Pheochromocytoma in Urologic Practice

Clinicopathological features analysis of Paraganglioma of urinary bladder: A retrospective study

Paraganglioma of urinary bladder (PUB) is a rare neuroendocrine neoplasm. This study is a retrospective analysis of clinicopathological features in 11 cases of PUB. The studied cohort included seven male and four female patients with a median age of 64 years (range 37-73 years). The maximum tumor diameter ranged from 1 to 4 cm (median: 2.5 cm). Macroscopically, most lesions appeared as smooth, polypoid intraluminal protrusions; one case exhibited a nodular mass extending into the outer bladder wall. Microscopic evaluation demonstrated tumor infiltration into the muscularis propria (6 cases) or both lamina propria and muscularis propria (5 cases). Tumor cells were arranged in nested (Zellballen) or organoid patterns. Tumor cells uniformly expressed CD56, synaptophysin, and chromogranin. The Ki-67 proliferation index was ≤8 % in 10 cases; one case with a 4 cm tumor demonstrated a higher Ki-67 index (20 %), correlating with infiltrative growth and increased mitotic activity. Among the 10 cases that were evaluated, 2 (20 %) showed a loss of SDHB expression; Eight (80 %) of 10 cases were GATA3-positive, and all cases were negative for OCT3/4. Nine (81.8 %) underwent transurethral resection of bladder tumor, and 2 (18.2 %) underwent partial cystectomy. Intraoperative blood pressure fluctuations were observed in 2 patients (18.2 %). The median follow-up time was 26 months (range 4-73 months); one patient experienced a recurrence of endometrial cancer 4 years later and was lost to follow-up at 73 months; the remaining 10 patients survived without recurrence or metastasis. Improved preoperative recognition of PUBs relies on integrating clinical, biochemical, and imaging findings. Standardized immunohistochemical panels may enhance diagnostic accuracy.

Pheochromocytoma and Paragangliomas: Current Management Strategies

Pheochromocytomas and paragangliomas are rare neuroendocrine tumors with complex clinical presentations and potential for malignancy. This review highlights advancements in biochemical testing, imaging, genetic counseling, and surgical management, which have improved diagnostic accuracy and patient outcomes. Minimally invasive surgical approaches are commonly preferred, but open surgery remains necessary for larger or complex tumors. Emerging treatments in the metastatic stage, such as targeted therapies and radioligand therapy, show promise. However, access to advanced imaging and treatment options varies globally, underscoring the need for multidisciplinary care and further research to optimize management strategies.

Non-functional muscle-invasive bladder paraganglioma-a case report

Background

Extra-adrenal pheochromocytoma (paraganglioma) of the urinary bladder is a rare tumor, accounting for 0.05% of bladder tumors and less than 1% of all paragangliomas. In the genitourinary tract, paragangliomas are most commonly found in the bladder. These tumors have aggressive malignant potential, so complete surgical resection for localized disease is important. Paragangliomas may be non-functional or functional with catecholamine secretions. Although these tumors are rare and difficult to distinguish from urothelial carcinoma (UC), intraoperative manipulation of these tumors may lead to a catecholamine surge and intraoperative complications. Preoperative or early intraoperative recognition of this tumor would facilitate appropriate alpha blockade to minimize morbidity.

Case Description

Herein we report a rare non-functional paraganglioma arising from the bladder of a 46-year-old male. This case is notable for the location of the mass, requiring a 70-degree cystoscopic lens for complete visualization near the bladder neck, and for the identification of a golden-yellow sessile mass during the resection. Upon visualization of this mass, the operation should be paused for close hemodynamic monitoring and assess for signs of hypertensive crisis prior to continuing without alpha blockade.

Conclusions

Suspected localized bladder paraganglioma cases should be optimized hemodynamically and managed surgically. Visualization of a sessile bladder mass on gross examination with golden-yellow tumor during the resection should prompt suspicion for a paraganglioma. Biochemical evaluation with serum or urine catecholamines, metanephrines, and normetanephrines should be performed to assess for tumor functionality.

SWEET'S SYNDROME ASSOCIATED WITH PHEOCHROMOCYTOMA: A RARE CASE REPORT AND REVIEW OF LITERATURE

Background

Sweet's syndrome (SS) or acute febrile neutrophilic dermatosis is a dermatological illness that can be described by tender erythematous plaques or nodules and acute onset fever. The etiology is multifactorial and is not fully understood. SS is separated in three subclasses: classical, malignancy-associated, and drug-induced. It was shown that this syndrome can reveal an underlying hematological or solid malignancy.

