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Najjar R, Paver E, McGuane J, Frahm‐Jensen G. Dissecting a diagnostic enigma: Hypertension in a young patient from an organ of Zuckerkandl paraganglioma. Clin Case Rep 2023; 11:e8061. [PMID: 37854255 PMCID: PMC10580690 DOI: 10.1002/ccr3.8061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/17/2023] [Accepted: 09/27/2023] [Indexed: 10/20/2023] Open
Abstract
Hypertension in young patients can mask rare conditions like paragangliomas, especially in the absence of conventional symptoms. A comprehensive diagnostic evaluation and multidisciplinary approach are crucial for optimal management and outcomes.
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Affiliation(s)
- Reabal Najjar
- The Australian National University Medical School, College of Health and Medicine, Australian Capital TerritoryCanberraAustralian Capital TerritoryAustralia
- The Canberra Hospital, Canberra Health ServicesCanberraAustralian Capital TerritoryAustralia
| | - Elizabeth Paver
- The Australian National University Medical School, College of Health and Medicine, Australian Capital TerritoryCanberraAustralian Capital TerritoryAustralia
- ACT Pathology, The Canberra HospitalCanberraAustralian Capital TerritoryAustralia
| | - Jonathan McGuane
- The Australian National University Medical School, College of Health and Medicine, Australian Capital TerritoryCanberraAustralian Capital TerritoryAustralia
- ACT Pathology, The Canberra HospitalCanberraAustralian Capital TerritoryAustralia
| | - Gert Frahm‐Jensen
- Department of Vascular SurgeryThe Canberra HospitalCanberraAustralian Capital TerritoryAustralia
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Eisenhofer G, Pamporaki C, Lenders JWM. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev 2023; 44:862-909. [PMID: 36996131 DOI: 10.1210/endrev/bnad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
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Constantinescu G, Preda C, Constantinescu V, Siepmann T, Bornstein SR, Lenders JWM, Eisenhofer G, Pamporaki C. Silent pheochromocytoma and paraganglioma: Systematic review and proposed definitions for standardized terminology. Front Endocrinol (Lausanne) 2022; 13:1021420. [PMID: 36325453 PMCID: PMC9618947 DOI: 10.3389/fendo.2022.1021420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors with heterogeneous clinical presentations and potential lethal outcomes. The diagnosis is based on clinical suspicion, biochemical testing, imaging and histopathological confirmation. Increasingly widespread use of imaging studies and surveillance of patients at risk of PPGL due to a hereditary background or a previous tumor is leading to the diagnosis of these tumors at an early stage. This has resulted in an increasing use of the term "silent" PPGL. This term and other variants are now commonly found in the literature without any clear or unified definition. Among the various terms, "clinically silent" is often used to describe the lack of signs and symptoms associated with catecholamine excess. Confusion arises when these and other terms are used to define the tumors according to their ability to synthesize and/or release catecholamines in relation to biochemical test results. In such cases the term "silent" and other variants are often inappropriately and misleadingly used. In the present analysis we provide an overview of the literature and propose standardized terminology in an attempt at harmonization to facilitate scientific communication.
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Affiliation(s)
- Georgiana Constantinescu
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
| | - Cristina Preda
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
| | - Victor Constantinescu
- Center of Clinical Neuroscience, University Clinic Carl-Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Timo Siepmann
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan R. Bornstein
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Jacques W. M. Lenders
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Graeme Eisenhofer
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University of Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
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Zhang HX, Wang K, Hong P, Lu M, Liu Z, Liu L, Wang GL, Ma LL. Clinical experience with the treatment of retroperitoneal vascular leiomyosarcoma originating from large veins. BMC Surg 2021; 21:326. [PMID: 34392834 PMCID: PMC8364698 DOI: 10.1186/s12893-021-01322-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retroperitoneal vascular leiomyosarcoma (RVLMS) is an extremely rare disease in clinical practice, and it has poor prognosis. This article is to explore the diagnosis and treatment of RVLMS and present our experience. METHODS Data of RVLMS patients were continuously collected in our hospital from August 2018 to February 2020: two males and two females with a median age of 56 (min-max = 33-61) years were included. Patients in whom paraganglioma could not be excluded were asked to take phenoxybenzamine before surgery. A multi-disciplinary team (MDT) meeting had been held and surgery was recommended. The operation procedures varied based on the tumor location, shape, and stage, and the core steps were "exposure of the retroperitoneum and tumor, identification of vital blood vessels, blocking the bloodstream, complete removal of the tumor and tumor thrombus, and release of blood flow". A Satinsky clamp was used to partially block the blood vessels. Follow-up was conveyed by revisits and phone calls. RESULTS One patient underwent open surgery, and three patients underwent laparoscopic surgery, one of whom underwent conversion to open surgery. The procedures were finished successfully, with a median operative time of 314.5 (min-max = 224-467) mins. The median amount of intraoperative bleeding was 550 (min-max = 200-1500) ml, and three patients had transfusion during the operation. The mass was irregular in shape, with a median maximum size of 7.45 (min-max = 4.2-10.7) cm, and the pathological examination confirmed RVLMS, which has spindle-shape, high mitotic activity and atypia. One week after the operation, the median serum creatinine level was 85 (min-max = 70-99) µmol/L. The median follow-up time was 16 (min-max = 13-21) months, and 1 case reported asymptomatic recurrence. CONCLUSION Uncharacteristic manifestations and imaging features contribute to the problematic diagnosis of RVLMS. Comprehensive preoperative evaluation and careful surgical planning are essential. Multicenter research is needed in the future to reach a dominant consensus.
