The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer

A Case of Retroperitoneal Paraganglioma Presenting As Dizziness and Chest Pain With a Coexisting Contralateral Primary Renal Tumor

Paraganglioma is a rare type of neuroendocrine tumor with variable clinical presentations, making diagnosis relatively challenging. In this report, we present a case of retroperitoneal paraganglioma in a patient who experienced intermittent episodes of dizziness and chest pain. Imaging studies conducted during the patient's hospitalization revealed the presence of a lesion in the upper region of the right kidney, as well as a mass in the left retroperitoneal area that was suspected to be a paraganglioma. Biochemical studies were collected, including 24-hour urine metanephrines, urine catecholamines, urine cortisol, plasma metanephrines, renin, and aldosterone. However, it took an extended period of time for these results to come back. Given high clinical suspicion, alpha-blockade was initiated without a definite diagnosis of paraganglioma. Ultimately, the patient underwent tumor resection and the final pathology confirmed paraganglioma. The pathology of the contralateral renal mass showed oncocytoma. This case serves as an illustration of the difficulties that can arise when diagnosing and treating undiagnosed paragangliomas within a community healthcare setting.

The Use of Telemedicine in the Preoperative Care of Pheochromocytoma: A Systematic Review

Pheochromocytoma (PCC) is a neuroendocrine tumor that may present with headaches, palpitations, and hypertension, and if left unresected, it can lead to serious complications and fatal cardiac mortality. Adequate preoperative management can decrease the risk of intraoperative complications. In this systematic review, we address and discuss what has been published in the literature about the optimization of pheochromocytoma preoperative care via various types of telemedicine (TM). We searched health research databases PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), the Cochrane Library, and Google Scholar for literature on various types of TM employed for PCC preoperative management. We searched peer-reviewed literature in the English language published in the literature until November 5, 2022, using medical subject heading (MeSh) terms in PubMed like "telemedicine" and "pheochromocytoma." We used "telemedicine" or "telehealth" and "pheochromocytoma" in other databases. We considered all types of TM, including synchronous, asynchronous, and remote patient monitoring. Our search yielded five publications in PubMed, 59 results in Google Scholar, and none in the Cochrane Library. After excluding duplicates and evaluating the articles for relevance, five papers were selected for this review. Studies came from the United States and Italy. Findings from these studies suggested safe outcomes and reduced costs compared to what is traditionally followed in physical settings. Overall, this systematic review shows the convenience and safety of TM use for a broad spectrum of patients. Further studies are needed to consolidate these findings. Moreover, guidelines on patients' selection and procedures for safe and effective TM care for patients with PCC are required.

Minimally Invasive Management of Hemorrhagic Pheochromocytoma—A Rare Case Report

Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. The diagnosis is usually suggested by its classic history, presence of a strong family history, or discovery of an incidental mass on imaging in an asymptomatic patient. Hemorrhage into an occult pheochromocytoma is a rare complication with ∼1 to 2 per 100,000 individuals diagnosed annually. We report a case of a 29-year-old woman, who presented with abdominal pain (with no other significant history) due to a right hemorrhagic pheochromocytoma. Computed tomographic imaging and magnetic resonance imaging revealed the source of retroperitoneal hemorrhage as the right adrenal mass. They lacked the typical features of a pheochromocytoma which was eventually proven by the biochemical tests. The patient underwent preoperative stabilization with α and β adrenergic receptor blockers for 7 days following which laparoscopic adrenalectomy was performed successfully with an uneventful postoperative period. This is the eighth reported case in literature managed laparoscopically. Histopathology confirmed it as pheochromocytoma. The treacherous and deceptive nature of pheochromocytomas and its hemorrhage make it crucial to detect and treat it promptly; otherwise, it will almost certainly be fatal from cardiovascular complications or metastasis.

Pheochromocytoma disguised as gestational hypertensive disease during pregnancy: A case report

Pheochromocytoma is often diagnosed prior to pregnancy. Sometimes, the disease may be diagnosed for the first-time during pregnancy masking itself as a hypertensive disease in pregnancy. Early diagnosis and timely, appropriate management reduce possible maternal and fetal complications. We identified a case of pheochromocytoma during pregnancy misdiagnosed as preeclampsia.

Is transperitoneal laparoscopic adrenalectomy for pheochromocytoma really more challenging? A propensity score-matched analysis

PURPOSE

Minimally invasive surgery is the gold standard treatment for adrenal masses, but it may be a challenging procedure in the case of pheochromocytoma (PHEO). The aim of the present study is to report the results of transperitoneal laparoscopic adrenalectomy (TLA) in cases of PHEO in comparison to other types of adrenal lesions.

METHODS

From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients, respectively, were excluded because they underwent bilateral and open adrenalectomy, leaving 572 patients for inclusion. Of these, 114 patients had PHEO (Group A), and 458 had other types of lesions (Group B). To adjust for potential baseline confounders, a propensity score matching (PSM) analysis was conducted.

RESULTS

After PSM, 114 matched pairs of patients were identified from each group. Statistically significant differences were not observed when comparing the median operative time (85 and 90 min in Groups A and B, respectively, p = 0.627), conversion rate [6 (5.3%) in each group, p = 1.000], transfusion rate [4 (3.5%) and 3 (2.6%) in Groups A and B, respectively, p = 1.000], complication rate [7 (6.1%) and 9 (7.9%) in Groups A and B, respectively, p = 0.796), median postoperative hospital stay (3.9 and 3.6 days in Groups A and B, respectively, p = 0.110), and mortality rate [1 (0.9%) in each group, p = 1.000].

CONCLUSIONS

Based on this analysis, the results of TLA for PHEO are equivalent to those of TLA for other types of adrenal lesions, but the fundamental requirements are multidisciplinary patient management and adequate surgeon experience. Further prospective studies are required to draw definitive conclusions.

Metastatic paraganglioma

A man in his 70s, with a history of a glomus jugulare paraganglioma diagnosed 18 years ago, presented with an unprovoked deep vein thrombosis (DVT). The paraganglioma had been treated by radiotherapy, and yearly scans had not shown any progression since treatment. A sclerotic focus in L4 vertebral body was reported on a CT scan of the neck and trunk which was done to exclude a neoplastic process being the precipitating factor for the DVT. Nuclear imaging showed multiple areas of bony uptake, suggestive of metastases. A bone biopsy of the left femur resulted positive for metastatic paraganglioma. A monthly intramuscular injection of octreotide 30 mg was prescribed.

Intracardiac paraganglioma with a cough as the first symptom

BACKGROUND

Cardiac paragangliomas (PGLs) are clinically rare, with hypertension and metabolic changes as the main symptoms. The tumor is highly related to gene mutation, and surgery is presently the effective treatment. Medical history and clinical manifestations of the patient, routine laboratory examinations and imaging examinations, and pathological examination can help the final diagnosis.

CASE PRESENTATION

The present study presents a 31-year-old male patient with a left atrial mass. The initial symptom was cough. Cardiac enlargement was found during the chest X-ray. The follow-up imaging examination revealed a left atrial occupying lesion, and the possibility of malignant occupying lesions was not ruled out. The patient underwent surgical resection of the mass. The final pathological result revealed paraganglioma. The thoracic computed tomography review two months after the operation revealed that the original occupying lesion disappeared, and no new lesion was found.

