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Ge T, Xie X, Liu J. A rare case of pheochromocytoma in a pregnant woman presenting with chest pain: extraordinary management. BMC Cardiovasc Disord 2024; 24:261. [PMID: 38769478 PMCID: PMC11103813 DOI: 10.1186/s12872-024-03943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/15/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Pheochromocytoma is rare in pregnant women. It presents as diverse symptoms, including hypertension and sweating. The symptoms of pregnant women with pheochromocytoma and comorbid hypertension often mimic the clinical manifestations of preeclampsia, and these women are often misdiagnosed with preeclampsia. CASE PRESENTATION In this case, a pregnant woman presented with chest pain as the primary symptom, and a diagnosis of pheochromocytoma was considered after ruling out myocardial ischemia and aortic dissection with the relevant diagnostic tools. This patient then underwent successful surgical resection using a nontraditional management approach, which resulted in a positive clinical outcome. CONCLUSIONS It is essential to consider pheochromocytoma as a potential cause of chest pain and myocardial infarction-like electrocardiographic changes in pregnant women, even if they do not have a history of hypertension.
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Affiliation(s)
- Tao Ge
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China
| | - Xiangrong Xie
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China
| | - Jichun Liu
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, No. 2, Zhe Shan West Road, Wuhu, 241001, Anhui, China.
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2
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McConnell MM, Kanin MR, Auerbach MS, Yu R. Clinical Progression of a Paraganglioma Over Many Years in a Man With Congenital Heart Disease. AACE Clin Case Rep 2023; 9:193-196. [PMID: 38045797 PMCID: PMC10690415 DOI: 10.1016/j.aace.2023.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 12/05/2023] Open
Abstract
Background Documented symptomatic progression of a paraganglioma (PGL) over many years is unusual. Our objective is to report a young man with such an occurrence. Case Report A 27-year-old male presented with headache, sweating, and palpitation. He had a history of cyanotic congenital heart disease. Five years before presentation, he had 24-hour urine metanephrines 43 mcg/d (25-222), vanillylmandelic acid 3 mg/d (<6), and homovanillic acid 2.4 mg/d (1.6-7.5) levels and a 3.13 cm mass in the upper aortocaval space. Subsequent imaging showed slow growth of the mass. On admission, his blood pressure was 197/134 mm Hg, heart rate was 163 beats per minute, respiratory rate was 25 per minute, and oxygen saturation was 76% on room air. His 24-hour urine normetanephrine level was 2644 mcg/d (81-667) while metanephrine was 405 mcg/d (55-320). Plasma free metanephrine level was 0.92 nmol/L (0-0.49) and normetanephrine was 11.85 nmol/L (0-0.89). DOTATATE positron emission tomography-computed tomography revealed a 4.3 × 3.1 × 4.9 cm mass with activity in the right upper aortocaval space. He was treated with Prazosin. Two months later, he underwent resection of the mass. Pathology diagnosed a 4.9 cm PGL. He had improvement in metanephrine levels. Discussion PGL is diagnosed by documenting excess catecholamines and identifying a lesion on imaging. False negative laboratory testing is rare but can occur. Patients with cyanotic congenital heart disease have a greater risk of developing PGL. Conclusion It is crucial to evaluate a patient for PGL if clinical conditions suggest catecholamine excess, especially if a retroperitoneal tumor has grown or the patient has risk factors.
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Affiliation(s)
- Megan M. McConnell
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Maralee R. Kanin
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Martin S. Auerbach
- Department of Nuclear Medicine and Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Run Yu
- Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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3
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Eisenhofer G, Pamporaki C, Lenders JWM. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev 2023; 44:862-909. [PMID: 36996131 DOI: 10.1210/endrev/bnad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
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Kestenbaum B, Ix JH, Gansevoort R, Granda ML, Bakker SJL, Groothof D, Kieneker LM, Hoofnagle AN, Chen Y, Wang K, Katz R, Prince DK. Population-Based Limits of Urine Creatinine Excretion. Kidney Int Rep 2022; 7:2474-2483. [PMID: 36531868 PMCID: PMC9751685 DOI: 10.1016/j.ekir.2022.08.025] [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: 02/07/2022] [Revised: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022] Open
Abstract
Introduction The validity of a timed urine collection is typically judged by measurement of urine creatinine excretion, but prevailing limits may be unreliable. We sought to empirically derive population-based limits of excretion for evaluating the validity of a timed urine collection. Methods Covariate and 24-hour urine data were obtained from 3582 participants in the Chronic Renal Insufficiency Cohort (CRIC) study, 814 participants in the Modification of Diet in Renal Disease (MDRD) study, 1010 participants in the Jackson Heart Study (JHS), and 8536 participants in the Prevention of Renal Vascular End Stage Disease (PREVEND) study. Weight, height, age, sex, and serum creatinine concentrations were evaluated as potential predictors of urine creatinine excretion using Akaike Information Criteria, R-squared values, and deviance. Bias and precision of the fitted models were assessed by analyses of residuals. Agreement between 24-hour creatinine clearance and 125I-iothalamate clearance was assessed before and after exclusion of potentially invalid urine samples. Results A best-fitting model to predict 24-hour urine creatinine excretion among the 9199 discovery cohort members included sex-specific terms for weight, height, and age (R-squared = 0.328). This model had a median bias of +4.3 mg creatinine/day (95% confidence interval -5.6, +13.3 mg/day) in 4599 validation cohort members, and 82% of observed values were within 30% of predicted model. Serum creatinine concentrations only marginally improved model precision but reduced bias in persons with advanced chronic kidney disease (CKD). Conclusion The limits of urine creatinine excretion derived here represent the most valid and representative data for appraising the adequacy of a timed urine collection.
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Affiliation(s)
- Bryan Kestenbaum
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Joachim H Ix
- Division of Nephrology, Department of Medicine, University of California, San Diego, California, USA
| | - Ron Gansevoort
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Michael L Granda
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Stephan J L Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dion Groothof
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lyanne M Kieneker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andy N Hoofnagle
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Yan Chen
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Ke Wang
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Ronit Katz
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - David K Prince
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, Washington, USA
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5
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Anyfanti P, Mastrogiannis Κ, Lazaridis Α, Tasios Κ, Vasilakou D, Kyriazidou Α, Aroutsidis F, Pavlidou O, Papoutsopoulou Ε, Tiritidou A, Kotsis V, Triantafyllou Α, Zarifis Ι, Douma S, Gkaliagkousi Ε. Clinical presentation and diagnostic evaluation of pheochromocytoma: case series and literature review. Clin Exp Hypertens 2022; 45:2132012. [PMID: 36218060 DOI: 10.1080/10641963.2022.2132012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Pheochromocytoma is a rare tumor frequently overlooked mainly due to the wide range of its clinical presentation, which may vary from entirely untypical signs and symptoms to life-threatening complications. METHODS The present study aims to present a case series recently treated in our center, with emphasis placed on patients' specific characteristics, clinical presentation and diagnostic evaluation. Relevant literature and current guidelines are being briefly reviewed to summarize screening for pheochromocytoma and appropriate diagnostic procedures. RESULTS While the classic symptoms include headache, palpitations and sweating with permanent or paroxysmal hypertension, a wide range of clinical manifestations may be attributed to pheochromocytoma. The initial screening test is measurement of plasma or 24-hour urine metanephrine levels. Abdominal computerized tomography with intravenous contrast infusion is suggested as the imaging examination of choice, whereas magnetic resonance imaging should be preferred over CT in exceptional cases. 123I-metaiodobenzylguanidine scintigraphy is particularly useful for establishing the diagnosis of pheochromocytoma and should be further applied to detect or exclude possible metastatic lesions. CONCLUSION Early diagnosis of pheochromocytoma is of great significance not only because it represents a curable form of secondary hypertension, but also because it is often related to familial syndromes, malignancy or metastatic disease. Physicians need to be familiar with relevant clinical manifestations and diagnostic steps to raise clinical suspiction of pheochromocytoma and establish a timely diagnosis.