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Affiliation(s)
- Hong-Xian Zhang
- Department of Urology, Peking University Third Hospital, 100191, Beijing, People's Republic of China
| | - Kai Wang
- Department of Urology, Peking University Third Hospital, 100191, Beijing, People's Republic of China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, 100191, Beijing, People's Republic of China
| | - Min Lu
- Department of Pathology, Peking University Third Hospital, 100191, Beijing, People's Republic of China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, 100191, Beijing, People's Republic of China
| | - Lei Liu
- Department of Urology, Peking University Third Hospital, 100191, Beijing, People's Republic of China
| | - Guo-Liang Wang
- Department of Urology, Peking University Third Hospital, 100191, Beijing, People's Republic of China.
| | - Lu-Lin Ma
- Department of Urology, Peking University Third Hospital, 100191, Beijing, People's Republic of China.
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Mintegui G, Mendoza B, Guarneri C. Normotensive pheochromocytoma associated with ganglioneuroma. Med Clin (Barc) 2021; 158:43-44. [PMID: 34034915 DOI: 10.1016/j.medcli.2021.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - Beatriz Mendoza
- Clinics Hospital, School of Medicine, UdelaR, Montevideo, Uruguay
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Babinska A, Kaszubowski M, Kmieć P, Sworczak K. Selected adipocytokines in patients with an incidentally discovered pheochromocytoma. MINERVA ENDOCRINOL 2019; 45:117-126. [PMID: 31738032 DOI: 10.23736/s0391-1977.19.03007-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Adipose tissue secretes many adipokines and cytokines, which may be an additional risk factor of cardiovascular and metabolic diseases in patients with an incidentally discovered pheochromocytoma (PHEO). The aim of the study was to investigate levels of selected adipocytokines in these patients. METHODS This prospective study included 12 patients with an incidentally discovered PHEO and 18 healthy participants. In all participants plasma/serum concentrations of triglycerides, HDL and LDL cholesterol, insulin, glucose, adipocytokines (adiponectin, leptin, resistin, TNFα, IL6, and MCP1) were determined, hormonal tests were performed in patients. RESULTS Patients and controls did not differ significantly in terms of age, sex, and body mass index. Among incidentally discovered PHEO patients, adiponectin levels were lower, while TNFα concentrations higher than in controls. Concentrations of adiponectin correlated with 24-hour urinary excretion of normetanephrine in women. Significantly higher TNFα concentrations were found in hypertensive than in normotensive PHEO patients as well as in non-diabetic PHEO patients than controls. Further, resistin concentration was higher in PHEO patients with diabetes than in non-diabetic ones (P<0.001). Incidentally discovered PHEO tumor size correlated with leptin and IL6 levels. Adiponectin levels were higher, while TNFα and resistin lower among five patients re-examined after tumor resection. CONCLUSIONS Among patients with an incidentally discovered pheochromocytoma, lower adiponectin, and higher resistin and TNFα levels may constitute additional factors for HT and DM. In our study, for the first time, correlations between incidentally discovered PHEO tumor size and concentrations of leptin as well as IL6 were found.
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Affiliation(s)
- Anna Babinska
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland -
| | - Mariusz Kaszubowski
- Institute of Statistics, Department of Economic Sciences, Faculty of Management and Economics, Gdansk University of Technology, Gdansk, Poland
| | - Piotr Kmieć
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdansk, Gdansk, Poland
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Amar L, Lussey-Lepoutre C, Lenders JWM, Djadi-Prat J, Plouin PF, Steichen O. MANAGEMENT OF ENDOCRINE DISEASE: Recurrence or new tumors after complete resection of pheochromocytomas and paragangliomas: a systematic review and meta-analysis. Eur J Endocrinol 2016; 175:R135-45. [PMID: 27080352 DOI: 10.1530/eje-16-0189] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/13/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To systematically review the incidence and factors associated with recurrences or new tumors after apparent complete resection of pheochromocytoma or thoraco-abdomino-pelvic paraganglioma. DESIGN A systematic review and meta-analysis of published literature was performed. METHODS Pubmed and Embase from 1980 to 2012 were searched for studies published in English on patients with non-metastatic pheochromocytoma or thoraco-abdomino-pelvic paraganglioma, complete tumor resection, postoperative follow-up exceeding 1 month, and recurrence or new tumor documented by pathology, hormonal dosages, or imaging tests. Incidence rates of new events after curative surgery were calculated for each study that had sufficient information and pooled using random-effect meta-analysis. RESULTS In total, 38 studies were selected from 3518 references, of which 36 reported retrospective cohorts from the USA, Europe, and Asia. Patient follow-up was neither standardized nor exhaustive in the included studies. A clear description of patient retrieval methods was available for nine studies and the follow-up protocol and patient flow for four studies. Only two studies used multivariable methods to assess potential predictors of postoperative events.The overall rate of recurrent disease from 34 studies was 0.98 events/100 person-years (95% confidence interval 0.71, 1.25). Syndromic diseases and paragangliomas were consistently associated with a higher risk of a new event in individual studies and in meta-regression analysis. CONCLUSIONS The risk of recurrent disease after complete resection of pheochromocytoma may be lower than that previously estimated, corresponding to five events for 100 patients followed up for 5 years after complete resection. Risk stratification is required to tailor the follow-up protocol after complete resection of a pheochromocytoma or paraganglioma. Large multicenter studies are needed to this end.
