Analysis of large versus small pheochromocytomas: Operative approaches and patient outcomes

The role of laparoscopic adrenalectomy in the treatment of large pheochromocytomas (>6 cm): a meta-analysis and systematic review

BACKGROUND

The effectiveness and safety of laparoscopic adrenalectomy (LA) under different routes for the treatment of large pheochromocytomas (PCCs) is unknown.

MATERIALS AND METHODS

This meta-analysis and systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines. Three databases were systematically searched, including Medline, PubMed, and Web of Science. The time frame of the search was set from the creation of the database to October 2022. Perioperative outcomes were divided into two groups according to tumor size: SMALL group (≤6 cm in diameter), LARGE group (>6 cm in diameter).

RESULTS

Eight studies including 600 patients were included. In the LA group, complications was comparable in both groups (SMALL group and LARGE group), and the LARGE group had longer operative time [OT weighted mean difference (WMD)=32.55; 95% CI: 11.17, 53.92; P <0.01], length of stay (LOS WMD=0.82; 95% CI: 0.19, 1.44; P <0.05), more estimated blood loss (EBL WMD=85.26; 95% CI: 20.71, 149.82; P <0.05), hypertension [odds ratio (OR)=3.99; 95% CI: 1.84, 8.65; P <0.01], hypotension (OR=1.84; 95% CI: 1.11, 3.05; P <0.05), and conversion (OR=5.60; 95% CI: 1.56, 20.13; P <0.01). In the transabdominal LA group, OT, LOS, EBL, complications, hypertension, and hypotension were the same in both groups. In the retroperitoneal LA group, complications and hypotension were the same in both groups, while the LARGE group had longer OT (WMD=52.07; 95% CI: 26.95, 77.20; P <0.01), LOS (WMD=0.51; 95% CI: 0.00, 1.01; P <0.05), more EBL (WMD=92.99; 95% CI: 27.70, 158.28; P <0.01) and higher rates of hypertension (OR=6.03; 95% CI: 1.95, 18.61; P <0.01).

CONCLUSIONS

LA remains a safe and effective approach for large PCC. Transabdominal LA is superior to retroperitoneal LA.

Tips and Tricks in Laparoscopic Adrenalectomy for Pheochromocytoma. How We Do It

"Pheochromocytomas are rare neuroendocrine tumors that frequently have genetic involvement and can present a particular risk in terms of the anesthetic-surgical procedure. Current worldwide medical recommendations state that laparoscopic adrenalectomy is the conventional treatment for pheochromocytoma, however, the ideal surgical strategy is still being developed as specialized surgeons gain experience with these rare tumors. The study's purpose was to thoroughly evaluate our film library and identify the best surgical steps that represent our standardized procedure. We developed a comprehensive set of surgical critical strategies for either a left or right adrenalectomy, providing helpful advice on patient positioning, port placement, the adrenal gland approach, as well as other surgical methods specifically designed for tumor mobilization and dissection. The current paper aims to synthesize our clinical experience in terms of preoperative preparation, patient positioning, intraoperative complications, causes of conversion, and specimen extraction. The main conclusions concern both the best surgical approach and the importance of surgical experience in the clinical management of these rare tumor types. "

Minimally invasive adrenalectomy for large pheochromocytoma: not recommendable yet? Results from a single institution case series

BACKGROUND

Minimally invasive adrenalectomy represents the treatment of choice of pheochromocytoma (PCC). For large or invasive PCCs, an open approach is currently recommended, in order to ensure complete tumor resection, prevent tumor rupture, avoid local recurrence, and limit perioperative hemodynamic instability. The aim of this study is to analyze perioperative outcomes of laparoscopic adrenalectomies (LAs) for large adrenal PCCs.

METHODS

All consecutive LAs for PCC performed at a single institution between 1998 and 2020 were included. Two groups were defined: lesions larger (group 1) and smaller (group 2) than 5 cm. Short-term outcomes were compared in order to find any significant difference between the two groups.

OUTCOMES

One hundred fourteen patients underwent LA during the study period: 46 for lesions larger and 68 for lesions smaller than 5 cm. No significant differences were found in patients' characteristics, median operative time, conversion rate, intraoperative hemodynamic and metabolic parameters, postoperative intensive care unit (ICU) admission rate, complications rate, and length of hospital stay. Long-term oncologic outcomes were similar, with a recurrence rate of 5.1% in group 1 vs 3.6% in group 2 (p = 1).

CONCLUSION

Minimally invasive adrenalectomy seems to be safe and effective even in large PCC. The recommendation to prefer an open approach for large PCCs should probably be reconsidered.

[Strategy of reoperation for pheochromocytoma and paraganglioma]

OBJECTIVE

To explore the surgical strategy and experience of reoperation for pheochromocytoma and paraganglioma which is very challenging.