CONCLUSIONS

Pheochromocytomas and paragangliomas (PPGLs) are a kind of neuroendocrine tumors. PPGLs can cause secondary hypertension, and lead to a series of clinical syndromes, including myocardial injury, metabolic changes, and so on. The occurrence of PPGIs is related to gene mutation. Biochemical detection, imaging examination, and genetic testing can help diagnose. The tumor should be surgically removed as soon as possible after the diagnosis. As a functional tumor, PPGLs should be fully prepared before surgery to avoid anesthesia and huge fluctuations in blood pressure during and after surgery, or the occurrence of fatal hypertensive crisis and intractable hypotension after tumor resection. Adequate preoperative preparation directly affects the prognosis of patients after surgery. Therefore, multidisciplinary cooperation before, during, and after the operation is extremely important.

Huge Hematoma as First Manifestation of Adrenocortical Carcinoma: A Case Report

BACKGROUND Adrenocortical carcinoma (ACC) is a rare malignancy associated with unfavorable prognosis. It is mainly diagnosed in the fifth or sixth decade of life. Symptoms of ACC are associated with hormonal activity, presence of metastases, and size of the tumor. The treatment and prognosis depend on the stage of the disease assessed with the ENSAT staging system. CASE REPORT A 38-year-old White man was admitted to our department from the city hospital due to a huge hematoma of the right adrenal gland (130×100 mm). On admission, the patient's condition was stable, and no active bleeding or other complications were present. Therefore, initially, conservative treatment was performed. The control CT scan showed reduction of the hematoma (90×80 mm). Due to the unknown character of the tumor and the sudden onset of bleeding, the patient was prepared for elective surgery according to the phaeochromocytoma surgery protocol. Following preparation, the patient underwent right-sided adrenalectomy. In the postoperative histopathological examination, adrenocortical carcinoma was diagnosed, which allowed the patient to receive appropriate oncological treatment. CONCLUSIONS There is currently no clear algorithm for the management of adrenal hemorrhage. A hemodynamically unstable patient requires urgent surgical treatment. Patients in good general condition should be prepared for early elective surgery.

Pheochromocytoma associated with a succinate dehydrogenase subunit B mutation: A minireview and a case report

Objective. Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that arise from the chromaffin cells of the adrenal medulla or extra-adrenal tissues. These tumors are characterized by an excessive secretion of catecholamines, which are responsible for the clinical manifestation of the disease. Although most of these tumors are sporadic, underlying genetic abnormalities may be present in up to 24% of the cases. A succinate dehydrogenase subunit B (SDHB) mutation represents one of the rare presentations of the disease. In this study, we represent a rare case of pheochromocytoma associated with SDHB mutation. Methods. We performed a retrospective review of our case in addition to reviewing the available literature on the same topic. Results. A 17-year-old patient presented with sustained hypertension. Clinical, laboratory, and radiological evaluations confirmed the diagnosis of catecholamine-secreting tumor. Laparoscopic adrenalectomy was performed. Histopathological and genetic testing confirmed a pheochromocytoma associated with SDHB mutation. No recurrence was detected on two-years of follow up. Conclusion. Pheochromocytoma associated with SDHB mutation is a rare presentation. Genetic testing for suspecting cases is essential to help to establish the appropriate follow-up plan.

Correlation between the size of pheochromocytoma and the level of metanephrines

Objective. Pheochromocytomas (PHEO) and paraganglioma (PGLs) are rare neuroendocrine catecholamine-producing tumors that arise from the chromaffin cells of either the adrenal medulla or extra-adrenal paraganglionic tissues. Despite the recent advances in imaging technologies, biochemical evidence of excessive catecholamine production by the tumor is considered the most important test for the diagnosis of these tumors. The aim of the present study is to investigate the role of the catecholamine metabolites (normetanephrine and metanephrine) levels in the diagnosis of PHEO/PGLs and to evaluate if their levels correlate with the size of these tumors. Patients and Methods. Twenty-five patients were included in the study during the time period of 10 years. Their data were compared with another set of 25 patients to obtain the sensitivity and specificity of metanephrine and normetanephrine in the diagnosis of PHEO/PGLs. The tumor size was reviewed in every patient to obtain the correlation coefficient between the tumor sizes and the plasma/24-hour urinary metanephrine levels. Results. The sensitivity and specificity rates for plasma metanephrine were 80-92% and 92-96%, respectively; while for 24-hour urinary metanephrine were 80-90% and 95-100%, respectively. We found a strong positive relationship between the tumor size and the plasma levels of normetanephrine (r=0.518, p<0.01), and metanephrine (r=0.577, p<0.01). While the relation with the 24-hour urinary concentrations of normetanephrine (r=0.384, p=0.01) and 24-h urinary meta-nephrine (r=0.138, p<0.01) was low. Conclusion. The determination of plasma and 24-hour urinary levels of metanephrines is a reliable test for the diagnosis of PHEO, as they are continuously produced by the tumor cells in contrast to catecholamines.

A Clinicopathologic and Molecular Analysis of Fumarate Hydratase-deficient Pheochromocytoma and Paraganglioma

Up to 40% of pheochromocytomas (PCCs) and paragangliomas (PGLs) are hereditary. Germline mutations/deletions in fumarate hydratase ( FH ) cause hereditary leiomyomatosis and renal cell carcinoma syndrome which manifests predominantly with FH-deficient uterine/cutaneous leiomyomas and renal cell carcinomas (RCCs)-tumors characterized by loss of immunohistochemical (IHC) expression of FH and/or positive staining for S-(2-succino)-cysteine. Occasional patients develop PCC/PGL. We investigated the incidence, morphologic, and clinical features of FH-deficient PCC/PGL. We identified 589 patients with PCC/PGLs that underwent IHC screening for FH and/or S-(2-succino)-cysteine. Eight (1.4%) PCC/PGLs were FH deficient (1.1% in an unselected population). The median age for FH-deficient cases was 55 (range: 30 to 77 y) with 50% arising in the adrenal. All 4 with biochemical data were noradrenergic. Two (25%) metastasized, 1 dying of disease after 174 months. Germline testing was performed on 7 patients, 6 of whom had FH missense mutations. None were known to have a significant family history before presentation or developed cutaneous leiomyomas, or FH-deficient RCC at extended follow-up. The patient wild-type for FH on germline testing was demonstrated to have somatic FH mutation and loss of heterozygosity corresponding to areas of subclonal FH deficiency in her tumor. One patient did not undergo germline testing, but FH mutation was demonstrated in his tumor. We conclude that FH-deficient PCC/PGL are underrecognized but can be identified by IHC. FH-deficient PCC/PGL are strongly associated with germline missense mutations but are infrequently associated with leiomyoma or RCC, suggesting there may be a genotype-phenotype correlation. FH-deficient PCC/PGL may have a higher metastatic risk.

Palliative Symptom Management in Malignant Pheochromocytoma: Safe Use of Fentanyl and a Review of Medications Used

Background: Pheochromocytoma is a tumor arising from adrenomedullary chromaffin cells. Five-year survival with malignant pheochromocytoma is <50%. Difficulty arises when prescribing for patients, given the potential to precipitate catecholamine crisis, a life-threatening emergency. Clinical Case: A 60-year-old woman presented with abdominal fullness and discomfort. Liver biopsy confirmed pheochromocytoma. Upper and lower abdominal pain was noted and described as "dragging" and "sharp" in nature. The Endocrine Society Clinical Practice guideline for management of pheochromocytoma recommends avoidance of morphine and codeine. Subcutaneous fentanyl was tolerated with good effect, and a continuous subcutaneous infusion was commenced. She was transitioned to a fentanyl patch and her pain was controlled. Conclusion: Symptom control in patients with pheochromocytoma remains challenging. Common opioid analgesics, dopamine-receptor antagonists, corticosteroids, and tricyclic antidepressants are medications known to precipitate a crisis. There is a lack of published research to support the safe prescribing of medications for these patients.