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Affiliation(s)
- Panagiota Anyfanti
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Κonstantinos Mastrogiannis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Αntonios Lazaridis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Κonstantinos Tasios
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Despoina Vasilakou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Αnastasia Kyriazidou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Aroutsidis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Olga Pavlidou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Εleni Papoutsopoulou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athina Tiritidou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Kotsis
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Αreti Triantafyllou
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ιoannis Zarifis
- Department of Cardiology, Papanikolaou General Hospital, Thessaloniki, Greece
| | - Stella Douma
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Εugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Overexpression of miR-375 and L-type Amino Acid Transporter 1 in Pheochromocytoma and Their Molecular and Functional Implications. Int J Mol Sci 2022; 23:ijms23052413. [PMID: 35269556 PMCID: PMC8910416 DOI: 10.3390/ijms23052413] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/06/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Pheochromocytoma (Pheo) is a tumor derived from chromaffin cells. It can be studied using 18F-dihydroxyphenylalanine (DOPA)—positron emission tomography (PET) due to its overexpression of L-type amino acid transporters (LAT1 and LAT2). The oncogenic pathways involved are still poorly understood. This study examined the relationship between 18F-DOPA-PET uptake and LAT1 expression, and we explored the role of miR-375 and putative target genes. A consecutive series of 58 Pheo patients were retrospectively analyzed, performing 18F-DOPA-PET in 32/58 patients. Real-time quantitative PCR was used to assess the expression of LAT1, LAT2, phenylethanolamine N-methyltransferase (PNMT), miR-375, and the major components of the Hippo and Wingless/Integrated pathways. Principal germline mutations associated with hereditary Pheo were also studied. Pheo tissues had significantly higher LAT1, LAT2, and PNMT mRNA levels than normal adrenal tissues. MiR-375 was strongly overexpressed. Yes-associated protein 1 and tankyrase 1 were upregulated, while beta-catenin, axin2, monocarboxylate transporter 8, and Frizzled 8 were downregulated. A positive relationship was found between 18F-DOPA-PET SUV mean and LAT1 gene expression and for 24 h-urinary norepinephrine and LAT1. This is the first experimental evidence of 18F-DOPA uptake correlating with LAT1 overexpression. We also demonstrated miR-375 overexpression and downregulated (Wnt) signaling and identified the Hippo pathway as a new potentially oncogenic feature of Pheo.
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Kline GA, Boyd J, Sadrzadeh HSM, Leung AA. Inpatient Measurements of Urine Metanephrines are Indistinguishable from Pheochromocytoma: Retrospective Cohort Study. Am J Med 2021; 134:1039-1046.e3. [PMID: 33864763 DOI: 10.1016/j.amjmed.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/06/2021] [Accepted: 03/08/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pheochromocytoma is a rare cause of acute cardiovascular disease; however, any severe illness may have high catecholamines, simulating pheochromocytoma. We determined the spectrum of urine metanephrines from inpatient and outpatient collections without pheochromocytoma, compared with confirmed pheochromocytoma patients. METHODS Retrospective analysis using centralized laboratory data serving all outpatients and hospitals in southern Alberta. The analysis comprised 24-hour urine normetanephrine and metanephrine (UNM-UMN) results collected from hospital inpatients, community outpatients, and patients from a comprehensive provincial pheochromocytoma registry. RESULTS There were 974 unique inpatients (including 132 from intensive care), 6802 outpatients, and 58 pheochromocytoma patients. Among outpatient, general ward, and intensive care unit (ICU) patients, 18.7%, 34.4%, and 67.4% of results, respectively, were supranormal. Although pheochromocytoma patients had higher median UNM-UMN vs inpatients, there was substantial overlap. Receiver operating characteristic (ROC) analysis showed area under the curve (AUC) of 0.64-0.91 to detect true pheochromocytoma (P < .0001), with progressively poorer discrimination among hospitalized and ICU-dependent patients. A 24-hour urine normetanephrine >6.95 nmol/d had 98% specificity for pheochromocytoma when inpatient general ward samples were included, but only 46% sensitivity and 13% positive predictive value for pheochromocytoma. Considering ICU collections, 98% specificity required results more than fivefold above the upper reference limit and still had poor positive predictive value. A model combining both UNM and UMN results as a cross-product marginally improved the ROC AUC, but improved sensitivity in outpatients and ward patients but not ICU patients. CONCLUSION There is a high degree of overlap in UNM-UMN between hospitalized patients and pheochromocytoma; high test specificity is not achieved in this population unless >3-5 times the upper reference limit.
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Affiliation(s)
| | - Jessica Boyd
- Department of Pathology and Laboratory Medicine, University of Calgary, Alb, Canada; Alberta Precision Laboratories, Calgary, Canada
| | - Hossein S M Sadrzadeh
- Department of Pathology and Laboratory Medicine, University of Calgary, Alb, Canada; Alberta Precision Laboratories, Calgary, Canada
| | - Alexander A Leung
- Cumming School of Medicine, Department of Medicine; Department of Community Health Sciences, University of Calgary, Alb, Canada
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A Critical Appraisal of Contemporary and Novel Biomarkers in Pheochromocytomas and Adrenocortical Tumors. BIOLOGY 2021; 10:biology10070580. [PMID: 34201922 PMCID: PMC8301201 DOI: 10.3390/biology10070580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/16/2021] [Accepted: 06/22/2021] [Indexed: 12/21/2022]
Abstract
Simple Summary Pheochromocytomas/paragangliomas (PPGLs) and adrenocortical tumors are neoplasms that originate from different regions of the adrenal gland and display significant heterogeneity with respect to their biological and clinical behavior. They may be sporadic or develop in the context of hereditary syndromes. Adrenocortical tumors are mostly benign but less than 2% are carcinomas associated with a poor outcome when diagnosed in advanced disease. The majority of PPGLS are benign, but a subset may develop metastatic disease. In particular, for PPGLs, it is mandatory to identify biomarkers of high sensitivity and specificity that lead to accurate diagnosis and predict patients with a malignant potential that would benefit from aggressive surveillance and administration of early treatment. Current biomarkers include mostly histopathological and genetic parameters but none of them can be considered independent predictive factors. Recent genomic studies have implemented new molecular biomarkers of high accuracy for the diagnosis and management of PPGLs and adrenocortical tumors. In this review, we summarize the current and novel biomarkers that may be considered valuable tools for diagnosis and prediction of malignancy in patients with PPGLs and adrenocortical tumors. Abstract Pheochromocytomas/Paragangliomas (PPGLs) and adrenocortical tumors are rare neoplasms with significant heterogeneity in their biologic and clinical behavior. Current diagnostic and predictive biomarkers include hormone secretion, as well as histopathological and genetic features. PPGL diagnosis is based on biochemical measurement of catecholamines/metanephrines, while histopathological scoring systems have been proposed to predict the risk of malignancy. Adrenocortical tumors are mostly benign, but some can be malignant. Currently, the stage of disease at diagnosis and tumor grade, appear to be the most powerful prognostic factors. However, recent genomic and proteomic studies have identified new genetic and circulating biomarkers, including genes, immunohistochemical markers and micro-RNAs that display high specificity and sensitivity as diagnostic or prognostic tools. In addition, new molecular classifications have been proposed that divide adrenal tumors in distinct subgroups with different clinical outcomes.
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Battistella E, Ferrari S, Pomba L, Toniato A. Adrenal surgery: Review of 35 years experience in a single centre. Surg Oncol 2021; 37:101554. [PMID: 33848760 DOI: 10.1016/j.suronc.2021.101554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/15/2021] [Accepted: 03/26/2021] [Indexed: 12/07/2022]
Abstract
INTRODUCTION The rate of adrenal disease diagnosed is progressively increasing due to the diagnostic tools improvement. We analysed patients that underwent to adrenalectomy in our centre for different adrenal pathologies and we tried to established guidelines for the surgical therapy. METHODS Demographic and clinical data were prospectively entered in a computerized endocrine surgery registry for all patients who underwent surgery for adrenal lesions at our institution over a 35-year period and statistical analyses was performed. RESULTS Between 1986 and 2020, 502 patients underwent adrenalectomy: open adrenalectomy (OA) was performed in 104 patients (28,6%), laparoscopic adrenalectomy (LA) in 398 patients (71,4%). The rate of conversion to OA was 5,9% (21 patients). The mean operating time in laparoscopic approach was 84.3 min (range 40-180) while in open approach was 121.9 min (40-210). The average length of stay (LOS) for LA was 3.6 days, while for OA was 7.4 days. The time to return to normal activity for LA was 21 days while for OA was 37 days. CONCLUSIONS The progressive increase in the number of adrenalectomies performed is due more to a better understanding of adrenal disease than to the availability of minimally invasive techniques. The choice of a laparoscopic approach should depend on the surgeon's experience, regardless the dimension of the lesion. Considering our long experience, we suggest OA for lesion of more of 6 cm, for malignant lesion with a diameter higher than 3 cm or with a pre-operatory evidence of invasion of the surrounding tissue.
