Extra-adrenal phaeochromocytoma: report of three interesting cases

Functional Paraganglioma: A Rare Conus-cauda Lesion

Conus-cauda syndrome is caused due to involvement of the lower end of the spinal cord and arising bunch of nerve roots. It is caused commonly due to traumatic injury, spinal stenosis, spinal tumors, inflammatory, and infectious conditions, but paraganglioma is a rare cause. These tumors are rarely functional and secrete catecholamine. Till now only five case reports of functional spinal paragangliomas are available to the best of our knowledge. We report a 50-year-old hypertensive male patient with a lobulated lesion extending from lower border of D12 to L2, which was reported as ependymoma on imaging studies done preoperatively. This lesion was confirmed to be a functional paraganglioma postoperatively after the patient died because of its furious complication, thus highlighting the importance of its preoperative diagnosis and management. In conclusion conus-cauda functional paragangliomas are very rare entity. Diagnosing them in preoperative condition is critical from the therapeutic point of view, both medical and surgical. During surgery these tumors should be handled very gently to avoid spillage of catecholamines into blood. These tumors require assistance of expert anesthetist and endocrinologist in the perioperative period.

Functioning paraganglioma of the cervical spine

Extradural paraganglioma of the cervical spine is rarely seen. Few reports of this functioning disorder appear in the literature. A 29-year-old woman presented with a 1-year history of left shoulder pain and occasional transitional dizziness. This is the first case of a functioning cervical spinal paraganglioma with symptoms of catecholamine excess throughout the operation. A mass in the neck region was discovered by the patient 2 months prior to hospital admission. Physical examination revealed an egg-shaped soft and unflexible mass with no clear boundary in the anterior left part of the neck. Neither sensory disturbance nor motor weakness was evident in the upper and lower extremities. Laboratory studies were normal. Both computed tomography and magnetic resonance imaging implied neurilemmoma. Embolization of the branches supplying the mass was taken to reduce perioperative bleeding complications 1 day preoperatively. The patient demonstrated frequent hypertensive spikes with tumor handling. The blood pressure changed between 80/40 mm Hg and 200/105 mm Hg throughout the surgery. The tumor was dissected successfully from the paraspinal tissues, followed by spinal cord decompression of C4 to C6, C5 corpectomy, anterior column reconstruction, and anterior internal fixation with a plate. The histopathological examination yielded a postoperative diagnosis of paraganglioma. Diagnosis and treatment of this rare case require comprehensive perioperative management and meticulous surgical excision.

Functioning paraganglioma of the thoracic spine: case report

OBJECTIVE AND IMPORTANCE

Paragangliomas of the thoracic spine are rare. Previously described cases involved nonfunctioning tumors. This report documents the diagnosis and surgical treatment for a patient who presented with a functioning thoracic paraganglioma.

CLINICAL PRESENTATION

A 53-year-old woman presented with a 10-month history of headaches, facial flushing, and palpitations associated with hypertension. Urinary catecholamine levels were markedly elevated. Magnetic resonance imaging and m-[(123)I]iodobenzylguanidine scans demonstrated an extradural tumor located within the T12 vertebra, with a significant paraspinal component. The neurological examination revealed mild hypesthesia in the right T12 dermatome.

INTERVENTION

The patient underwent resection of the tumor after alpha-adrenergic receptor blockade. Grossly complete excision was achieved without neurological complications. Postoperatively, the patient was normotensive and exhibited catecholamine levels within the normal range.

CONCLUSION

Functioning paragangliomas of the thoracic spine are rare lesions that are difficult to treat. Successful treatment requires careful surgical planning and expert pharmacological manipulation.

The preoperative management of phaeochromocytoma

Although the preoperative use of alpha-receptor antagonist drugs is generally accepted for patients with phaeochromocytoma, evidence on the most appropriate treatment and its timing is scarce. In this retrospective study, the effectiveness of the preoperative preparation of fourteen patients who required surgical excision of a phaeochromocytoma was examined in the light of their operative stability. A simple score was developed of blood pressure stability by scoring the need for additional antihypertensive agents intraoperatively before, and blood pressure support after, tumour removal. A higher score indicated greater instability. Twelve patients received phenoxybenzamine and their stability was superior to the two patients treated with labetalol and with prazosin. There was no correlation between the duration of treatment with phenoxybenzamine and the operative stability (r = 0.18 P = 0.55 Spearman). The five patients who were treated with phenoxybenzamine for longer than 10 days did not have better perioperative blood pressure stability than the five patients who had treatment for less than a week. Predictive factors for intra-operative blood pressure stability were also sought. The degree of postural hypotension after treatment with phenoxybenzamine did not predict operative stability (r = -0.31, P = 0.33 Spearman). However, the peak total catecholamine level found during surgery correlated quite well with more operative instability (r = 0.65, P = 0.031, Spearman), suggesting that patients with phaeochromocytomas with high production of catecholamines are more likely to show cardiovascular instability.

An intra-abdominal tumour

Images

Phaeochromocytoma: intraoperative changes in blood pressure and plasma catecholamines

The aim of this study was to assess the relationship between changes in plasma catecholamine concentrations and intra-arterial blood pressure (BP) measured simultaneously during resection of phaeochromocytoma (n = 14). Arterial plasma concentrations of noradrenaline (NA), adrenaline (A) and dopamine (DA) were measured by a radio-enzymatic method. Arterial NA concentrations (pmol/ml; median and Wilcoxon 95% CI) were 71.8 (46,162) before induction of anaesthesia, 113.0 (79,231) after intubation, 375.0 (285,931) during tumour handling and 32.5 (18,88) following tumour removal. Simultaneous mean BP values (mmHg; Mean +/- SEM) were 119 +/- 8, 114 +/- 7, 159 +/- 7 (p = 0.0001) and 72 +/- 6 (p < 0.0001) respectively. At the time of tumour handling there was a weak correlation between plasma NA and A combined and mean BP (r = 0.583, p = 0.029) and a stronger correlation between log plasma NA and A combined and pulse pressure (r = 0.749, p = 0.008). The very large rises in plasma catecholamine concentrations and in BP are likely to have been causally related. Individual patients maintained a constant ratio of NA to A in plasma from pre-induction to tumour handling (r = 0.916, p < 0.0001). The maintenance of a constant NA:A ratio suggests that the pattern of catecholamine synthesis and release may be a characteristic of the individual tumour.