1
|
Beninato T, Duh QY, Long KL, Kiernan CM, Miller BS, Patel S, Randle RW, Wachtel H, Zanocco KA, Zern NK, Drake FT. Challenges and controversies in adrenal surgery: A practical approach. Curr Probl Surg 2023; 60:101374. [PMID: 37770163 DOI: 10.1016/j.cpsurg.2023.101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Affiliation(s)
- Toni Beninato
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Quan-Yang Duh
- Veterans Affairs Medical Center, San Francisco, San Francisco, CA
| | | | - Colleen M Kiernan
- Vanderbilt University Medical Center, Veterans Affairs Medical Center, Tennessee Valley Health System, Nashville, TN
| | - Barbra S Miller
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Snehal Patel
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Kyle A Zanocco
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | | | | |
Collapse
|
2
|
Kong H, Li N, Tian J, Bao Z, Liu L, Wu K, Gao Y, Jin B, Zhang Z, Fang D, Zhang J, Zhou L. The use of doxazosin before adrenalectomy for pheochromocytoma: is the duration related to intraoperative hemodynamics and postoperative complications? Int Urol Nephrol 2020; 52:2079-2085. [PMID: 32621102 PMCID: PMC7575471 DOI: 10.1007/s11255-020-02539-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022]
Abstract
Purpose No conclusion exists for the optimum duration of preoperative administration of doxazosin (DOX) before adrenalectomy for pheochromocytoma. The purpose of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of DOX administration. Methods In total, 132 patients managed preoperatively with single α-receptor blocker DOX were enrolled. All patients underwent adrenalectomy for pheochromocytoma in the Department of Urology, Peking University First Hospital, between January 2001 and July 2019. Patients were divided into three groups based on the duration of preoperative administration of DOX: group A (≤14 days), group B (15–30 days), and group C (>30 days). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared. Results These patients included 57 men and 75 women, with an average age of 48 years. Clinical characteristics, preoperative hemodynamics, medicine management and surgical approaches were comparable between the three groups. Among the three groups, we found that group C (>30 days) had the lowest intraoperative minimum heart rate [group A vs. group B vs. group C = 60 (52–67) vs. 59 (50–61) vs. 51.5 (50–58.75), p = 0.024] and highest risk of postoperative hypotension requiring vasopressor support [group A vs. group B vs. group C = 14 (20.3%) vs. 12 (27.9%) vs. 10 (50.0%), p = 0.032]. Conclusion The current study indicated that preoperative management of pheochromocytoma with single α-receptor blocker DOX for more than 30 days after final dose adjustment might lead to intraoperative bradycardia and more postoperative hypotension requiring vasopressor support. Thus, our study does not support long-term (over 30 days) preoperative administration of pheochromocytoma with single α-receptor blocker DOX in the final dose.
Collapse
Affiliation(s)
- Hao Kong
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Nan Li
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Jie Tian
- Department of Urology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.,Institute of Urology, Peking University, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.,National Urological Cancer Center, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Zhengqing Bao
- Department of Urology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.,Institute of Urology, Peking University, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.,National Urological Cancer Center, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Lu Liu
- Department of Endocrinology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Kai Wu
- Department of Endocrinology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Ying Gao
- Department of Endocrinology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Bo Jin
- Department of Clinical Laboratory, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| | - Zheng Zhang
- Department of Urology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China. .,Institute of Urology, Peking University, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China. .,National Urological Cancer Center, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Dong Fang
- Department of Urology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China. .,Institute of Urology, Peking University, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China. .,National Urological Cancer Center, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China. .,Andrology Center, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Junqing Zhang
- Department of Endocrinology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.,Institute of Urology, Peking University, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China.,National Urological Cancer Center, No. 8 Xishiku Street, Xicheng District, Beijing, 100034, China
| |
Collapse
|
3
|
Fang F, Ding L, He Q, Liu M. Preoperative Management of Pheochromocytoma and Paraganglioma. Front Endocrinol (Lausanne) 2020; 11:586795. [PMID: 33117294 PMCID: PMC7551102 DOI: 10.3389/fendo.2020.586795] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/14/2020] [Indexed: 01/10/2023] Open
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, characterized by excessive release of catecholamines (CAs), and manifested as the classic triad of headaches, palpitations, profuse sweating, and a variety of other signs and symptoms. The diagnosis of PPGL requires both evidence of excessive release of CAs and anatomical localization of CA-secreting tumor. Surgery is the mainstay of treatment for all patients with PPGL unless contraindicated. However, without proper preparation, the release of excessive CAs, especially during surgery, can result in lethal cardiovascular complications. Herein, we briefly reviewed the pathogenesis of this disease, discussed the current approaches and evidence available for preoperative management, summarizing the results of the latest studies which compared the efficacies of preoperative management with or without α adrenergic-receptor antagonists, aiming to facilitate better understanding of the preoperative management of PPGL for the physicians.
