1
|
Clifton-Bligh RJ. The diagnosis and management of pheochromocytoma and paraganglioma during pregnancy. Rev Endocr Metab Disord 2023; 24:49-56. [PMID: 36637675 PMCID: PMC9884650 DOI: 10.1007/s11154-022-09773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 01/14/2023]
Abstract
Diagnosis of pheochromocytoma or paraganglioma (PPGL) in pregnancy has been associated historically with high rates of materno-fetal morbidity and mortality. Recent evidence suggests outcomes are improved by recognition of PPGL before or during pregnancy and appropriate medical management with alpha-blockade. Whether antepartum surgery (before the third trimester) is required remains controversial and open to case-based merits. Women with PPGL in pregnancy are more commonly delivered by Caesarean section, although vaginal delivery appears to be safe in selected cases. At least some PPGLs express the luteinizing hormone/chorionic gonadotropin receptor (LHCGR) which may explain their dramatic manifestation in pregnancy. PPGLs in pregnancy are often associated with heritable syndromes, and genetic counselling and testing should be offered routinely in this setting. Since optimal outcomes are only achieved by early recognition of PPGL in (or ideally before) pregnancy, it is incumbent for clinicians to be aware of this diagnosis in a pregnant woman with hypertension occurring before 20 weeks' gestation, and acute and/or refractory hypertension particularly if paroxysmal and accompanied by sweating, palpitations and/or headaches. All women with a past history of PPGL and/or heritable PPGL syndrome should be carefully assessed for the presence of residual or recurrent disease before considering pregnancy.
Collapse
Affiliation(s)
- Roderick J Clifton-Bligh
- University of Sydney, Sydney, NSW, Australia.
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
| |
Collapse
|
2
|
Tingi E, Kyriacou A, Verghese L. Recurrence of phaeochromocytoma in pregnancy in a patient with multiple endocrine neoplasia 2A: a case report and review of literature. Gynecol Endocrinol 2016; 32:875-880. [PMID: 27808580 DOI: 10.1080/09513590.2016.1236242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Multiple endocrine neoplasia type 2A (MEN 2A) is an autosomal dominant inherited condition with a prevalence of one in 40 000 individuals. It causes the development of tumours in endocrine glands, such as medullary thyroid cancer, pheochromocytomas, as well as primary hyperparathyroidism. MEN 2A in pregnancy is very rare with only 29 cases reported in the literature. The presence of pheochromocytoma is a rare cause of hypertension during pregnancy with an incidence of 0.007% of all pregnancies. This has severe implications on both mother and the foetus. This case report describes a 22-year-old nulliparous Caucasian woman with known MEN2A syndrome, who underwent thyroidectomy for medullary thyroid carcinoma in childhood and excision of left sided pheochromocytoma at the age of 19. She was found to have a recurrence of pheochromocytoma in the right adrenal gland during pregnancy at 16 weeks of gestation and was oddly normotensive. Catecholamine effects were blocked with phenoxybenzamine and she delivered by an uneventful elective caesarean section at 36 weeks gestation. She underwent a laparoscopic right adrenalectomy six weeks postpartum, followed by lifelong corticosteroid replacement.
