1
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Casey RT, Hendriks E, Deal C, Waguespack SG, Wiegering V, Redlich A, Akker S, Prasad R, Fassnacht M, Clifton-Bligh R, Amar L, Bornstein S, Canu L, Charmandari E, Chrisoulidou A, Freixes MC, de Krijger R, de Sanctis L, Fojo A, Ghia AJ, Huebner A, Kosmoliaptsis V, Kuhlen M, Raffaelli M, Lussey-Lepoutre C, Marks SD, Nilubol N, Parasiliti-Caprino M, Timmers HHJLM, Zietlow AL, Robledo M, Gimenez-Roqueplo AP, Grossman AB, Taïeb D, Maher ER, Lenders JWM, Eisenhofer G, Jimenez C, Pacak K, Pamporaki C. International consensus statement on the diagnosis and management of phaeochromocytoma and paraganglioma in children and adolescents. Nat Rev Endocrinol 2024:10.1038/s41574-024-01024-5. [PMID: 39147856 DOI: 10.1038/s41574-024-01024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2024] [Indexed: 08/17/2024]
Abstract
Phaeochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumours that arise not only in adulthood but also in childhood and adolescence. Up to 70-80% of childhood PPGL are hereditary, accounting for a higher incidence of metastatic and/or multifocal PPGL in paediatric patients than in adult patients. Key differences in the tumour biology and management, together with rare disease incidence and therapeutic challenges in paediatric compared with adult patients, mandate close expert cross-disciplinary teamwork. Teams should ideally include adult and paediatric endocrinologists, oncologists, cardiologists, surgeons, geneticists, pathologists, radiologists, clinical psychologists and nuclear medicine physicians. Provision of an international Consensus Statement should improve care and outcomes for children and adolescents with these tumours.
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Affiliation(s)
- Ruth T Casey
- Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK.
- Department of Endocrinology, Cambridge Cancer Centre and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Emile Hendriks
- Department of Paediatric Diabetes and Endocrinology, Cambridge Cancer Centre and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Cheri Deal
- Endocrine and Diabetes Service, CHU Sainte-Justine and University of Montreal, Montreal, Québec, Canada
| | - Steven G Waguespack
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Verena Wiegering
- University Children's Hospital, Department of Paediatric Hematology, Oncology and Stem Cell Transplantation, University of Würzburg, Würzburg, Germany
| | - Antje Redlich
- Paediatric Oncology Department, Otto von Guericke University Children's Hospital, Magdeburg, Germany
| | - Scott Akker
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Rathi Prasad
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Roderick Clifton-Bligh
- Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Laurence Amar
- Université de Paris, Paris, France
- Hypertension Unit, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Stefan Bornstein
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, Azienda Ospedaliera Universitaria (AOU) Careggi, Florence, Italy
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Paediatrics, National and Kapodistrian University of Athens Medical School, 'Aghia Sophia' Children's Hospital, Athens, Greece
| | | | - Maria Currás Freixes
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre (CNIO) and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Ronald de Krijger
- Princess Maxima Center for Paediatric Oncology, Utrecht, Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Luisa de Sanctis
- Department of Public Health and Paediatric Sciences, University of Turin, Turin, Italy
| | - Antonio Fojo
- Division of Hematology/Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Amol J Ghia
- Department of Radiation Oncology, University Hospital of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Angela Huebner
- Department of Paediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Vasilis Kosmoliaptsis
- Department of Surgery, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
- Blood and Transplant Research Unit in Organ Donation and Transplantation, National Institute for Health Research, University of Cambridge, Cambridge, UK
| | - Michaela Kuhlen
- Paediatrics and Adolescent Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Marco Raffaelli
- U.O.C. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Charlotte Lussey-Lepoutre
- Service de médecine nucléaire, Inserm U970, Sorbonne université, Groupe hospitalier Pitié-Salpétrière, Paris, France
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR GOSH Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mirko Parasiliti-Caprino
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti, Turin, Italy
| | - Henri H J L M Timmers
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Anna Lena Zietlow
- Clinical Child and Adolescent Psychology, Institute of Clinical Psychology and Psychotherapy, Department of Psychology, TU Dresden, Dresden, Germany
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre (CNIO) and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Institute of Health Carlos III (ISCIII), Madrid, Spain
| | - Anne-Paule Gimenez-Roqueplo
- Université Paris Cité, PARCC, INSERM, Paris, France
- Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Ashley B Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
- ENETS Centre of Excellence, Royal Free Hospital, London, UK
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - Eamonn R Maher
- Department of Medical Genetics, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD, USA
| | - Christina Pamporaki
- Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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2
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Passman JE, Wachtel H. Management of Pheochromocytomas and Paragangliomas. Surg Clin North Am 2024; 104:863-881. [PMID: 38944505 DOI: 10.1016/j.suc.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Pheochromocytomas and paragangliomas are distinctive neuroendocrine tumors which frequently produce excess catecholamines with resultant cardiovascular morbidity. These tumors have a strong genetic component, with up to 40% linked to hereditary pathogenic variants; therefore, germline genetic testing is recommended for all patients. Surgical resection offers the only potential cure in the case of localized disease. Given the potential for catecholaminergic crises, appropriate perioperative management is crucial, and all patients should undergo alpha-adrenergic blockade before resection. Therapeutic options for metastatic disease are limited and include surgical debulking, radiopharmaceutical therapies, and conventional chemotherapy.
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Affiliation(s)
- Jesse E Passman
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 4th Floor, Maloney Building, Philadelphia, PA 19104, USA.
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 4th Floor, Maloney Building, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
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3
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Sukrithan V, Perez K, Pandit-Taskar N, Jimenez C. Management of metastatic pheochromocytomas and paragangliomas: when and what. Curr Probl Cancer 2024; 51:101116. [PMID: 39024846 DOI: 10.1016/j.currproblcancer.2024.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/22/2024] [Indexed: 07/20/2024]
Abstract
Recently, the treatment landscape for metastatic pheochromocytomas and paragangliomas (MPPGL) has seen both progress and setbacks. We provide an up-to-date review of the multimodality management of MPPGL and discuss novel opportunities and current challenges in the treatment landscape. Given the unique clinical presentation of MPPGL, we discuss the management of hormone-related clinical sequelae and traditional modalities of therapy. Advances in the understanding of the molecular biology of these diverse tumors have enabled novel strategies such as augmenting DNA damage by targeted delivery of radionuclides such as 131I and 177Lu, abrogating tumor angiogenesis, hypoxia resistance, and DNA damage repair. Despite progress, we address the significant challenges still faced by patients and researchers engaged in efforts to improve outcomes in these rare cancers.
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Affiliation(s)
- Vineeth Sukrithan
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States.
| | - Kimberly Perez
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Neeta Pandit-Taskar
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Camilo Jimenez
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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4
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Ozawa H. Current management of carotid body tumors. Auris Nasus Larynx 2024; 51:501-506. [PMID: 38522353 DOI: 10.1016/j.anl.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/03/2024] [Accepted: 01/23/2024] [Indexed: 03/26/2024]
Abstract
Carotid body tumors (CBTs) are neoplasms that occur at the bifurcation of the carotid artery and are pathologically classified as paragangliomas. In the 4th edition of the WHO classification, paragangliomas are categorized as neoplasms with malignant potential. Clinically, about 5% of CBTs present with malignant features such as metastasis. Currently, it is challenging to distinguish between tumors with benign courses and those that present malignantly. Recent advances in genetic testing have elucidated the genetic characteristics of paragangliomas, including carotid body tumors. Over 20 genes have been identified as being involved in tumor development. Particularly in head and neck paragangliomas, abnormalities in genes related to succinate dehydrogenase are frequently observed. Research is ongoing to understand the mechanisms by which these genes contribute to tumor development. The definitive treatment for CBTs is surgical resection. These tumors are prone to bleeding and often adhere firmly to the carotid artery, making intraoperative bleeding control challenging. The risk of lower cranial nerve paralysis is relatively high, and there is a risk of stroke because of manipulation of the carotid artery. Preoperative evaluation with angiography is essential, and a multi-disciplinary surgical team approach is necessary. In cases where the tumor is difficult to resect or has metastasized, radiation therapy or chemotherapy are employed. Clinical trials involving targeted molecular therapies and radiopharmaceuticals have recently been conducted, with some applied clinically. The development of various new treatments is anticipated, providing hope for therapeutic options in refractory cases.
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Affiliation(s)
- Hiroyuki Ozawa
- Department of Otolaryngology, Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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McCormack S, Hamad E, Hamad A. Paraganglioma of the Neck: A Rare Case With Spinal Metastasis. Case Rep Oncol Med 2024; 2024:2025115. [PMID: 38706789 PMCID: PMC11068453 DOI: 10.1155/2024/2025115] [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: 01/08/2024] [Revised: 03/28/2024] [Accepted: 04/12/2024] [Indexed: 05/07/2024] Open
Abstract
Paragangliomas are rare neuroendocrine tumors that arise from the paraganglia, which are clusters of neuroendocrine cells associated with the autonomic nervous system. These tumors are commonly found in the adrenal medulla but can also occur in other locations outside the adrenal gland. Here, we present a case report of a slow-growing paraganglioma in the left neck with spinal metastasis in a 60-year-old man. This case highlights the importance of considering paraganglion tumors in the differential diagnosis of neck masses and the need for early diagnosis and management to prevent potential complications. Importantly, both the clinical picture and anatomical location of these tumors is important when determining treatment plans.
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Affiliation(s)
- Sean McCormack
- Saint James School of Medicine, Cane Hall Road, Arnos Vale, Saint Vincent and the Grenadines
| | - Eyad Hamad
- Northwestern School of Medicine, Chicago, Illinois, USA
| | - Amar Hamad
- Department of Hemetology/Oncology, Advocate Christ Hospital, Oak Lawn, Illinois, USA
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6
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Jeeyavudeen MS, Mathiyalagan N, Fernandez James C, Pappachan JM. Tumor metabolism in pheochromocytomas: clinical and therapeutic implications. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:349-373. [PMID: 38745767 PMCID: PMC11090696 DOI: 10.37349/etat.2024.00222] [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: 10/13/2023] [Accepted: 12/27/2023] [Indexed: 05/16/2024] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) have emerged as one of the most common endocrine tumors. It epitomizes fascinating crossroads of genetic, metabolic, and endocrine oncology, providing a canvas to explore the molecular intricacies of tumor biology. Predominantly rooted in the aberration of metabolic pathways, particularly the Krebs cycle and related enzymatic functionalities, PPGLs manifest an intriguing metabolic profile, highlighting elevated levels of oncometabolites like succinate and fumarate, and furthering cellular malignancy and genomic instability. This comprehensive review aims to delineate the multifaceted aspects of tumor metabolism in PPGLs, encapsulating genetic factors, oncometabolites, and potential therapeutic avenues, thereby providing a cohesive understanding of metabolic disturbances and their ramifications in tumorigenesis and disease progression. Initial investigations into PPGLs metabolomics unveiled a stark correlation between specific genetic mutations, notably in the succinate dehydrogenase complex (SDHx) genes, and the accumulation of oncometabolites, establishing a pivotal role in epigenetic alterations and hypoxia-inducible pathways. By scrutinizing voluminous metabolic studies and exploiting technologies, novel insights into the metabolic and genetic aspects of PPGLs are perpetually being gathered elucidating complex interactions and molecular machinations. Additionally, the exploration of therapeutic strategies targeting metabolic abnormalities has burgeoned harboring potential for innovative and efficacious treatment modalities. This review encapsulates the profound metabolic complexities of PPGLs, aiming to foster an enriched understanding and pave the way for future investigations and therapeutic innovations in managing these metabolically unique tumors.