METHODS

The clinical data of 7 patients with pheochromocytoma and paraganglioma who underwent reoperation in Department of Urology, Peking University Third Hospital from August 2016 to February 2021 were analyzed retrospectively. There were 4 males and 3 females, with an average age of (44.1±11.5) years (28-60 years), 6 cases on the right side and 1 case on the left side. The causes of the operations included: (1) 2 cases of tumor recurrence after resection; (2) The primary operations failed to completely remove the tumors in 3 cases, because the tumors were large and closely related to blood vessels. (3) Pheochromocytoma and paraganglioma wasn't diagnosed before primary operation, therefore, drug preparation wasn't prepared. Two cases were interrupted by severe blood pressure fluctuations during the primary operations. Imaging evaluation, catecholamine biochemical examination and adequate adrenergic α receptor blockers were administrated in all the cases. The surgical approaches included open transperitoneal surgery in 4 cases, robot-assisted laparoscopy in 1 case and retroperitoneal laparoscopy in 2 cases. The innovative techniques included mobilization of the liver, inferior vena cava transection and anastomosis, and transection of left renal vein.

RESULTS

The average tumor size was (8.0±3.2) cm (3.6-13.9 cm). The median interval between the reoperation and the primary operation was 9 months (IQR: 6, 19 months). The median operation time was 407 min (IQR: 114, 430 min) and the median blood loss was 1 500 mL (IQR: 20, 3 800 mL). Operations of 5 cases were performed successfully, and 1 case failed only by exploration during the operation. One case died perioperatively. There were 5 cases of intraoperative blood transfusion, the median transfusion volume of red blood cells was 800 mL (IQR: 0, 2 000 mL). One case experienced postoperative lymphorrhagia, and recovered after conservative treatment. The renal function was normal in 2 cases after resection and anastomosis of inferior vena cava or transection of left renal vein. The average postoperative hospital stay was (7.2±3.3) d (4-13 d). The median follow-up time of 6 patients was 33.5 months (IQR: 4.8, 48.0 months). The case who failed in the reoperation still survived with tumor and there was no recurrence in the rest of the patients.

CONCLUSION

The reoperation of pheochromocytoma and paraganglioma, which can not be resected in the primary operation or recurred postoperatively, is difficult with high risk of hemorrhage, and there is a risk of failure and perioperative death. Different surgical approaches and strategies need to be adopted based on the different situation.

Outcomes of malignant pheochromocytoma based on operative approach: A National Cancer Database analysis

BACKGROUND

Malignant pheochromocytoma is often managed with adrenalectomy. Most literature focusing on postoperative outcomes are from single institutions. This study aimed to describe outcomes of adrenalectomy for malignant pheochromocytoma using a national database. We hypothesized that minimally invasive approaches might be associated with improved short-term outcomes but potentially inferior oncologic efficacy.

METHODS

Patients who underwent adrenalectomy for malignant pheochromocytoma were identified in the National Cancer Database (2010-2016). Patients were categorized as minimally invasive adrenalectomy or open adrenalectomy. Short- and long-term outcomes were compared.

RESULTS

A total of 276 patients underwent adrenalectomy for malignant pheochromocytoma: 50.7% open adrenalectomy and 49.3% minimally invasive adrenalectomy. Demographics were similar, except those who underwent open adrenalectomy had larger tumors compared to minimally invasive adrenalectomy (8.2 cm vs 4.7 cm; P < .001). Tumor size ≥6 cm was associated with a reduced likelihood of minimally invasive adrenalectomy (relative to open adrenalectomy) on multivariable regression (odds ratio = 0.23; P < .001). Open adrenalectomy was associated with longer duration of stay relative to minimally invasive adrenalectomy (6 vs 3 days; P < .001). Rates of positive margins, unplanned readmissions, or 30-/90-day mortalities were similar based on operative approach. Five-year survival rates were similar (open adrenalectomy 74.3%, minimally invasive adrenalectomy 79.1%). There was no association between overall survival and operative approach on multivariable Cox analysis when controlling for tumor size, laterality, and clinicodemographic variables.

CONCLUSION

Patients with larger malignant pheochromocytomas were more likely to undergo an open adrenalectomy. With the exception of an increased duration of stay, there was no difference in short- or long-term postoperative outcomes. These data suggest that minimally invasive adrenalectomy appears safe among tumors <6 cm.

Surgery for Pheochromocytoma: A Single-Center Review of 60 Cases from South Africa

BACKGROUND

There is a paucity of data on the presentation and surgical management of pheochromocytoma in developing nations, particularly in Africa.

METHODS

This study was a retrospective review, which included all patients managed by the Groote Schuur Hospital/University of Cape Town Endocrine Surgery unit for pheochromocytoma and abdominal paragangliomas, from January 2002 to June 2019.

RESULTS

Sixty patients were included in the study, of which 33% were male and 67% female. The mean age was 47 years (range 14-81). The median tumor size was 6 cm, with 45% larger than 6 cm. 92% were located in the adrenal gland (87% unilateral, 5% bilateral), and 8% were extra-adrenal. The conversion rate for laparoscopic cases was 20%, with 55% of cases overall completed laparoscopically. Eleven patients with tumors > 6 cm were initially attempted laparoscopically, of which 3 were converted to open, without any associated increased morbidity. A major adverse event was recorded for 5 cases (8%), including 1 mortality. Overall morbidity, blood loss, operating time and hospital stay were all significantly reduced in the laparoscopic group. There were 5 patients with malignant disease (8%).

CONCLUSION

This large series, from an established academic endocrine surgery unit in Africa, can serve as a benchmark for units with similar settings and resource limitations, to compare their surgical management and perioperative outcomes.