Catecholamine crisis after endoscopic ultrasound-guided fine-needle biopsy: A case report

RATIONALE

The function and use of endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has developed in recent years, particularly in distinguishing malignant from benign masses. It is a generally safe method that can be completed without any uncommon complications. Here, although no complications from EUS-FNB were noted, we report about an unexpected catecholamine crisis that occurred after EUS-FNB.

PATIENTS CONCERNS

A 60-year-old man visited an outpatient clinic with an incidental diagnosis of a retroperitoneal mass on his last abdominopelvic computed tomography (APCT) scan taken at the time of a previous liver abscess treatment. On presentation, the patient showed no symptoms.

DIAGNOSES

A retroperitoneal mass was incidentally discovered on APCT, and risk for lymphoma, gastrointestinal tumor, or neuroendocrine tumor was noted on the APCT reading.

INTERVENTIONS

EUS-FNB was performed on retroperitoneal mass.

OUTCOMES

The procedure was completed without any complications; however, the patient's condition deteriorated due to hemodynamic instability and cardiovascular collapse. During intensive care unit (ICU) treatment, the biopsy results were found to be paraganglioma. Catecholamine crisis occurred after biopsy of paraganglioma.

LESSONS

The case presented here gives a caution of complication that may occur after EUS-FNB. Although EUS-FNB is known to be relatively safe, careful evaluation is required when performing biopsy of lesions around the aorta.

The evolution of peri-operative care in the safe management of pheochromocytoma

Background

The use of pre- and intra-operative vasoactive agents for improved blood pressure control has transformed the outcomes following pheochromocytoma (PC) resection. The first agent utilized was phenoxybenzamine, but selective alpha-1 antagonists (SAA) and calcium channel antagonists (CCA) have also been used with success. We sought to define the relationship between pre-operative treatment and intra-operative hemodynamics associated with each of these agents in patients with PC.

Methods

A retrospective, single-institution review of patients >18 years with resected PC from 1996-2020 was performed. Pre-operative blockade was at the discretion of the treating providers. Adequacy of pre-operative blockade was determined by the attending surgeon prior to proceeding with PC resection. To determine the effectiveness of pre-operative blockade during surgery, vital signs throughout the operation were examined.

Results

The final dataset included 166 patients. Phenoxybenzamine (55%) and SAA (24%) were the most commonly used pre-operative medications but phenoxybenzamine use decreased over time. Patients who experienced a hypertensive crisis had a higher initial systolic blood pressure and were older. There was no predilection for developing a hypertensive crisis based on race, sex, tumor size or type of pre-operative medication used. Patients in the early group (2010-2015) were found to have more pronounced hemodynamic instability when compared to patients in the late group (2016-2020).

Conclusion

Although there are no demonstrated differences between antihypertensives, the prescription pattern has evolved away from phenoxybenzamine. However, as this is transition happening, patients exhibit better hemodynamic control. We hypothesize that this is due to greater experience by the intra-operative team.

Immune Checkpoint Inhibitor Therapy in Neuroendocrine Tumors

Neuroendocrine tumors (NETs) occur in various regions of the body and present with complex clinical and biochemical phenotypes. The molecular underpinnings that give rise to such varied manifestations have not been completely deciphered. The management of neuroendocrine tumors (NETs) involves surgery, locoregional therapy, and/or systemic therapy. Several forms of systemic therapy, including platinum-based chemotherapy, temozolomide/capecitabine, tyrosine kinase inhibitors, mTOR inhibitors, and peptide receptor radionuclide therapy have been extensively studied and implemented in the treatment of NETs. However, the potential of immune checkpoint inhibitor (ICI) therapy as an option in the management of NETs has only recently garnered attention. Till date, it is not clear whether ICI therapy holds any distinctive advantage in terms of efficacy or safety when compared to other available systemic therapies for NETs. Identifying the characteristics of NETs that would make them (better) respond to ICIs has been challenging. This review provides a summary of the current evidence on the value of ICI therapy in the management of ICIs and discusses the potential areas for future research.

Effects of epidural anesthesia in pheochromocytoma and paraganglioma surgeries: A protocol for systematic review and meta-analysis

OBJECTIVE

Anesthetic management is a great challenge during the surgical resection of pheochromocytomas and paragangliomas (PPGLs) due to potential hemodynamic fluctuations and/or postoperative complications. Although combined epidural-general anesthesia is commonly used in PPGLs surgeries, there is still no consensus whether combined epidural-general anesthesia was superior than general anesthesia alone for these populations. For the first time, we conducted this systematic review and meta-analysis to summarize the effects of combined epidural-general anesthesia versus general anesthesia alone on hemodynamic fluctuations as well as postoperative complications in patients undergone PPGLs surgeries.

METHODS

This systematic review and meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses statement. The primary outcome were hemodynamic fluctuations, including intraoperative hypotension, postoperative hypotension, and hypertensive crisis. Secondary outcome was the incidence of postoperative complications during hospital stay.

RESULTS

Finally, three retrospective cohort studies involving 347 patients met the inclusion criteria. A meta-analysis was not performed since outcomes from included studies were not available to be pooled. On the basis of the findings of non-randomized controlled trials (RCTs) literature, 2 studies suggested that combined epidural-general anesthesia was associated with intraoperative and postoperative hypotension, although one study reported that epidural anesthesia use reduced the incidence of postoperative complications in patients undergone surgical resection of PPGLs.

CONCLUSIONS

Currently, no published RCTs have yet assessed clinically relevant outcomes with respect to the application of epidural anesthesia during PPGLs surgeries. Well-designed RCTs should nonetheless be encouraged to properly assess the efficacy and safety of epidural anesthesia for PPGLs surgeries.

Total thyroidectomy vs thyroid lobectomy for localized medullary thyroid cancer in adults: A propensity-matched survival analysis

BACKGROUND

This study aimed to clarify whether the extent of thyroidectomy (total thyroidectomy vs thyroid lobectomy) influences survival in adults with localized medullary thyroid cancer.

METHODS

Patients with localized medullary thyroid cancer were identified using the Surveillance, Epidemiology, and End Results database (2000-2018). An independent cohort of patients with localized medullary thyroid cancer were retrospectively reviewed from three medical centers in China from 2010 to 2020. The patients were grouped by the extent of surgery (total thyroidectomy vs thyroid lobectomy). Primary end points were overall survival and disease-specific survival.