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Affiliation(s)
| | - Navin Mathiyalagan
- Department of Medical Oncology, Nottingham University Hospitals NHS Trust, NG5 1PB Nottingham, UK
| | - Cornelius Fernandez James
- Department of Endocrinology & Metabolism, Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, PE21 9QS Boston, UK
| | - Joseph M. Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Trust, PR2 9HT Preston, UK
- Faculty of Science, Manchester Metropolitan University, M15 6BH Manchester, UK
- Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL Manchester, UK
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Yit LFN, Li Y. A Review of the Evolving Role of Radiotherapy in the Treatment of Neuroendocrine Neoplasms. Neuroendocrinology 2024; 114:856-865. [PMID: 38432216 DOI: 10.1159/000538140] [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: 11/27/2023] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Neuroendocrine neoplasms (NENs) are rare tumours that develop from neuroendocrine cells in various parts of the body. The management of this disease poses a significant challenge because of the heterogeneous clinical presentation and varying degrees of aggressiveness. A multidisciplinary approach is often required in complex clinical situations. Radiotherapy (RT) plays a key role in managing NETs in both curative and palliative settings. SUMMARY In this review, we summarize and discuss recent developments in the field of advanced RT in early-stage, locally advanced, and metastatic NENs. We highlight limitations in current approaches and discuss future potential treatment strategies for patients with NENs.
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Affiliation(s)
- Ling Fung Nelson Yit
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Youquan Li
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Mihai R, De Crea C, Guerin C, Torresan F, Agcaoglu O, Simescu R, Walz MK. Surgery for advanced adrenal malignant disease: recommendations based on European Society of Endocrine Surgeons consensus meeting. Br J Surg 2024; 111:znad266. [PMID: 38265812 PMCID: PMC10805373 DOI: 10.1093/bjs/znad266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/02/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Radu Mihai
- Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Carmela De Crea
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell’Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- Endocrine Surgery Unit, Hospital Fatebenefratelli Isola Tiberina—Gemelli Isola, Rome, Italy
| | - Carole Guerin
- Department of Endocrine and Metabolic Surgery, Aix-Marseille University, Hôpital de La Conception, Marseille, France
| | - Francesca Torresan
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Orhan Agcaoglu
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Razvan Simescu
- Department of General and Endocrine Surgery, Medlife-Humanitas Hospital, Cluj-Napoca, Romania
| | - Martin K Walz
- Department of Surgery and Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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Xu S, Hu G, Du J, Ma L, Zou L, Li Q. Middle mediastinal paraganglioma: A case report and review of the literature. Medicine (Baltimore) 2023; 102:e36327. [PMID: 38013330 PMCID: PMC10681380 DOI: 10.1097/md.0000000000036327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/06/2023] [Indexed: 11/29/2023] Open
Abstract
RATIONAL Paragangliomas are rare and can occur in many places throughout the body, but mediastinal paragangliomas are even rarer, accounting for less than 0.3% of mediastinal masses. Extremely susceptible to misdiagnosis and mistreatment, which may lead to the death of the patient. PATIENT CONCERNS We report a case of a giant paraganglioma of the middle mediastinum. A 40-year-old woman was admitted to the hospital with a rib fracture and a chest computed tomography suggesting a giant occupying tumor in the middle mediastinum. DIAGNOSIS Immunohistochemistry revealed positive for S100 fraction and Syn, focally positive for CgA, while negative for CKp and succinate dehydrogenase complex iron sulfur subunit B gene, and Ki67index ≈ 5%. The imaging and immunohistochemical features suggested a final diagnosis of Paragangliomas. INTERVENTIONS This patient underwent lateral open heart surgery to remove a mediastinal mass. OUTCOMES One month after being discharged, the patient was contacted by phone for a follow-up visit and reported feeling OK. Unfortunately, as of the date of submission, the patient did not come to our hospital for review. LESSONS Mediastinal paraganglioma as a rare and potentially malignant tumor susceptible to misdiagnosis and mistreatment. Organ pathology examination is the gold standard for diagnosis, and surgery is an important treatment method. A clear diagnosis and thorough preoperative examination are important guarantees for the success of surgery.
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Affiliation(s)
- Shaopeng Xu
- Department of General Thoracic Surgery, 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou, China
- Ningxia Medical University, Yinchuan, China
| | - Gawei Hu
- Department of General Thoracic Surgery, 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou, China
| | - Jinchen Du
- Department of General Thoracic Surgery, 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou, China
| | - Linchong Ma
- Department of General Thoracic Surgery, 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou, China
| | - Lei Zou
- Department of General Thoracic Surgery, 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou, China
| | - Qingxin Li
- Department of General Thoracic Surgery, 940th Hospital of Joint Logistic Support Force of Chinese People’s Liberation Army, Lanzhou, China
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10
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Gabiache G, Zadro C, Rozenblum L, Vezzosi D, Mouly C, Thoulouzan M, Guimbaud R, Otal P, Dierickx L, Rousseau H, Trepanier C, Dercle L, Mokrane FZ. Image-Guided Precision Medicine in the Diagnosis and Treatment of Pheochromocytomas and Paragangliomas. Cancers (Basel) 2023; 15:4666. [PMID: 37760633 PMCID: PMC10526298 DOI: 10.3390/cancers15184666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
In this comprehensive review, we aimed to discuss the current state-of-the-art medical imaging for pheochromocytomas and paragangliomas (PPGLs) diagnosis and treatment. Despite major medical improvements, PPGLs, as with other neuroendocrine tumors (NETs), leave clinicians facing several challenges; their inherent particularities and their diagnosis and treatment pose several challenges for clinicians due to their inherent complexity, and they require management by multidisciplinary teams. The conventional concepts of medical imaging are currently undergoing a paradigm shift, thanks to developments in radiomic and metabolic imaging. However, despite active research, clinical relevance of these new parameters remains unclear, and further multicentric studies are needed in order to validate and increase widespread use and integration in clinical routine. Use of AI in PPGLs may detect changes in tumor phenotype that precede classical medical imaging biomarkers, such as shape, texture, and size. Since PPGLs are rare, slow-growing, and heterogeneous, multicentric collaboration will be necessary to have enough data in order to develop new PPGL biomarkers. In this nonsystematic review, our aim is to present an exhaustive pedagogical tool based on real-world cases, dedicated to physicians dealing with PPGLs, augmented by perspectives of artificial intelligence and big data.
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Affiliation(s)
- Gildas Gabiache
- Department of Radiology, Rangueil University Hospital, 31400 Toulouse, France (F.-Z.M.)
| | - Charline Zadro
- Department of Radiology, Rangueil University Hospital, 31400 Toulouse, France (F.-Z.M.)
| | - Laura Rozenblum
- Department of Nuclear Medicine, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, 75013 Paris, France
| | - Delphine Vezzosi
- Department of Endocrinology, Rangueil University Hospital, 31400 Toulouse, France
| | - Céline Mouly
- Department of Endocrinology, Rangueil University Hospital, 31400 Toulouse, France
| | | | - Rosine Guimbaud
- Department of Oncology, Rangueil University Hospital, 31400 Toulouse, France
| | - Philippe Otal
- Department of Radiology, Rangueil University Hospital, 31400 Toulouse, France (F.-Z.M.)
| | - Lawrence Dierickx
- Department of Nuclear Medicine, IUCT-Oncopole, 31059 Toulouse, France;
| | - Hervé Rousseau
- Department of Radiology, Rangueil University Hospital, 31400 Toulouse, France (F.-Z.M.)
| | - Christopher Trepanier
- New York-Presbyterian Hospital/Department of Radiology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Laurent Dercle
- New York-Presbyterian Hospital/Department of Radiology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Fatima-Zohra Mokrane
- Department of Radiology, Rangueil University Hospital, 31400 Toulouse, France (F.-Z.M.)
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11
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Terakawa A, Tanabe A, Nakayama H, Minamimoto R. External Beam Radiotherapy in Advanced Pheochromocytoma and Paraganglioma: An Observation of a Rare Abscopal Effect. JCEM CASE REPORTS 2023; 1:luad111. [PMID: 37908203 PMCID: PMC10580418 DOI: 10.1210/jcemcr/luad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Indexed: 11/02/2023]
Abstract
Metastatic pheochromocytoma and paraganglioma are incurable, and effective treatment of systemic symptoms resulting from catecholamine excess and local symptoms from tumor growth are crucial to prolong survival and improve quality of life. We report the first case of metastatic pheochromocytoma wherein external beam radiotherapy (EBRT) demonstrated efficacy in both target and nontarget lesions, demonstrating the "abscopal effect." EBRT reduced tumor volume and catecholamine secretion and improved catecholamine excess-related complications, including glycemic control. EBRT is an effective treatment option for metastatic pheochromocytoma and paraganglioma because of its minimal invasiveness, safety, and potential for the rare abscopal effect.