Laparoscopic versus open surgery for pheochromocytoma: a meta-analysis

Background

Surgical resection is the main treatment for pheochromocytoma (PHEO). Although open surgery (OS) has been shown to be safe and feasible, the safety and efficacy of laparoscopic surgery (LS) for PHEO remain controversial due to the uncertain effects of pneumoperitoneum on haemodynamics and the complexity of the tumour itself. This study was performed to compare the treatment outcomes of OS with those of LS for patients with PHEO.

Methods

A systematic search through November 11, 2019, was conducted. All studies comparing outcomes of LS and OS for PHEO were included according to eligibility criteria. This meta-analysis was conducted using Review Manager Software, version 5.3, and STATA software, version 12.0. The quality of the included studies was assessed using the Newcastle-Ottawa scale.

Results

Fourteen studies involving 626 patients were included in this meta-analysis. LS was associated with lower rates of intraoperative haemodynamic instability (IHD) [odds ratio (OR) = 0.61, 95% CI: 0.37 to 1.00, P = 0.05], less intraoperative blood loss [weighted mean difference (WMD) = − 115.27 ml, 95% confidence interval (CI): − 128.54 to − 101.99, P < 0.00001], lower blood transfusion rates [OR = 0.33, 95% CI: 0.21 to 0.52, P < 0.00001], earlier ambulation (WMD = − 1.57 d, 95% CI: − 1.97 to − 1.16, P < 0.00001) and food intake (WMD = − 0.98 d, 95% CI: − 1.36 to − 0.59, P < 0.00001), shorter drainage tube indwelling time (WMD = − 0.51 d, 95% CI: − 0.96 to − 0.07, P = 0.02) and postoperative stay (WMD = − 3.17 d, 95% CI: − 4.76 to − 1.58, P < 0.0001), and lower overall complication rates (OR = 0.56, 95% CI: 0.35 to 0.88, P = 0.01). However, no significant differences in operative time, postoperative blood pressure control, rates of severe complications, postoperative hypotension or cardiovascular disease (CVD) were found between the two groups.

Conclusions

LS is safe and effective for PHEO resection. Compared with OS, LS caused less IHD, providing an equal chance to cure hypertension while also yielding a faster and better postoperative recovery.

Precision Surgery for Pheochromocytomas and Paragangliomas

Since Felix Fränkel's account of pheochromocytoma in 1886, great discoveries and vast advancements in the diagnosis, genetics, anatomical and functional imaging techniques, and surgical management of pheochromcytoma and paraganglioma (P-PGL) have been made. The improved insight in the pathophysiology of P-PGL and more accurate detection methods enable physicians to tailor the treatment plan to an individual based on the genetic profile and tumor behavior. This review will cover briefly the clinical features, diagnosis, genetic mutations, and imaging modalities that are used to guide current surgical management of these rare and interesting endocrinopathies.

Perioperative management during laparoscopic resection of large pheochromocytomas: A single-institution retrospective study

BACKGROUND AND OBJECTIVES

The safety of laparoscopic resection of very large pheochromocytomas is unclear, and preoperative preparation may benefit from refinement. This retrospective study was designed to determine the correlation between tumor size and perioperative characteristics by evaluating data from patients who underwent laparoscopic resection of pheochromocytomas.

METHODS

A total of 253 patients were grouped according to their tumor diameter: diameter ≥8 cm, Glarge (G_lg ) (n = 30); diameter 6 to 8 cm, Gmedium (G_md ) (n = 57); and diameter <6 cm, Gsmall (G_sm ) (n = 166). The perioperative data were compared among the three groups using the analysis of variance test, Wilcoxon's rank-sum test, and the chi-square test.

RESULTS

Patients in the G_lg and G_md groups had a higher preoperative phenoxybenzamine daily dose and 24-hour urine levels of noradrenaline and adrenaline than those in the G_sm group, as they needed longer vasopressor support. Transfusion of allogeneic blood products was found to be increased in patients of the G_lg group compared with the other two groups and their intensive care unit stays were longer.

CONCLUSIONS

Compared with small-sized pheochromocytomas, laparoscopic resection of medium-sized pheochromocytomas requires vigilant monitoring and resolution of hemodynamic fluctuations. Patients with very large pheochromocytomas are at greater risk of intraoperative bleeding and may benefit from the ensured availability of blood products and intensive postoperative monitoring.

MANAGEMENT OF ENDOCRINE DISEASE: Recurrence or new tumors after complete resection of pheochromocytomas and paragangliomas: a systematic review and meta-analysis

OBJECTIVES

To systematically review the incidence and factors associated with recurrences or new tumors after apparent complete resection of pheochromocytoma or thoraco-abdomino-pelvic paraganglioma.

DESIGN

A systematic review and meta-analysis of published literature was performed.

METHODS

Pubmed and Embase from 1980 to 2012 were searched for studies published in English on patients with non-metastatic pheochromocytoma or thoraco-abdomino-pelvic paraganglioma, complete tumor resection, postoperative follow-up exceeding 1 month, and recurrence or new tumor documented by pathology, hormonal dosages, or imaging tests. Incidence rates of new events after curative surgery were calculated for each study that had sufficient information and pooled using random-effect meta-analysis.

