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Baechle JJ, Smith PM, Ortega CA, Wang TS, Solórzano CC, Kiernan CM. Clinical Predictors of Pseudohypoxia-Type Pheochromocytomas. Ann Surg Oncol 2022; 29:3536-3546. [PMID: 35233740 DOI: 10.1245/s10434-022-11419-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 01/16/2022] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- J J Baechle
- School of Medicine, Meharry Medical College, Nashville, TN, USA
| | - P Marincola Smith
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C A Ortega
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - T S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - C C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C M Kiernan
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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2
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Uslar T, San Francisco IF, Olmos R, Macchiavelo S, Zuñiga A, Rojas P, Garrido M, Huete A, Mendez GP, Cortinez I, Zemelman JT, Cifuentes J, Castro F, Olivari D, Domínguez JM, Arteaga E, Fardella CE, Valdés G, Tagle R, Baudrand R. Clinical Presentation and Perioperative Management of Pheochromocytomas and Paragangliomas: A 4-Decade Experience. J Endocr Soc 2021; 5:bvab073. [PMID: 34377881 PMCID: PMC8336720 DOI: 10.1210/jendso/bvab073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose Latin American reports on pheochromocytomas and paragangliomas (PPGLs) are scarce. Recent studies demonstrate changes in clinical presentation and management of these patients. Herein, we assessed the main characteristics of PPGL patients in our academic center over the past 4 decades. Methods Demographic, clinical, biochemical, and perioperative data from 105 PPGL patients were retrospectively and prospectively collected over the 1980–2019 period. Data were organized into 4 periods by decade. Results Age at diagnosis, gender, tumor size and percentage of bilaterality, percentage of paragangliomas, and metastases remained stable across the 4 decades. The proportion of genetic testing and incidentalomas increased in recent decades (all P < 0.001). Therefore, we compared PPGLs diagnosed as incidentalomas (36%) with those clinically suspected (64%). Incidentalomas had fewer adrenergic symptoms (38 vs. 62%; P < 0.001) and lower rates of hypertension (64% vs. 80%; P = 0.01) and hypertensive crisis (28% vs. 44%; P = 0.02); also, they had lower functionality (79% vs. 100%; P = 0.01) and lower catecholamines levels (8.4-fold vs. 12.5-fold above upper cutoffs; P = 0.04). Regarding management of all PPGLs over the decades, we observed significant increases in both perioperative doxazosin dose (P = 0.003) and laparoscopic approach rates (P < 0.001), along with a decrease in the length of hospital stays (P = 0.007). Conclusions We observed a change in the clinical presentation of PPGL in recent decades, with a marked increase in incidental cases and milder symptoms. The implementation of a multidisciplinary program for adrenal disorders in our institution has translated into more timely diagnoses, more genetic testing, and improvements in perioperative management.
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Affiliation(s)
- Thomas Uslar
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Programa de Trastornos Suprarrenales, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Centro Traslacional en Endocrinología (CETREN-UC), Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Ignacio F San Francisco
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Urología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Roberto Olmos
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Programa de Trastornos Suprarrenales, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Centro Traslacional en Endocrinología (CETREN-UC), Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Stefano Macchiavelo
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Alvaro Zuñiga
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Programa de Trastornos Suprarrenales, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Urología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Pablo Rojas
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Urología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Marcelo Garrido
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Hemato-Oncología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Alvaro Huete
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Programa de Trastornos Suprarrenales, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Radiología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Gonzalo P Mendez
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Programa de Trastornos Suprarrenales, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Anatomía Patológica, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Ignacio Cortinez
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Programa de Trastornos Suprarrenales, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Anestesiología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - José Tomás Zemelman