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Affiliation(s)
- Aiko Terakawa
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo, 162-8655, Japan
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo, 162-8655, Japan
| | - Hidetsugu Nakayama
- Department of Radiation Oncology, National Center for Global Health and Medicine, Tokyo, 162-8655, Japan
| | - Ryogo Minamimoto
- Division of Nuclear Medicine, Department of Radiology, National Center for Global Health and Medicine, Tokyo, 162-8655, Japan
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12
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Kanj AN, Young WF, Ryu JH. Mediastinal Paraganglioma: A retrospective analysis of 51 cases. Respir Med 2023:107296. [PMID: 37257785 DOI: 10.1016/j.rmed.2023.107296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Paragangliomas are rarely found in the mediastinum, where they account for a small proportion of mediastinal masses. This study aimed to better characterize the presenting features and relevant aspects in optimizing the diagnosis and treatment of mediastinal paragangliomas. METHODS A computer-assisted search of electronic health records was performed to identify adult patients (≥18 years) who underwent evaluation for a primary mediastinal paraganglioma at Mayo Clinic between January 2000 and April 2022. Medical charts, laboratory tests and radiology images were reviewed to collect data. RESULTS The study included 51 patients, each with a single mediastinal paraganglioma. The median age was 47 years (IQR: 39-67), 67% females. Symptoms of catecholamine excess were manifest in 39% of patients, and 14% presented with mass effect, while the remaining 47% had no paraganglioma-related symptoms. Genetic testing was performed in 35 patients; 66% harbored a pathogenic variant in the succinate dehydrogenase enzyme complex. Most paragangliomas (71%) were in the middle mediastinum and showed uptake of intravenous contrast on chest imaging. Biopsies were performed in 30 (59%) patients; 27% were inconclusive and 10% resulted in major complications. Surgical resection occurred in 75%, primarily for relief of symptoms (50%) followed by proximity to critical structures (45%). Perioperative complications were common (66%), but there were no cases of local tumor recurrence during the follow-up period (median 8 years; IQR: 4-13). CONCLUSION Mediastinal paragangliomas are most located in the middle mediastinum and can often be diagnosed noninvasively using a combination of clinical, biochemical, and radiological features.
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Affiliation(s)
- Amjad N Kanj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA.
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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13
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Eid M, Foukal J, Sochorová D, Tuček Š, Starý K, Kala Z, Mayer J, Němeček R, Trna J, Kunovský L. Management of pheochromocytomas and paragangliomas: Review of current diagnosis and treatment options. Cancer Med 2023. [PMID: 37145019 DOI: 10.1002/cam4.6010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/06/2023] Open
Abstract
Pheochromocytomas (PCCs) are rare neuroendocrine tumors derived from the chromaffin cells of the adrenal medulla. When these tumors have an extra-adrenal location, they are called paragangliomas (PGLs) and arise from sympathetic and parasympathetic ganglia, particularly of the para-aortic location. Up to 25% of PCCs/PGLs are associated with inherited genetic disorders. The majority of PCCs/PGLs exhibit indolent behavior. However, according to their affiliation to molecular clusters based on underlying genetic aberrations, their tumorigenesis, location, clinical symptomatology, and potential to metastasize are heterogenous. Thus, PCCs/PGLs are often associated with diagnostic difficulties. In recent years, extensive research revealed a broad genetic background and multiple signaling pathways leading to tumor development. Along with this, the diagnostic and therapeutic options were also expanded. In this review, we focus on the current knowledge and recent advancements in the diagnosis and treatment of PCCs/PGLs with respect to the underlying gene alterations while also discussing future perspectives in this field.
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Affiliation(s)
- Michal Eid
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jakub Foukal
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Dana Sochorová
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Štěpán Tuček
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Karel Starý
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Mayer
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Radim Němeček
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Trna
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Lumír Kunovský
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- 2nd Department of Internal Medicine - Gastroenterology and Geriatrics, University Hospital Olomouc, Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic
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14
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Taïeb D, Wanna GB, Ahmad M, Lussey-Lepoutre C, Perrier ND, Nölting S, Amar L, Timmers HJLM, Schwam ZG, Estrera AL, Lim M, Pollom EL, Vitzthum L, Bourdeau I, Casey RT, Castinetti F, Clifton-Bligh R, Corssmit EPM, de Krijger RR, Del Rivero J, Eisenhofer G, Ghayee HK, Gimenez-Roqueplo AP, Grossman A, Imperiale A, Jansen JC, Jha A, Kerstens MN, Kunst HPM, Liu JK, Maher ER, Marchioni D, Mercado-Asis LB, Mete O, Naruse M, Nilubol N, Pandit-Taskar N, Sebag F, Tanabe A, Widimsky J, Meuter L, Lenders JWM, Pacak K. Clinical consensus guideline on the management of phaeochromocytoma and paraganglioma in patients harbouring germline SDHD pathogenic variants. Lancet Diabetes Endocrinol 2023; 11:345-361. [PMID: 37011647 PMCID: PMC10182476 DOI: 10.1016/s2213-8587(23)00038-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 04/05/2023]
Abstract
Patients with germline SDHD pathogenic variants (encoding succinate dehydrogenase subunit D; ie, paraganglioma 1 syndrome) are predominantly affected by head and neck paragangliomas, which, in almost 20% of patients, might coexist with paragangliomas arising from other locations (eg, adrenal medulla, para-aortic, cardiac or thoracic, and pelvic). Given the higher risk of tumour multifocality and bilaterality for phaeochromocytomas and paragangliomas (PPGLs) because of SDHD pathogenic variants than for their sporadic and other genotypic counterparts, the management of patients with SDHD PPGLs is clinically complex in terms of imaging, treatment, and management options. Furthermore, locally aggressive disease can be discovered at a young age or late in the disease course, which presents challenges in balancing surgical intervention with various medical and radiotherapeutic approaches. The axiom-first, do no harm-should always be considered and an initial period of observation (ie, watchful waiting) is often appropriate to characterise tumour behaviour in patients with these pathogenic variants. These patients should be referred to specialised high-volume medical centres. This consensus guideline aims to help physicians with the clinical decision-making process when caring for patients with SDHD PPGLs.
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Affiliation(s)
- David Taïeb
- Department of Nuclear Medicine, Aix-Marseille University, La Timone University Hospital, Marseille, France
| | - George B Wanna
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maleeha Ahmad
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Charlotte Lussey-Lepoutre
- Université Paris Cité, Inserm, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France; Department of Nuclear Medicine, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Nancy D Perrier
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Svenja Nölting
- Svenja Nölting, Department of Endocrinology, Diabetology, and Clinical Nutrition, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Laurence Amar
- Université Paris Cité, Inserm, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France; Unité d'hypertension artérielle, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Zachary G Schwam
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, UTHealth Houston, McGovern Medical School, Memorial Hermann Hospital Heart and Vascular Institute, Houston, TX, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Erqi Liu Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lucas Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Ruth T Casey
- Department of Medical Genetics, NIHR Cambridge Biomedical Research Centre, Cancer Research UK Cambridge Centre, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Frédéric Castinetti
- Department of Endocrinology, Aix-Marseille University, Conception University Hospital, Marseille, France; INSERM U1251, Aix-Marseille University, Conception University Hospital, Marseille, France
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia; Cancer Genetics Laboratory, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Eleonora P M Corssmit
- Department of Endocrinology, Center of Endocrine Tumors Leiden, Leiden University Medical Centre, Leiden, Netherlands
| | - Ronald R de Krijger
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Jaydira Del Rivero
- Developmental Therapeutics Branch, Rare Tumor Initiative, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hans K Ghayee
- Division of Endocrinology and Metabolism, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Anne-Paule Gimenez-Roqueplo
- Université Paris Cité, Inserm, PARCC, Equipe Labellisée par la Ligue contre le Cancer, Paris, France; Département de Médecine Génomique des Tumeurs et des Cancers, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ashley Grossman
- Green Templeton College, University of Oxford, Oxford, UK; NET Unit, Royal Free Hospital, London, UK
| | - Alessio Imperiale
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe, IPHC, UMR 7178, CNRS, University of Strasbourg, Strasbourg, France
| | - Jeroen C Jansen
- Department of Otorhinolaryngology, Leiden University Medical Centre, Leiden, Netherlands
| | - Abhishek Jha
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Michiel N Kerstens
- Department of Endocrinology, University Medical Center Groningen, Groningen, Netherlands
| | - Henricus P M Kunst
- Department of Otolaryngology and Head & Neck Surgery, Dutch Academic Alliance Skull Base Pathology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Otolaryngology and Head & Neck Surgery, Dutch Academic Alliance Skull Base Pathology, Maastricht University Medical Center, Maastricht, Netherlands
| | - James K Liu
- Department of Neurosurgical Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Eamonn R Maher
- Department of Medical Genetics, NIHR Cambridge Biomedical Research Centre, Cancer Research UK Cambridge Centre, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Daniele Marchioni
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital of Verona, Verona, Italy
| | - Leilani B Mercado-Asis
- Section of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine & Surgery, University of Santo Tomas Hospital, University of Santo Tomas, Manila, Philippines
| | - Ozgur Mete
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Endocrine Pathology Society, Toronto, ON, Canada
| | - Mitsuhide Naruse
- Medical Center and Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Neeta Pandit-Taskar
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Frédéric Sebag
- Department of Endocrine Surgery, Aix-Marseille University, Conception University Hospital, Marseille, France
| | - Akiyo Tanabe
- Division of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan
| | - Jiri Widimsky
- Third Department of Medicine, Department of Endocrinology and Metabolism of the First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Leah Meuter
- Department of Physician Assistant Studies, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jacques W M Lenders
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
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15
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Gu Z, Hu K, Liang Y, Zhang F, Tong A, Hou X. Favorable outcome in advanced pheochromocytoma and paraganglioma after hypofractionated intensity modulated radiotherapy. J Endocrinol Invest 2023; 46:477-485. [PMID: 36121637 DOI: 10.1007/s40618-022-01908-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 08/19/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE The purpose of this study was to review outcomes of patients with advanced/metastatic pheochromocytoma/paraganglioma (PPGL) treated at our institution with Intensity-modulated radiotherapy (IMRT), describe the treatment outcomes, and determine predictors. METHODS A retrospective study on patients with advanced/metastatic PPGL who received IMRT at Peking Union Medical College Hospital between 2014 and 2019. A total of 14 patients with 17 lesions were included in this study. Ultra-hypofractionated radiation therapy was used for 7 lesions in 5 patients, while hypofractionated radiation therapy was used for 8 lesions in 7 patients. 2 patients got conventional fractionated radiotherapy. Patients who received external beam radiation therapy were given a median total radiation dose of 74.4/130 Gy (BED10/3) in a median of 13 fractions. RESULTS OS at 2 years was 78% for all patients. For lesions evaluated by RECIST response, at least stable disease of the target lesion was achieved in 94% and distant progression in 28.5%, with an average time to progression of 5.2 months. Patients with locally advanced primary tumors or recurred in situ (n = 8) achieved 100% local control, and none of them got recurrence or distant metastasis after radiotherapy at last follow-up (median 29 months). Of patients with catecholamine-related syndromes (n = 12), 91% of symptomatic lesions improved following radiation therapy and a more than 50% decline in catecholamines. CONCLUSIONS We have found hypofractionated IMRT effective as an additional therapy for patients with advanced primary tumors or recurrence in situ and not amenable to complete surgical resection.
