Pediatric patients with pheochromocytoma: Experience of a tertiary health center

Pediatric total fractionated metanephrines: age-related reference intervals in spot urine

BACKGROUND

Sparse metanephrines reference intervals in pediatric populations are available and different study designs and technologies/ assays used in these studies lead to hardly transferable data from a laboratory to another. The aim of this study was to update pediatric reference intervals of total fractionated metanephrines in spot urine samples, using a commercial extraction kit run on a specific high-pressure liquid chromatograph coupled with an electrochemical detector.

METHODS

Four hundred and fifty-two spot pediatric urinary samples previously submitted to urinalysis were consecutively included in the study with the exclusion of children's samples with diagnosis or clinical suspicion of paraganglioma/pheochromocytoma, kidney diseases and arterial hypertension. Urinary metanephrine, normetanephrine and 3-methoxytyramine were extracted with ClinRep^® HPLC Complete kit and run on HPLC Prominence liquid chromatograph LC-20AT (Shimadzu Italia S.r.l. Milan, Italy) coupled with Decade II electrochemical detector (Antec Scientific, Zoeterwoude, the Nederlands, provided by Alfatech S.r.l., Genoa, Italy). Results were expressed as the ratio analyte-to-creatinine.

RESULTS

Any of the three analytes required a repartition by gender (metanephrine P=0.27; normetanephrine P=0.90 and 3-methoxytyramine P=0.18). A significant statistically inversely proportional relation with age was found for metanephrine (P<0.0001; ρ=-0.72), normetanephrine (P<0.0001; ρ=-0.75) and 3-methoxytyramine (P<0.0001; ρ=-0.83). Reference intervals were calculated as function of age.

CONCLUSIONS

This study provides pediatric reference intervals for urinary fractionated total metanephrines in spot urine calibrated on a specific instrumentation and extraction commercial kit.

Research on the Damage of Adrenal Pheochromocytoma to Patients’ Cardiovascular Vessels and Its Correlation with Hypertension

Chromaffin cell-centered pheochromocytoma (Pheo) is a rare tumour. Pheochromocytoma and how it affects the heart will be the topic of this article. Due to the comparable symptoms and indications of the sympathetic nervous system, a pheochromocytoma might be difficult to detect early. There are also other frequent differential diagnoses that might delay the detection of a pheochromocytoma. One of the most common side effects of pheochromocytoma is unmanageable hypertension. Hypertensive crisis (extreme increases in blood pressure) can develop, which is a life-threatening condition that leads to strokes or arrhythmia. Estimated to affect African Americans significantly, they frequently go undetected due to a lack of resources or accessibility of services. Because this tumour is difficult to identify and its symptoms often resemble those of other diseases, it is frequently overlooked. A pheochromocytoma's long-term consequences can include cardiac muscle deterioration, congestive heart failure (CHF), a higher diabetes risk and possibly death. Masked hypertension (MH) is more common in people with adrenal pheochromocytoma, which has been related to an increased risk of heart disease. With the use of ambulatory blood pressure monitoring, this research set out to find out how common mental health issues are among people with APs. There were 85 participants in all, 43 of whom had APs and 42 of whom had the same age, gender, BMI, smoking and diabetes as the AP patients. Measurements were made of the BP and AP in both the diseased and control groups. Retrospective data collection was used to gather biochemical, hormonal and radiological information on the patients. The Pearson–Boltzmann CNN method was then used to assess risk based on the diagnosis results. Furthermore, depending on the risk score, more nonselective blockers (e.g., prazosin, doxazosin, terazosin, and metyrosine) have been used to lower perioperative catecholamine levels, hence reducing illness risk. After a successful surgical excision of the tumour, the recommended therapy can usually be stopped quickly.

Adrenal Tumors in Children: Spectrum of Presentation and Surgical Approach in a Tertiary Care Institute

Context: Adrenal tumors can arise either from cortex or from medulla; both the regions being structurally and functionally different. Current knowledge on childhood adrenocortical tumors (ACTs), the management approach, and the outcome is limited due to limited number of cases and studies. Neuroblastoma is a neoplasm of the neural crest origin and 50% arise from adrenal medulla. Pheochromocytoma (PCC) is an exciting and rare neoplasm in childhood. Aims: To evaluate the clinical presentation, spectrum of pathology, and management of adrenal tumors in children. Subjects and Methods: The study was conducted in a tertiary care pediatric institute over 5 years on children with intra-abdominal solid tumors. Adrenal tumors were diagnosed on radiological studies and postoperatively confirmed by histopathology. Results: Sixty-three patients were operated for intra-abdominal solid tumors, and Wilms tumor (39) was the most common finding. Of 11 cases of adrenal tumors confirmed by histopathology, eight were adrenal neuroblastoma, one 14-month-old female baby was detected as PCC, while two female children presented with the features of Cushing syndrome and virilization at the age of 3 and 7 years. Postoperatively, one of them was found to be adrenal adenoma and one was found to be adrenocortical carcinoma. Conclusions: ACTs are rare and potentially fatal in childhood. Complete surgical resection is the mainstay of therapy in adrenal tumors and is curative for associated hypertension. Neuroblastoma was the third common intra-abdominal solid tumor after Wilms tumor and retroperitoneal teratoma. The patient with PCC contributed to “Rule of 10s” because of the absence of hypertension and childhood occurrence.