RESULTS

From 1,686 patients with medullary thyroid cancer identified in SEER, 1,122 patients met inclusion for matching, with a median follow-up of 99 months. After propensity score matching, 122 patients underwent a total thyroidectomy and 122 patients underwent a thyroid lobectomy. The 10-year overall survival was 85.2% (77.9%-90.7%) and 83.1% (75.5%-90.7%) in total thyroidectomy group and in thyroid lobectomy group, respectively. The 10-year disease-specific survival was 100% and 96.8% (93.1%-100%) in total thyroidectomy group and in thyroid lobectomy group, respectively. There was no statistically significant difference in overall survival or disease-specific survival in patients with localized medullary thyroid cancer undergoing total thyroidectomy or thyroid lobectomy (hazard ratio = 0.83, 95% confidence interval 0.44-1.57, P = .57 and hazard ratio = 0.49, 95% confidence interval 0.10-2.41, P = .39, respectively). Forty-seven patients with localized medullary thyroid cancer were identified in an independent Chinese cohort (n = 29 in total thyroidectomy group vs n = 18 in thyroid lobectomy group). After a median follow-up of 47 months, there was no mortality observed in either group.

CONCLUSION

This study suggests that the extent of thyroidectomy does not influence survival for patients with early-stage localized medullary thyroid cancer and that thyroid lobectomy might be adequate in this patient population.

Clinical presentation and diagnostic evaluation of pheochromocytoma: case series and literature review

BACKGROUND

Pheochromocytoma is a rare tumor frequently overlooked mainly due to the wide range of its clinical presentation, which may vary from entirely untypical signs and symptoms to life-threatening complications.

METHODS

The present study aims to present a case series recently treated in our center, with emphasis placed on patients' specific characteristics, clinical presentation and diagnostic evaluation. Relevant literature and current guidelines are being briefly reviewed to summarize screening for pheochromocytoma and appropriate diagnostic procedures.

RESULTS

While the classic symptoms include headache, palpitations and sweating with permanent or paroxysmal hypertension, a wide range of clinical manifestations may be attributed to pheochromocytoma. The initial screening test is measurement of plasma or 24-hour urine metanephrine levels. Abdominal computerized tomography with intravenous contrast infusion is suggested as the imaging examination of choice, whereas magnetic resonance imaging should be preferred over CT in exceptional cases. 123I-metaiodobenzylguanidine scintigraphy is particularly useful for establishing the diagnosis of pheochromocytoma and should be further applied to detect or exclude possible metastatic lesions.

CONCLUSION

Early diagnosis of pheochromocytoma is of great significance not only because it represents a curable form of secondary hypertension, but also because it is often related to familial syndromes, malignancy or metastatic disease. Physicians need to be familiar with relevant clinical manifestations and diagnostic steps to raise clinical suspiction of pheochromocytoma and establish a timely diagnosis.

Role of imaging test with radionuclides in the diagnosis and treatment of pheochromocytomas and paragangliomas

Radionuclide imaging tests with [¹²³I] Metaiodobenzylguanidine (MIBG), [¹⁸F] -fluorodeoxyglucose, [¹⁸F]-fluorodopa, or ⁶⁸Ga-DOTA(0)-Tyr(3)-octreotate are useful for the diagnosis, staging and follow-up of pheochromocytomas (PHEOs) and paragangliomas (PGLs) (PPGLs). In addition to their ability to detect and localize the disease, they allow a better molecular characterization of the tumours, which is useful for planning targeted therapy with iodine-131 (¹³¹I) -labelled MIBG or with peptide receptor radionuclide therapy (PRRT) with [¹⁷⁷Lu]-labelled DOTATATE or other related agents in patients with metastatic disease. In this review we detail the main characteristics of the radiopharmaceuticals used in the functional study of PPGLs and the role of nuclear medicine tests for initial evaluation, staging, selection of patients for targeted molecular therapy, and radiation therapy planning. It also offers a series of practical recommendations regarding the functional imaging according to the different clinical and genetic scenarios in which PPGLs occur, and on the indications and efficacy of therapy with [¹³¹I]-MIBG and ¹⁷⁷Lu-DOTATATE.

Pheochromocytoma manifestation associated withacute infectious disease

Pheochromocytoma (PHEO) manifestation can be triggered by many different factors, including infectious diseases. In 2019, measles continued to spread in global outbreaks around the world. According to WHO data, more than 60 % of all measles cases in European Region were reported in Ukraine, a leader in measles occurrence. Measles is a dangerous viral disease, which remains an overwhelmingly important problem for healthcare system. Measles cause various life-threatening complications, which not only affect patients’ health and decrease quality of their lives, but can also lead to onset of many other medical conditions. Authors provide an example from their own clinical experience, which they have observed during the measles outbreak. PatientD., 22y.o., female, was admitted to Lviv Infectious Diseases Communal Clinical Hospital because of measles. Condition was followed by severe intoxication, fever, hacking cough, skin rash all over the body. On 4th day after the appearance of rash patient developed atypical hypertensive crisis: in supine position started severe tachycardia, thumping headache, tremor of proximities and whole body, arterial blood pressure increased to 180/110 mm Hg; after changing the sitting position, symptoms started slowly decrease, in this regard patient had to spend a few days crouched in bed, she also complained about exaltation, insomnia, psychic tension, asthenia. Patient has undergone surgical treatment— laparoscopic left adrenalectomy. Perform differential diagnostics of hypertension accurately, paying special attention to determining its’ reason. Take into consideration, that PHEO manifestation and hypertonic PHEO crises can be provoked by multiple reasons. If PHEO is suspected, hormonal, visualization and morphological examination methods should be performed. Keep in mind, that PHEO can be a constituent part of number of hereditary diseases: MEN 2A, MEN 2B, Von Recklinghausen’s Disease (Neurofibromatosis 1), Von Hippel-Lindau syndrome and can be possibly malignant.

Multimodality imaging appearance of intrapericardial paragangliomas

Paragangliomas are neuroendocrine tumours of the sympathetic and parasympathetic nervous systems originating from neural crest cells. Less than 1% of paragangliomas in the heart originate from intrinsic cardiac ganglia cells in the posterior wall of the atria, atrioventricular groove, and along the root of the great vessels. We describe the tumour characteristics, patient demographics, presentation, means of diagnosis, pathology correlation, management, and outcome in 11 patients with intrapericardial paragangliomas. To the authors' knowledge, this is the largest case series reported, with emphasis on multimodality imaging findings.

Neuroendocrine Carcinoma of the Uterine Cervix With Metastases to the Thyroid Gland: A Case Report and Clinical Pathological Review

Thyroid metastasis from a neuroendocrine carcinoma (NEC) is atypical, and the most common site of origin is the lung. We present the case of a 48-year-old lady with a history of NEC in the uterine cervix, classified initially as a p16-positive high-grade endocervical adenocarcinoma with endometrioid differentiation in a cervical biopsy. The patient, after having a thyroid ultrasound due to thyroid nodules, showing a multinodular goiter and suspicious nodules, and a subsequent fine-needle aspiration with a diagnosis of papillary thyroid carcinoma, presented to our hospital for a total thyroidectomy. Histologically, there were metastatic high-grade carcinoma foci within the thyroid, consistent with metastasis from the cervical primary tumor based on the morphology and immunohistochemical stains, the tumor was re-classified as an NEC. The thyroid gland is an uncommon site for metastasis from primary sites, and a very rare site for an NEC origin; besides, this tumor type is infrequent in the uterine cervix and bears an unfavorable prognosis when present. Therefore, when encountering a high-grade metastatic tumor within the thyroid, an NEC has to be considered in the differential diagnosis for a prompt diagnosis and an appropriate treatment.