Collapse
Affiliation(s)
- Efterpi Tingi
- a Specialist Registrar in Obstetrics and Gynaecology, St. Mary's Hospital , Manchester , UK
| | - Angelos Kyriacou
- b Consultant in Endocrinology and Diabetes, Salford Royal Hospital , Manchester , UK
- c Diabetes & Metabolism, Centre of Endocrinology , Limassol , Cyprus , and
| | - Lynda Verghese
- d Consultant in Obstetrics and Gynaecology, Wrexham Maelor Hospital , Wales , UK
| |
Collapse
|
3
|
Dealing with Pheochromocytoma during the First Trimester of Pregnancy. Case Rep Obstet Gynecol 2015; 2015:439127. [PMID: 25838955 PMCID: PMC4369956 DOI: 10.1155/2015/439127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 02/20/2015] [Indexed: 11/22/2022] Open
Abstract
Purpose. Pheochromocytoma in association with pregnancy is a very rare, without specific symptoms, life-threatening condition, increasing both maternal and fetal mortality up to 50%. The present paper illustrates the case of a pregnant woman, diagnosed with pheochromocytoma, aiming to demonstrate and discuss the difficulties that arouse during the diagnosis and the problems concerning the treatment. Patient. A 34-year-old woman, in the 9th week of pregnancy, complained for headache, sweating, and a feeling of heavy weight on the right renal area. A tumor of 10 cm diameter at the site of the right adrenal was found. Twenty-four-hour urine catecholamine and VMA excretion levels were well raised. Results. Multidisciplinary approach treated the patient conservatively. Surgical resection of the tumor was performed after the 14th week of pregnancy at the completion of organogenesis. Neither postoperative complications occurred nor hypertension relapse was recorded. The fetus was delivered without complications at the 36th week. Conclusions. There are no consensus and guidelines for treating pheochromocytoma during pregnancy, especially when it is diagnosed in the first trimester. The week of pregnancy and a multidisciplinary approach will determine whether the pregnancy should be continued or not, as well as the time and the approach of surgical treatment.
Collapse
|
4
|
Muzannara MA, Tawfeeq N, Nasir M, Al Harbi MK, Geldhof G, Dimitriou V. Vaginal delivery in a patient with pheochromocytoma, medullary thyroid cancer, and primary hyperparathyroidism (multiple endocrine neoplasia type 2A, Sipple's syndrome). Saudi J Anaesth 2014; 8:437-9. [PMID: 25191209 PMCID: PMC4141407 DOI: 10.4103/1658-354x.136652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Multiple endocrine neoplasia 2A (MEN 2A), or Sipple's syndrome is a rare inherited dominant syndrome, characterised by medullary thyroid carcinoma, adrenal pheochromocytoma and hyperparathyroidism, due to specific RET proto-oncogene mutations. The women with MEN 2A syndrome are at risk of complicated pregnancy because of unrecognised pheochromocytoma and transmission of RET mutation to the progeny. We report a case of a woman with MEN 2A diagnosed in early pregnancy. Alpha-blockade medical therapy was used effectively and time was given for fetal maturation. Uncomplicated vaginal delivery performed under epidural analgesia. Six weeks postpartum adrenalectomy, thyroidectomy and parathyroidectomy were performed uneventfully.
Collapse
Affiliation(s)
| | - Nasser Tawfeeq
- Department of Anesthesia, King Abdulaziz Medical City, Riyadh, KSA
| | - Mahmood Nasir
- Department of Anesthesia, King Abdulaziz Medical City, Riyadh, KSA
| | | | - Georges Geldhof
- Department of Anesthesia, King Abdulaziz Medical City, Riyadh, KSA
| | | |
Collapse
|
5
|
|
6
|
Abstract
Background The American Thyroid Association (ATA) and more recently the European Thyroid Association (ETA) Guidelines on diagnosis and treatment of medullary thyroid carcinoma (MTC) have provided an excellent tool which was formerly lacking in the field of management of MTC. However, some relevant clinical questions, as the use of somatostatin analogues in the treatment of MTC and the management of pregnant patients with MTC, which were recommended in the guidelines, have been lately extensively revised. Moreover the current issue whether GLP-1 (a glucagon-like peptide-1) analogue is associated with MTC has only superficially been analyzed. Methods Publications have been retrieved in MEDLINE at Pubmed (there is no fix date retrospectively) up to October 2012 using the terms “medullary thyroid carcinoma”, “somatostatin”, “pregnancy” and “incretins”. The recommendations made by ATA and ETA were considered. Conclusions There are no data supporting the application of somatostatin analogues in the treatment of MTC, while thyroid cancer during or after pregnancy has no impact on the prognosis of disease or on the outcome of pregnancy. However, women with MEN 2 should be carefully controlled before any planned or during any unplanned pregnancy. In contrast to animal studies, there are no consistent human data supporting a stimulatory effect of GLP-1 receptor activation by liraglutide, an incretin mimetic, on calcitonin levels, though establishment of a registry and further studies are required to exclude any association between GLP-1 analogue and MTC.