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Affiliation(s)
- Enrico Battistella
- Department of Surgery, Endocrine Surgery Unit, Veneto Institute of Oncology, IOV-IRCSS, Padua, Italy.
| | - Stefania Ferrari
- Department of Surgery, Endocrine Surgery Unit, Veneto Institute of Oncology, IOV-IRCSS, Padua, Italy
| | - Luca Pomba
- Department of Surgery, Endocrine Surgery Unit, Veneto Institute of Oncology, IOV-IRCSS, Padua, Italy
| | - Antonio Toniato
- Department of Surgery, Endocrine Surgery Unit, Veneto Institute of Oncology, IOV-IRCSS, Padua, Italy
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10
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Shin T, Hoang TD, Plunkett MT, Shakir MKM. False elevations in urinary metanephrines: under-recognised pitfall with 24-hour urinary volume collection. BMJ Case Rep 2021; 14:14/2/e241147. [PMID: 33541972 PMCID: PMC7868217 DOI: 10.1136/bcr-2020-241147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
One pitfall in 24-hour urine collection is the input of incorrect urinary volume by the reference laboratory. This may lead to an incorrect diagnosis of pheochromocytoma or paraganglioma. A 48-year-old African-American woman was seen in the clinic for an elevated 24-hour urine metanephrine screen during workup for secondary hypertension. Urine volume was found to be incorrectly inputted by the lab as 9750 mL rather than 975 mL. The urinary metanephrines were then recalculated and the 24-hour urinary metanephrines resulted within normal limits. This case highlights this unique and potentially under-recognised error in testing with 24-hour urine volume collection.
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Affiliation(s)
- Terry Shin
- Endocrinology, Womack Army Medical Center, Fort Bragg, North Carolina, USA .,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Thanh Duc Hoang
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Mohamed K M Shakir
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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11
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Holscher I, van den Berg TJ, Dreijerink KMA, Engelsman AF, Nieveen van Dijkum EJM. Recurrence Rate of Sporadic Pheochromocytomas After Curative Adrenalectomy: A Systematic Review and Meta-analysis. J Clin Endocrinol Metab 2021; 106:588-597. [PMID: 33125073 DOI: 10.1210/clinem/dgaa794] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Evidence on follow-up duration for patients with sporadic pheochromocytomas is absent, and current guidelines of the European Society of Endocrinology, American Association of Clinical Endocrinologists and Endocrine Surgeons, and the Endocrine Society are ambiguous about the appropriate duration of follow-up. The aim of this systematic review and meta-analysis is to evaluate the recurrence rate of sporadic pheochromocytomas after curative adrenalectomy. MATERIALS AND METHODS A literature search in PubMed, Embase, and the Cochrane Library was performed. A study was eligible if it included a clear report on the number of sporadic patients, recurrence rate, and follow-up duration. Studies with an inclusion period before 1990, <2 years of follow-up, <10 patients, and unclear data on the sporadic nature of pheochromocytomas were excluded. A meta-analysis on recurrence was performed provided that the heterogeneity was low (I2 < 25%) or intermediate (I2 26-75%). Hozo's method was used to calculate weighted mean follow-up duration and weighted time to recurrence with combined standard deviations (SDs). RESULTS A total of 13 studies, including 430 patients, were included in the synthesis. The meta-analysis results describe a pooled recurrence rate after curative surgery of 3% (95% confidence interval: 2-6%, I2 = 0%), with a weighted mean time to recurrence of 49.4 months (SD = 30.7) and a weighted mean follow-up period of 77.3 months (SD = 32.2). CONCLUSIONS This meta-analysis shows a very low recurrence rate of 3%. Prospective studies, including economical and health effects of limited follow-up strategies for patients with truly sporadic pheochromocytomas should be considered.
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Affiliation(s)
- Isabelle Holscher
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, AZ, The Netherlands
| | - Tijs J van den Berg
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, AZ, The Netherlands
| | - Koen M A Dreijerink
- Amsterdam UMC, VU University Medical Center, Department of Endocrinology, Amsterdam, HV, The Netherlands
| | - Anton F Engelsman
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, HV, The Netherlands
| | - Els J M Nieveen van Dijkum
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, AZ, The Netherlands
- ENETS Center of Excellence, Amsterdam UMC, University of Amsterdam, Amsterdam, AZ, The Netherlands
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12
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Bloomer ZW, Bauer EM, Hoang TD, Shakir MK. Eletriptan (Relpaxa™) Causing False Positive Elevations In Urinary Metanephrines. AACE Clin Case Rep 2020; 6:e286-e289. [DOI: 10.4158/accr-2020-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/01/2020] [Indexed: 11/15/2022] Open
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13
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Yamada T, Fukuoka H, Hosokawa Y, Odake Y, Yoshida K, Matsumoto R, Bando H, Okada Y, Hirota Y, Iguchi G, Ogawa W, Takahashi Y. Patients with pheochromocytoma exhibit low aldosterone renin ratio-preliminary reports. BMC Endocr Disord 2020; 20:140. [PMID: 32917197 PMCID: PMC7488748 DOI: 10.1186/s12902-020-00620-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 01/14/2020] [Accepted: 08/31/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Plasma renin activity (PRA) is generally increased in patients with pheochromocytoma (PCC) due to low circulating plasma volume and activation of β-1 adrenergic receptor signaling. However, there has been no study on the aldosterone renin ratio (ARR) in patients with PCC. To elucidate the issue, this study aimed to determine the PRA, plasma aldosterone concentration (PAC), and ARR in patients with PCC and compare them with those in patients with subclinical Cushing's syndrome (SCS) and non-functioning adrenal adenoma (NFA). METHODS In this retrospective single-center, cross-sectional study, 67 consecutive patients with adrenal tumors (PCC (n = 18), SCS (n = 18), and NFA (n = 31)) diagnosed at Kobe University Hospital between 2008 and 2014 were enrolled. RESULTS PRA was significantly higher in patients with PCC than in those with SCS and NFA (2.1 (1.3 ~ 2.8) vs. 0.7 (0.5 ~ 1.8) and 0.9 (0.6 ~ 1.4) ng/mL/h; p = 0.018 and p = 0.025). Although PACs were comparable among the three groups, ARR was significantly lower in patients with PCC than in those with SCS and NFA (70.5 (45.5 ~ 79.5) vs. 156.0 (92.9 ~ 194.5) and 114.9 (90.1 ~ 153.4); p = 0.001 and p < 0.001). Receiver operating characteristic curve analysis demonstrated that, in differentiating PCC from NFA, PRA > 1.55 ng/mL/h showed a sensitivity of 70.0% and specificity of 80.6%. Interestingly, ARR < 95.4 showed a sensitivity of 83.3% and specificity of 86.7%, which were higher than those in PRA. CONCLUSIONS ARR decreased in patients with PCC, which was a more sensitive marker than PRA. Further study is necessary to understand the usefulness of this convenient marker in the detection of PCC. TRIAL REGISTRATION This study was not registered because of the retrospective analysis.
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Affiliation(s)
- Tomoko Yamada
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Yusei Hosokawa
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yukiko Odake
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Kenichi Yoshida
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Ryusaku Matsumoto
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yuko Okada
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yutaka Takahashi
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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14
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Pheochromocytoma and paraganglioma-an update on diagnosis, evaluation, and management. Pediatr Nephrol 2020; 35:581-594. [PMID: 30603807 DOI: 10.1007/s00467-018-4181-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 12/02/2018] [Accepted: 12/14/2018] [Indexed: 12/31/2022]
Abstract
Pheochromocytomas and paragangliomas (PPGLs) generally grouped together are rare catecholamine-secreting endocrine tumors. Symptoms of catecholamine excess are non-specific and therefore a high index of suspicion in children with sustained hypertension, family history of endocrine tumors, or features of syndromes associated with PPGLs leads to a timely diagnosis and treatment. Free metanephrines in the plasma or 24-h urine are the preferred tests to establish catecholamine excess. Considerations for false-positive conditions improve diagnostic yield and accuracy. Functional imaging, targeting either specific cell membrane transporters or vesicular catecholamine transport systems, is indicated for incidental lesions suspicious for PPGLs with inconclusive biochemical testing, assessment of regional extension or multifocality, and exclusion of metastases. Surgery is the mainstay of treatment for PPGLs. Preoperatively, sequential use of alpha adrenergic receptor blockade and volume expansion followed by beta blockade is mandatory to reduce intraoperative intravascular instability and blood pressure fluctuation due to tumor manipulation. Since genetic mutations have been reported in tumor susceptibility genes in nearly 50% of patients with PPGLs, genetic counselling and testing should be considered in all patients with a confirmed tumor.