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Affiliation(s)
- Laurence Amar
- Faculty of MedicineUniversité Paris-Descartes, Paris, France Hypertension UnitAP-HP, Hôpital Européen Georges Pompidou, Paris, France Paris Cardiovascular Research CenterINSERM UMR970, Paris, France
| | - Charlotte Lussey-Lepoutre
- Hypertension UnitAP-HP, Hôpital Européen Georges Pompidou, Paris, France Paris Cardiovascular Research CenterINSERM UMR970, Paris, France
| | - Jacques W M Lenders
- Department of Internal MedicineRadboud University Medical Center, Nijmegen, The Netherlands Department of Internal Medicine IIITechnische Universität Dresden, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Juliette Djadi-Prat
- Clinical Research UnitAP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Pierre-Francois Plouin
- Faculty of MedicineUniversité Paris-Descartes, Paris, France Hypertension UnitAP-HP, Hôpital Européen Georges Pompidou, Paris, France Paris Cardiovascular Research CenterINSERM UMR970, Paris, France
| | - Olivier Steichen
- Faculty of MedicineSorbonne Universités, UPMC Univ Paris 06, Paris, France INSERMU1142, LIMICS, Paris, France Department of Internal MedicineAP-HP, Hôpital Tenon, Paris, France
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Sarveswaran V, Kumar S, Kumar A, Vamseedharan M. A giant cystic pheochromocytoma mimicking liver abscess an unusual presentation - a case report. Clin Case Rep 2014; 3:64-8. [PMID: 25678978 PMCID: PMC4317216 DOI: 10.1002/ccr3.149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 07/18/2014] [Accepted: 08/23/2014] [Indexed: 11/30/2022] Open
Abstract
Giant cystic pheochromocytoma is a rare neuroendocrine tumor. The possibility of cystic pheochromocytoma should be considered for any peri-adrenal mass even in absence of characteristic symptoms and negative biochemical analysis. The key in the management of a case of cystic pheochromocytoma is the preoperative suspicion and the intraoperative crisis management.
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Affiliation(s)
- Venugopal Sarveswaran
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
| | - Surees Kumar
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
| | - Amit Kumar
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
| | - Muthukumar Vamseedharan
- Department of General Surgery, Sri Ramakrishna Hospital 395, Sarojini Naidu Road, Sidhapudur, Coimbatore, Tamilnadu, 641044, India
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Kaltsas G, Chrisoulidou A, Piaditis G, Kassi E, Chrousos G. Current status and controversies in adrenal incidentalomas. Trends Endocrinol Metab 2012; 23:602-9. [PMID: 23041413 DOI: 10.1016/j.tem.2012.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 08/19/2012] [Accepted: 09/05/2012] [Indexed: 12/27/2022]
Abstract
Adrenal incidentalomas (AI) are serendipitously discovered lesions during abdominal imaging studies that need to be investigated for evidence of hormonal hypersecretion and/or malignancy. Because imaging modalities can reliably identify lesions that carry a high risk of malignancy, we focus on the identification of hypersecretory lesions and those with subclinical activity, particularly Cushing syndrome. Because diverse diagnostic tests and cut-offs are employed, the prevalence of hypersecretory AI varies widely, and there is controversy regarding their long-term sequelae. In this article we provide information regarding current radiological means to define the nature of AI, and the most appropriate biochemical tests for delineating hypersecretory states. We also discuss the duration and intensity of AI follow-up as well as the identification of AI that require specific therapeutic intervention.
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Affiliation(s)
- Gregory Kaltsas
- Department of Pathophysiology, National University of Athens, Mikras Asias 75, 11527, Greece.
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Yu R. Sizable but clinically inapparent adrenal pheochromocytomas. J Endocrinol Invest 2012; 35:349-50. [PMID: 22555409 DOI: 10.1007/bf03345427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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