Case presentation

We report the case of a 55-year-old female patient referred to the Urology department for management of pheochromocytoma in the right adrenal gland, revealed by abdominal imaging in another medical unit during the evaluation and diagnosis of multiple mucocutaneous lesions, characterized by erythematous-violaceous plaques and nodules, and painful aphthous ulcers of the tongue. The eruption of each lesion was preceded by low-grade fever and chills. The hormonal profile highlighted the presence of elevated normetanephrines. We performed 3D laparoscopic transperitoneal right adrenalectomy after preoperative treatment with alpha blocker therapy. The clinical outcome was favourable, given that the cutaneous lesions started to heal after the surgery.

Conclusions

Sweet's syndrome in association with pheochromocytoma is a very rare condition, only few cases were described in literature to our knowledge. The multidisciplinary collaboration is extremely important in the management of such cases.

Laparoscopic adrenalectomy for adrenal tumors with endocrine activity: Perioperative management pathways for reduced complications and improved outcomes

The major adrenal tumors with endocrine activity are primary aldosteronism, Cushing's syndrome/mild autonomous cortisol secretion, and pheochromocytoma/paraganglioma. Excessive aldosterone secretion in primary aldosteronism causes cardiovascular, renal, and other organ damage in addition to hypertension and hypokalemia. Cortisol hypersecretion in Cushing's syndrome/mild autonomous cortisol secretion causes obesity, hypertension, impaired glucose tolerance, and cardiometabolic syndrome. Massive secretion of catecholamines in pheochromocytoma/paraganglioma causes hypertension and cerebrocardiovascular disease due to rapid blood pressure fluctuation. Moreover, pheochromocytoma multi-system crisis is a feared and possibly fatal presentation of pheochromocytoma/paraganglioma. Thus, adrenal tumors with endocrine activity are considered an indication for adrenalectomy, and perioperative management is very important. They have a risk of perioperative complications, either due to direct hemodynamic effects of the hormone hypersecretion or due to hormone-related comorbidities. In the last decades, deliberate preoperative evaluation and advanced perioperative management have significantly reduced complications and improved outcomes. Furthermore, improvements in anesthesia and surgical techniques with the feasibility of laparoscopic adrenalectomy have contributed to reduced morbidity and mortality. However, there are still several challenges to be considered in the perioperative care of these patients. There are very few data available prospectively to guide clinical management, due to the rarity of adrenal tumors with endocrine activity. Therefore, most guidelines are based on retrospective data analyses or small case series. In this review, the latest knowledge is summarized, and practical pathways to reduce perioperative complications and improve outcomes in adrenal tumors with endocrine activity are presented.

Clinically Advanced Pheochromocytomas and Paragangliomas: A Comprehensive Genomic Profiling Study

Simple Summary

Clinically advanced pheochromocytomas and paragangliomas are a rare form of endocrine malignancy which can occur in familial and sporadic clinical settings and feature a variety of genomic alterations. Comprehensive genomic profiling (CGP) was performed to characterize the genomic alterations (GA) in clinically advanced disease to enable the search for potential therapy targets. Although the GA/tumor is relatively low for clinically advanced disease, CGP can reveal important potential targets for therapy in the metastatic setting including RET, NF1 and FGFR1. Based on this data, further study of CGP as a method of developing precision therapies for clinically advanced disease appears warranted.

Abstract

Patients with clinically advanced paragangliomas (CA-Para) and pheochromocytomas (CA-Pheo) have limited surgical or systemic treatments. We used comprehensive genomic profiling (CGP) to compare genomic alterations (GA) in CA-Para and CA-Pheo to identify potential therapeutic targets. Eighty-three CA-Para and 45 CA-Pheo underwent hybrid-capture-based CGP using a targeted panel of 324 genes. Tumor mutational burden (TMB) and microsatellite instability (MSI) were determined. The GA/tumor frequencies were low for both tumor types (1.9 GA/tumor for CA-Para, 2.3 GA/tumor for CA-Pheo). The most frequent potentially targetable GA in CA-Para were in FGFR1 (7%, primarily amplifications), NF1, PTEN, NF2, and CDK4 (all 2%) and for CA-Pheo in RET (9%, primarily fusions), NF1 (11%) and FGFR1 (7%). Germline mutations in known cancer predisposition genes were predicted in 13 (30%) of CA-Pheo and 38 (45%) of CA-Para cases, predominantly involving SDHA/B genes. Both CA-Para and CA-Para had low median TMB, low PD-L1 expression levels and none had MSI high status. While similar GA frequency is seen in both CA-Para and CA-Para, germline GA were seen more frequently in CA-Para. Low PD-L1 expression levels and no MSI high status argue against strong potential for novel immune checkpoint inhibitors. However, several important potential therapeutic targets in both CA-Para and CA-Para are identified using CGP.