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15
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Abstract
Pheochromocytomas are rare neuroendocrine chromaffin-derived tumors that arise within the adrenal medulla. They are usually benign, but if not diagnosed or if left untreated, they can have devastating consequences. Clinical consideration of the diagnosis is paramount, as they may have protean manifestations, and a high index of suspicion is essential if serious consequences are to be avoided. An accurate biochemical diagnosis is crucial for the management of these patients: either plasma or urinary metanephrines are both highly sensitive and specific if correctly employed, but knowledge of pre- and post-analytic interference is essential. Diagnostic imaging with cross-sectional CT and/or MRI offers high sensitivity in their detection, but lack specificity. The introduction of PET/CT/MR has led to a dramatic improvement in the localization of both pheochromocytomas and paragangliomas, together with the increasing availability of new functional imaging radionuclides. Optimal investigation and accurate diagnosis is best achieved at 'centers of excellence' with expert multidisciplinary teams.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, 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
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16
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Kumar RM, Violette PD, Tran C, Tomiak E, Izard J, Bathini V, Rowe NE. Canadian Urological Association Best Practice Report: Long-term surveillance following resection of pheochromocytoma. Can Urol Assoc J 2019; 13:372-376. [PMID: 31799918 DOI: 10.5489/cuaj.6254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Ravi M Kumar
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Philippe D Violette
- Departments of Health Research Methods Evidence and Impact, and Surgery, McMaster, Hamilton, ON, Canada
| | - Christopher Tran
- Division of Endocrinology and Metabolism, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Eva Tomiak
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Jason Izard
- Department of Urology, Kingston Health Sciences Centre, Queen's University, Kingston, ON Canada
| | - Varun Bathini
- Division of Urology, Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada
| | - Neal E Rowe
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
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17
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Hirsch D, Grossman A, Nadler V, Alboim S, Tsvetov G. Pheochromocytoma: Positive predictive values of mildly elevated urinary fractionated metanephrines in a large cohort of community-dwelling patients. J Clin Hypertens (Greenwich) 2019; 21:1527-1533. [PMID: 31486577 DOI: 10.1111/jch.13657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/09/2019] [Accepted: 07/16/2019] [Indexed: 11/28/2022]
Abstract
The diagnostic utility of different thresholds of elevated urinary fractionated metanephrine (UFM) for pheochromocytoma-paraganglioma (PPGL) was evaluated in 10 164 community-dwelling subjects (2012-2017). Levels were ≥1.5× the upper normal limit (UNL) in 276 subjects (2.7%) and ≥2×UNL in 138 (1.4%). PPGL was subsequently diagnosed in 59 (mean age 51.9 ± 14.3, 64% female); 58 (98.3%) with UFM ≥ 2×UNL. Positive predictive values (PPV) were 42% for UFM ≥ 2×UNL, 55% for UFM ≥ 2.5×UNL, and 69% for UFM ≥ 3×UNL. The main reason for PPGL screening (52.5%) was adrenal incidentaloma. Mean (median) metanephrine/normetanephrine levels were 6.7 ± 9×UNL (3 × UNL) and 6.1 ± 8.9×UNL (2.5 × UNL). Six patients (10.2%) had an extra-adrenal tumor (one malignant paraganglioma); one had bilateral pheochromocytoma. Only one patient presented with the "classic triad" (headache, palpitations, sweating). In conclusion, after excluding obvious reasons for false-positive results, thorough diagnostic assessment for PPGL is justified in all subjects with UFM ≥ ×2UNL. The PPV of milder UFM elevations is very low.
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Affiliation(s)
- Dania Hirsch
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Health Care Services, Tel Aviv, Israel
| | - Alon Grossman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Health Care Services, Tel Aviv, Israel.,Department of Internal Medicine B, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Varda Nadler
- Maccabi Health Care Services-Central Laboratory, Rehovot, Israel
| | - Sandra Alboim
- Maccabi Health Care Services-Central Laboratory, Rehovot, Israel
| | - Gloria Tsvetov
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Health Care Services, Tel Aviv, Israel
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18
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Wan W, Nguyen B, Graybill S, Kim J. Clonidine suppression testing for pheochromocytoma in neurofibromatosis type 1. BMJ Case Rep 2019; 12:12/6/e228263. [PMID: 31243023 DOI: 10.1136/bcr-2018-228263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Compared with the general population, rates of pheochromocytoma are higher in neurofibromatosis type 1 (NF1) patients. However, pheochromocytoma testing is often plagued by false positive results. Here we present a patient with NF1, elevated urinary metanephrine levels, and an indeterminate adrenal nodule. Clonidine suppression testing aided diagnosis and led to definitive surgical treatment that confirmed a pheochromocytoma. Pheochromocytoma screening and clonidine suppression testing can both aid in the evaluation for catecholamine-secreting tumours.
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Affiliation(s)
- WingYee Wan
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Bichle Nguyen
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Sky Graybill
- Endocrinology Department, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Jonathan Kim
- Internal Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
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19
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Volkova NI, Davidenko IY. The role of the general practitioner in the diagnostics of endocrine arterial hypertension. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-2-84-93] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- N. I. Volkova
- Rostov State Medical University, of the Ministry of Health of Russia
| | - I. Yu. Davidenko
- Rostov State Medical University, of the Ministry of Health of Russia
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20
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Gómez R, Hernaiz M, de Miguel V, Aparicio L, Marín M, Lupi S, Barontini M. Enfoque diagnóstico de feocromocitomas y paragangliomas. HIPERTENSION Y RIESGO VASCULAR 2019; 36:34-43. [DOI: 10.1016/j.hipert.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 06/30/2018] [Indexed: 02/09/2023]
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21
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Liu S, Song A, Zhou X, Kong X, Li WA, Wang Y, Liu Y. Malignant pheochromocytoma with multiple vertebral metastases causing acute incomplete paralysis during pregnancy: Literature review with one case report. Medicine (Baltimore) 2017; 96:e8535. [PMID: 29095319 PMCID: PMC5682838 DOI: 10.1097/md.0000000000008535] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE We present a rare case of malignant pheochromocytoma with thoracic metastases during pregnancy that presented with symptoms of myelopathy and was treated with circumferential decompression, stabilization, and radiation. The management of this unique case is not well documented. The clinical manifestations, imaging results, pathological characteristics, treatment and prognosis of the case were analyzed. PATIENT CONCERNS A 26-year-old pregnant woman with a history of paroxysmal hypertension during the second trimester presented with lower extremity weakness, numbness, urinary incontinence, and back pain. Imaging studies revealed a right adrenal pheochromocytoma, multiple metastases at T8, T11, T12, and the pelvis girdle causing significant multilevel cord compression and significant osteolytic lesions at T11 and T12. DIAGNOSES We believe this is the first reported case of metastatic pheochromocytoma of the thoracic spine presenting with symptoms of myelopathy during pregnancy. INTERVENTIONS A healthy neonate was delivered by emergency caesarean section at 34 weeks. Subsequently, the patient underwent a circumferential spinal cord decompression and a stabilization procedure. OUTCOMES The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 6-month follow-up visit. LESSONS This article emphasizes that metastatic pheochromocytoma of the spine, although rare, should be part of the differential when a patient presents with elevated blood pressure, weakness, and urinary incontinence.
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Affiliation(s)
- Shuzhong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - An Song
- Department of Endocrinology, Key Laboratory of Endocrinology, National Health and Family Planning Commission, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College
| | - Xi Zhou
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Xiangyi Kong
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - William A. Li
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI
| | - Yipeng Wang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences
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22
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Abstract
The advent of mass spectrometry into the clinical laboratory has led to an improvement in clinical management of several endocrine diseases. Liquid chromatography tandem mass spectrometry found some of its first clinical applications in the diagnosis of inborn errors of metabolism, in quantitative steroid analysis, and in drug analysis laboratories. Mass spectrometry assays offer analytical sensitivity and specificity that is superior to immunoassays for many analytes. This article highlights several areas of clinical endocrinology that have witnessed the use of liquid chromatography tandem mass spectrometry to improve clinical outcomes.
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Affiliation(s)
- Siva S Ketha
- Department of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Ravinder J Singh
- Department of Pathology and Laboratory Medicine, Mayo Clinic, 200 2nd Street, Rochester, MN, 55905, USA
| | - Hemamalini Ketha
- Department of Pathology, University Hospital, University of Michigan Hospital and Health Systems, 1500 East Medical Center Drive, Room 2F432, Ann Arbor, MI, 48109, USA.
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23
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Abstract
Pheochromocytomas are rare endocrine tumors that can have a significant impact on a variety of organ systems, including the cardiovascular system. Although the pathophysiology is not completely understood, pheochromocytomas exert their effects through high levels of catecholamines, mainly epinephrine and norepinephrine, which stimulate adrenergic receptors, including those within the cardiovascular system. Although the most common cardiovascular manifestation is hypertension, patients with pheochromocytoma can present with arrhythmia, hypotension, shock, myocardial ischemia, cardiomyopathy, aortic dissection, and peripheral ischemia. The medical management of the cardiovascular effects of pheochromocytoma is via blockade of adrenergic receptors, usually through the use of alpha blockers, with the addition of beta blockers if needed. However, only surgical resection of the pheochromocytoma is potentially curative, and this tumor requires unique management perioperatively. Because of the variability of presentation and the significant morbidity and mortality of patients with an undiagnosed pheochromocytoma, this entity should not be overlooked in the evaluation of patients with a wide variety of cardiovascular disorders.