Minimally invasive management for multifocal pelvic retroperitoneal malignant paraganglioma: a neuropelveological approach

Background

Pheochromocytoma and Paraganglioma (PGL) are rare neuroendocrine tumors, with an estimated incidence of about 0.6 cases per 100.000 person/year. Overall, 3–8% of them are malignant. These tumors are characterized by a classic triad of symptoms (headaches, palpitations, profuse sweating) due to hypersecretion of catecholamines. Despite several advantages of minimally invasive surgery (MIS) for PGL debulking, the surgical approach is not standardized yet. In this scenario, we aimed to report a case of a multiple recurrent PGL with metastatic retroperitoneal localization involving the pelvic sidewall, excised with MIS.

Case presentation

We performed complete laparoscopic-assisted neuronavigation (LANN technique) with isolation of the sacral routes and the sciatic nerve to obtain complete exposure of the main anatomic landmarks. Robotic surgery was used to perform neurolysis of sacral plexus, and partial resection of left splanchnic nerves was needed. After the resection of the first mass, extensive neurolysis of all sacral routes, obturator nerve, pudendal nerve till the entrance of the pudendal (Alcock) canal, and sciatic nerve was performed. Finally, the mass was identified after trans gluteal incision and dissection of the maximum gluteal muscle, and a partial resection of the superior gluteal nerve and slicing of the sciatic nerve were needed to obtain a radical excision of the mass. Then neurorrhaphy of the sectioned nerve fibers of the superior gluteal nerve was performed, and nerve protection was obtained using a collagen nerve wrap. After 18 months of follow-up, the patient is free of disease at the MRI imaging and 123I-metaiodobenzylguanidine scintigraphy.

Conclusions

Minimally invasive gynecological surgery with neuropelveological approach could be considered as a feasible option in case of multifocal pelvic retroperitoneal malignant paraganglioma of the pelvic side wall.

Incidental T1 stage medullary thyroid carcinoma: The effect of tumour diameter on prognosis and therapeutic implications

OBJECTIVE

The definition of the tumour diameter of micro-medullary thyroid carcinoma (micro-MTC) is insufficient. It is controversial to perform a completion thyroidectomy immediately for incidental T1 stage MTC.

DESIGN

We used the Surveillance, Epidemiology and End Results (SEER) registry to retrospectively analyze all patients with T1 stage MTC diagnosed between 2004 and 2015. The tumour diameter 1.0 and 0.5 cm were used as the cut-off points to group and analyze the differences of clinicopathological features. We analyzed the prognosis of patients with less than total thyroidectomy.

METHODS

The disease-specific survival was the main outcome. Survival was estimated with Kaplan-Meier curves and Cox regression models estimated hazard ratios for tumour characteristics.

RESULTS

A total of 908 patients diagnosed with T1 stage MTC in the SEER database were included. Our study found that tumour diameter 1.0 cm is a key point affecting the prognosis of T1 stage MTC patients, although patients with tumour diameter ≤ 0.5 cm had a lower rate of lymph node metastasis and no distant metastasis. Cox proportional hazard multivariate analysis showed that distant metastasis was the only risk factor for survival in patients with T1 stage MTC. Kaplan-Meier survival analysis showed that, regardless of tumour diameter, there was no significant difference between less than total thyroidectomy and total thyroidectomy in T1 stage patients.

CONCLUSIONS

For incidental MTC with tumour diameter ≤ 1.0 cm and without distant metastasis, if there is no significant increase in serum calcitonin level after surgery and ret proto-oncogene (RET) gene mutation is negative, it may be not necessary to perform completion thyroidectomy immediately.

LIBRETTO-531: a phase III study of selpercatinib in multikinase inhibitor-naïve RET-mutant medullary thyroid cancer

Selpercatinib is a first-in-class, highly selective and potent, central nervous system-active RET kinase inhibitor. In the phase I/II trial, selpercatinib demonstrated clinically meaningful antitumor activity with manageable toxicity in heavily pre-treated and treatment-naive patients with RET-mutant medullary thyroid cancer (MTC). LIBRETTO-531 (NCT04211337) is a multicenter, open-label, randomized, controlled, phase III trial comparing selpercatinib to cabozantinib or vandetanib in patients with advanced/metastatic RET-mutant MTC. The primary objective is to compare progression-free survival (per RECIST 1.1) by blinded independent central review of patients with progressive, advanced, multikinase inhibitor-naive, RET-mutant MTC treated with selpercatinib versus cabozantinib or vandetanib. Key secondary objectives are to compare other efficacy outcomes (per RECIST 1.1) and tolerability of selpercatinib versus cabozantinib or vandetanib.

Circulating Biomarkers in Thyroid Cancer

Thyroid cancer is the most important endocrine cancer with increasing incidence. While thyroid cancers, especially papillary thyroid cancers, are known to exhibit generally a favorable outcome with excellent survival rates, some thyroid cancers are more aggressive with a poor prognosis. Several different biomarkers have been introduced for the diagnosis of disease, identification of tumor load, assessment of therapy response, and the detection of recurrence during follow-up of the thyroid cancer patients. This chapter gives a brief overview of the circulating biomarkers used in thyroid cancer patients.

Case report: Significant liver atrophy due to giant cystic pheochromocytoma

INTRODUCTION

Pheochromocytoma is a neuroendocrine tumor originating from chromaffin cells in the adrenal medulla. Giant pheochromocytomas with a maximum diameter of over 20 cm are particularly rare.

CASE PRESENTATION

We present a case of giant cystic pheochromocytoma in a 64-year-old woman who was found to have a right abdominal mass during an ultrasound examination, which is the largest pheochromocytoma ever documented in China. Meanwhile, obvious atrophy of the right lobe of the liver was found in preoperative CT and during the operation. Our literature review identified 20 cases with a diameter of over 20 cm. The average age at diagnosis was 51.7 (range 17-85), and 35% of cases did not exhibit classic symptoms.

CONCLUSION

Giant pheochromocytoma is an uncommon neoplasm. It can be discovered late due to a lack of clinical manifestations. Diagnosis is dependent on imaging recognition together with catecholamine secretion. Surgical resection is the only curative treatment for such tumors.

Pheochromocytoma manifesting as cortical blindness secondary to PRES with associated TMA: a case report and literature review

BACKGROUND

Pheochromocytomas are neoplasms originating from neuroectodermal chromaffin cells leading to excess catecholamine production. They are notorious for causing a triad of headaches, palpitations, and sweats. Though the Menard triad is one to be vigilant of, symptomatic presentation can vary immensely, hence the tumor earning the label "the great masquerader."

CASE PRESENTATION

We report a case of pheochromocytoma initially presenting with cortical blindness secondary to posterior reversible encephalopathy syndrome and thrombotic microangiopathy from malignant hypertension. Our patient was seen in our facility less than a week prior to this manifestation and discharged after an unremarkable coronary ischemia work-up. In the outpatient setting, she had been prescribed multiple anti-hypertensives with remarkably elevated blood pressure throughout her hospitalization history.

CONCLUSION

Pheochromocytoma presenting with malignant hypertension and hypertensive encephalopathy should be expected if left untreated; nonetheless, the precipitation of cortical blindness is rare in the literature. This case contributes an additional vignette to the growing literature revolving adrenal tumors and their symptomatic presentation along with complex management. It also serves to promote increased diagnostic suspicion among clinicians upon evaluating patients with refractory hypertension.