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Affiliation(s)
- Z Gu
- Department of Radiation Oncology, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Dongdansantiao No. 5, Dongcheng District, Beijing, China
| | - K Hu
- Department of Radiation Oncology, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Dongdansantiao No. 5, Dongcheng District, Beijing, China
| | - Y Liang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Dongdansantiao No. 5, Dongcheng District, Beijing, China
| | - F Zhang
- Department of Radiation Oncology, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Dongdansantiao No. 5, Dongcheng District, Beijing, China
| | - A Tong
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health Commission of the People's Republic of China, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - X Hou
- Department of Radiation Oncology, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Hospital, Dongdansantiao No. 5, Dongcheng District, Beijing, China.
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16
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Linder T, Wakamatsu C, Jacovino J, Hsieh YH, Mueller M. Stereotactic body radiation therapy as an alternative to adrenalectomy for the treatment of pheochromocytomas in 8 dogs. Vet Comp Oncol 2023; 21:45-53. [PMID: 36149359 DOI: 10.1111/vco.12859] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 11/27/2022]
Abstract
The objective of this report is to describe the use and outcome of stereotactic body radiation therapy (SBRT) for treatment of pheochromocytomas in 8 dogs. Pheochromocytomas are an uncommon but challenging tumour to manage. Adrenalectomy is the standard of care for treatment of pheochromocytomas in both animals and humans; however, unpredictable catecholamine secretion from the tumour and vascular and local invasion of the tumour and thrombi can pose life-threatening perioperative and anaesthetic risks. SBRT has been investigated as an alternative to adrenalectomy in human patients with pheochromocytomas. Eight dogs with clinical signs, an adrenal mass, and cytology and/or urine normetanephrine/creatinine ratios consistent with pheochromocytoma were treated with SBRT in lieu of adrenalectomy. Three dogs presented with acute hemoabdomen. Seven dogs had caval tumour invasion, 3 with extension into the right atrium. Following SBRT, all dogs had complete resolution of clinical signs and reduced urine normetanephrine/creatinine ratio and/or tumour size. No significant anaesthetic complications were encountered. Acute radiation toxicity was limited to grade I gastrointestinal signs in 3 dogs and resolved within 1-2 days of symptomatic therapy. Five of 8 dogs were alive at the time of follow up, with a median follow up time of 25.8 months. SBRT resulted in a favourable outcome and mitigated the life-threatening risks of adrenalectomy in these 8 dogs. SBRT may be a safe and effective alternative to adrenalectomy for pheochromocytomas in dogs with non-resectable tumours, or for owners averse to the risks of surgery.
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Affiliation(s)
- Teresa Linder
- VCA West Los Angeles Animal Hospital, Los Angeles, California, USA
| | - Cory Wakamatsu
- VCA West Los Angeles Animal Hospital, Los Angeles, California, USA
| | - Joseph Jacovino
- VCA West Los Angeles Animal Hospital, Los Angeles, California, USA
| | - Yu Hung Hsieh
- VCA West Los Angeles Animal Hospital, Los Angeles, California, USA
| | - Maureen Mueller
- VCA West Los Angeles Animal Hospital, Los Angeles, California, USA
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17
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An Incidentally discovered paraaortic paraganglioma. ANGIOLOGIA 2023. [DOI: 10.20960/angiologia.00477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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18
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Wang K, Crona J, Beuschlein F, Grossman AB, Pacak K, Nölting S. Targeted Therapies in Pheochromocytoma and Paraganglioma. J Clin Endocrinol Metab 2022; 107:2963-2972. [PMID: 35973976 PMCID: PMC9923802 DOI: 10.1210/clinem/dgac471] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Indexed: 11/19/2022]
Abstract
Molecular targeted therapy plays an increasingly important role in the treatment of metastatic pheochromocytomas and paragangliomas (PPGLs), which are rare tumors but remain difficult to treat. This mini-review provides an overview of established molecular targeted therapies in present use, and perspectives on those currently under development and evaluation in clinical trials. Recently published research articles, guidelines, and expert views on molecular targeted therapies in PPGLs are systematically reviewed and summarized. Some tyrosine kinase inhibitors (sunitinib, cabozantinib) are already in clinical use with some promising results, but without formal approval for the treatment of PPGLs. Sunitinib is the only therapeutic option which has been investigated in a randomized placebo-controlled clinical trial. It is clinically used as a first-, second-, or third-line therapeutic option for the treatment of progressive metastatic PPGLs. Some other promising molecular targeted therapies (hypoxia-inducible factor 2 alpha [HIF2α] inhibitors, tumor vaccination together with checkpoint inhibitors, antiangiogenic therapies, kinase signaling inhibitors) are under evaluation in clinical trials. The HIF2α inhibitor belzutifan may prove to be particularly interesting for cluster 1B-/VHL/EPAS1-related PPGLs, whereas antiangiogenic therapies seem to be primarily effective in cluster 1A-/SDHx-related PPGLs. Some combination therapies currently being evaluated in clinical trials, such as temozolomide/olaparib, temozolomide/talazoparib, or cabozantinib/atezolizumab, will provide data for novel therapy for metastatic PPGLs. It is likely that advances in such molecular targeted therapies will play an essential role in the future treatment of these tumors, with more personalized therapy options paving the way towards improved therapeutic outcomes.
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Affiliation(s)
- Katharina Wang
- Department of Internal Medicine IV, University Hospital, LMU Klinikum, Ludwig Maximilian University of Munich, 80336 Munich, Germany
| | - Joakim Crona
- Department of Medical Sciences, Uppsala University, 75185 Uppsala, Sweden
| | - Felix Beuschlein
- Department of Internal Medicine IV, University Hospital, LMU Klinikum, Ludwig Maximilian University of Munich, 80336 Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), 8091 Zurich, Switzerland
| | - Ashley B Grossman
- Green Templeton College, University of Oxford, Oxford OX2 6HG, United Kingdom
- NET Unit, ENETS Centre of Excellence, Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-1109, USA
| | - Svenja Nölting
- Department of Internal Medicine IV, University Hospital, LMU Klinikum, Ludwig Maximilian University of Munich, 80336 Munich, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), 8091 Zurich, Switzerland
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Tang SS, Lee JWK, Wijerethne S, Iyer SG, Hue S, En NM, Parameswaran R. Locally invasive recurrence or metastasis of pheochromocytoma into the liver?—clinicopathological challenges. World J Surg Oncol 2022; 20:360. [DOI: 10.1186/s12957-022-02817-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
AbstractPheochromocytomas (PCC) are rare and functional neuroendocrine tumors developing from adrenal chromaffin cells. Predicting malignant behavior especially in the absence of metastasis can be quite challenging even in the era of improved understanding of the molecular mechanisms involved in PCCs. Currently, two histopathological grading systems Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) and Grading of Adrenal Pheochromocytoma and Paraganglioma (GAPP) score are used in clinical practice, but these are subject to significant interobserver variability. Some of the most useful clinical factors associated with malignancy are large size ([4–5 cm), and genetic features such as presence of SDHB germline mutations. Local invasion is uncommon in PCC and metastasis seen in 10 to 17% but higher in germline mutations and when this occurs management can be challenging. Here, we report on a case with challenges faced by the pathologist and clinicians alike in diagnosis and management of PCC recurrence.
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20
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Provenzano A, Chetta M, De Filpo G, Cantini G, La Barbera A, Nesi G, Santi R, Martinelli S, Rapizzi E, Luconi M, Maggi M, Mannelli M, Ercolino T, Canu L. Novel Germline PHD2 Variant in a Metastatic Pheochromocytoma and Chronic Myeloid Leukemia, but in the Absence of Polycythemia. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081113. [PMID: 36013579 PMCID: PMC9416477 DOI: 10.3390/medicina58081113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/16/2022]
Abstract
Background: Pheochromocytoma (Pheo) and paraganglioma (PGL) are rare tumors, mostly resulting from pathogenic variants of predisposing genes, with a genetic contribution that now stands at around 70%. Germline variants account for approximately 40%, while the remaining 30% is attributable to somatic variants. Objective: This study aimed to describe a new PHD2 (EGLN1) variant in a patient affected by metastatic Pheo and chronic myeloid leukemia (CML) without polycythemia and to emphasize the need to adopt a comprehensive next-generation sequencing (NGS) panel. Methods: Genetic analysis was carried out by NGS. This analysis was initially performed using a panel of genes known for tumor predisposition (EGLN1, EPAS1, FH, KIF1Bβ, MAX, NF1, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, TMEM127, and VHL), followed initially by SNP-CGH array, to exclude the presence of the pathogenic Copy Number Variants (CNVs) and the loss of heterozygosity (LOH) and subsequently by whole exome sequencing (WES) comparative sequence analysis of the DNA extracted from tumor fragments and peripheral blood. Results: We found a novel germline PHD2 (EGLN1) gene variant, c.153G>A, p.W51*, in a patient affected by metastatic Pheo and chronic myeloid leukemia (CML) in the absence of polycythemia. Conclusions: According to the latest guidelines, it is mandatory to perform genetic analysis in all Pheo/PGL cases regardless of phenotype. In patients with metastatic disease and no evidence of polycythemia, we propose testing for PHD2 (EGLN1) gene variants. A possible correlation between PHD2 (EGLN1) pathogenic variants and CML clinical course should be considered.