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24
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Därr R, Kuhn M, Bode C, Bornstein SR, Pacak K, Lenders JWM, Eisenhofer G. Accuracy of recommended sampling and assay methods for the determination of plasma-free and urinary fractionated metanephrines in the diagnosis of pheochromocytoma and paraganglioma: a systematic review. Endocrine 2017; 56:495-503. [PMID: 28405881 PMCID: PMC6297899 DOI: 10.1007/s12020-017-1300-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/05/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine the accuracy of biochemical tests for the diagnosis of pheochromocytoma and paraganglioma. METHODS A search of the PubMed database was conducted for English-language articles published between October 1958 and December 2016 on the biochemical diagnosis of pheochromocytoma and paraganglioma using immunoassay methods or high-performance liquid chromatography with coulometric/electrochemical or tandem mass spectrometric detection for measurement of fractionated metanephrines in 24-h urine collections or plasma-free metanephrines obtained under seated or supine blood sampling conditions. RESULTS Application of the Standards for Reporting of Diagnostic Studies Accuracy Group criteria yielded 23 suitable articles. Summary receiver operating characteristic analysis revealed sensitivities/specificities of 94/93% and 91/93% for measurement of plasma-free metanephrines and urinary fractionated metanephrines using high-performance liquid chromatography or immunoassay methods, respectively. Partial areas under the curve were 0.947 vs. 0.911. Irrespective of the analytical method, sensitivity was significantly higher for supine compared with seated sampling, 95 vs. 89% (p < 0.02), while specificity was significantly higher for supine sampling compared with 24-h urine, 95 vs. 90% (p < 0.03). Partial areas under the curve were 0.942, 0.913, and 0.932 for supine sampling, seated sampling, and urine. Test accuracy increased linearly from 90 to 93% for 24-h urine at prevalence rates of 0.0-1.0, decreased linearly from 94 to 89% for seated sampling and was constant at 95% for supine conditions. CONCLUSIONS Current tests for the biochemical diagnosis of pheochromocytoma and paraganglioma show excellent diagnostic accuracy. Supine sampling conditions and measurement of plasma-free metanephrines using high-performance liquid chromatography with coulometric/electrochemical or tandem mass spectrometric detection provides the highest accuracy at all prevalence rates.
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Affiliation(s)
- Roland Därr
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Freiburg, Germany.
| | - Matthias Kuhn
- Institute for Medical Informatics and Biometry, Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Centre Freiburg, Freiburg, Germany
| | - Stefan R Bornstein
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Jacques W M Lenders
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Graeme Eisenhofer
- Department of Medicine ΙΙI, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
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25
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Chaaya G, Morales J, Castiglioni A, Subhani N, Asmar A. Paraganglioma of the Urinary Bladder: A Rare Cause of Hypertension and Urinary Tract Infections. Am J Med Sci 2017; 355:191-194. [PMID: 29406048 DOI: 10.1016/j.amjms.2017.03.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/28/2017] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
Pheochromocytoma is a neoplasm, which develops from cells of the chromaffin tissues that are derived from the ectodermic neural system and mostly situated within the adrenal medulla. Approximately 15% of pheochromocytoma cases arise from extra-adrenal chromaffin tissue. Pheochromocytoma of the bladder is rare and accounts for less than 0.06% of all bladder neoplasms and less than 1% of all pheochromocytomas. We report a case of a young woman who presented with uncontrolled hypertension, recurrent urinary tract infections and micturition attacks and was found to have a metastatic bladder paraganglioma. In addition, we provide a summary table of the clinical manifestations of paragangliomas based on anatomic locations.
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Affiliation(s)
- Gerard Chaaya
- University of Central Florida College of Medicine, Orlando, Florida
| | - Jorge Morales
- University of Central Florida College of Medicine, Orlando, Florida
| | - Analia Castiglioni
- University of Central Florida College of Medicine, Orlando, Florida; Orlando VA Medical Center, Orlando, Florida
| | - Noman Subhani
- University of Central Florida College of Medicine, Orlando, Florida; Osceola Regional Medical Center, Kissimmee, Florida
| | - Abdo Asmar
- University of Central Florida College of Medicine, Orlando, Florida; Orlando VA Medical Center, Orlando, Florida.
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27
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Bhat HS, Tiyadath BN. Management of Adrenal Masses. Indian J Surg Oncol 2017; 8:67-73. [PMID: 28127186 PMCID: PMC5236029 DOI: 10.1007/s13193-016-0597-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022] Open
Abstract
An adrenal mass can be either symptomatic or asymptomatic in the form of adrenal incidentalomas (AIs) in up to 8 % in autopsy and 4 % in imaging series. Once a diagnosis of adrenal mass is made, we need to differentiate whether it is functioning or nonfunctioning, benign, or malignant. In this article, we provide a literature review of the diagnostic workup including biochemical evaluation and imaging characteristics of the different pathologies. We also discuss the surgical strategies with laparoscopy as the mainstay with partial adrenalectomy in select cases and adrenalectomy in large masses. Follow-up protocol of AIs and adrenocortical carcinoma is also discussed.
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Affiliation(s)
- Hattangadi Sanjay Bhat
- Department of Urology and Renal transplantation, Rajagiri Hospital, Munnar Rd Chunagamvely Aluva, Kochi, Kerala 683112 India
| | - Balagopal Nair Tiyadath
- Department of Urology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita lane elmakkara, Kochi, Kerala 682041 India
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28
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Képénékian L, Mognetti T, Lifante JC, Giraudet AL, Houzard C, Pinson S, Borson-Chazot F, Combemale P. Interest of systematic screening of pheochromocytoma in patients with neurofibromatosis type 1. Eur J Endocrinol 2016; 175:335-44. [PMID: 27450695 DOI: 10.1530/eje-16-0233] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/22/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Pheochromocytoma (PHEO) may occur in 0.1-5.7% of patients presenting with a neurofibromatosis type 1 (NF1). Current recommendations are to explore only symptomatic patients. The objective of the study is to evaluate the prevalence and the interest of a systematic PHEO screening in this population. DESIGN A prospective study in a French tertiary center including consecutive NF1 patients older than 18 years. METHODS A systematic screening combining abdominal imaging and urinary fractionated metanephrines was proposed. In case of positivity of one or both exams, (123)I-metaiodobenzylguanidine scintigraphy or [(18)F]-fluoro-dihydroxyphenylalanine PET imaging was performed. The diagnosis of secreting PHEO was retained in case of elevated urinary metanephrines associated with positive scintigraphy and non-secreting PHEO when urinary metanephrines were normal with a positive scintigraphy. RESULTS Between January 2014 and August 2015, 234 patients were included and 156 patients (66.7%) completed both exams. In these 156 patients, 12 PHEOs were diagnosed, representing a prevalence of 7.7%. Of these, six PHEOs were secreting, with only two symptomatic patients. The tumor size of these PHEOs were bigger than that of non-secreting PHEO (25.2 ± 6.6 vs 14 ± 6.9 mm, P = 0.0165). One lesion was bilateral. Mean metanephrine and normetanephrine levels were 3.2 ± 2.6N and 2.8 ± 1N respectively. Three patients underwent surgery. The six patients with non-secreting PHEO were asymptomatic. One of them had bilateral lesion and one underwent surgery. CONCLUSIONS PHEO in NF1, whether or not secreting, are mostly asymptomatic. The current strategy to explore only symptomatic patients leads to an underestimation of prevalence with the risks inherent to the existence of an unrecognized PHEO.
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Affiliation(s)
- Lori Képénékian
- Department of Endocrinology and DiabetologyHospices Civils de Lyon, Groupement Hospitalier Est, Hôpital Louis Pradel, Bron Cedex, France
| | - Thomas Mognetti
- Department of Nuclear MedicineLéon Bérard Comprehensive Cancer Center, Lyon, France
| | - Jean-Christophe Lifante
- Department of GeneralDigestive and Endocrine Surgery, Centre Hospitalier Lyon Sud, Université Claude Bernard Lyon 1, Pierre Bénite, France
| | - Anne-Laure Giraudet
- Department of Nuclear MedicineLéon Bérard Comprehensive Cancer Center, Lyon, France
| | - Claire Houzard
- Nuclear Medicine UnitImaging Department, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Stéphane Pinson
- Molecular Genetics LaboratoryHôpital Edouard Herriot, Bâtiment E, Lyon, France
| | - Françoise Borson-Chazot
- Department of Endocrinology and DiabetologyHospices Civils de Lyon, Groupement Hospitalier Est, Hôpital Louis Pradel, Bron Cedex, France
| | - Patrick Combemale
- Rhône-Alpes Auvergne Competence Center for the treatment of Neurofibromatosis type 1Léon Bérard Comprehensive Cancer Center, Lyon, France
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Boca S, Farcau C, Baia M, Astilean S. Metanephrine neuroendocrine tumor marker detection by SERS using Au nanoparticle/Au film sandwich architecture. Biomed Microdevices 2016; 18:12. [DOI: 10.1007/s10544-016-0037-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gunawardane PTK, Grossman A. Phaeochromocytoma and Paraganglioma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:239-259. [PMID: 27888488 DOI: 10.1007/5584_2016_76] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Phaeochromocytomas and paragangliomas are relatively uncommon tumours which may be manifest in many ways, specifically as sustained or paroxysmal hypertension, episodes of palpitations, sweating, headache and anxiety, or increasingly as an incidental finding. Recent studies have shown that an increasing number are due to germline mutations. This review concentrates on the diagnosis, biochemistry and treatment of these fascinating tumours.