Nomograms for the Prediction of Survival for Patients with Pediatric Adrenal Cancer after Surgery

Purpose: To develop and validate a nomogram to postoperatively evaluate overall survival (OS) and cancer-specific survival (CSS) in patients with pediatric adrenal cancer. Methods: In total, 847 eligible patients diagnosed between 1988 and 2015 form the Surveillance Epidemiology, and End Results (SEER) database were enrolled in this study according to the specified inclusion and exclusion criteria. They were divided into a training set (n = 661) and a validation set (n = 186). Multivariate Cox proportional hazards regression algorithm was used to identify the independent predictors of OS and CSS in the training set, and develop the predicting models, which were presented two nomograms. The performance of the nomograms (discrimination, calibration and clinical usefulness) was assessed in the training set and validated in the validation set. Results: Based on the multivariate Cox proportional hazards regression analyses, three independent predictors including age at diagnosis, tumor size and M stage were identified for both OS and CSS. Then, an OS nomogram and a CSS nomogram were developed incorporating these three predictors, respectively. The OS nomogram showed good calibration and discrimination in the training set (C-index [95% CI], 0.744 [0.711-0.777]), which was confirmed in the validation set (C-index [95% CI], 0.746 [0.656-0.836]). Favorable calibration and discrimination of the CSS nomogram were also observed in the training set (C-index [95% CI], 0.749 [0.715-0.783]) and validation set (C-index [95% CI], 0.789 [0.710-0.868]). Moreover, the nomograms successfully distinguished patients with high risk of all-cause and cancer-specific mortality in all patients and in the stratified analyses. Decision curve analysis demonstrated the usefulness of the nomograms. Conclusion: The presented nomograms show favorable predictive accuracy for OS and CSS in patients with pediatric adrenal cancer after surgery. Further validation is warranted prior to clinical implementation.

Clinical Presentation and Treatment Outcomes of Children and Adolescents With Pheochromocytoma and Paraganglioma in a Single Center in Korea

PURPOSE

Pheochromocytoma (PCC) and paraganglioma (PGL) (PPGL) are rare neuroendocrine tumors, and data on managing these conditions in children and adolescents are lacking. The objective of this study was to demonstrate the clinical presentation and treatment outcomes in children and adolescents with PPGL in a single tertiary care center in Korea.

METHODS

This retrospective study included 23 patients diagnosed with PCC (n = 14) and PGL (n = 9) before the age of 21 at Samsung Medical Center (from June 1994 to June 2019). We describe age, gender, family history, clinical characteristics, laboratory findings, pathologic findings, therapeutic approaches, and treatment outcomes.

RESULTS

Of the 23 patients, 14 had PCC and nine had PGL. The median age at diagnosis was 16.8 years (range, 6.8-20.8 years). The common presenting symptoms were hypertension (n = 10), headache (n = 9), palpitation (n = 4), and sweating (n = 4). The plasma or 24-hour urine catecholamine and/or metabolite concentrations were markedly elevated in 22 patients with PPGL, but were normal in one patient with carotid body PGL. All tumors were visualized on computed tomography. Genetic tests were performed in 15 patients, and seven patients showed mutations in RET (n = 3), SDHB (n = 3), and VHL (n = 1). All patients underwent surgery, and complete excision was performed successfully. Three patients with metastasis underwent postoperative adjuvant therapy.

CONCLUSION

This study suggests that pediatric PPGL tends to be extra-adrenal and bilateral and shows a higher potential for genetic mutations. Considering the hereditary predisposition of pediatric PPGL, genetic screening tests are strongly recommended, and lifelong follow-up is needed to detect recurrence and metastasis. Further research with a larger sample size and routine genetic screening is needed to better understand the genetic conditions and long-term prognosis of PPGL.

Pheochromocytoma in a Child without Hypertension: A Contribution to the "Rule of 10s"

Pheochromocytoma (PCC) is a neuroendocrine tumor originating from chromaffin tissue in adrenal medulla. Its diagnosis and treatment are well defined in adults, but experience in children is limited. Children constitute only 10% of reported cases, the average age at presentation being 11 years. The most common presentation is sustained hypertension, which is absent in only 10% of children. We managed a 14-month-old female child with PCC, but she was not hypertensive. We report two unusual features, in this case, an extremely young age at presentation and a childhood case of nonhypertensive PCC contributing for “rule of 10s.”