Collapse
Affiliation(s)
- Leonidas H Duntas
- Unit of Endocrinology, Diabetes and Metabolism, Evgenidion Hospital, University of Athens Medical School, 20 Papadiamantopoulou St,, 115 28 Athens, Greece.
| |
Collapse
|
7
|
Abstract
Abstract
Background
Phaeochromocytoma in pregnancy is a rare and potentially dangerous situation for mother and fetus. This review aimed to assess current mortality rates and how medical and surgical management affect these.
Methods
Articles in English published between 2000 and 2011 were obtained from a MEDLINE search. Eligible publications presented women diagnosed with phaeochromocytoma in the antenatal or immediate postnatal period, and reported management and outcomes.
Results
A total of 135 reports were identified. After applying inclusion criteria, 77 pregnancies involving 78 fetuses were analysed. Fetal and maternal mortality rates were 17 per cent (13 of 78) and 8 per cent (6 of 77) respectively. Better outcomes were achieved when the diagnosis of phaeochromocytoma was made in the antenatal period than when it was made during labour or immediately postpartum (survival of both mother and fetus(es) in 48 of 56 versus 12 of 21 respectively; P = 0·012). When the diagnosis was made before 23 weeks' gestation, there was no difference in outcomes when phaeochromocytoma surgery was carried out in the second trimester, compared with when it was postponed to the third trimester or after delivery (fetal death 2 of 18 versus 2 of 8 respectively; P = 0·563).
Conclusion
This review, although limited by the rarity of the condition and level of available evidence, demonstrated that survival rates are improved if the diagnosis of phaeochromocytoma can be established antenatally. With diagnosis before 23 weeks' gestation, no definite advantage of proceeding with tumour removal during the second trimester could be demonstrated.
Collapse
Affiliation(s)
- M A Biggar
- Department of Endocrine Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Department of Surgery, Middlemore Hospital, Counties Manukau District Health Board, Otahuhu, Auckland, New Zealand
| | - T W J Lennard
- Department of Endocrine Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
8
|
Sherer DM, Dalloul M, Salame G, Shah T, Serur E, Zinn HL, Abulafia O. Sonographic Findings of Medullary Thyroid Carcinoma Leading to Diagnosis of Multiple Endocrine Neoplasia Type 2a during Pregnancy. AJP Rep 2011; 1:59-64. [PMID: 23705087 PMCID: PMC3653543 DOI: 10.1055/s-0031-1280572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 03/06/2011] [Indexed: 11/18/2022] Open
Abstract
Multiple endocrine neoplasia (MEN) type 2a (Sipple's syndrome) is characterized by medullary thyroid carcinoma and pheochromocytoma, and in a smaller percentage of cases, multiglandular parathyroid hyperplasia. This autosomal-dominant syndrome is due to a mutation in the rearranged during transfection (RET) proto-oncogene located on chromosome 10cen-10q11.2 and rarely complicates pregnancy. We present an unusual case in a patient with an enlarged thyroid with sonographic findings characteristic of thyroid cancer, which led to diagnosis and subsequent management of RET proto-oncogene-positive MEN type 2a complicating pregnancy.
Collapse
Affiliation(s)
- David M Sherer
- Divisions of Maternal-Fetal Medicine and Gynecologic Oncology, Departments of Obstetrics and Gynecology and Radiology, State University of New York, Downstate Medical Center, Brooklyn, New York
| | | | | | | | | | | | | |
Collapse
|
9
|
Sarathi V, Bandgar TR, Menon PS, Shah NS. Pheochromocytoma and medullary thyroid carcinoma in a pregnant multiple endocrine neoplasia-2A patient. Gynecol Endocrinol 2011; 27:533-5. [PMID: 20672905 DOI: 10.3109/09513590.2010.507285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We describe a rare combination of pheochromocytoma and medullary thyroid carcinoma (MTC) during pregnancy. METHODS Twenty-three-years old lady, primigravida, was detected to be hypertensive at 12 weeks of gestation and was found to have left adrenal mass on routine obstetric scan. She had a goitre on examination which was proven to be MTC on fine needle aspiration cytology. Twenty-four hours urinary vanillyl mandelic acid and serum calcitonin levels were elevated. After adequate α and β blockade she underwent left adrenalectomy during second trimester of gestation with no significant perioperative complications. Twelve days later she underwent total thyroidectomy. RESULTS Adrenal mass was confirmed to be pheochromocytoma while MTC was confirmed in the thyroidectomy specimen. Post-operatively, she was normotensive and delivered a healthy female baby at term. Both mother and the baby tested positive for germline RET mutation (C634W) in exon 11. CONCLUSION We describe a rare case of pregnant multiple endocrine neoplasia-2A patient with pheochromocytoma and MTC.