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Affiliation(s)
- Aldesia Provenzano
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
| | - Massimiliano Chetta
- Medical Genetics, Azienda Ospedaliera di Rilievo Nazionale (A.O.R.N.) Cardarelli, Padiglione, 80131 Naples, Italy
| | - Giuseppina De Filpo
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
| | - Giulia Cantini
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
| | - Andrea La Barbera
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
| | - Gabriella Nesi
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Raffaella Santi
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Serena Martinelli
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
| | - Elena Rapizzi
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, 50139 Florence, Italy
| | - Michaela Luconi
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
| | - Mario Maggi
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
- Endocrinology Unit, Azienda Ospedaliera-Universitaria Careggi, 50139 Florence, Italy
| | - Massimo Mannelli
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
| | - Tonino Ercolino
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
- Endocrinology Unit, Azienda Ospedaliera-Universitaria Careggi, 50139 Florence, Italy
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy
- Centro di Ricerca e Innovazione sulle Patologie Surrenaliche, AOU Careggi, 50139 Florence, Italy
- European Network for the Study of Adrenal Tumors (ENS@T) Center of Excellence, 50139 Florence, Italy
- Endocrinology Unit, Azienda Ospedaliera-Universitaria Careggi, 50139 Florence, Italy
- Correspondence:
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21
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Lin EP, Chin BB, Fishbein L, Moritani T, Montoya SP, Ellika S, Newlands S. Head and Neck Paragangliomas: An Update on the Molecular Classification, State-of-the-Art Imaging, and Management Recommendations. Radiol Imaging Cancer 2022; 4:e210088. [PMID: 35549357 DOI: 10.1148/rycan.210088] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Paragangliomas are neuroendocrine tumors that derive from paraganglia of the autonomic nervous system, with the majority of parasympathetic paragangliomas arising in the head and neck. More than one-third of all paragangliomas are hereditary, reflecting the strong genetic predisposition of these tumors. The molecular basis of paragangliomas has been investigated extensively in the past couple of decades, leading to the discovery of several molecular clusters and more than 20 well-characterized driver genes (somatic and hereditary), which are more than are known for any other endocrine tumor. Head and neck paragangliomas are largely related to the pseudohypoxia cluster and have been previously excluded from most molecular profiling studies. This review article introduces the molecular classification of paragangliomas, with a focus on head and neck paragangliomas, and discusses its impact on the management of these tumors. Genetic testing is now recommended for all patients with paragangliomas to provide screening and surveillance recommendations for patients and relatives. While CT and MRI provide excellent anatomic characterization of paragangliomas, gallium 68 tetraazacyclododecane tetraacetic acid-octreotate (ie, 68Ga-DOTATATE) has superior sensitivity and is recommended as first-line imaging in patients with head and neck paragangliomas with concern for multifocal and metastatic disease, patients with known multifocal and metastatic disease, and in candidates for targeted peptide-receptor therapy. Keywords: Molecular Imaging, MR Perfusion, MR Spectroscopy, Neuro-Oncology, PET/CT, SPECT/CT, Head/Neck, Genetic Defects © RSNA, 2022.
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Affiliation(s)
- Edward P Lin
- From the Departments of Imaging Sciences (E.P.L., S.E.) and Otolaryngology (S.N.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642; Departments of Radiology (B.B.C.) and Medicine (L.F.), University of Colorado School of Medicine, Denver, Colo; Department of Radiology, University of Michigan, Ann Arbor, Mich (T.M.); Eastern Radiologists, East Carolina University, Vidant Medical Center, Greenville, NC (S.P.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (S.P.M.)
| | - Bennett B Chin
- From the Departments of Imaging Sciences (E.P.L., S.E.) and Otolaryngology (S.N.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642; Departments of Radiology (B.B.C.) and Medicine (L.F.), University of Colorado School of Medicine, Denver, Colo; Department of Radiology, University of Michigan, Ann Arbor, Mich (T.M.); Eastern Radiologists, East Carolina University, Vidant Medical Center, Greenville, NC (S.P.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (S.P.M.)
| | - Lauren Fishbein
- From the Departments of Imaging Sciences (E.P.L., S.E.) and Otolaryngology (S.N.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642; Departments of Radiology (B.B.C.) and Medicine (L.F.), University of Colorado School of Medicine, Denver, Colo; Department of Radiology, University of Michigan, Ann Arbor, Mich (T.M.); Eastern Radiologists, East Carolina University, Vidant Medical Center, Greenville, NC (S.P.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (S.P.M.)
| | - Toshio Moritani
- From the Departments of Imaging Sciences (E.P.L., S.E.) and Otolaryngology (S.N.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642; Departments of Radiology (B.B.C.) and Medicine (L.F.), University of Colorado School of Medicine, Denver, Colo; Department of Radiology, University of Michigan, Ann Arbor, Mich (T.M.); Eastern Radiologists, East Carolina University, Vidant Medical Center, Greenville, NC (S.P.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (S.P.M.)
| | - Simone P Montoya
- From the Departments of Imaging Sciences (E.P.L., S.E.) and Otolaryngology (S.N.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642; Departments of Radiology (B.B.C.) and Medicine (L.F.), University of Colorado School of Medicine, Denver, Colo; Department of Radiology, University of Michigan, Ann Arbor, Mich (T.M.); Eastern Radiologists, East Carolina University, Vidant Medical Center, Greenville, NC (S.P.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (S.P.M.)
| | - Shehanaz Ellika
- From the Departments of Imaging Sciences (E.P.L., S.E.) and Otolaryngology (S.N.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642; Departments of Radiology (B.B.C.) and Medicine (L.F.), University of Colorado School of Medicine, Denver, Colo; Department of Radiology, University of Michigan, Ann Arbor, Mich (T.M.); Eastern Radiologists, East Carolina University, Vidant Medical Center, Greenville, NC (S.P.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (S.P.M.)
| | - Shawn Newlands
- From the Departments of Imaging Sciences (E.P.L., S.E.) and Otolaryngology (S.N.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642; Departments of Radiology (B.B.C.) and Medicine (L.F.), University of Colorado School of Medicine, Denver, Colo; Department of Radiology, University of Michigan, Ann Arbor, Mich (T.M.); Eastern Radiologists, East Carolina University, Vidant Medical Center, Greenville, NC (S.P.M.); and Department of Radiology, Massachusetts General Hospital, Boston, Mass (S.P.M.)
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22
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Nölting S, Bechmann N, Taieb D, Beuschlein F, Fassnacht M, Kroiss M, Eisenhofer G, Grossman A, Pacak K. Personalized Management of Pheochromocytoma and Paraganglioma. Endocr Rev 2022; 43:199-239. [PMID: 34147030 PMCID: PMC8905338 DOI: 10.1210/endrev/bnab019] [Citation(s) in RCA: 125] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Indexed: 02/07/2023]
Abstract
Pheochromocytomas/paragangliomas are characterized by a unique molecular landscape that allows their assignment to clusters based on underlying genetic alterations. With around 30% to 35% of Caucasian patients (a lower percentage in the Chinese population) showing germline mutations in susceptibility genes, pheochromocytomas/paragangliomas have the highest rate of heritability among all tumors. A further 35% to 40% of Caucasian patients (a higher percentage in the Chinese population) are affected by somatic driver mutations. Thus, around 70% of all patients with pheochromocytoma/paraganglioma can be assigned to 1 of 3 main molecular clusters with different phenotypes and clinical behavior. Krebs cycle/VHL/EPAS1-related cluster 1 tumors tend to a noradrenergic biochemical phenotype and require very close follow-up due to the risk of metastasis and recurrence. In contrast, kinase signaling-related cluster 2 tumors are characterized by an adrenergic phenotype and episodic symptoms, with generally a less aggressive course. The clinical correlates of patients with Wnt signaling-related cluster 3 tumors are currently poorly described, but aggressive behavior seems likely. In this review, we explore and explain why cluster-specific (personalized) management of pheochromocytoma/paraganglioma is essential to ascertain clinical behavior and prognosis, guide individual diagnostic procedures (biochemical interpretation, choice of the most sensitive imaging modalities), and provide personalized management and follow-up. Although cluster-specific therapy of inoperable/metastatic disease has not yet entered routine clinical practice, we suggest that informed personalized genetic-driven treatment should be implemented as a logical next step. This review amalgamates published guidelines and expert views within each cluster for a coherent individualized patient management plan.
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Affiliation(s)
- Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), CH-8091 Zurich, Switzerland.,Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Nicole Bechmann
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - David Taieb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, 13273 Marseille, France
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich (USZ) and University of Zurich (UZH), CH-8091 Zurich, Switzerland.,Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Martin Fassnacht
- Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Matthias Kroiss
- Department of Medicine IV, University Hospital, LMU Munich, 80336 Munich, Germany.,Department of Medicine, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, 97080 Würzburg, Germany
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany.,Department of Medicine III, University Hospital Carl Gustav Carus, Medical Faculty Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford OX2 6HG, UK.,Centre for Endocrinology, Barts and the London School of Medicine, London EC1M 6BQ, UK.,ENETS Centre of Excellence, Royal Free Hospital, London NW3 2QG, UK
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD 20847, USA
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23
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Moscona-Nissan A, Saldívar-Rodea CA, Enríquez-García R, Rincón-Ángel LI, Calzada AN, Seidman-Sorsby A, Cruz-Zermeño M. Bilateral carotid body tumor case: A novel preoperative management. Radiol Case Rep 2022; 17:1021-1029. [PMID: 35140832 PMCID: PMC8813562 DOI: 10.1016/j.radcr.2021.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
Paragangliomas are rare neuroendocrine neoplasms. The most common form of these tumors in head and neck are non-functional carotid body tumors. These neoplasms may present an extensive growth and compromise vital neurovascular structures in the neck, such as carotid vessels. Carotid body tumors usually present clinically as painless neck masses and occur most frequently in adults averaging 45 to 50 years, being the majority of these tumors unilateral and only 5% of all cases bilateral. The main treatment for carotid body paragangliomas is surgical resection, which can be extremely challenging due to tumor hypervascularity and significant blood loss. We present a bilateral carotid body tumor case in a 61-year-old woman who presented due to a pulsatile and painless mass in the right carotid region of the neck of 1-year of evolution. The tumor was found encasing the external carotid artery and classified as Shamblin II. A novel approach for preoperative management was performed, placing a covered graft-stent in the right common and proximal (C1) internal carotid arteries in order to splint and provide structural protection for carotid vessels during surgical resection and temporarily reduce blood flow of the carotid body tumor.
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Affiliation(s)
- Alberto Moscona-Nissan
- School of Medicine, Universidad Panamericana, Mexico City, Mexico
- Corresponding author. Alberto Moscona-Nissan.
| | - Carlos A Saldívar-Rodea
- Interventional Radiology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - Rocío Enríquez-García
- Interventional Radiology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
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24
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Pheochromocytomas and Abdominal Paragangliomas: A Practical Guidance. Cancers (Basel) 2022; 14:cancers14040917. [PMID: 35205664 PMCID: PMC8869962 DOI: 10.3390/cancers14040917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare. They can be discovered incidentally by imaging with computed tomography or magnetic resonance imaging and during hormonal surveillance in patients with known genetic variants that are associated with PPGLs. As most PPGLs are functioning, a hormonal work-up evaluating for catecholamine excess is recommended. Classical symptoms, such as tachycardia, hypertension and headache, can be present, but when the PPGL is discovered as an incidentaloma, symptoms may be lacking or be more discrete. PPGLs carry malignant potential, and patients should undergo close surveillance, as recurrence of disease or metastasis may develop. Genetic susceptibility for multifocal disease has gained more attention, and germline variants are commonly detected, thus facilitating detection of hereditary cases and afflicted family members. Any patient with a PPGL should be managed by an expert multidisciplinary team consisting of endocrinologists, radiologists, surgeons, pathologists and clinical geneticists. Abstract Pheochromocytomas and abdominal paragangliomas (PPGLs) are rare tumors arising from the adrenal medulla or the sympathetic nervous system. This review presents a practical guidance for clinicians dealing with PPGLs. The incidence of PPGLs has risen. Most cases are detected via imaging and less present with symptoms of catecholamine excess. Most PPGLs secrete catecholamines, with diffuse symptoms. Diagnosis is made by imaging and tests of catecholamines. Localized disease can be cured by surgery. PPGLs are the most heritable of all human tumors, and germline variants are found in approximately 30–50% of cases. Such variants can give information regarding the risk of developing recurrence or metastases as well as the risk of developing other tumors and may identify relatives at risk for disease. All PPGLs harbor malignant potential, and current histological and immunohistochemical algorithms can aid in the identification of indolent vs. aggressive tumors. While most patients with metastatic PPGL have slowly progressive disease, a proportion of patients present with an aggressive course, highlighting the need for more effective therapies in these cases. We conclude that PPGLs are rare but increasing in incidence and management should be guided by a multidisciplinary team.
