up testing is essential and should be recommended and ensured on a yearly basis. Managing such patients must now also take into account possible underlying mutations and the appropriate selection of genes for testing according to disease presentation. Patients and family members with identified mutations then require an individualized approach to management. This includes consideration of distinct patterns of biochemical test results during screening and the appropriate choice of imaging studies for tumor localization according to the mutation and associated differences in predisposition to adrenal, extra-adrenal and metastatic disease.
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Därr R, Eisenhofer G, Kotzerke J, Zöphel K, Stroszczynski C, Deinum J, Schultze Kool LJ, Pistorius S, Neumann H, Bornstein SR, Hofbauer LC. Is there still a place for adrenal venous sampling in the diagnostic localization of pheochromocytoma? Endocrine 2011; 40:75-9. [PMID: 21509651 DOI: 10.1007/s12020-011-9471-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 03/29/2011] [Indexed: 10/18/2022]
Abstract
Our objective is to outline the utility of adrenal venous sampling (AVS) with measurements of metanephrine to normetanephrine ratios for diagnostic localization of phaeochromocytoma in a patient with normal plasma levels of catecholamines. A 53-year-old-woman was referred for evaluation of recurrent pheochromocytoma following a right adrenalectomy 14 years earlier. Diagnosis of recurrent disease was established from elevations in plasma metanephrines with normal levels of catecholamines. Magnetic resonance imaging indicated two 1-2 cm masses in the right surgical bed and another 1-1.5 cm mass in the left adrenal. These masses were negative on (123)I-metaiodobenzylguanidine scintigraphy. There was no evidence of a hereditary syndrome. We, therefore, carried out two investigational approaches to identify the tumor masses. Hybrid positron emission tomography/computed tomography with (68)Ga-DOTATOC ((68)Ga-DOTATOC-PET/CT) confirmed the presence of recurrent disease in the right surgical bed and also suggested additional left adrenal involvement. Normal plasma catecholamines precluded the use of adrenal venous sampling (AVS) with catecholamine measurements. Hence, we performed AVS with measurements of plasma metanephrines, which were 4- to 7-fold higher in the left adrenal vein than in central venous plasma. We observed a reversal of the normally high metanephrine to normetanephrine ratio (mean value ± SD 5.28 ± 1.86; range 3.36-8.84, n = 13) to 0.73, establishing the presence of a left adrenal pheochromocytoma. Surgical pathology confirmed bilateral disease. This case highlights a scenario where a combination of (68)Ga-DOTATOC-PET/CT and AVS with measurement of the metanephrine to normetanephrine ratio was crucial for the preoperative assessment of a patient with bilateral pheochromocytoma.
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Affiliation(s)
- Roland Därr
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III, Dresden Technical University Medical Center, Fetscherstr. 74, 01307, Dresden, Germany
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