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Joaquín Cifuentes
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Fernando Castro
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Daniela Olivari
- Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - José Miguel Domínguez
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Centro Traslacional en Endocrinología (CETREN-UC), Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Eugenio Arteaga
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Centro Traslacional en Endocrinología (CETREN-UC), Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Carlos E Fardella
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Centro Traslacional en Endocrinología (CETREN-UC), Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Gloria Valdés
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Nefrología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Rodrigo Tagle
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Departamento de Nefrología, Diagonal Paraguay 362, 8330077, Santiago, Chile
| | - Rene Baudrand
- Departamento de Endocrinología, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Facultad de Medicina, Pontificia Universidad Católica de Chile, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Programa de Trastornos Suprarrenales, Diagonal Paraguay 362, 8330077, Santiago, Chile.,Centro Traslacional en Endocrinología (CETREN-UC), Diagonal Paraguay 362, 8330077, Santiago, Chile
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Majewska A, Budny B, Ziemnicka K, Ruchała M, Wierzbicka M. Head and Neck Paragangliomas-A Genetic Overview. Int J Mol Sci 2020; 21:ijms21207669. [PMID: 33081307 PMCID: PMC7589036 DOI: 10.3390/ijms21207669] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
Pheochromocytomas (PCC) and paragangliomas (PGL) are rare neuroendocrine tumors. Head and neck paragangliomas (HNPGL) can be categorized into carotid body tumors, which are the most common, as well as jugular, tympanic, and vagal paraganglioma. A review of the current literature was conducted to consolidate knowledge concerning PGL mutations, familial occurrence, and the practical application of this information. Available scientific databases were searched using the keywords head and neck paraganglioma and genetics, and 274 articles in PubMed and 1183 in ScienceDirect were found. From these articles, those concerning genetic changes in HNPGLs were selected. The aim of this review is to describe the known genetic changes and their practical applications. We found that the etiology of the tumors in question is based on genetic changes in the form of either germinal or somatic mutations. 40% of PCC and PGL have a predisposing germline mutation (including VHL, SDHB, SDHD, RET, NF1, THEM127, MAX, SDHC, SDHA, SDHAF2, HIF2A, HRAS, KIF1B, PHD2, and FH). Approximately 25–30% of cases are due to somatic mutations, such as RET, VHL, NF1, MAX, and HIF2A. The tumors were divided into three main clusters by the Cancer Genome Atlas (TCGA); namely, the pseudohypoxia group, the Wnt signaling group, and the kinase signaling group. The review also discusses genetic syndromes, epigenetic changes, and new testing technologies such as next-generation sequencing (NGS).
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Affiliation(s)
- Anna Majewska
- Department of Otolaryngology, Head and Neck Surgery, Poznan University of Medical Sciences, 60-355 Poznań, Poland;
- Correspondence:
| | - Bartłomiej Budny
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland; (B.B.); (K.Z.); (M.R.)
| | - Katarzyna Ziemnicka
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland; (B.B.); (K.Z.); (M.R.)
| | - Marek Ruchała
- Department of Endocrinology, Metabolism and Internal Diseases, Poznan University of Medical Sciences, 60-355 Poznań, Poland; (B.B.); (K.Z.); (M.R.)
| | - Małgorzata Wierzbicka
- Department of Otolaryngology, Head and Neck Surgery, Poznan University of Medical Sciences, 60-355 Poznań, Poland;
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Wang EY, Pak JS, Virk RK, Anderson CB, Healy KA, Lee JA, Benson MC, McKiernan JM. Bladder Preservation for Patients With Bladder Paragangliomas: Case Series and Review of the Literature. Urology 2020; 143:194-205. [PMID: 32437773 DOI: 10.1016/j.urology.2020.04.098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/21/2020] [Accepted: 04/26/2020] [Indexed: 12/27/2022]
Abstract
Bladder paragangliomas are rare tumors, with no prospective studies or guidelines on the management of this disease. We present a case series of 6 patients managed with bladder preservation over a median follow-up period of 124 months. We also present a review of the recent literature on bladder paragangliomas. We aim to provide a timely synthesis of the recent evidence on bladder paragangliomas as changing paradigms necessitate individualized treatment.
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Affiliation(s)
- Elizabeth Y Wang
- Department of Urology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY; Columbia University Vagelos College of Physicians and Surgeons, New York, NY.
