Pheochromocytoma and recurrent chemodectomas over a twenty-five-year period

Metastatic adrenal pheochromocytoma to the thoracic spine

To report on a case of pheochromocytoma metastases to the spine occurring more than 20 years after initial diagnosis. A 34-year-old female with a history of metastatic pheochromocytoma diagnosed at age 12 presented with weakness, heart palpitations, and circumferential back pain of five months duration. The patient had undergone multiple laparatomies for abdominal and hepatic metastases. Work-up revealed a destructive lesion at T9. After two weeks of preoperative phenoxybenzamine to control her hypertension, she underwent decompression, posterior fixation and fusion. Surgical intervention was followed by radiation therapy, zoledronic acid, and only one cycle of chemotherapy due to intolerance of side effects. The patient survived 25 years after original diagnosis, which far exceeds the average survival of less than 15 years. The patient died 26 months postoperatively due to progression of disease. Pheochromocytoma with spine metastases occurring more than 20 years after diagnosis is very uncommon, and should be considered in the differential diagnosis of a patient with a history of pheochromocytoma.

Case report: A 32-year-old woman with familial parangangliomas and acute cardiomyopathy

We describe the first case of a patient with familial paragangliomas, acute postoperative catecholamine-induced cardiomyopathy, and the subsequent diagnosis of an unsuspected adrenal pheochromocytoma. Relevant literature is reviewed, and treatment options are discussed.

Alterations in the suppressor gene PPP2R1B in parathyroid hyperplasias and adenomas

Deletion of chromosome 11q23 is a common alteration in parathyroid adenomas and hyperplasias. A new potential suppressor gene PPP2R1B encoding the beta isoform of the A subunit of the serine/threorine protein phosphatase 2A was recently identified and localized to chromosome 11q23. We performed polymerase chain reaction-based single-strand conformation polymorphism and direct sequencing on six parathyroid hyperplasias and 12 adenomas to evaluate the role of PPP2R1B in the pathogenesis of parathyroid lesions. A previously identified germline G-A transition (GGC-GAC) in codon 90, changing glycine (Gly) to aspartic acid (Asp), was detected in one adenoma. Both the common Gly allele and the variant Asp allele were detected by direct sequencing in the patient's somatic cells. We conclude mutations of PPP2R1B are not frequent in parathyroid lesions, and that other genes located at 11q23 may be more closely associated with pathogenesis of parathyroid hyperplasia and adenoma.

Relapsing paraganglioma of the inferior laryngeal paraganglion: case report and review of the literature

BACKGROUND

Laryngeal paragangliomas are very rare neoplasms derived from the superior or inferior laryngeal paraganglia. The paragangliomas of the inferior laryngeal paraganglion, depending on their anatomic variability, can give rise to two different clinical expressions of the same process, namely the so-called thyroid paragangliomas and the inferior laryngeal or subglottic paragangliomas.

METHODS

We present a case for which we have not found any previous descriptions of a cervical and subglottictracheal relapse of a thyroid paraganglioma removed 3 years earlier. We review the literature.

RESULTS

We have found a total of 22 paragangliomas of the inferior laryngeal paraganglia, 23 including our case.

CONCLUSIONS

Thyroid paragangliomas and inferior laryngeal or subglottic paragangliomas should be included under the term "paragangliomas" of the inferior laryngeal paraganglion. These tumors are slow growing, benign, hypervascular, and much more common in middle-aged women. Immunohistochemistry is essential for its diagnosis. Open, conservative surgery is the treatment of choice.

Functioning thoracic paraganglioma: association with Von Hippel-Lindau syndrome

Functioning thoracic paraganglioma (pheochromocytoma) is unusual and therefore suggestive of a pathogenesis distinct from that of sporadic adrenal pheochromocytoma. To determine whether the pheochromocytoma-associated syndromes Von Hippel-Lindau disease (VHL) and multiple endocrine neoplasia type 2 (MEN 2) play a role in the development of thoracic functioning paragangliomas, germline DNA from five unselected patients with this rare tumor was analyzed for mutations in the genes that predispose to VHL and MEN 2. Genetic investigations and further clinical data revealed that three had VHL, with two different germline mutations of the vhl gene, but no individual was affected by MEN 2. Two of the three patients with VHL did not show any additional VHL-associated lesions. This result suggests that VHL should be considered in the differential diagnosis of thoracic pheochromocytoma, as such a diagnosis carries further important implications for the patient and family. Conversely, in patients suspected of a catecholamine-secreting tumor and known VHL, thoracic localization should be considered if an adrenal pheochromocytoma cannot be detected.