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25
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De Filpo G, Cantini G, Rastrelli G, Vannini G, Ercolino T, Luconi M, Mannelli M, Maggi M, Canu L. Management and outcome of metastatic pheochromocytomas/paragangliomas: a monocentric experience. J Endocrinol Invest 2022; 45:149-157. [PMID: 34227051 PMCID: PMC8741659 DOI: 10.1007/s40618-021-01629-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/28/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors releasing catecholamines. Metastatic pheochromocytomas/paragangliomas (PPGLs) occur in about 5-26% of cases. To date, the management of patients affected by metastatic disease is a challenge in the absence of guidelines. AIM The aim of this study was to evaluate the overall survival (OS) and the progression-free survival (PFS) in metastatic PPGLs. METHODS Clinical data of 20 patients referred to the Careggi University Hospital (Florence, Italy) were retrospectively collected. Follow-up ranged from 1989 to 2019. Site and size of primary tumor, biochemical activity, genetic analysis and employed therapies were considered. Data were analyzed with SPSS version 27. RESULTS Nine PHEOs (45%) and 11 PGLs (55%) were enrolled. Median age at diagnosis was 43.5 years [30-55]. Mean follow-up was 104.6 ± 89.3 months. Catecholamines were released in 70% of cases. An inherited disease was reported in 50% of patients. OS from the initial diagnosis (OSpt) and from the metastatic appearance (OSmtx) were lower in older patients (OSpt p = 0.028; OSmtx p < 0.001), abdominal PGLs (OSpt p = 0.007; OSmtx p = 0.041), larger tumors (OSpt p = 0.008; OSmtx p = 0.025) and sporadic disease (OSpt p = 0.013; OSmtx p = 0.008). CONCLUSION Our data showed that older age at the initial diagnosis, sympathetic extra-adrenal localization, larger tumors and wild-type neoplasms are related to worse prognosis. Notably, the employed therapies do not seem to influence the survival of our patients. At present, effective treatments for metastatic PPGLs are missing and a multidisciplinary approach is indispensably required.
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Affiliation(s)
- G De Filpo
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy.
| | - G Cantini
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - G Rastrelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - G Vannini
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - T Ercolino
- Endocrinology Unit, Careggi University Hospital, Florence, Italy
| | - M Luconi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - M Mannelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - M Maggi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - L Canu
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
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26
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Zhang X, Zhong S. PDK1 Inhibitor GSK-470 Exhibits Potent Anticancer Activity in a Pheochromocytoma PC12 Cell Tumor Model via Akt/mTOR Pathway. Anticancer Agents Med Chem 2021; 20:828-833. [PMID: 32188393 DOI: 10.2174/1871520620666200318100701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/09/2020] [Accepted: 02/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Phosphoinositide-Dependent Kinase 1 (PDK1) is now widely studied in malignant solid tumors. Researchers have previously revealed that targeting PDK1 is thought of as a promising anticancer treatment strategy. The aim of this study was designed to evaluate the anticancer activity of GSK-470, a novel and highly specific inhibitor of PDK1, in Pheochromocytoma (PCC) tumor model. METHODS PC12 cells were xenografted into nude mice to build PCC tumor model. Animals were treated with GSK-470 vs vehicle. Mean tumor volume was calculated and compared across groups. TUNEL was used to detect apoptosis. The effects of PDK1 inhibitor GSK-470 on activation of the Akt signaling and its downstream Akt/mTOR pathway in xenotransplant tumor tissues were examined by western bolt. RESULTS The mean tumor volume in GSK-470 group was significantly less than that in control group. TUNEL results found that cell apoptosis was markedly increased in GSK-470 group compared with the control group. The western bolt analysis showed that the phosphorylation of Akt at threonine 308 was significantly reduced in GSK-470 group. Also, GSK-470 strongly inhibited phosphorylation of mTOR on Ser2448, a marker for mTORC1 activity, as well as phosphorylation of p70S6K, best characterized targets of mTOR. CONCLUSION Our results showed that GSK-470 exhibited potent anticancer activity in PC12 tumor-bearing mice. Also, we found that this effect appeared to be mediated by the inhibition of the Akt/mTOR pathway. The present study once again provides new insights into the therapeutic effects of inhibiting PDK1 in the treatment of malignant PCC. Therefore, we propose that GSK-470 might be an effective therapeutic agent for the treatment of malignant PCC.
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Affiliation(s)
- Xiaohua Zhang
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shan Zhong
- Department of Urology, Huashan Hospital, Fudan University, Shanghai, China
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27
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Granberg D, Juhlin CC, Falhammar H. Metastatic Pheochromocytomas and Abdominal Paragangliomas. J Clin Endocrinol Metab 2021; 106:e1937-e1952. [PMID: 33462603 PMCID: PMC8063253 DOI: 10.1210/clinem/dgaa982] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGLs) are believed to harbor malignant potential; about 10% to 15% of pheochromocytomas and up to 50% of abdominal paragangliomas will exhibit metastatic behavior. EVIDENCE ACQUISITION Extensive searches in the PubMed database with various combinations of the key words pheochromocytoma, paraganglioma, metastatic, malignant, diagnosis, pathology, genetic, and treatment were the basis for the present review. DATA SYNTHESIS To pinpoint metastatic potential in PPGLs is difficult, but nevertheless crucial for the individual patient to receive tailor-made follow-up and adjuvant treatment following primary surgery. A combination of histological workup and molecular predictive markers can possibly aid the clinicians in this aspect. Most patients with PPGLs have localized disease and may be cured by surgery. Plasma metanephrines are the main biochemical tests. Genetic testing is important, both for counseling and prognostic estimation. Apart from computed tomography and magnetic resonance imaging, molecular imaging using 68Ga-DOTATOC/DOTATATE should be performed. 123I-MIBG scintigraphy may be performed to determine whether 131I-MIBG therapy is a possible option. As first-line treatment in patients with metastatic disease, 177Lu-DOTATATE or 131I-MIBG is recommended, depending on which shows best expression. In patients with very low proliferative activity, watch-and-wait or primary treatment with long-acting somatostatin analogues may be considered. As second-line treatment, or first-line in patients with high proliferative rate, chemotherapy with temozolomide or cyclophosphamide + vincristine + dacarbazine is the therapy of choice. Other therapies, including sunitinib, cabozantinib, everolimus, and PD-1/PDL-1 inhibitors, have shown modest effect. CONCLUSIONS Metastatic PPGLs need individualized management and should always be discussed in specialized and interdisciplinary tumor boards. Further studies and newer treatment modalities are urgently needed.
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Affiliation(s)
- Dan Granberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Carl Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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28
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Dillon JS, Bushnell D, Laux DE. High-specific-activity 131iodine-metaiodobenzylguanidine for therapy of unresectable pheochromocytoma and paraganglioma. Future Oncol 2021; 17:1131-1141. [PMID: 33506713 DOI: 10.2217/fon-2020-0625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPG) are rare cancers arising from the adrenal medulla (pheochromocytoma) or autonomic ganglia (paraganglioma). They have highly variable biological behavior. Most PPG express high-affinity norepinephrine transporters, allowing active uptake of the norepinephrine analog, 131iodine-metaiodobenzylguanidine (131I-MIBG). Low-specific-activity forms of 131I-MIBG have been used since 1983 for therapy of PPG. High-specific-activity 131I-MIBG therapy improves hypertension management, induces partial radiological response or stable disease, decreases biochemical markers of disease activity and is well tolerated by patients. This drug, approved in the USA in July 2018, is the first approved agent for patients with unresectable, locally advanced or metastatic PPG and imaging evidence of metaiodobenzylguanidine uptake, who require systemic anticancer therapy.
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Affiliation(s)
- Joseph S Dillon
- Division of Endocrinology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - David Bushnell
- Department of Radiology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Douglas E Laux
- Division of Oncology, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
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29
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González ID, Vallejo A, Guerrero Lizcano E, Pabón Girón A. Adrenal Pheochromocytoma Treated With Stereotactic Body Radiation Therapy. Cureus 2021; 13:e12456. [PMID: 33552774 PMCID: PMC7856918 DOI: 10.7759/cureus.12456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pheochromocytoma is a rare neuroendocrine tumor arising from chromaffin cells in the adrenal medulla. In most cases, it is benign and tends to remain localized. However since it leads to the development of cardiovascular disease, it is associated with high rates of morbidity and mortality. Treatment options include medical, surgical, or ablative measures, which often adequately control the disease. Primary pheochromocytoma is conventionally treated with external beam radiation therapy (EBRT), while stereotactic body radiation therapy (SBRT) is preferred for cases with metastasis. However, literature regarding the use of SBRT for the treatment of primary disease is scarce. This case report describes a patient with an inoperable primary adrenal gland pheochromocytoma who was treated with SBRT, resulting in adequate symptomatic control during clinical follow-up.
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Affiliation(s)
- Iván D González
- Radiation Oncology, Universidad Militar Nueva Granada, Bogota, COL
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De Filpo G, Maggi M, Mannelli M, Canu L. Management and outcome of metastatic pheochromocytomas/paragangliomas: an overview. J Endocrinol Invest 2021; 44:15-25. [PMID: 32602077 DOI: 10.1007/s40618-020-01344-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/23/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Metastatic pheochromocytomas and paragangliomas (PPGLs) occur in about 5-26% of cases and are characterized by a heterogeneous prognosis. Metastases can be synchronous at the initial diagnosis, but they can occur also many years after surgery for the primary tumor. To date, the treatment of patients affected by metastatic PPGLs represents a clinical challenge because of the lack of guidelines. AIM The aim of this article is to review the available management options and their impact on the outcomes of patients with metastatic PPGLs. RESULTS Generally, treatments are not curative. Surgery, when possible, can be used to reduce hormonal symptoms and cardiovascular morbidity. Chemotherapy plays a role in patients with high burden tumor and rapid disease progression. Tyrosine kinases inhibitors (TKIs) might be considered for their ability to block the angiogenesis and cell growth. Radiation therapy and interventional radiology techniques can help in the management of local metastases to control symptoms and avoid tumor progression. On the other hand, peptide receptor radionuclide therapy (PRRT), using 90Y or 177Lu-DOTATATE, could be a promising therapy. In addition, high specific 131I-MIBG was approved by the Food and Drug Administration (FDA) in the US for the treatment of patients affected by metastatic and unresectable 131I-MIBG positive PPGLs. Considering the different pathways involved in the pathogenesis of PPGLs, several target therapies have been proposed and are under evaluation in clinical trials. CONCLUSIONS The choice of the appropriate treatment should be based on multidisciplinary and personalized approach taking into account the rarity and the variability of these tumors.