RESULTS

In total, 38 studies were selected from 3518 references, of which 36 reported retrospective cohorts from the USA, Europe, and Asia. Patient follow-up was neither standardized nor exhaustive in the included studies. A clear description of patient retrieval methods was available for nine studies and the follow-up protocol and patient flow for four studies. Only two studies used multivariable methods to assess potential predictors of postoperative events.The overall rate of recurrent disease from 34 studies was 0.98 events/100 person-years (95% confidence interval 0.71, 1.25). Syndromic diseases and paragangliomas were consistently associated with a higher risk of a new event in individual studies and in meta-regression analysis.

CONCLUSIONS

The risk of recurrent disease after complete resection of pheochromocytoma may be lower than that previously estimated, corresponding to five events for 100 patients followed up for 5 years after complete resection. Risk stratification is required to tailor the follow-up protocol after complete resection of a pheochromocytoma or paraganglioma. Large multicenter studies are needed to this end.

Feasibility and safety of laparoscopic adrenalectomy for large tumours

Objective

To verify the feasibility and safety of laparoscopic adrenalectomy for large tumours, as since it was described, the laparoscopic approach for adrenalectomy has become the ‘gold standard’ for small tumours and for large and non-malignant adrenal tumours many studies have reported acceptable results.

Patients and methods

This is a retrospective study from a general surgery department from January 2006 to December 2013 including 45 patients (56 laparoscopic adrenalectomies). We divided patients into two groups according to tumour size: <5 or ⩾5 cm, we compared demographic data and peri- and postoperative outcomes.

Results

There was no statistical difference between the two groups for conversion rate (3.7% vs 11.7% P = 0.32), postoperative complications (14% vs 12%, P = 0.4), postoperative length of hospital stay (5 vs 6 days P = 0.43) or mortality (3.5% vs 0% P = 0.99). The only statistical difference was the operating time, at a mean (SD) 155 (60) vs 247 (71) min (P < 0.001).

Conclusion

Laparoscopic adrenalectomy for large tumours needs more time but appears to be safe and feasible when performed by experienced surgeons.

Randomized clinical trial of posterior retroperitoneoscopic adrenalectomy versus lateral transperitoneal laparoscopic adrenalectomy with a 5-year follow-up

OBJECTIVE

To test if posterior retroperitoneoscopic adrenalectomy (PRA) is superior to lateral transperitoneal laparoscopic adrenalectomy (LTLA).

BACKGROUND

Most popular LTLA has been recently challenged by an increasing popularity of PRA, which is believed by many surgeons (not evidence-based) as superior to LTLA in the treatment of small and benign adrenal tumors.

METHODS

Participants were assigned randomly to PRA or LTLA and followed for 5 years after surgery. The primary endpoint was the duration of surgery. Secondary endpoints were blood loss, conversion rate, postoperative recovery, morbidity, and costs.

RESULTS

Sixty-five patients were included, of whom 61 (PRA 30, LTLA 31) completed the 5-year follow-up. The following differences were identified in favor of PRA vs LTLA: shorter duration of surgery (50.8 vs 77.3 minutes), lower intraoperative blood loss (52.7 vs 97.8 mL), diminished pain intensity within 48 hours postoperatively, lower prevalence of shoulder-tip pain (3.0% vs 37.5%), shorter time to oral intake (4.4 vs 7.3 hours), shorter time to ambulation (6.1 vs 11.5 hours), shorter length of hospital stay, and lower cost (1728 € vs 2315 €), respectively (P<0.001 for all). No differences were noted in conversion rate or morbidity except for herniation occurring more often after LTLA than PRA (16.1% vs 0%, P=0.022) and need for hernia repair (12.9% vs 0%, P=0.050), respectively.

CONCLUSIONS

Both approaches were equally safe. However, outcomes of PRA operations were superior to LTLA in terms of shorter surgery duration, lower blood loss, lower postoperative pain, faster recovery, improved cost-effectiveness, and abolished risk of surgical access site herniation.

REGISTRATION NUMBER

NCT01959711 (http://www.clinicaltrials.gov).

Influence of adrenal pathology on perioperative outcomes: a multi-institutional analysis

BACKGROUND

Endoscopic or open adrenalectomies are performed for variable pathologies. We investigated if adrenal pathology affects perioperative outcomes independent of operative approach.

METHODS

A multi-institutional retrospective review of 345 adrenalectomies was performed. A multivariate analysis was utilized.

RESULTS

Pathology groups included benign non-pheochromocytoma tumors (50.4%), pheochromocytomas (41%), adrenocortical carcinomas (5.2%), and metastatic tumors (3.4%). Controlling for age, body mass index, tumor size, procedure type, and pathology, pheochromocytomas exhibited greater blood loss (92 mL more, P = .007) and operative times (33 min more, P < .001) than benign non-pheochromocytoma tumors. Metastatic tumors demonstrated longer operative times (53 min more, P = .013). Open adrenalectomy was associated with greater blood loss (396 mL more, P = .001), transfusion requirement (P = .021), operative times (79 min more, P < .001), hospital stay (6.6 days more, P < .001) and complications (P < .001) when compared with endoscopic adrenalectomy.

CONCLUSIONS

The type of adrenal pathology appears to influence blood loss and operative time but not complications in patients undergoing adrenalectomy. Open adrenalectomy remains a major driver of adverse perioperative outcomes.