Magnetic resonance imaging or metaiodobenzylguanidine scintigraphy for the demonstration of paragangliomas? Correlations and disparities

Paragangliomas are tumours arising from paraganglionic tissue dispersed from the base of the skull to the pelvic diaphragm. These tumours produce symptoms by secreting catecholamines (functioning tumours) or by local tumour expansion. They can be part of several hereditary disorders. The introduction of magnetic resonance (MR) imaging and metaiodobenzylguanidine (MIBG) scintigraphy has provided new insights into paragangliomas and has tremendously changed the topographic diagnosis of paragangliomas. Both techniques have proven to be adequate in localising paragangliomas. In this report, the performance of these two noninvasive imaging methods in the examination of paragangliomas is compared and the merits and deficits of the two techniques are discussed. Both techniques produce comparable results in the detection of functioning paragangliomas. MR imaging, however, also demonstrates tumours that do not take up MIBG. MR imaging does not involve the use of ionising radiation and is not hampered by medication. Moreover, MR imaging has a higher spatial resolution. Because of these merits it is concluded that for demonstration of paragangliomas, whole-body MR imaging is the preferred and initial method of investigation. MIBG scintigraphy, on the other hand, continues to be a reliable method for non-invasive detection of functioning paragangliomas. At present it is clearly faster in whole-body imaging than MRI and it is definitely patient-friendly (no claustrophobia). It could be reserved for cases where a strong suspicion of a functioning paraganglioma persists, despite normal MR imaging findings, and for cases where doubt exists about the functional activity of one or more multicentric tumours. MIBG scintigraphy must be used in the evaluation of patients referred for iodine-131 MIBG treatment.

The glomus tumor and its biology

This section has attempted to detail the histopathologic, biologic, pathophysiologic, and epidemiologic characteristics of jugulotympanic paragangliomas. These features do not stand devoid of clinical significance, but rather lay the foundation for the formulation of logical diagnostic and therapeutic approaches to these fascinating tumors.

Phaeochromocytoma--investigation and management of 10 cases

Since 1960 we have diagnosed phaeochromocytoma (paraganglioma) in 10 children. The cases include a 15 year old girl who over a three year period presented with multiple paragangliomata and an associated malignant carotid body tumour. All children were hypertensive, eight of 10 presenting with severe headaches. Diagnosis was based on finding a raised urinary vanillylmandelic acid excretion and plasma noradrenaline concentration. In addition six of eight children were hypercalcaemic with raised plasma calcitonin concentrations; plasma parathyroid hormone concentrations were high in two of seven and four out of eight children had raised plasma renin activities on presentation. No child, however, was found to have a multiple endocrine neoplasia syndrome. Despite the introduction of newer techniques for the detection of catecholamine producing tumours we found that selective arteriography and venous catecholamine sampling were superior for tumour localisation compared with ultrasound scanning, computed tomography, and metaiodo-benzyl-guanidine (MIBG) scanning.

Multiple endocrine neoplasia syndromes

The multiple endocrine neoplasia (MEN) syndromes are characterized by autosomal dominant inheritance with a high degree of penetrance but varying expression. This review gives a classification of these syndromes and a short summary of the historical background. The pathogenesis of the disease and its possible origin in the APUD cell system are discussed together with the mechanisms underlying normal and ectopic hormone production by MEN tumors on the basis of recent findings in molecular endocrinology. The natural history and the clinical manifestations of the different syndromes are described. The sensitivity and discriminative capacity of the tests used to detect the syndromes in an early stage are compared. The choice of therapy and criteria for the timing and extensiveness of treatment are also considered. Lastly, problems associated with the ethical and legal aspects of screening, central registration, and monitoring of relatives at risk are described.

Familial multiple glomus tumors and pheochromocytomas

Isolated cases of cervical cranial glomus tumors have been reported in association with pheochromocytoma. Two family pedigrees are presented and four individual cases discussed indicating a hereditary syndrome of pheochromocytoma associated with multiple glomus tumors of the head and neck. The hereditary potential has not previously been described. In three of the patients, the pheochromocytomas were asymptomatic at the time of initial presentation. These pheochromocytomas were discovered by arteriography after one of the patients developed a hypertensive crisis with the induction of anesthesia. The silent presence of pheochromocytomas in patients with multiple glomus tumors should be considered in the evaluation of these patients.

Bilateral chemodectoma in the neck

A 55-year-old man with bilateral cervical chemodectoma is reported. The differences between tumours of the carotid body and those of the glomus intravagale are described and a brief review of the investigation and management of such tumours is given.