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Affiliation(s)
- G De Filpo
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy.
| | - M Maggi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - M Mannelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - L Canu
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
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Shi H, Wang C, Qiang W, Sun B, Wang H, Yuan Y, Hu W. Case Report: Successful Control of Pulmonary Metastatic Pheochromocytoma With Iodine-125 Seed Implantation. Front Endocrinol (Lausanne) 2021; 12:714006. [PMID: 34434169 PMCID: PMC8380843 DOI: 10.3389/fendo.2021.714006] [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: 05/24/2021] [Accepted: 07/22/2021] [Indexed: 11/20/2022] Open
Abstract
Pheochromocytoma with lung metastases is rare in clinics, and the prognosis of metastatic pheochromocytoma is generally poor. In this case, a 57-year-old woman who presented with hypertension and palpitations was diagnosed with left adrenal pheochromocytoma with lung metastasis in 2010. The patient received left adrenalectomy for pheochromocytoma 10 years ago, but pulmonary lesions had significant progression 7 years ago. The patient was treated with iodine-125 (125I) seed implantation for pulmonary lesions. All of the 5 pulmonary lesions achieved partial response 6 months later, further shrank 1 year later, and were successfully controlled for 7 years. This case indicated that 125I seed implantation could be an alternative local therapy for metastatic pheochromocytoma in the lung.
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Abstract
PURPOSE OF REVIEW To discuss selected endocrine causes of hypertension and to provide practical clinical recommendations regarding the evaluation and treatment of these disorders. RECENT FINDINGS More than 15 endocrine disorders with varying rates of prevalence can cause hypertension. For example, primary aldosteronism may exist in up to 20% of patients with resistant hypertension. Recognition of these important secondary causes of hypertension is essential to provide contemporary targeted therapies in order to improve long-term disease outcomes. Clinicians must have a broad understanding of the prevalence, clinical presentation, and current diagnostic modalities for endocrine causes of hypertension to facilitate prompt referral, identification, and optimal management of these disorders. Endocrine causes of hypertension are multifactorial and, in some cases, widely prevalent. It is important for clinicians considering secondary causes of hypertension to be knowledgeable about the underlying pathophysiology of these disorders and to understand when additional evaluation and treatment may be needed.
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Tanabe A, Naruse M. Recent advances in the management of pheochromocytoma and paraganglioma. Hypertens Res 2020; 43:1141-1151. [PMID: 32778780 DOI: 10.1038/s41440-020-0531-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 12/12/2022]
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare tumors that cause refractory hypertension and hypertensive crisis. Although metastatic disease accounts for 30% of PPGLs, the diagnosis of malignancy is difficult without the presence of metastatic lesions. Here, we review several advancements in the diagnosis and treatment of PPGL. A nationwide epidemiological survey in Japan revealed that the annual number of patients with PPGL was 3000, which was higher than that reported previously. While plasma and urine fractionated metanephrines are recommended for use in specific biochemical testing for diagnosis, creatinine-corrected fractionated metanephrines in spot urine samples that had been widely used in Japan as a convenient screening test were shown to be as useful as 24-h urine fractionated metanephrines. Regarding imaging studies, a more specific functional imaging for PPGLs, 68Ga DOTATATE, was newly developed. 68Ga DOTATATE provides a clear image with high sensitivity and specificity. Currently, PASS or GAPP histological scores and SDHB immunostaining are clinically used to attempt to discriminate benign from malignant tumors. However, since this distinguishing process remains difficult, all cases were classified as malignant with the possibility of metastasis in the WHO classification of endocrine tumors updated in 2017. Approximately 60% of PPGLs have germline mutations in PPGL-related genes. Currently, the genes are classified into two clusters based on their mechanism for the etiology of tumorigenesis. Based on the possible mechanisms of tumor development associated with gene mutations, several molecular target drugs are under evaluation to explore more promising treatments for malignant PPGL.
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Affiliation(s)
- Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Shinjuku-ku, Tokyo, Japan.
| | - Mitsuhide Naruse
- Clinical Research Institute of Endocrinology and Metabolism, NHO Kyoto Medical Center, Kyoto, Japan.,Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
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Roll W, Müther M, Sporns PB, Zinnhardt B, Suero Molina E, Seifert R, Schäfers M, Weckesser M, Stegger L, Beule AG, Stummer W, Rahbar K. Somatostatin Receptor-Targeted Radioligand Therapy in Head and Neck Paraganglioma. World Neurosurg 2020; 143:e391-e399. [PMID: 32745642 DOI: 10.1016/j.wneu.2020.07.165] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Surgical resection is the therapy of choice in head and neck paraganglioma but is associated with considerable morbidity. For treatment of inoperable or progressive disease, less aggressive adjuvant options are warranted. This study assessed effectiveness and safety of peptide receptor radionuclide therapy (PRRT) with lutetium-177-DOTATATE for head and neck paraganglioma with emphasis on response assessment. METHODS A retrospective analysis of 7 patients with head and neck paraganglioma treated with PPRT between May 2014 and October 2016 was performed. Three patients had jugulotympanic paraganglioma, 3 patients had carotid body tumors, and 1 patient had a combination of both. Patients underwent PRRT after discussion in the local tumor board regarding progressive disease, inoperability, or lack of other adjuvant options. All patients underwent 3-5 cycles of PRRT. Treatment response was evaluated by gallium-68-DOTATATE positron emission tomography/computed tomography and contrast-enhanced computed tomography or magnetic resonance imaging. Outcome measures were two-dimensional tumor diameters and total tumor volumes. RESULTS Median patient age was 60 years (interquartile range: 14-84 years). All patients had stable disease at posttherapy assessment. Decreasing tumor volumes were found in 4 patients. Clinical symptoms improved in 2 patients. No progression or adverse events occurred during a median follow-up of 39 months (interquartile range: 35-47 months). CONCLUSIONS Somatostatin receptor-targeted therapy using lutetium-177-DOTATATE shows promising effectiveness with a high safety profile. Patients in whom surgical morbidity outweighs oncologic benefit should be informed about PRRT as a treatment option.
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Affiliation(s)
- Wolfgang Roll
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Michael Müther
- Department of Neurosurgery, University Hospital Münster, Münster, Germany.
| | - Peter B Sporns
- Institute of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Bastian Zinnhardt
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany; European Institute of Molecular Imaging, University of Münster, Münster, Germany
| | - Eric Suero Molina
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Robert Seifert
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany; European Institute of Molecular Imaging, University of Münster, Münster, Germany
| | - Michael Schäfers
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany; European Institute of Molecular Imaging, University of Münster, Münster, Germany
| | - Matthias Weckesser
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Lars Stegger
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
| | - Achim G Beule
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - Kambiz Rahbar
- Department of Nuclear Medicine, University Hospital Münster, Münster, Germany
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Young WF. Metastatic Pheochromocytoma: In Search of a Cure. Endocrinology 2020; 161:5775763. [PMID: 32126137 DOI: 10.1210/endocr/bqz019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/18/2020] [Indexed: 11/19/2022]
Affiliation(s)
- William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Jasim S, Jimenez C. Metastatic pheochromocytoma and paraganglioma: Management of endocrine manifestations, surgery and ablative procedures, and systemic therapies. Best Pract Res Clin Endocrinol Metab 2020; 34:101354. [PMID: 31685417 DOI: 10.1016/j.beem.2019.101354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metastatic pheochromocytomas and paragangliomas (MPPGs) are rare neuroendocrine tumors. Most patients present with advanced disease that is associated with manifestations of catecholamine release. Surgical resection of the primary tumor and ablative therapies of metastases-whenever possible-may improve clinical outcomes and, perhaps, lengthen the patient's overall survival. Significant steps in understanding the genetic alterations linked to MPPGs and scientific progress made on cancers that share a similar pathogenesis are leading to the recognition of potential systemic therapeutic options. Data derived from clinical trials evaluating targeted therapies such as tyrosine kinase inhibitors, radiopharmaceuticals, immunotherapy, and combinations of these will likely improve the outcomes of patients with advanced and progressive MPPGs. Exemplary of this success is the recent approval in the United States of the high-specific-activity iodine131 meta-iodine-benzylguanidine (MIBG) for patients with unresectable and progressive MPPGs that express the noradrenaline transporter. This review will discuss the therapeutic approaches for patients with MPPGs.
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Affiliation(s)
- Sina Jasim
- The Division of Endocrinology, Metabolism and Lipid Research, Campus box 8127, Washington University, School of Medicine, 660 S. Euclid Ave., St. Louis, Missouri 63110, USA
| | - Camilo Jimenez
- The Department of Endocrine Neoplasia and Hormonal Disorders at the University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA.
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Taïeb D, Jha A, Treglia G, Pacak K. Molecular imaging and radionuclide therapy of pheochromocytoma and paraganglioma in the era of genomic characterization of disease subgroups. Endocr Relat Cancer 2019; 26:R627-R652. [PMID: 31561209 PMCID: PMC7002202 DOI: 10.1530/erc-19-0165] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 12/13/2022]
Abstract
In recent years, advancement in genetics has profoundly helped to gain a more comprehensive molecular, pathogenic, and prognostic picture of pheochromocytomas and paragangliomas (PPGLs). Newly discovered molecular targets, particularly those that target cell membranes or signaling pathways have helped move nuclear medicine in the forefront of PPGL precision medicine. This is mainly based on the introduction and increasing experience of various PET radiopharmaceuticals across PPGL genotypes quickly followed by implementation of novel radiotherapies and revised imaging algorithms. Particularly, 68Ga-labeled-SSAs have shown excellent results in the diagnosis and staging of PPGLs and in selecting patients for PRRT as a potential alternative to 123/131I-MIBG theranostics. PRRT using 90Y/177Lu-DOTA-SSAs has shown promise for treatment of PPGLs with improvement of clinical symptoms and/or disease control. However, more well-designed prospective studies are required to confirm these findings, in order to fully exploit PRRT's antitumoral properties to obtain the final FDA approval. Such an approval has recently been obtained for high-specific-activity 131I-MIBG for inoperable/metastatic PPGL. The increasing experience and encouraging preliminary results of these radiotherapeutic approaches in PPGLs now raises an important question of how to further integrate them into PPGL management (e.g. monotherapy or in combination with other systemic therapies), carefully taking into account the PPGLs locations, genotypes, and growth rate. Thus, targeted radionuclide therapy (TRT) should preferably be performed at specialized centers with an experienced interdisciplinary team. Future perspectives include the introduction of dosimetry and biomarkers for therapeutic responses for more individualized treatment plans, α-emitting isotopes, and the combination of TRT with other systemic therapies.