[A clinical study of laparoscopic adrenalectomy for pheochromocytoma--analysis of clinical parameters influencing operative time and intraoperative systolic blood pressure]

PURPOSE

We retrospectively analyzed the preoperative clinical parameters which influence operative time and intraoperative maximum systolic blood pressure in patients undergoing laparoscopic adrenalectomy for pheochromocytoma.

MATERIALS AND METHODS

Between January 1992 and September 2010, we performed 28 laparoscopic adrenalectomies for pheochromocytoma at Hamamatsu University School of Medicine. These 28 cases were characterized based on the following parameters: body mass index (BMI), tumor size, history of hypertension, preoperative blood pressure, serum concentration of catecholamine, and 24-h urinary excretion of catecholamine metabolite. We retrospectively analyzed whether or not these parameters influenced operative time or intraoperative maximum systolic blood pressure.

RESULTS

All 28 cases of laparoscopic adrenalectomy were performed safely and without intraoperative complications and needed neither blood transfusion nor conversion to laparotomy. The median operative time was 203 minutes, and intraoperative hypertension (systolic blood pressure > 200 mmHg) occurred in 46% (13/28) of cases. Median day of discharge in all patients was post-operative day 5. Significant positive correlation was shown between tumor size and operative time and between intraoperative maximum systolic blood pressure and serum concentration of catecholamine or 24-h urinary excretion of catecholamine metabolite (p < 0.05).

CONCLUSION

The lengthened operative time for large tumors and elevated intraoperative blood pressure for tumors with high preoperative catecholamine activity necessitate careful perioperative management in patients receiving laparoscopic adrenalectomy for pheochromocytoma.

Safety and feasibility of laparoscopic resection for large (≥ 6 CM) pheochromocytomas without suspected malignancy

OBJECTIVE

To determine whether laparoscopic adrenalectomy in patients without radiologic evidence of cancer compromises the perioperative and long-term outcomes in patients with large (≥ 6 cm) pheochromocytomas.

METHODS

We analyzed a prospective adrenal database of consecutive patients who underwent adrenalectomy at our institution between September 2000 and September 2010. Patients with diagnosed pheochromocytoma who underwent laparoscopic adrenalectomy were included. Patients with tumors smaller than 6 cm were compared with those presenting with tumors 6 cm or larger.

RESULTS

One hundred fifty-seven patients underwent adrenalectomy, and there were 32 catecholamine-secreting tumors. Of the 33, 7 were excluded from the study because of open surgery. Thus, 25 patients presented with 26 pheochromocytomas and underwent laparoscopic adrenalectomy. Thirteen of the 25 patients (52%) were women. Mean age (± standard error of the mean) was 53 ± 3 years. Mean tumor size was 5.2 ± 0.5 cm, and 11 pheochromocytomas (42%) were 6 cm or larger. Tumor size was significantly different between the large pheochromocytoma and the small pheochromocytoma groups (7.6 ± 0.4 vs 3.6 ± 0.4 cm, P<.001), but there was no significant difference in intraoperative complications, estimated blood loss, cancer diagnosis, or recurrence. The length of stay was comparable between the 2 cohorts, and there were no incidents of capsular invasion or adverse cardiovascular events.

CONCLUSION

Laparoscopic adrenalectomy of pheochromocytomas larger than 6 cm is feasible and safe with comparable results to those achieved with laparoscopic adrenalectomy in patients with smaller pheochromocytomas.

Malignant pheochromocytomas and paragangliomas: a diagnostic challenge

INTRODUCTION

Malignant pheochromocytomas (PCCs) and paragangliomas (PGLs) are rare disorders arising from the adrenal gland, from the glomera along parasympathetic nerves or from paraganglia along the sympathetic trunk. According to the WHO classification, malignancy of PCCs and PGLs is defined by the presence of metastases at non-chromaffin sites distant from that of the primary tumor and not by local invasion. The overall prognosis of metastasized PCCs/PGLs is poor. Surgery offers currently the only change of cure. Preferably, the discrimination between malignant and benign PCCs/PGLs should be made preoperatively.

METHODS

This review summarizes our current knowledge on how benign and malignant tumors can be distinguished.

CONCLUSION

Due to the rarity of malignant PCCs/PGLs and the obvious difficulties in distinguishing benign and malignant PCCs/PGLs, any patient with a PCC/PGL should be treated in a specialized center where a multidisciplinary setting with specialized teams consisting of radiologists, endocrinologist, oncologists, pathologists and surgeons is available. This would also facilitate future studies to address the existing diagnostic and/or therapeutic obstacles.

A patient with a large recurrent pheochromocytoma demonstrating the pitfalls of diagnosis

BACKGROUND

A 59-year-old man presented for a follow-up, 6 years after surgery for a large pheochromocytoma. He had suffered from diabetes mellitus, hypertension and abdominal pain in the right flank region. Previous postoperative follow-up did not reveal tumor recurrence.

INVESTIGATION

Measurement of plasma free metanephrine and normetanephrine by high-performance liquid chromatography and radioimmunoassay; 123I-metaiodobenzylguanidine (MIBG) scintigraphy; hybrid 123I-MIBG single-photon emission CT (SPECT)-CT; MRI; testing for plasma norepinephrine and epinephrine; intraoperative ultrasonography; histological staining for chromogranin A and synaptophysin; and postoperative 18F-dihydroxyphenylalanine (DOPA) PET scan.