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Affiliation(s)
- P T Kavinga Gunawardane
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK.,Ministry of Health, Colombo, Sri Lanka
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK.
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Petramala L, Concistrè A, Marinelli C, Zinnamosca L, Iannucci G, Lucia P, De Vincentis G, Letizia C. Adrenal Pheochromocytoma Incidentally Discovered in a Patient With Parkinsonism. Medicine (Baltimore) 2015; 94:e1855. [PMID: 26496334 PMCID: PMC4620812 DOI: 10.1097/md.0000000000001855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To evaluate the diagnostic route of pheochromocytoma (PHEO) in a patient under dopaminergic treatment.A 70-year-old man with Parkinsonism and under treatment with levodopa and carbidopa came to our observation for evaluation of arterial hypertension and right adrenal mass discovered incidentally.To evaluate adrenal hormone levels we performed a dexamethasone suppression test, plasma aldosterone levels and 24-hr urinary metanephrine, which revealed elevated levels of catecholamines metabolities. 123-I-metaiodobenzylguanidine SPECT scintiscan revealed raised activity within the right adrenal gland concordant with the mass. The diagnosis of PHEO was posed and an elective laparoscopic adrenalectomy was performed; histopathological examination confirmed the PHEO diagnosis.Recently the coexistence of PHEO and Parkinsonism is a very rare association of diseases, with only 3 cases reported in literature. In this article, another case is reported and diagnostic procedures are discussed.
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Affiliation(s)
- Luigi Petramala
- From the Specialized Center of Secondary Hypertension (LP, AC, CM, LZ, CL); Department of Internal Medicine and Medical Specialties (LP, AC, CM, LZ, GI, PL, CL); and Department of Radiology, Section Nuclear Medicine, University of Rome "La Sapienza," Rome, Italy (GDV)
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Thomas RM, Ruel E, Shantavasinkul PC, Corsino L. Endocrine hypertension: An overview on the current etiopathogenesis and management options. World J Hypertens 2015; 5:14-27. [PMID: 26413481 PMCID: PMC4582789 DOI: 10.5494/wjh.v5.i2.14] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 12/06/2014] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
Endocrine causes of secondary hypertension include primary aldosteronism, pheochromocytoma, cushing’s syndrome, hyperparathyroidism and hypo- and hyperthyroidism. They comprise 5%-10% of the causes of secondary hypertension. Primary hyperaldosteronism, the most common of the endocrine cause of hypertension often presents with resistant or difficult to control hypertension associated with either normo-or hypokalemia. Pheochromocytoma, a great mimicker of many conditions, is associated with high morbidity and mortality if left untreated. A complete history including pertinent family history, physical examination along with a high index of suspicion with focused biochemical and radiological evaluation is important to diagnose and effectively treat these conditions. The cost effective targeted genetic screening for current known mutations associated with pheochromocytoma are important for early diagnosis and management in family members. The current review focuses on the most recent evidence regarding causes, clinical features, methods of diagnosis, and management of these conditions. A multidisciplinary approach involving internists, endocrinologists and surgeons is recommended in optimal management of these conditions.
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Chortis V, Bancos I, Crowley RK, Arlt W. Supine or sitting? Economic considerations regarding patient position during plasma metanephrine analysis for the exclusion of chromaffin tumours. Clin Endocrinol (Oxf) 2015; 82:462-3. [PMID: 25130622 DOI: 10.1111/cen.12587] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Vasileios Chortis
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK.
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Lenders JWM, Eisenhofer G. Pathophysiology and diagnosis of disorders of the adrenal medulla: focus on pheochromocytoma. Compr Physiol 2014; 4:691-713. [PMID: 24715564 DOI: 10.1002/cphy.c130034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The principal function of the adrenal medulla is the production and secretion of catecholamines. During stressful challenging conditions, catecholamines exert a pivotal homeostatic role. Although the main adrenomedullary catecholamine, epinephrine, has a wide array of adrenoreceptor-mediated effects, its absence does not cause life-threatening problems. In contrast, excess production of catecholamines due to an adrenomedullary tumor, specifically pheochromocytoma, results in significant morbidity and mortality. Despite being rare, pheochromocytoma has a notoriously bad reputation because of its potential devastating effects if undetected and untreated. The paroxysmal signs and symptoms and the risks of missing or delaying the diagnosis are well known for most physicians. Nevertheless, even today the diagnosis is still overlooked in a considerable number of patients. Prevention and complete cure are however possible by early diagnosis and appropriate treatment but these patients remain a challenge for physicians. Yet, biochemical proof of presence or absence of catecholamine excess has become more easy and straightforward due to developments in assay methodology. This also applies to radiological and functional imaging techniques for locating the tumor. The importance of genetic testing for underlying germline mutations in susceptibility genes for patients and relatives is increasingly recognized. Yet, the effectiveness of genetic testing, in terms of costs and benefits to health, has not been definitively established. Further improvement in knowledge of genotype-phenotype relationships in pheochromocytoma will open new avenues to a more rationalized and personalized diagnostic approach of affected patients.
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Affiliation(s)
- Jacques W M Lenders
- Department of Internal Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Shada AL, Stokes JB, Turrentine FE, Simpson VB, Padia SH, Carey RM, Hanks JB, Smith PW. Adrenalectomy for Adrenal-mediated Hypertension: National Surgical Quality Improvement Program Analysis of an Institutional Experience. Am Surg 2014. [DOI: 10.1177/000313481408001133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Adrenal-mediated hypertension (AMH) has been increasingly treated by laparoscopic adrenalectomy (LA). Metabolic derangements in patients with AMH could result in perioperative complications and mortality. Long-term operative and clinical outcomes after laparoscopic treatment of AMH have not been evaluated using large clinical databases. The institutional National Surgical Quality Improvement Program (NSQIP) data for patients undergoing adrenalectomy for AMH between 2002 and 2012 were reviewed. Patient demographics, perioperative variables, and outcomes were analyzed and compared with national NSQIP adrenalectomy data. Improvement in AMH was recorded when discontinuation or reduction of antihypertensive medication occurred or with a decrease of blood pressure on the preoperative antihypertensive regimen. Ninety-four patients underwent adrenalectomy. There were 48 patients with pheochromocytoma (PHE) and 46 patients with aldosterone-producing adenoma (APA). Eighty-five patients (90%) were taking antihypertensive medications preoperatively compared with 36 patients (38%) post-operatively ( P < 0.0001). Patients with PHE were more likely to discontinue all medications compared with the patients with APA (80 vs 20%, respectively, P < 0.0001). Patients with PHE and APA, respectively, took an average of 2.0 and 3.2 antihypertensive medications preoperatively compared with 0.3 and 1.2 postoperatively. There were no conversions to open procedures or 30-day mortality. Our results were 0 per cent for cerebral vascular accident, 0 per cent for myocardial infarction, and 0.5 per cent for transfusions compared with the national NSQIP data of 0.2, 0, and 6.7 per cent, respectively. Patients presenting with significant AMH including PHE and APA can be effectively and safely treated with LA with minimal complications and with a significant number of patients eliminating or decreasing their need for antihypertensive medications.
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Affiliation(s)
| | | | | | | | - Shetal H. Padia
- Division of Endocrinology & Metabolism, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M. Carey
- Division of Endocrinology & Metabolism, University of Virginia Health System, Charlottesville, Virginia
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Berkel AV, Lenders JWM. Pheochromocytoma. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2014. [DOI: 10.2217/ije.14.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pheochromocytoma and paraganglioma are catecholamine-producing tumors that are associated with substantial serious morbidity and mortality. A carefully taken medical history and early consideration of such tumors are key for early diagnosis and treatment. The biochemical diagnosis should include measurements of metanephrines in either plasma or urine. In addition to anatomical imaging, sensitive functional imaging modalities offer extra benefit for most patients in locating the tumor and eventual metastases. In at least 30% of all patients with a pheochromocytoma/paraganglioma, an underlying germline is responsible for tumor development and genetic testing should be considered in all patients. Current treatment options for malignant pheochromocytoma/paraganglioma are still very modest. New developments in the therapeutic armamentarium may improve the prospect for these patients.