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Affiliation(s)
- David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - Abhishek Jha
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Giorgio Treglia
- Clinic of Nuclear Medicine and PET/CT Center, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital, Lausanne, Switzerland
- Health Technology Assessment Unit, General Directorate, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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Wang B, Qiu J. Progress in the diagnosis and treatment of paraganglioma. Transl Cancer Res 2019; 8:2624-2635. [PMID: 35117020 PMCID: PMC8797373 DOI: 10.21037/tcr.2019.10.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/24/2019] [Indexed: 11/09/2022]
Abstract
Neuroendocrine tumors derived from the adrenal medulla and the adrenal gland are called pheochromocytoma (PHEO) and paraganglioma (PGL), respectively. PGLs are neuroepithelial cell clusters associated with sympathetic or parasympathetic nerves, and are scattered throughout the body. According to the World Health Organization, the presence of distant metastases indicates malignant PGL. Most PGLs are benign, but their high secretion of catecholamines in the blood is associated with high blood pressure, cardiovascular disease, and death. Further research on PGL is required to provide a theoretical basis for clinical diagnosis and treatment. This article reviews the genetics, clinical manifestations, benign and malignant forms, current major diagnostic methods, and progress in the treatment of PGL.
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Affiliation(s)
- Ben Wang
- Xi’an Medical University, Xi’an 710068, China
| | - Jian Qiu
- Department of General Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, China
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Nölting S, Ullrich M, Pietzsch J, Ziegler CG, Eisenhofer G, Grossman A, Pacak K. Current Management of Pheochromocytoma/Paraganglioma: A Guide for the Practicing Clinician in the Era of Precision Medicine. Cancers (Basel) 2019; 11:cancers11101505. [PMID: 31597347 PMCID: PMC6827093 DOI: 10.3390/cancers11101505] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/18/2019] [Accepted: 09/24/2019] [Indexed: 12/13/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PCC/PGLs) are rare, mostly catecholamine-producing neuroendocrine tumors of the adrenal gland (PCCs) or the extra-adrenal paraganglia (PGL). They can be separated into three different molecular clusters depending on their underlying gene mutations in any of the at least 20 known susceptibility genes: The pseudohypoxia-associated cluster 1, the kinase signaling-associated cluster 2, and the Wnt signaling-associated cluster 3. In addition to tumor size, location (adrenal vs. extra-adrenal), multiplicity, age of first diagnosis, and presence of metastatic disease (including tumor burden), other decisive factors for best clinical management of PCC/PGL include the underlying germline mutation. The above factors can impact the choice of different biomarkers and imaging modalities for PCC/PGL diagnosis, as well as screening for other neoplasms, staging, follow-up, and therapy options. This review provides a guide for practicing clinicians summarizing current management of PCC/PGL according to tumor size, location, age of first diagnosis, presence of metastases, and especially underlying mutations in the era of precision medicine.
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Affiliation(s)
- Svenja Nölting
- Department of Medicine IV, University Hospital, LMU Munich, Ziemssenstraße 1, 80336 München, Germany.
| | - Martin Ullrich
- Department of Radiopharmaceutical and Chemical Biology, Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf, Bautzner Landstrasse 400, 01328 Dresden, Germany.
| | - Jens Pietzsch
- Department of Radiopharmaceutical and Chemical Biology, Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf, Bautzner Landstrasse 400, 01328 Dresden, Germany.
- Department of Chemistry and Food Chemistry, School of Science, Technische Universität Dresden, Mommsenstrasse 9, 01062 Dresden, Germany.
| | - Christian G Ziegler
- Department of Medicine III, University Hospital Carl Gustav Carus Dresden, Fetscherstraße 74, 01307 Dresden, Germany.
| | - Graeme Eisenhofer
- Department of Medicine III, University Hospital Carl Gustav Carus Dresden, Fetscherstraße 74, 01307 Dresden, Germany.
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, 01307 Dresden, Germany.
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford Ox3 7LJ, UK.
- Department of Gastroenterology, Royal Free Hospital ENETS Centre of Excellence, London NW3 2QG, UK.
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20814, USA.
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Labib M, Ismail A, Elmansy H, Shahrour W, Prowse O, Kotb A. Adrenalectomy for huge solid pheochromocytoma: a challenging surgery or piece of cake? J Surg Case Rep 2019; 2019:rjz255. [PMID: 31462986 PMCID: PMC6705450 DOI: 10.1093/jscr/rjz255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/26/2019] [Accepted: 08/03/2019] [Indexed: 12/17/2022] Open
Abstract
Pheochromocytoma (PCC) is an uncommon adrenal tumor that is occasionally diagnosed during the work up for patients with uncontrolled hypertension. Treatment of PCC is mainly surgical. This case represents the largest PCC reported to date, which was safely removed.
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Affiliation(s)
- Mahmoud Labib
- Anesthesia Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Asmaa Ismail
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Hazem Elmansy
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Walid Shahrour
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Owen Prowse
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Ahmed Kotb
- Urology Department, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
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Hamidi O. Metastatic pheochromocytoma and paraganglioma: recent advances in prognosis and management. Curr Opin Endocrinol Diabetes Obes 2019; 26:146-154. [PMID: 30893083 DOI: 10.1097/med.0000000000000476] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Metastatic pheochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumors with variable prognosis. This review highlights recent studies on outcomes and management of patients with metastatic PPGL. RECENT FINDINGS Latest advances were made in identifying predictors of favorable outcomes of patients with metastatic PPGL. Recent studies evaluated the efficacy of tyrosine kinase inhibitors, high-specific-activity radiopharmaceuticals, and peptide receptors radionuclide therapy in treatment of metastatic disease. Moreover, ongoing studies are assessing the effects of hypoxia-inducible factor 2αα and heat shock protein 90 inhibitors as potential therapies. SUMMARY Several active studies are evaluating the efficacy of systemic chemo, immuno, radiopharmaceutical, and peptide receptor radionuclide therapies to relieve local and adrenergic symptoms and provide survival benefit for patients with symptomatic and/or progressive advanced metastatic PPGL. Owing to rarity and wide-outcome variability, multidisciplinary team effort and personalized approach are central in caring for patients with metastatic PPGL.
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Affiliation(s)
- Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Nölting S, Grossman A, Pacak K. Metastatic Phaeochromocytoma: Spinning Towards More Promising Treatment Options. Exp Clin Endocrinol Diabetes 2019; 127:117-128. [PMID: 30235495 PMCID: PMC7443617 DOI: 10.1055/a-0715-1888] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Phaeochromocytomas (PCC) and paragangliomas (PGL) are rare tumours arising from the chromaffin cells of the adrenal medulla (PCC) or the paraganglia located outside the adrenal gland (PGL). However, their incidence is likely to be underestimated; around 10% of all PCC/PGL are metastatic, with higher metastatic potential of PGLs compared to PCCs. If benign, surgery is the treatment of choice, but if metastatic, therapy is challenging. Here we review the currently existing therapy options for metastatic PCCs/PGLs including conventional chemotherapy (the original Averbuch scheme, but updated), radiopharmaceutical treatments (131I-MIBG, 90Y- and 177Lu-DOTATATE) and novel targeted therapies (anti-angiogenic tyrosine kinase inhibitors and mTORC1 inhibitors), emphasising future therapeutic approaches (HIF-2α and PARP inhibitors, temozolomide alone, metronomic temozolomide, somatostatin analogues) based on the oncogenic signalling pathways related to three different clusters comprising more than 20 well-characterised PCC/PGL susceptibility genes. We suggest that targeted combination therapies including repurposed agents may offer more effective future options worthy of exploration.
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Affiliation(s)
- Svenja Nölting
- Medizinische Klinik und Poliklinik IV, Interdisciplinary Center of Neuroendocrine Tumours of the GastroEntero-Pancreatic System (GEPNET-KUM), Klinikum der Universität München (KUM), Ludwig-Maximilians-University, Munich, Germany
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, Royal Free Hospital ENETS Centre of Excellence, London, and Barts and the London Scool of Medicine, London, UK
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Mak IYF, Hayes AR, Khoo B, Grossman A. Peptide Receptor Radionuclide Therapy as a Novel Treatment for Metastatic and Invasive Phaeochromocytoma and Paraganglioma. Neuroendocrinology 2019; 109:287-298. [PMID: 30856620 DOI: 10.1159/000499497] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/09/2019] [Indexed: 11/19/2022]
Abstract
At present there is no clinical guideline or standardised protocol for the treatment of metastatic or invasive phaeochromocytoma and paraganglioma (collectively known as PPGL) due to the rarity of the disease and the lack of prospective studies or extended national databases. Prognosis is mainly determined by genetic predisposition, tumour burden, rate of disease progression, and location of metastases. For patients with progressive or symptomatic disease that is not amenable to surgery, there are various palliative treatment options available. These include localised therapies including radiotherapy, radiofrequency, or cryoablation, as well as liver-directed therapies for those patients with hepatic metastases (e.g., transarterial chemoembolisation) and systemic therapies including chemotherapy or molecular targeted therapies. There is currently intense research interest in the value of radionuclide therapy for neuroendocrine tumours, including phaeochromocytoma and paraganglioma, with either iodine-131 (131I)-radiolabelled metaiodobenzylguanidine or very recently peptide receptor radionuclide therapy (PRRT), and the most important contemporary clinical studies will be highlighted in this review. The studies to date suggest that PRRT may induce major clinical, biochemical, and radiological changes, with 177Lu-DOTATATE being most efficacious and presenting less toxicity than 90Y-DOTATATE. Newer combination therapies with combined radioisotopes, or combinations with chemotherapeutic agents, also look promising. Given the favourable efficacy, logistic, and safety profiles, we believe that PRRT will probably become the standard treatment for inoperable metastatic PPGL in the near future, but we await data from definitive randomised controlled trials to understand its role.
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Affiliation(s)
- Ingrid Y F Mak
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom,
| | - Aimee R Hayes
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom
| | - Bernard Khoo
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom
| | - Ashley Grossman
- Neuroendocrine Tumour Unit, ENETS Centre of Excellence, Royal Free Hospital, London, United Kingdom
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