DIAGNOSIS

Recurrent pheochromocytoma.

MANAGEMENT

Laparotomy with tumor resection. Reduction of antihypertensive medications. Further follow-up by MRI, hybrid 123I-MIBG SPECT-CT and testing for plasma catecholamines and free metanephrines.

Malignant giant pheochromocytoma: a case report and review of the literature

Malignant pheochromocytoma is a rare disease and surgical resection is the only curative treatment. There are no definitive histological or cytological criteria of malignancy, as it is impossible to determine this condition in the absence of advanced locoregional disease or metastases. We report a case of a patient with a giant retroperitoneal tumour, the second largest to be published, which was diagnosed as a malignant pheochromocytoma; it was treated with surgery. The literature is reviewed to evaluate tumour features and criteria to distinguish between benign and malignant pheochromocytomas.

Multiple endocrine neoplasia 2a presenting with pheochromocytoma and pituitary macroadenoma

Multiple Endocrine Neoplasia type 2A (MEN-2a) is a rare disease associated with tumors of endocrine organs. Presentation most commonly is with medullary thyroid cancer and infrequently with other complaints. Pituitary adenoma has been seen coincidentally with this disease very rarely. Presented is a case of coincident MEN-2a with a symptomatic pituitary adenoma and an asymptomatic pheochromocytoma. A brief review is also provided.

Clinically silent chromaffin-cell tumors: Tumor characteristics and long-term prognosis in patients with incidentally discovered pheochromocytomas

BACKGROUND

Chromaffin-cell tumors (CCT), a rare group of catecholamine producing endocrine neoplasms, are traditionally suspected and diagnosed in patients presenting with episodic hypertension, together with the classic triad of headache, sweating, and tachycardia. Asymptomatic CCT are increasingly diagnosed, frequently as "incidentalomas". We have conducted a multicenter retrospective study, to assess the characteristics of a group of patients with clinically silent CCT, compared with a group of patients with typical CCT.

METHODS

Forty-three consecutive patients with CCT (24 with silent and 19 with typical tumors) have been retrospectively studied for a period of up to 20 yr (between 1989 and 2009); clinical picture, biochemical tests, as well as topographic and functional assessment were analyzed at diagnosis and periodically following treatment. Surgical samples were reviewed for neuroendocrine markers and for signs of invasiveness.

RESULTS

Patients with clinically silent CCT were significantly older than the typical ones (56.3±3.4 vs 48.0±4.8 yr; p<0.05); 15 of them (63%) were completely asymptomatic, and 9 patients (37%) complained of non-specific abdominal symptoms. Hypertension was present in only 6 silent CCT patients (25%), it was well controlled [mean blood pressure (BP) 134/84 mmHg], and persisted after surgery in only 2 patients. Fourteen out of twenty-four silent CCT patients (58%) were managed pre-operatively with prophylactic combination of α and β blockade, despite normal BP values. Clinically silent CCT were larger than typical CCT (mean diameter of 5.2±2.3 cm vs 4.6±1.5 cm, p<0.05) and secreted higher a mounts of normeta neph rines. All clinically silent CCT patients were defined as "cured" after surgery.

CONCLUSION

Clinically silent CCT are more prevalent than previously reported. With an adequate pre-surgical diagnosis and patient preparation, the prognosis of silent tumors is usually excellent.

Laparoscopic adrenalectomy for large unilateral pheochromocytoma: experience in a large academic medical center

BACKGROUND

Laparoscopic adrenalectomy is the treatment of choice for most adrenal lesions. Concerns have persisted about its application to large pheochromocytomas due to reports of hemodynamic instability, difficult dissection, and tumor spillage.

METHODS

Thirty patients underwent laparoscopic adrenalectomy for unilateral pheochromocytoma between 1998 and 2006. Outcome measures including operative time, blood loss, intraoperative hemodynamic instability, conversion rate, complications, and disease recurrence were analyzed based on tumor size.

RESULTS

Twenty-two patients had small tumors and eight had large lesions. These groups did not differ in terms of operative time, blood loss, conversion rate, length of stay or complication rate. Intraoperative hemodynamic instability occurred in 56.7% of cases, but was not different between groups. There were no recurrences in either group.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe and effective treatment for large pheochromocytomas. Intraoperative hemodynamic instability remains a frequent occurrence regardless of tumor size. There were no cases of disease recurrence or iatrogenic pheochromocytosis.

Outcomes of minimally invasive surgery for phaeochromocytoma

Laparoscopic adrenalectomy is now accepted as the procedure of choice for the resection of benign adrenocortical tumours, but few studies have assessed whether the outcomes of laparoscopic adrenalectomy for adrenal phaeochromocytoma are similar to that of other adrenal tumour types. This is a retrospective cohort study. Clinical and operative data were obtained from an adrenal tumour database and hospital records. A total of 191 patients had laparoscopic adrenalectomy, of which 36 were for phaeochromocytoma, over a 12-year period. Length of hospital stay (4.8 vs 3.6 days, P= 0.03) and total operating times (183 vs 157 min, P= 0.01) were greater in the laparoscopic phaeochromocytoma resection group. Despite the greater size of the phaeochromocytomas compared to the remaining adrenal tumour types (44 mm vs 30 mm, P < 0.01), however, rate of conversion and morbidity were no different. Laparoscopic adrenalectomy for phaeochromocytoma is a safe procedure with similar outcomes to laparoscopic adrenalectomy for other adrenal tumour types.