Clinical practice guidelines for management of medullary thyroid carcinoma: An AGREE II appraisal

PURPOSE

Medullary thyroid carcinoma (MTC) is a rare and aggressive form of thyroid neoplasia that requires multidisciplinary collaboration for effective management. We systematically appraise the quality of clinical practice guidelines (CPG) for the diagnosis and treatment of MTC using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

MATERIALS AND METHODS

A systematic literature search was performed to identify CPGs pertaining to the diagnosis and treatment of MTC. Data were abstracted from guidelines meeting inclusion criteria and appraised by four independent reviewers in the six domains of quality defined by the AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to qualify interrater reliability.

RESULTS

Fourteen guidelines met inclusion criteria. No guideline achieved a score of >60 % in five or more AGREE II quality domains, which is required to gain designation as 'high' quality. One "average quality" guideline authored by the British Thyroid Association achieved a score of >60 % in three quality domains. The remaining thirteen (92.9 %) CPGs demonstrated low quality content, with deficits most pronounced in domains 3, 5, and 6, suggesting a lack of rigorously developed, clinically applicable, and transparent information.

CONCLUSIONS

As the diagnosis and treatment of MTC continues to evolve, the development of high-quality guidelines becomes increasingly important; few existing meet appropriate standards.

Co-occurrence of VHL and SDHA Pathogenic Variants: A Case Report

Von Hippel Lindau(VHL)syndrome presents with cerebellar and spinal hemangioblastomas, renal cell cancer, neuroendocrine pancreatic tumor, and pheochromocytoma and it is caused by germline mutations in the VHL gene. Pathogenic germline variants in the succinate dehydrogenase A (SDHA) gene are associated with paraganglioma and pheochromocytoma. Here we report co-occurrence of germline pathogenic variants in both VHL and SDHA genes in a patient who presented with pancreatic neuroendocrine tumor. As these genes converge on the pseudo-hypoxia signaling pathway, further studies are warranted to determine the significance of co-occurrence of these variants in relation to tumor penetrance, disease severity, treatment response and clinical outcomes in this selected group of patients.

The Mount Sinai Clinical Pathway for the Diagnosis and Management of Hypercortisolism due to Ectopic ACTH Syndrome

Neoplasms that secrete ectopic adrenocorticotropin (ACTH) may cause severe, life-threatening hypercortisolism. These tumors are often difficult to localize and treat, requiring a comprehensive and systematic management plan orchestrated by a multidisciplinary team. The Mount Sinai Adrenal Center hosted an interdisciplinary retreat of experts in adrenal disorders and neuroendocrine tumors (NETs) with the aim of developing a clinical pathway for the management of Cushing syndrome due to ectopic ACTH production. The result was institutional recommendations for the diagnosis, localization, surgical approaches to intrathoracic tumors and bilateral adrenalectomy, and perioperative and postoperative medical management of hypercortisolism and its sequelae. Specific recommendations were made regarding the timing and selection of therapies based on the considerations of our team as well as a review of the current literature. Our clinical pathway can be applied by other institutions directly or serve as a guide for institution-specific management.

Medullary thyroid carcinoma: a narrative historical review

INTRODUCTION

Sporadic or hereditary medullary thyroid carcinoma (MTC) is an uncommon thyroid malignancy arising from calcitonin secreting parafollicular C cells. Interestingly, MTC and calcitonin were distinct entities that were discovered independently yet concurrently, and their association was unknown.

AREAS COVERED

This review aims to present a historical review of the evolution of our understanding of MTC and its tumor marker calcitonin to highlight the prominent individuals that influenced and shaped our knowledge of this uncommon thyroid cancer type up to the dawn of the 21^st century. An overview of all published reports of novel research and work summarizing important findings for MTC and calcitonin was carried out.

EXPERT OPINION

Surgery remains the cornerstone of treatment for localized MTC. However, several new treatment options are either available or in development for advanced or metastatic MTC, including several novel small molecules targeting oncogenic RET and peptide receptor radionuclide therapy, immunotherapy, radioimmunotherapy, and radiofrequency ablation. In the near future, these novel treatments hold promise for therapy of this very distinct thyroid cancer type.

Clinical Predictors of Pseudohypoxia-Type Pheochromocytomas

INTRODUCTION

Pheochromocytomas (PCCs) are rare tumors of neural crest origin with divergent transcriptional and metabolic profiles associated with mutational cluster types. Pseudohypoxia-type (PHT) PCCs have a poor prognosis; however diagnostic genetic testing is not always available. We aimed to investigate clinical parameters predictive of PHT PCCs.

METHODS

Patients who underwent resection and genetic testing for PCC at two academic centers from 2006-2020 were retrospectively studied. Patients with PHT mutations (SDH-AF2/B/C/D, VHL) were compared to non-pseudohypoxia-type (nonPHT) PCCs to identify widely available clinical parameters predictive of PHT PCCs. Demographic, clinical, and pathologic characteristics were compared using student's T and ANOVA tests. Operative hemodynamic instability was defined as systolic blood pressure (SBP) >  200 mmHg, SBP increase of >  30% relative to baseline, and/or heart rate (HR) > 110 bpm. Mann-Whitney U test was used to assess area under the curve (AUC), sensitivity, and specificity. Recursive partitioning was used to model predictive thresholds for PHT PCC and develop a predictive score.

RESULTS

Of the 79 patients included in the cohort, 17 (22%) had PHT and 62 (78%) had nonPHT PCCs. PCC patients with >  2 of the examined predictive clinical parameters (preoperative weight loss [> 10% body weight], elevated preoperative hematocrit [>  50%], normal baseline heart rate [< 100 bpm], and normal plasma metanephrines [< 0.60 nmol/L]) were more likely to have PHT PCCs (AUC = 0.831, sensitivity = 0.882, specificity = 0.694, all p < 0.001).

CONCLUSIONS

Widely available preoperative clinical parameters including indicators of erythropoiesis (hemoglobin, hematocrit, and red blood cell count), baseline heart rate, plasma metanephrines, and weight loss may be useful predictors of PHT PCCs and may help guide management of PCCs when genetic testing is unavailable/delayed.

A Nomogram to Accurately Identify Pancreatic Neuroendocrine Tumors Metastasizing to Distant Organs: A Study Based on Two National Population-Based Cohorts From the United States and China

Background:

Distant organ metastasis is the leading cause of death in pancreatic neuroendocrine tumor (pNET) patients. In the present study, we aimed to develop and validate a nomogram that could accurately identify pNET metastasizing to distant organs.

Methods:

The cases extracted from the Surveillance, Epidemiology, and End Results (SEER) program were assigned to the training cohort and validation cohort. The cases from the Chinese Gastrointestinal Neuroendocrine Tumors program were assigned to the external validation cohort. The strategy was developed with the support of a nomogram, and the predictive value of this strategy was evaluated by the receiver operating characteristic (ROC) curve analysis.

Results:

In total, 2024 American cases were involved in the present study. Besides, 1450 and 574 patients were allocated into training and internal validation cohorts, respectively. In addition, 122 Chinese patients were assigned to the external validation cohort. The results of the univariate logistic regression analysis suggested that tumor grade, tumor size, and the number of metastatic lymph nodes were the risk of metastasis to distant organs, and these 3 clinicopathological characteristics were used to develop the nomogram. We observed that the accuracy of the nomogram for predicting metastasis to distant organs was 0.797, 0.819, and 0.837 in the training cohort, internal validation cohort, and external validation cohort, respectively.