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Affiliation(s)
- Anouk van Berkel
- Department of Internal Medicine, Radboud University Medical Centre, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, The Netherlands
| | - Jacques WM Lenders
- Department of Internal Medicine, Radboud University Medical Centre, Geert Grooteplein Zuid 8, 6525 GA, Nijmegen, The Netherlands
- Department of Medicine III, University Hospital Carl Gustav Carus, Dresden, Germany
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Lenders JWM, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SKG, Murad MH, Naruse M, Pacak K, Young WF. Pheochromocytoma and paraganglioma: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2014; 99:1915-42. [PMID: 24893135 DOI: 10.1210/jc.2014-1498] [Citation(s) in RCA: 1529] [Impact Index Per Article: 152.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim was to formulate clinical practice guidelines for pheochromocytoma and paraganglioma (PPGL). PARTICIPANTS The Task Force included a chair selected by the Endocrine Society Clinical Guidelines Subcommittee (CGS), seven experts in the field, and a methodologist. The authors received no corporate funding or remuneration. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. The Task Force reviewed primary evidence and commissioned two additional systematic reviews. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, European Society of Endocrinology, and Americal Association for Clinical Chemistry reviewed drafts of the guidelines. CONCLUSIONS The Task Force recommends that initial biochemical testing for PPGLs should include measurements of plasma free or urinary fractionated metanephrines. Consideration should be given to preanalytical factors leading to false-positive or false-negative results. All positive results require follow-up. Computed tomography is suggested for initial imaging, but magnetic resonance is a better option in patients with metastatic disease or when radiation exposure must be limited. (123)I-metaiodobenzylguanidine scintigraphy is a useful imaging modality for metastatic PPGLs. We recommend consideration of genetic testing in all patients, with testing by accredited laboratories. Patients with paraganglioma should be tested for SDHx mutations, and those with metastatic disease for SDHB mutations. All patients with functional PPGLs should undergo preoperative blockade to prevent perioperative complications. Preparation should include a high-sodium diet and fluid intake to prevent postoperative hypotension. We recommend minimally invasive adrenalectomy for most pheochromocytomas with open resection for most paragangliomas. Partial adrenalectomy is an option for selected patients. Lifelong follow-up is suggested to detect recurrent or metastatic disease. We suggest personalized management with evaluation and treatment by multidisciplinary teams with appropriate expertise to ensure favorable outcomes.
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Affiliation(s)
- Jacques W M Lenders
- Radboud University Medical Center (J.W.M.L.), 6500 HB Nijmegen, The Netherlands; VA Medical Center and University of California, San Francisco (Q.-Y.D.), San Francisco, California 94121; University Hospital Dresden (G.E.), 01307 Dresden, Germany; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, (A.-P.G.-R.), F-75015 Paris, France; Université Paris Descartes (A.-P.G.-R.), F-75006 Paris, France; Mayo Clinic (S.K.G.G., M.H.M.), Rochester, Minnesota 55905; National Hospital Organisation Kyoto Medical Center (M.N.), Kyoto 612-8555; Japan; Eunice Kennedy Shriver National Institute of Child Health & Human Development (K.P.), Bethesda, Maryland 20892; and Mayo Clinic (W.F.Y.), Rochester, Minnesota 55905
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van Berkel A, Lenders JWM, Timmers HJLM. Diagnosis of endocrine disease: Biochemical diagnosis of phaeochromocytoma and paraganglioma. Eur J Endocrinol 2014; 170:R109-19. [PMID: 24347425 DOI: 10.1530/eje-13-0882] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Adrenal phaechromocytomas and extra-adrenal sympathetic paragangliomas (PPGLs) are rare neuroendocrine tumours, characterised by production of the catecholamines: noradrenaline, adrenaline and dopamine. Tumoural secretion of catecholamines determines their clinical presentation which is highly variable among patients. Up to 10-15% of patients present entirely asymptomatic and in 5% of all adrenal incidentalomas a PPGL is found. Therefore, prompt diagnosis of PPGL remains a challenge for every clinician. Early consideration of the presence of a PPGL is of utmost importance, because missing the diagnosis can be devastating due to potential lethal cardiovascular complications of disease. First step in diagnosis is proper biochemical analysis to confirm or refute the presence of excess production of catecholamines or their metabolites. Biochemical testing is not only indicated in symptomatic patients but also in asymptomatic patients with adrenal incidentalomas or identified genetic predispositions. Measurements of metanephrines in plasma or urine offer the best diagnostic performance and are the tests of first choice. Paying attention to sampling conditions, patient preparation and use of interfering medications is important, as these factors can largely influence test results. When initial test results are inconclusive, additional tests can be performed, such as the clonidine suppression test. Test results can also be used for estimation of tumour size or prediction of tumour location and underlying genotype. Furthermore, tumoural production of 3-methoxytyramine is associated with presence of an underlying SDHB mutation and may be a biomarker of malignancy.
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Abstract
The current work-up of a patient suspected to have a pheochromocytoma starts with the measurement of plasma or urine metanephrines. Notably, up to a quarter of these patients will have a false positive result. When the plasma or urine metanephrines are less than the 4-fold upper limit of normal, clinicians struggle between the fear of missing a potentially fatal condition and ordering costly follow up tests. In many cases, ordering unnecessary imaging studies may only increase the level of patient anxiety. This article will review various physiologic factors, pathologic conditions and medications that may influence the levels of catecholamines and their metabolites yielding false positive or false negative results. Acquiring familiarity with these conditions as well as interfering medications will equip clinicians with better interpretation skills of the biochemical tests.
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Affiliation(s)
- Georgiana A Dobri
- a Department of Endocrinology and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Emmanuel Bravo
- b Department of Hypertension and Nephrology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Amir H Hamrahian
- a Department of Endocrinology and Metabolism, Cleveland Clinic Foundation, Cleveland, OH, USA
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Pamporaki C, Därr R, Bursztyn M, Glöckner S, Bornstein SR, Lenders JWM, Pacak K, Krinner A, Eisenhofer G. Plasma-free vs deconjugated metanephrines for diagnosis of phaeochromocytoma. Clin Endocrinol (Oxf) 2013; 79:476-83. [PMID: 23461656 PMCID: PMC3762922 DOI: 10.1111/cen.12191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 01/13/2013] [Accepted: 02/09/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnosis of phaeochromocytoma is commonly performed by the measurements of plasma-free normetanephrine and metanephrine. Plasma-deconjugated normetanephrine and metanephrine have been proposed as alternative, equivalent, but easier to measure biomarkers. OBJECTIVE The aim of this study was to compare the diagnostic performance of plasma-free vs deconjugated normetanephrine and metanephrine in patients tested for phaeochromocytoma. METHODS The study population included a reference group of 262 normotensive and hypertensive volunteers, 198 patients with phaeochromocytoma and 528 patients initially suspected of having the tumour, but with negative investigations after at least 2 years of follow-up. Measurements were performed using liquid chromatography with electrochemical detection. RESULTS Plasma concentrations of free normetanephrine were 17-fold higher in patients with phaeochromocytoma than in the reference population, a 72% larger (P < 0·001) difference than that for the 10-fold higher levels of plasma-deconjugated normetanephrine. In contrast, relative increases in plasma concentrations of free and deconjugated metanephrine were similar. Using upper cut-offs established in the reference population, measurements of plasma-free metabolites provided superior diagnostic performance than deconjugated metabolites according to measures of both sensitivity (97% vs 92%, P = 0·002) and specificity (93% vs 89%, P = 0·012). The area under the receiver operating characteristic curve for the free metabolites was larger than that for the deconjugated metabolites (0·986 vs 0·965, P < 0·001). CONCLUSION Measurements of plasma-free normetanephrine and metanephrine are superior to the deconjugated metabolites for diagnosis of phaeochromocytoma.
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Affiliation(s)
- Christina Pamporaki
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstrasse 74, Dresden, Germany.
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Picard M, Giavina-Bianchi P, Mezzano V, Castells M. Expanding Spectrum of Mast Cell Activation Disorders: Monoclonal and Idiopathic Mast Cell Activation Syndromes. Clin Ther 2013; 35:548-62. [DOI: 10.1016/j.clinthera.2013.04.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/01/2013] [Accepted: 04/02/2013] [Indexed: 12/12/2022]
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Abstract
Pheochromocytomas or functioning paragangliomas can present in a dramatic manner with headache, palpitations and sometimes shock, but many occur with few symptoms despite at times markedly elevated catecholamine levels. Hypertension is not invariable, and may be paroxysmal. Increased diligence in the diagnosis of presymptomatic pheochromocytoma/paraganglioma is warranted from autopsy studies, suggesting that many of these tumors may be fatal at first presentation. Fortunately, an increasing number of pheochromocytomas/paragangliomas are now diagnosed before the advent of symptoms, either as an incidental finding on abdominal imaging or by targeted surveillance in subjects with known genetic susceptibility. The challenges and pitfalls associated with diagnosis of these silent pheochromocytoma/paragangliomas are reviewed in this article.