Pheochromocytoma: diagnostic and therapeutic update

Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the sympathetic nervous system. In 80-85% of cases, these tumors are located in the adrenal medulla while the remainder is located in extra-adrenal chromaffin tissues (paragangliomas). Pheochromocytomas account for 6.5% of incidentally discovered adrenal tumors. These tumors may be sporadic or the result of several genetic diseases: multiple endocrine neoplasia type 2, von Hippel-Lindau syndrome, neurofibromatosis type 1, and familial paraganglioma associated with mutations in succinate dehydrogenase subunits. Diagnosis of pheochromocytoma should first be established biochemically by measuring plasma free metanephrines and urinary fractionated metanephrines. The radiological imaging tests of choice are computed tomography (CT) or magnetic resonance imaging (MRI). The first-line specific functional imaging test is scintigraphy with (123)I-metaiodobenzylguanidine (MIBG); if this test is unavailable, scintigraphy with (131)I-MIBG is the second choice. Positron emission tomography (PET) with (18)F-F-fluorodopamine (F-DA) is useful in metastatic disease. The treatment of choice is laparoscopic surgery after adequate alpha adrenergic blockade. Approximately 10% of tumors are malignant. Chemotherapy is used for inoperable disease. Prognosis is good except in malignant disease, in which 5-year survival is less than 50%. The identification of the genes causing hereditary pheochromocytoma has led to changes in the recommendation for genetic testing.

Safety of laparoscopic adrenalectomy in patients with large pheochromocytomas: a single institution review

BACKGROUND

Laparoscopic adrenalectomy is the procedure of choice for small adrenal tumors, but some concerns have been voiced when this approach is adopted for larger tumors and pheochromocytomas. The aim of this study was to examine the results of the laparoscopic resection of large pheochromocytomas.

METHODS

A retrospective review of adrenalectomies performed for adrenal pheochromocytomas>6 cm in diameter. We compiled and analyzed the early operative complications, histologic findings, and cure rates with a minimum of 1 year of follow-up after surgery.

RESULTS

From 1996 to 2005, a total of 445 laparoscopic adrenalectomies were performed in our institution using the anterolateral transperitoneal approach. From this series we identified 18 procedures for pheochromocytomas with an average diameter on imaging of 78.2 mm (range 60-130 mm). All patients were rendered safe with a standard departmental protocol involving calcium-channel blockade initiated at least 2 weeks prior to surgery. The average peak intraoperative blood pressure was 187 mmHg. Capsular disruption occurred in two cases. One patient required an intraoperative blood transfusion due to intraoperative blood loss. No immediate conversions to an open procedure were required, but one patient underwent a delayed laparotomy for hematoma formation. Histologically, four of the adrenal tumors displayed evidence of vascular invasion. Biochemical cure was achieved in all patients after a median follow-up of 58 months (16-122 months).

CONCLUSIONS

Laparoscopic adrenalectomy appears to be a safe and effective approach for large pheochromocytomas when no preoperative or intraoperative evidence of local invasion is present.

Laparoscopic adrenalectomy for large adrenal masses

Open adrenalectomy has been the gold-standard therapy for adrenal neoplasms. Minimally invasive treatments, however, have assumed a more central role in the management of these lesions. The traditional benefits of laparoscopy, including reduced blood loss, shorter hospital duration, and improved convalescence, extend to adrenal disease without compromising the oncologic efficacy of the surgery. Contemporary series suggest that minimally invasive surgery is also a reasonable therapeutic modality for larger adrenal masses. Laparoscopic adrenalectomy for these large masses is a technically demanding procedure that should be undertaken by experienced laparoscopic surgeons familiar with retroperitoneal anatomy and adept with vascular techniques in the event of an open conversion. Oncologic outcomes collectively suggest that in the setting of adequate surgical resection, recurrence patterns relate more to disease-process biology than surgical approach. Neither size criteria, suspicion of malignancy, nor locally invasive disease should be considered an absolute contraindication to laparoscopic adrenalectomy.

Laparoscopic and Selective Open Resection for Adrenal and Extraadrenal Neuroendocrine Tumors

Laparoscopic resection is preferred for most adrenal tumors. From 1996 to 2007, 54 consecutive patients who underwent resection of an adrenal tumor or extraadrenal pheochromocytoma were reviewed to determine the outcome of laparoscopic resection and the rate of conversion and indications for open resection. Adrenalectomy was performed in 51 patients and resection of a pheochromocytoma of the organs of Zuckerkandl in three patients. Laparoscopic adrenalectomy was initiated in 42 patients, three (7.3%) of whom underwent conversion to an open approach because of bleeding from an accessory vein (one), tumor invasion (one), or adhesions (one) (median American Society of Anesthesiologists score = 2, estimated blood loss = 186 ± 235 mL, size = 5 ± 3 cm). Open resection was performed in 12 patients, six at the time of another procedure, three for pheochromocytoma of the organs of Zuckerkandl, two for bilateral adrenalectomy, and one for tumor invasion (median American Society of Anesthesiologists score = 3, estimated blood loss = 1525 ± 978 mL, size = 8 ± 4 cm). With proper patient selection, laparoscopic adrenalectomy can be successfully performed with a low conversion rate. When unrecognized, an accessory right adrenal vein may be a source of significant bleeding requiring conversion to an open approach. Open resection is indicated for tumor invasion, for extraadrenal pheochromocytoma, when laparoscopic resection cannot be performed safely, and for concomitant open procedures.