Conclusions:

A predictive nomogram was developed and validated, and it showed an acceptable performance in predicting metastasis to distant organs. The results will enable clinicians to identify pNETs, metastasizing to distant organs, and develop an effective individualized therapeutic strategy for these patients.

Wide Variability in Catecholamine Levels From Adrenal Venous Sampling in Primary Aldosteronism

INTRODUCTION

While adrenal venous sampling (AVS) differentiates between the unilateral and bilateral disease in patients with primary aldosteronism (PA), it is unknown if AVS can determine laterality of pheochromocytoma in patients with bilateral adrenal masses. This study analyzes adrenal vein (AV) epinephrine and norepinephrine levels in nonpheochromocytoma patients to determine the "normal" range.

MATERIALS AND METHODS

We reviewed patients who underwent AVS for PA between 2009 and 2019 at a single institution; pheochromocytoma was excluded. Aldosterone, cortisol, epinephrine, and norepinephrine levels were obtained from the inferior vena cava (IVC), left adrenal vein (LAV), and right adrenal vein (RAV). Successful AV cannulation was defined by an AV/IVC cortisol ratio of ≥3:1 or an AV epinephrine level ≥364 pg/mL. Plasma measurements (pg/mL) are median values with interquartile ranges; normal ranges for epinephrine and norepinephrine are 10-200 pg/mL and 80-520 pg/mL, respectively.

RESULTS

AVS was performed in 172 patients in 405 AVs (173 LAV and 232 RAV). Median epinephrine levels were IVC = 19 (14 and 34), LAV = 3811 (1870 and 6915), and RAV = 2897 (1500 and 5288). Median norepinephrine levels were IVC = 325 (186 and 479), LAV = 1450 (896 and 2050), and RAV = 786 (436 and 1582). There was a difference between LAV and RAV epinephrine levels (P = 0.024) and between LAV and RAV norepinephrine (P = 0.002) levels.

CONCLUSIONS

This extensive experience with AVS demonstrated a wide range of "normal" AV catecholamine levels in patients without pheochromocytoma, which suggests that the utility of AVS to determine disease laterality in patients with pheochromocytoma and bilateral adrenal nodules is likely to be limited.

Exceptional association of Budd-Chiari syndrome with pheochromocytoma

We are reporting a case revealed by an abdomino-thoracic painful syndrome associated with multi-organ failure. A 61-year-old hypertensive woman was hospitalized for the management of hypertensive emergency associating acute coronary syndrome and abdominal pain. A thoraco-abdomino-pelvic CT-scan showed a right adrenal mass associated with hepatic vein thrombosis. After medical preparation, an adrenalectomy was performed by way of open surgery; the study of the surgical specimen found a pheochromocytoma score PASS 4. The follow-up was marked by the normalization of blood pressure and biological abnormalities.

Bladder paragangliomas: a pictorial review

Bladder paragangliomas (bPGL) are rare neuroendocrine tumors arising from the sympathetic paraganglia present in the bladder wall. Bladder PGLs are typically submucosal or intramural but when subserosal may not be readily visible at cystoscopy. The average size at presentation is 3.9 cm (range 1.0-9.1 cm). When small, bPGL are usually spherical, well-marginated and homogeneous. Larger bPGL are typically more complex with peri- and intra-tumoral neovascularity and central necrosis. On ultrasound, increased color Doppler signal is typical. The increased soft tissue resolution of MRI enables localization of bPGL within the bladder wall more accurately than CT. Restricted diffusion and avid contrast enhancement help differentiate small bPGLs from leiomyomas, which have similar appearances on ultrasound and CT. Nuclear medicine techniques identify bPGLs and their metastases with high specificity, ⁶⁸Ga-DOTATATE PET/CT having largely replaced ¹²³I-mIBG SPECT/CT as the first line functional investigation. Imaging is essential to aid surgical planning, as endoscopic resection is often not possible or incomplete due to tumor location. For patients with advanced disease, ⁶⁸Ga-DOTATATE PET/CT and ¹²³I-mIBG SPECT/CT assess suitability for peptide receptor radionuclide therapy. Up to 63% of bPGL patients have a germline mutation, most commonly in the SDHB subunit gene, increasing their risk of developing pheochromocytomas and further paragangliomas; lifelong annual biochemical and periodic imaging screening from skull base to pelvis is therefore recommended.

Controversies about the systematic preoperative pharmacological treatment before pheochromocytoma or paraganglioma surgery

The question of systematic use of a pharmacological treatment before surgery in patients diagnosed with pheochromocytoma and paraganglioma (PPGL) remains highly controversial. While recent guidelines suggest that this should be used in all patients, some experienced teams consider it unnecessary in some cases, provided the surgery is performed in a dedicated center that has expert endocrinologists, cardiologists, surgeons, and anesthetists. This controversy is aimed at shedding light on the potential benefits and risks of such a treatment, focusing specifically on alpha blockers which are considered as the first-line medical treatments in patients with PPGL. After discussing the rationale for alpha blockers, hemodynamic instability, tolerance, and acute cardiac complications will then be discussed in the first part of the manuscript, defending a systematic use. The second section will focus on blood pressure control, tolerance of alpha blockers, and also the management of normotensive PPGL, examining the daily risks of PPGL and arguing against the systematic use of a preoperative pharmacological treatment before surgery. Finally, we will discuss the concept of expert centers and define the patients in whom the risk/benefit profile would favor the use of this preoperative treatment.

An automated magnetic bead extraction method for measuring plasma metanephrines and 3-methoxytyramine using liquid chromatography tandem mass spectrometry

Liquid chromatography tandem mass spectrometry (LC-MS/MS) is used routinely in clinical diagnostics; however, automating the sample pretreatment is challenging. We established and evaluated an automated method based on the magnetic bead extraction principle (MBE) to measure normetanephrine (NMN), metanephrine (MN), and 3-methoxytyramine (3-MT). The target analytes were extracted, purified, and concentrated using different solvents and chemical bond-modified magnetic beads transferred via a magnetic bar. The linearity, recovery, matrix effect, and precision of MBE were evaluated thoroughly, and compared with traditional solid-phase extraction (SPE) using 131 plasma samples. The chromatography peaks of metanephrines and 3-MT, extracted via MBE, are symmetrical, without interfering peaks. The linearity was excellent with correlation coefficient (r) > 0.99. The MBE exhibited good reproducibility with within-run coefficient variations (CVs) of 1.96-2.00%, 4.06-5.75%, and 3.89-4.90% for MN, NMN, and 3-MT, respectively. The total CVs for MN, NMN, and 3-MT were 1.96-2.80%, 5.12-5.75%, and 5.44-6.27%, respectively. The relative recoveries for MN, NMN, and 3-MT varied between 93.5 and 107.4%, whereas their biases were all within 10%. The results for MN, NMN, and 3-MT extracted via MBE compared with SPE exhibited excellent correlation, with r > 0.99; the mean bias% for MN, NMN, and 3-MT were small (-2.9%, -3.2%, and -3.2%, respectively). In conclusion, the automated MBE method for measuring plasma metanephrines and 3-MT can be applied in future routine clinical diagnostics, and the MBE principle may indicate a new era for LC-MS/MS in clinical application.