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Affiliation(s)
- Roderick Clifton-Bligh
- a University of Sydney, Sydney, NSW, Australia and Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
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Sharma N, Martin A, McCabe CJ. Mining the proteome: the application of tandem mass spectrometry to endocrine cancer research. Endocr Relat Cancer 2012; 19:R149-61. [PMID: 22555494 DOI: 10.1530/erc-12-0036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Tandem mass spectrometry (MS/MS) permits the detection of femtomolar quantities of protein from a wide variety of tissue sources. As endocrine cancers are frequently aetiologically complex, they are particularly amenable to mass spectrometry. The most widely studied aspect is the search for novel reliable biomarkers that would allow cancers to be diagnosed earlier and distinguished from benign tumours. MS/MS allows for the rapid analysis of blood and urine in addition to tumour tissue, and in this regard it has been applied on research involving thyroid, pancreatic, adrenal and ovarian cancers with varying degrees of success, as well as additional organ sites including breast and lung. The description of an individual cancer proteome potentially allows for personalized management of each patient, avoiding unnecessary therapies and targeting treatments to those which will have the most effect. The application of MS/MS to interaction proteomics is a field that has generated recent novel targets for chemotherapy. However, the technology involved in MS/MS has a number of drawbacks that at present prevent its widespread use in translational cancer research, including a poor reproducibility of results, in part due to the large amount of data generated and the inability to accurately differentiate true from false-positive results. Further, the current cost of running MS/MS restricts the number of times the experiments can be repeated, contributing to the lack of significance and concordance between studies. Despite these problems, however, MS/MS is emerging as a front line tool in endocrine cancer research and it is likely that this will continue over the next decade.
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Affiliation(s)
- Neil Sharma
- School of Clinical and Experimental Medicine, Institute for Biomedical Research and School of Cancer Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Restrepo CA, Etayo E. Reporte de un caso de coexistencia de feocromocitoma y adenoma cortical adrenal en un paciente con hipertensión severa. REVISTA COLOMBIANA DE CARDIOLOGÍA 2012. [DOI: 10.1016/s0120-5633(12)70122-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Mullins F, O’Shea P, FitzGerald R, Tormey W. Enzyme-linked immunoassay for plasma-free metanephrines in the biochemical diagnosis of phaeochromocytoma in adults is not ideal. Clin Chem Lab Med 2012; 50:105-10. [DOI: 10.1515/cclm.2011.742] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 09/20/2011] [Indexed: 11/15/2022]
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Sohn SY, Park HD, Lee SY, Kim JH, Jung BC, Kim HJ, Jang HW, Kim KW, Lee MK, Min YK, Kim JH. Different diagnostic cut-off values of urinary fractionated metanephrines according to sex for the diagnosis of pheochromocytoma in Korean subjects. Endocr J 2012; 59:831-8. [PMID: 22785075 DOI: 10.1507/endocrj.ej12-0052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The diagnosis of pheochromocytoma depends on the documentation of catecholamine overproduction. The use of urinary fractionated metanephrines has recently become common for the diagnosis of pheochromocytoma. In order to avoid false positive and false negative results, optimal cut-off levels are necessary; however, there have been few published reports on whether different cut-off levels are needed to diagnose pheochromocytoma according to sex. We reviewed the medical records of 815 subjects (including 103 pheochromocytoma patients) whose of 24-h urinary fractionated metanephrine was measured using high-performance liquid chromatography methods and adrenal imaging at Samsung Medical Center. Receiver operating characteristic (ROC) curves were used to determine cut-off values according to sex. The upper limit values of fractionated metanephrine in healthy volunteers and the control group were significantly higher in male subjects compared with females. When we applied cut-off values according to sex, the diagnostic efficacies (defining a positive test as either metanephrine or normetanephrine levels above the cut-off value) were a sensitivity of 96% in male subjects and 98.1% in female subjects and a specificity of 88.6% in male subjects and 94.1% in female subjects. However, when we applied cut-off values without considering sex, the specificity decreased from 88.6% to 77.8% in male subjects. In this study, urinary fractionated metanephrines had a high level of sensitivity and specificity for the diagnosis of pheochromocytoma. However, diagnostic cut-off values were higher in male subjects than in female subjects. Therefore, different cut-off values may be needed according to sex to diagnose pheochromocytoma in Koreans.
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Affiliation(s)
- Seo Young Sohn
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
OBJECTIVE To review the first reported cases of successfully treated pheochromocytoma and primary aldosteronism and to document the diagnostic and therapeutic advances that have occurred since the initial descriptions. METHODS The original case descriptions and the subsequent pertinent literature were reviewed. RESULTS The successful management of the initial cases of pheochromocytoma in 1926 and primary aldosteronism in 1954 was highlighted by keen clinical observation, clinical intuition, and application of scientific principles. Since those prismatic case descriptions, the technological advances in laboratory-based diagnosis, radiology-based tumor localization, and surgical approaches to the adrenal glands have been truly remarkable. CONCLUSIONS The evolution in the diagnosis and treatment of pheochromocytoma will continue to progress as we identify more genetic causes, develop biochemical markers for "preclinical" pheochromocytoma, identify better markers for malignant disease, and develop more effective treatment options for malignant pheochromocytoma. Over the next decade, we hope to determine the pathophysiology for bilateral idiopathic hyperaldosteronism, develop less invasive and less technically demanding tests to distinguish between unilateral aldosterone-producing adenoma and bilateral idiopathic hyperaldosteronism, determine where low renin hypertension stops and primary aldosteronism starts, and determine the impact of genetic and environmental factors on aldosterone secretion in patients with and without primary aldosteronism.
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Affiliation(s)
- William F Young
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Schwartz GL. Screening for adrenal-endocrine hypertension: overview of accuracy and cost-effectiveness. Endocrinol Metab Clin North Am 2011; 40:279-94, vii. [PMID: 21565667 PMCID: PMC3094544 DOI: 10.1016/j.ecl.2011.02.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Formal studies have not been performed to assess the cost-effectiveness of screening strategies for endocrine causes of hypertension. However, an understanding of the diagnostic accuracy of available screening tests and the clinical settings where disease identification will lead to improved health outcomes form the basis for a cost-effective strategy. Primary aldosteronism screening should be selective and restricted to settings where knowledge of the diagnosis has the greatest chance of improving health outcomes. Pheochromocytoma is rare; however, because it is a potentially fatal disease, screening strategies should err on the side of not missing the diagnosis, especially in high-risk clinical settings.
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Affiliation(s)
- Gary L Schwartz
- Division of Nephrology and Hypertension, College of Medicine, Mayo Clinic, West 19, Mayo Building, 200 First Street SW, Rochester, MN 55905, USA.
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Barron J. Phaeochromocytoma: diagnostic challenges for biochemical screening and diagnosis. J Clin Pathol 2010; 63:669-74. [PMID: 20547690 DOI: 10.1136/jcp.2009.071647] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The aim of this article is to provide knowledge of the origin of catecholamines and metabolites so that there can be an informed approach to the methods for biochemical screening for a possible phaeochromocytoma; The article includes a review of catecholamine and metadrenaline metabolism, with methods used in biochemical screening. In the adrenal medulla and a phaeochromocytoma, catecholamines continuously leak from chromaffin granules into the cytoplasm and are converted to metadrenalines. For a phaeochromocytoma to become biochemically detectable, metnoradrenaline secretion needs to rise fourfold, whereas noradrenaline secretion needs to rise 15-fold. The prevalence of a sporadic phaeochromocytoma is low; therefore false-positive results exceed true-positive results. Assay sensitivity is high because it is important not to miss a possible phaeochromocytoma. The use of urine or plasma fractionated metadrenalines as the first-line test has been recommended due to improved sensitivity. A negative result excludes a phaeochromocytoma. Only after a sporadic phaeochromocytoma has been diagnosed biochemically is it cost effective to request imaging. Sensitivities and specificities of the assays differ according to pre-test probabilities of the presence of a phaeochromocytoma, with hereditary and incidentalomas having a higher pre-test probability than sporadic phaeochromocytoma. In conclusion, in screening for a possible phaeochromocytoma, biochemical investigations should be completed first to exclude or establish the diagnosis. The preferred biochemical screening test is fractionated metadrenalines, including methoxytyramine so as not to miss dopamine-secreting tumours.
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Affiliation(s)
- Jeffrey Barron
- Department, Labtests, Penrose, Auckland1642, New Zealand.
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