Von Hippel-Lindau Disease: Current Challenges and Future Prospects

Understanding of molecular mechanisms of tumor growth has an increasing impact on the development of diagnostics and targeted therapy of human neoplasia. In this review, we summarize the current knowledge on molecular mechanisms and their clinical implications in von Hippel-Lindau (VHL) disease. This autosomal dominant tumor syndrome usually manifests in young adulthood and predisposes affected patients to the development of benign and malignant tumors of different organ systems mainly including the nervous system and internal organs. A consequent screening and timely preventive treatment of lesions are crucial for patients affected by VHL disease. Surgical indications and treatment have been evaluated and optimized over many years. In the last decade, pharmacological therapies have been evolving, but are largely still at an experimental stage. Effective pharmacological therapy as well as detection of biomarkers is based on the understanding of the molecular basis of disease. The molecular basis of von Hippel-Lindau disease is the loss of function of the VHL protein and subsequent accumulation of hypoxia-inducible factor with downstream effects on cellular metabolism and differentiation. Organs affected by VHL disease may develop frank tumors. More characteristically, however, they reveal multiple separate microscopic foci of neoplastic cell proliferation. The exact mechanisms of tumorigenesis in VHL disease are, however, still not entirely understood and knowledge on biomarkers and targeted therapy is scarce.

Genetics and imaging of pheochromocytomas and paragangliomas: current update

Pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare, heterogeneous neuroendocrine neoplasms of the autonomous nervous system of chromaffin cell origin that may arise within the adrenal medulla (PCCs) or the sympathetic and parasympathetic paraganglia (PGLs). Currently referred to by the umbrella term pheochromocytomas-paragangliomas (PPGLs), these distinct tumors are characterized by specific histopathology as well as biological and clinical profiles. PPGLs may occur as part of hereditary syndromes (40% of cases) or as sporadic tumors. Currently, there are 12 different hereditary syndromes with characteristic genetic abnormalities, at least 15 well-characterized driver genes and distinct tumor metabolic pathways. Based on the Cancer Genome Atlas (TCGA) taxonomic schemata, PPGLs have been classified into three main clusters of specific genetic mutations and tumor pathways with clinical, biochemical, and prognostic implications. Imaging plays a pivotal role in the initial diagnosis, tumor characterization, evaluation of treatment response, and long-term surveillance. While MDCT and MRI help in the anatomic localization, SPECT, and PET using different radiotracers are crucial in the functional assessment of these tumors. Surgery, chemotherapy, and radiotherapy are currently available treatment options for PPGLs; antiangiogenic drugs are also being used in treating metastatic disease. Evolving knowledge regarding the different genetic abnormalities involved in the pathogenesis of PPGLs has identified potential therapeutic targets that may be utilized in the discovery of novel drugs.

Pheochromocytoma arising in the settingof adrenal-renal fusion

Adrenal-renal fusion is an anomaly misclassified as a renal tumor due to the absence of pathognomonic radiographic features. Herein, we report a case of a 61-year-old male who underwent a right radical nephrectomy for a presumed renal malignancy. Pathologic evaluation demonstrated a pheochromocytoma in the context of adrenal-renal fusion. Neoplastic transformation of fused adrenal tissue is rare but not unheard of and is typically adrenal cortical in origin. To our knowledge, this is the first description of a pheochromocytoma originating from an adrenal-renal fusion. The clinical presentation did not raise a high index of suspicion for the ultimate diagnosis rendered.

Management of the Incidental Adrenal Mass

CONTEXT

Incidentally discovered adrenal masses are becoming more common in clinical practice.

OBJECTIVE

To review the management of the incidental adrenal mass, including initial evaluation, surveillance, medical therapy, and surgical therapy.

EVIDENCE ACQUISITION

A literature search of English-language publications that included the keywords adrenal incidentaloma and incidental adrenal mass was performed through July 2015 using PubMed. Relevant original articles and guidelines on the management of the incidental adrenal mass were ultimately selected for analysis, with the consensus of all authors.

EVIDENCE SYNTHESIS

Data from the manuscripts included in this review were synthesized, and findings were categorized into metabolic evaluation, imaging, biopsy, surgical considerations, and follow-up recommendations.

CONCLUSIONS

Ideally, management of patients with adrenal incidentalomas should involve a multidisciplinary approach with experienced surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection.

PATIENT SUMMARY

Management of patients with adrenal incidentalomas should involve a multidisciplinary approach with surgeons, radiologists, and endocrinologists to determine whether such lesions are benign or malignant and functional or nonfunctional and/or whether they require surgical resection.