Paraganglioma in pregnancy: A case series and literature review

Paragangliomas are rare neuroendocrine neoplasms which are often catecholamine-secreting and associated with familial syndromes. Described here are three women with a variety of pathology: isolated secretory paraganglioma diagnosed in pregnancy, secretory metastatic paraganglioma in pregnancy and non-secretory metastatic paraganglioma in pregnancy. Whilst paragangliomas are associated with morbidity and mortality during pregnancy, good maternal and fetal outcomes can be achieved through individualised care within the context of a multidisciplinary team. Although paragangliomas are associated with morbidity and mortality in pregnancy, good maternal and fetal outcomes can be achieved through individualised care within the context of a multidisciplinary team.

A Predictive Nomogram for Early Death in Pheochromocytoma and Paraganglioma

Background

Pheochromocytoma (PHEO) and paraganglioma (PGL) are relatively rare neuroendocrine tumors. The factors affecting patients with early death remain poorly defined. We aimed to study the demographic and clinicopathologic pattern and to develop and validate a prediction model for PHEO/PGL patients with early death.

Methods

Data of 800 participants were collected from the Surveillance Epidemiology and End Results (SEER) database as a construction cohort, while data of 340 participants were selected as a validation cohort. Risk factors considered included the year of diagnosis, age at diagnosis, gender, marital status, race, insurance status, tumor type, primary location, laterality, the presence of distant metastasis. Univariate and multivariate logistic regressions were performed to determine the risk factors. R software was used to generate the nomogram. Calibration ability, discrimination ability, and decision curve analysis were analyzed in both construction and validation cohorts.

Results

PHEO and PGL patients accounted for 54.3% (N=434) and 45.7% (N=366), respectively. More than half of tumors (N=401, 50.1%) occurred in the adrenal gland, while 16.9% (N=135) were in aortic/carotid bodies. For the entire cohort, the median overall survival (OS) was 116.0 (95% CI: 101.5-130.5) months. The multivariate analysis revealed that older age (versus age younger than 31; age between 31 and 60: OR=2.03, 95% CI: 1.03-4.03, P=0.042; age older than 60: OR=5.46, 95% CI: 2.68-11.12, P&lt;0.001), female gender (versus male gender; OR=0.59, 95% CI: 0.41-0.87, P=0.007), tumor located in aortic/carotid bodies (versus tumor located in adrenal gland; OR=0.49, 95% CI: 0.27-0.87, P=0.015) and the presence of distant metastasis (versus without distant metastasis; OR=4.80, 95% CI: 3.18-7.23, P&lt;0.001) were independent risk factors of early death. The predictive nomogram included variables: age at diagnosis, gender, primary tumor location, and distant metastasis. The model had satisfactory discrimination and calibration performance: Harrell’s C statistics of the prediction model were 0.733 in the construction cohort and 0.716 in the validation cohort. The calibration analysis showed acceptable coherence between predicted probabilities and observed probabilities.

Conclusions

We developed and validated a predictive nomogram utilizing data from the SEER database with satisfactory discrimination and calibration capability which can be used for early death prediction for PHEO/PGL patients.

Medullary thyroid carcinoma in children: current state of the art and future perspectives

Medullary thyroid carcinoma (MTC) is a distinct type of malignant thyroid tumor in cell origin, biological behavior, and natural history. It accounts for 1.6% of all thyroid cancers and presents either sporadically or as a hereditary disease, the latter occurring as a part of multiple endocrine neoplasia (MEN) 2A and MEN2B syndromes or as a familial MTC disease with no other manifestations. The gene responsible for the hereditary form is the rearranged during transfection (RET) gene, a proto-oncogene located to human chromosome 10. Most pediatric MTC cases have been discovered after genetic testing investigations, leading to the concept of prophylactic surgery in presymptomatic patients. Therefore, the genetic status of the child, along with serum calcitonin levels and ultrasonographic findings, determine the appropriate age for prophylactic surgical intervention. Nevertheless, a diagnosis at an early stage of MTC warrants total thyroidectomy and central lymph node dissection with the addition of lateral/contralateral lymph node dissection depending on the tumor size, ultrasonographic evidence of neck disease, or calcitonin levels. Conversely, locally advanced/unresectable or metastatic MTC is primarily treated with multikinase inhibitors, while more specific RET inhibitors are being tested in clinical trials with promising results.

New Insights on the Genetics of Pheochromocytoma and Paraganglioma and Its Clinical Implications

Simple Summary

Pheochromocytoma and paraganglioma (together PPGL) are rare neuroendocrine tumors that arise from chromaffin tissue and produce catecholamines. Approximately 40% of cases of PPGL carry a germline mutation, suggesting that they have a high degree of heritability. The underlying mutation influences the PPGL clinical presentation such as cell differentiation, specific catecholamine production, tumor location, malignant potential and genetic anticipation, which helps to better understand the clinical course and tailor treatment accordingly. Genetic testing for pheochromocytoma and paraganglioma allows an early detection of hereditary syndromes and facilitates a close follow-up of high-risk patients. In this review article, we present the most recent advances in the field of genetics and we discuss the latest guidelines on the surveillance of asymptomatic SDHx mutation carriers.

Abstract

Pheochromocytomas (PHEOs) and paragangliomas (PGLs) are rare neuroendocrine tumors that arise from chromaffin cells. PHEOs arise from the adrenal medulla, whereas PGLs arise from the neural crest localized outside the adrenal gland. Approximately 40% of all cases of PPGLs (pheochromocytomas/paragangliomas) are associated with germline mutations and 30–40% display somatic driver mutations. The mutations associated with PPGLs can be classified into three groups. The pseudohypoxic group or cluster I includes the following genes: SDHA, SDHB, SDHC, SDHD, SDHAF2, FH, VHL, IDH1/2, MHD2, EGLN1/2 and HIF2/EPAS; the kinase group or cluster II includes RET, NF1, TMEM127, MAX and HRAS; and the Wnt signaling group or cluster III includes CSDE1 and MAML3. Underlying mutations can help understand the clinical presentation, overall prognosis and surveillance follow-up. Here we are discussing the new genetic insights of PPGLs.

Imaging features of retroperitoneal extra-adrenal paragangliomas in 10 dogs

Retroperitoneal paragangliomas are rare tumors of the neuroendocrine system. Only a few canine case reports are available with rare descriptions of their imaging features. The objectives of this multi‐center, retrospective case series study were to describe the diagnostic imaging features of confirmed retroperitoneal paragangliomas and specify their location. Medical records and imaging studies of 10 affected dogs with cytological or histopathologic results concordant with retroperitoneal paragangliomas were evaluated. Dogs had a median age of 9 years. Four of them had clinical signs and laboratory reports compatible with excessive production of catecholamines. Six ultrasound, four CT, four radiographic, and one MRI studies were included. The paragangliomas did not have a specific location along the aorta. They were of various sizes (median 33 mm, range: 9–85 mm of length). Masses had heterogeneous parenchyma in six of 10 dogs, regardless of the imaging modality. Strong contrast enhancement was found in all CT studies. Encircling of at least one vessel was detected in six of 10 masses, clear invasion of a vessel was identified in one of 10 masses. In five of 10 cases, the masses were initially misconstrued as lymph nodes by the on‐site radiologist. Retroperitoneal paragangliomas appear along the abdominal aorta, often presenting heterogeneous parenchyma, possibly affecting the local vasculature, and displaying strong contrast enhancement on CT. Clinical signs can be secondary to mass effects or excessive catecholamine production. Underdiagnosis and misdiagnosis of this tumor are suspected as they can be silent, of small size, or confused with other structures.