Collapse
MESH Headings
- Adrenal Gland Neoplasms/diagnosis
- Adrenal Gland Neoplasms/genetics
- Adrenal Gland Neoplasms/physiopathology
- Adrenal Gland Neoplasms/surgery
- Adult
- Amino Acid Substitution
- Carcinoma, Medullary/diagnosis
- Carcinoma, Medullary/genetics
- Carcinoma, Medullary/physiopathology
- Carcinoma, Medullary/surgery
- Carcinoma, Neuroendocrine
- Female
- Humans
- Hypertension, Pregnancy-Induced/etiology
- Live Birth
- Multiple Endocrine Neoplasia Type 2a/diagnosis
- Multiple Endocrine Neoplasia Type 2a/genetics
- Multiple Endocrine Neoplasia Type 2a/physiopathology
- Multiple Endocrine Neoplasia Type 2a/surgery
- Mutation
- Pheochromocytoma/diagnosis
- Pheochromocytoma/genetics
- Pheochromocytoma/physiopathology
- Pheochromocytoma/surgery
- Pregnancy
- Pregnancy Complications, Neoplastic/diagnosis
- Pregnancy Complications, Neoplastic/genetics
- Pregnancy Complications, Neoplastic/physiopathology
- Pregnancy Complications, Neoplastic/surgery
- Pregnancy Trimester, First
- Proto-Oncogene Proteins c-ret/genetics
- Thyroid Neoplasms/diagnosis
- Thyroid Neoplasms/genetics
- Thyroid Neoplasms/physiopathology
- Thyroid Neoplasms/surgery
- Young Adult
Collapse
Affiliation(s)
- Vijaya Sarathi
- Department of Endocrinology, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India.
| | | | | | | |
Collapse
|
10
|
Snabboon T, Plengpanich W, Houngngam N, Buranasupkajorn P, Plengvidhya N, Sereepapong W, Sunthornyothin S, Shotelersuk V. Concurrent bilateral pheochromocytoma and thoracic paraganglioma during pregnancy. Endocrine 2010; 37:261-4. [PMID: 20960261 DOI: 10.1007/s12020-009-9292-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 12/16/2009] [Indexed: 10/20/2022]
Abstract
Although hypertension occurring during pregnancies is not uncommon and its prognosis is generally excellent, some of its unusual causes can lead to catastrophic consequences, especially in undiagnosed cases. Here, we report a pregnant woman who presented with hypertension in her early pregnancy. It was subsequently found to be caused by bilateral pheochromocytoma. After removal of both tumors, catecholamine levels unexpectedly and unexplainably remained elevated. At 23 weeks of gestation, the fetus was found dead in utero. After the fetal death, additional studies were performed and revealed a thoracic paraganglioma. To our knowledge, this is the first report of a case of three catecholamine-producing tumors occurring concurrently during a pregnancy. Genetic analysis helped identify this unprecedented condition; the patient harbored a heterozygous missense mutation c.482G>A in exon 3 of the VHL gene, indicating von Hippel-Lindau syndrome. Physicians who care for hypertensive pregnant patients should be aware of this condition as its diagnosis would probably lead to a better outcome.
Collapse
Affiliation(s)
- Thiti Snabboon
- Division of Endocrine and Metabolism, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Patumwan, Bangkok, 10330, Thailand.
| | | | | | | | | | | | | | | |
Collapse
|