Laparoscopic adrenalectomy using needlescopic instruments for adrenal tumors less than 5cm in 112 cases

OBJECTIVE

To examine the safety and efficacy of laparoscopic adrenalectomy with needlescopic instruments for most adrenal tumors less than 5cm.

METHODS

Transperitoneal laparoscopic adrenalectomy with needlescopic instruments for 112 patients with presumptively benign adrenal tumors < 5cm were enrolled from July 2000 to February 2005. Operative time, blood loss, conversion and complication rates, and postoperative data were analyzed by appropriate statistical methods.

RESULTS

All 112 operations were completed without any mortality or reoperation. Mean operative time was 151min and mean blood loss was 30ml. Only one patient required a blood transfusion and application of a hand-assisted device. Conversion to conventional laparoscopic instruments was necessary in another five patients (4.5%). The operative time of the latter 100 cases (147+/-5.1min, mean+/-standard error of mean) was significantly shorter than that of the initial 12 cases (183+/-8.8min, p=0.001). Larger tumors, previous abdominal surgery, and pheochromocytoma group were independent risk factors of a longer operative time. Except for one leiomyosarcoma, all other tumors were benign adrenal pathologies (57 aldosterone-producing adenomas, 23 Cushing's adenomas, 12 pheochromocytomas, and 20 incidentalomas).

CONCLUSION

The safety and effectiveness of laparoscopic adrenalectomy employing needlescopic instruments for most adrenal tumors less than 5cm was feasible with acceptable operative time. Pheochromocytomas can also be managed with a longer operative time. Patients with previous upper midline or ipsilateral upper quadrant open surgery might not be suitable candidates for such a technique.

Outcomes of Pheochromocytoma Management in the Laparoscopic Era

BACKGROUND

Laparoscopic adrenalectomy (LA) is the preferred surgical approach for pheochromocytomas. We have investigated the changes in diagnosis, management and outcome of pheochromocytomas treated since the widespread advent of LA.

METHODS

Data were collected retrospectively from 96 patients with pheochromocytomas that had been surgically treated at three tertiary referral centers.

RESULTS

There were 53 females. Mean age was 47 years (10-81). Tumors were found incidentally in 40% of patients. Of the 96 patients, 12 (13%) had familial syndromes. CT or MRI localized the adrenal lesion in all patients. MIBG scans obtained from 32 patients were concordant with the CT/MRI in 19, were false negative in 9 and misleading in 1, and altered management in only 3 patients. Mean tumor size was 5.6 cm (1.8-17). There were 92 adrenal pheochromocytomas and 9 paragangliomas. Laparoscopy was successful in 67 of 74 (91%) patients, with 20 of 67 (30%) having tumors of 6 cm or greater in size. Conversions to open procedures were performed in patients with 4 left, 2 right pheochromocytomas and 1 paraganglioma. Of the patients, 22 had an open procedure due to suspicion of malignancy or large tumors. Malignancy was observed in 4 of 92 (4.3%) pheochromocytomas and 4 of 9 (44%) paragangliomas. Average follow-up was 22 months (1-122). There were seven recurrences. Postoperative biochemical tests available in 64 patients were normal in 90%.

CONCLUSIONS

The diagnosis of pheochromocytoma was made incidentally in 40% of patients. MIBG is not necessary for unilateral non-hereditary pheochromocytomas localized by CT/MRI. LA is possible with excellent results in most patients, including for treatment of lesions 6 cm or greater in size with no signs of invasion. Laparoscopy should be used cautiously for paragangliomas because of a high rate of malignancy.

Pheochromocytoma as a catecholamine producing tumor: implications for clinical practice

Pheochromocytomas are catecholamine-producing tumors presenting with various clinical symptoms, but mostly with headache, sweating, palpitations and hypertension. If not properly diagnosed, secretion of catecholamines may lead to fatal cardiovascular consequences. Biochemical testing for pheochromocytoma should be performed not only in symptomatic subjects or in subjects with adrenal incidentaloma but also in subjects with a genetic predisposition for pheochromocytoma (multiple endocrine neoplasia type 2, Von Hippel-Lindau (VHL) syndrome, neurofibromatosis type 1 (NF 1)and mutations of succinate dehydrogenase (SDH) genes). Once a pheochromocytoma is proven, computed tomography (CT), magnetic resonance imaging (MRI) and functional imaging with [(123)I]-MIBG may be used for tumor localization. Adequate medical pre-treatment is essential for successful operation which is performed in most cases by laparoscopy. After tumor removal, further follow-up is necessary due to possible recurrence. Although prognosis after tumor resection is excellent, a significant proportion of pheochromocytomas recur, some as metastases. Thus, appropriate follow-up is mandatory.