| | - Jamie S Pak
- Department of Urology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Renu K Virk
- Department of Pathology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Christopher B Anderson
- Department of Urology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Kelly A Healy
- Department of Urology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - James A Lee
- Department of Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Mitchell C Benson
- Department of Urology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - James M McKiernan
- Department of Urology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
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5
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Albattal S, Alswailem M, Moria Y, Al-Hindi H, Dasouki M, Abouelhoda M, Alkhail HA, Alsuhaibani E, Alzahrani AS. Mutational profile and genotype/phenotype correlation of non-familial pheochromocytoma and paraganglioma. Oncotarget 2019; 10:5919-5931. [PMID: 31666924 PMCID: PMC6800268 DOI: 10.18632/oncotarget.27194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/16/2019] [Indexed: 12/11/2022] Open
Abstract
About 30%-40% of patients with pheochromocytoma (PCC) and paraganglioma (PGL) have underlying germline mutations in certain susceptibility genes despite absent family history of these tumors. Here, we present mutational profile of 101 such patients with PCC/PGL (PPGL) from the highly consanguineous population of Saudi Arabia. Results: Of 101 cases with PPGL, 37/101 (36.6%) had germline mutations. Mutations were detected in 30 cases by PCR and direct Sanger sequencing and in 7 additional cases by NGS. The most commonly mutated gene was SDHB (21/101 cases, 20.8%) and the most common SDHB mutation was c.268C>T, p.R90X occurring in 12/21 (57%) cases. Mutations also occurred in SDHC (4/101, 3.96%), SDHD (3/101, 3%), VHL (2/101, 2%) and MAX (2/101, 2%) genes. The following genes were mutated in 1 patient each (1%), RET, SDHA, SDHAF2, TMEM127 and NF1. Metastatic PPGL occurred in 6/21 cases (28.6%) with SDHB mutations and in 1 case with SDHAF2 mutation. Patients and Methods: DNA was isolated from peripheral blood (53 patients) or from non-tumorous formalin fixed paraffin embedded (FFPE) tissue (48 patients). PCR and direct Sanger sequencing of RET, SDHx, VHL, MAX and TMEM127 genes were performed. Cases without mutations were subjected to whole exome sequencing using next generation sequencing (NGS). Conclusion: About 37% of PPGL without family history of such tumors harbor germline mutations. The most commonly mutated gene is SDHB followed by SDHC, SDHD, VHL, MAX and rarely RET, SDHA, SDHAF2, TMEM127 and NF1. SDHB mutations were associated with metastatic PPGL in more than a quarter of cases.
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Affiliation(s)
- Shatha Albattal
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia.,Faculty of Science, King Saud University, Riyadh 11211, Saudi Arabia
| | - Meshael Alswailem
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Yosra Moria
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Hindi Al-Hindi
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Majed Dasouki
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia.,Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh 11211, Saudi Arabia
| | - Mohamed Abouelhoda
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia.,Saudi Human Genome Program, King Abdulaziz City for Science and Technology, Riyadh 11211, Saudi Arabia
| | - Hala Aba Alkhail
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | | | - Ali S Alzahrani
- Department of Molecular Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia.,Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
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Chen Y, Chomsky-Higgins K, Nwaogu I, Gosnell JE, Seib C, Shen WT, Suh I, Duh QY. Trends in Adrenal Surgery-The Changing Nature of Tumors and Patients. J Surg Res 2018; 236:129-133. [PMID: 30694747 DOI: 10.1016/j.jss.2018.11.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/09/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The volume of adrenal surgery is increasing. There has been a concern that the widespread use of axial imaging and minimally invasive approaches has led to changing indications for adrenalectomy. We reviewed trends in adrenal surgery at a single academic institution. MATERIALS AND METHODS This was a retrospective analysis of all patients who underwent adrenal surgery between 1993 and 2018 by the endocrine surgery service. Patient demographics, diagnosis, operative details, and perioperative complications were evaluated. Trend analysis was performed across ordered year groups (<2000, 2000-2004, 2005-2009, 2010-2014, and 2015-2018). RESULTS We identified 732 patients who underwent 751 adrenal operations. Fifty-seven percent of the patients were women, and the median age was 51 y (range: 5-88). There was an increase in the number of procedures performed (P < 0.01, trend analysis). Over time, there was a higher proportion of patients with hypertension (54.7% [<2000] versus 73.6% [>2015], P < 0.01), diabetes (4.7% versus 22.1%, P = 0.01), and classified as American Society of Anesthesiology class 3/4 (15.7% versus 45.7%, P < 0.01). More patients had their adrenal lesion found incidentally (19.4% versus 39.3%, P < 0.01), and there was a larger proportion of pheochromocytomas (25% versus 36.4%, P < 0.01) and fewer nonfunctioning adenomas (7.4% versus 4.3%, P = 0.03). Median tumor size decreased from 3.5 cm to 2.9 cm (P = 0.03). Complication rates increased over time (8.3% versus 15%, P < 0.01), but the overall 30-d mortality remained low (0.3%). CONCLUSIONS Adrenal surgery is being performed more commonly with an increasing number of incidentalomas and pheochromocytomas. Our patients have higher comorbidities with increase in complication rates over time, although perioperative mortality remains low. This highlights the importance of a thorough preoperative evaluation to identify suitable patients who may benefit from adrenalectomy.
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Affiliation(s)
- Yufei Chen
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California.
| | - Kathryn Chomsky-Higgins
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Iheoma Nwaogu
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Jessica E Gosnell
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Carolyn Seib
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Wen T Shen
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Insoo Suh
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Quan-Yang Duh
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
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