Collapse
|
4
|
The Duration of Preoperative Administration of Single α-Receptor Blocker Phenoxybenzamine before Adrenalectomy for Pheochromocytoma: 18 Years of Clinical Experience from Nationwide High-Volume Center. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2613137. [PMID: 31828097 PMCID: PMC6881764 DOI: 10.1155/2019/2613137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/19/2019] [Accepted: 09/17/2019] [Indexed: 12/22/2022]
Abstract
Purpose There is no consensus for the optimum duration of preoperative administration of phenoxybenzamine (PXB) before adrenalectomy for pheochromocytoma. The aim of this study is to investigate whether perioperative hemodynamics and postoperative outcomes are related to the duration of PXB administration. Methods In total, 102 patients managed preoperatively with single α-receptor blocker phenoxybenzamine were enrolled from 469 consecutive patients diagnosed histologically with pheochromocytoma. The patients received surgical treatment in the Department of Urology, Peking University First Hospital, between January 2001 and July 2018. All patients were divided into three groups: Group A (<14 d), Group B (14–30 d), and Group C (>30 d). Patient and tumor characteristics, intraoperative hemodynamics, and postoperative outcomes were recorded and compared among the three groups. Results These patients included 47 men and 55 women, with an average age of 43 years at the time of surgery. Clinical characteristics, except the status of preoperative biochemical tests (24 hr urine fractioned catecholamine or plasma-fractioned catecholamine) (p=0.020), preoperative hemodynamics, and medicine management and surgical approaches, in the three groups were comparable. Multivariate analyses demonstrated that the size of the tumor (p=0.034) was an independent risk factor for intraoperative hemodynamic instability. Among the three groups, we found no significant difference in intraoperative hemodynamics and postoperative outcomes. Conclusion The data from the current study indicated that the preoperative management of pheochromocytoma with single α-receptor blocker PXB for more than 2 weeks, after the final dose adjustment, could not further reduce the risk of intraoperative hemodynamic instability or postoperative complications. Thus, our study supports that 14 days would be enough for the duration of preoperative management of pheochromocytoma with single α-receptor blocker PXB in final dose.
Collapse
|
5
|
Ramachandran R, Rewari V. Factors affecting the haemodynamic behaviour of patients undergoing pheochromocytoma and paraganglioma removal: A review. Cardiovasc Endocrinol 2017; 6:73-80. [PMID: 31646123 PMCID: PMC6768518 DOI: 10.1097/xce.0000000000000090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/24/2016] [Indexed: 12/19/2022] Open
Abstract
Pheochromocytoma and paraganglioma are catecholamine-secreting tumours associated with major haemodynamic upheavals. The cardiovascular and other organ-related morbidity and even mortality has been ascribed to the major haemodynamic effects of these tumours. Many factors affect the nature and intensity of these haemodynamic changes. The rarity of these tumours as well as their extremely varied clinical presentation preclude conduct of randomized-controlled trials that may provide evidence in terms of these factors and the ways to predict and control them. Many retrospective studies and case reports, however, do provide some insight into their haemodynamic behaviour. Factors such as tumour pathology, associated genetic syndromes, anatomical attributes and perioperative drug therapy affect the haemodynamics of patients with these unique tumours. Knowledge of these factors and their presumed and known association with haemodynamic behaviour of the patients is important during the perioperative care of these patients. The review focuses on the tumour-related, patient-related and the perioperative care-related factors that affect the haemodynamic behaviour of these patients during the surgical removal of these tumours.
Collapse
Affiliation(s)
- Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, Delhi, India
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, Delhi, India
| |
Collapse
|
6
|
Preoperative Levels of Catecholamines and Metanephrines and Intraoperative Hemodynamics of Patients Undergoing Pheochromocytoma and Paraganglioma Resection. Urology 2017; 100:131-138. [DOI: 10.1016/j.urology.2016.10.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/05/2016] [Accepted: 10/10/2016] [Indexed: 01/22/2023]
|
7
|
Challis BG, Casey RT, Simpson HL, Gurnell M. Is there an optimal preoperative management strategy for phaeochromocytoma/paraganglioma? Clin Endocrinol (Oxf) 2017; 86:163-167. [PMID: 27696513 DOI: 10.1111/cen.13252] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/03/2016] [Accepted: 09/24/2016] [Indexed: 12/01/2022]
Abstract
Phaeochromocytomas and paragangliomas (PPGLs) are catecholamine secreting neuroendocrine tumours that predispose to haemodynamic instability. Currently, surgery is the only available curative treatment, but carries potential risks including hypertensive and hypotensive crises, cardiac arrhythmias, myocardial infarction and stroke, due to tumoral release of catecholamines during anaesthetic induction and tumour manipulation. The mortality associated with surgical resection of PPGL has significantly improved from 20-45% in the early 20th century (Apgar & Papper, AMA Archives of Surgery, 1951, 62, 634) to 0-2·9% in the early 21st century (Kinney et al. Journal of Cardiothoracic and Vascular Anesthesia, 2002, 16, 359), largely due to availability of effective pharmacological agents and advances in surgical and anaesthetic practice. However, surgical resection of PPGL still poses significant clinical management challenges. Preoperatively, alpha-adrenoceptor blockade is the mainstay of management, although various pharmacological strategies have been proposed, based largely on reports derived from retrospective data sets. To date, no consensus has been reached regarding the 'ideal' preoperative strategy due, in part, to a paucity of data from high-quality evidence-based studies comparing different treatment regimens. Here, based on the available literature, we address the Clinical Question: Is there an optimal preoperative management strategy for PPGL?
Collapse
Affiliation(s)
- B G Challis
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - R T Casey
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
- Department of Medical Genetics, National Institute for Health Research Biomedical Research Centre, Cambridge, UK
| | - H L Simpson
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - M Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| |
Collapse
|
8
|
Keegan MT. Preoperative α-blockade in catecholamine-secreting tumours: fight for it or take flight? Br J Anaesth 2017; 118:145-148. [PMID: 28100514 DOI: 10.1093/bja/aew414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M T Keegan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN, USA
| |
Collapse
|
9
|
Wachtel H, Kennedy EH, Zaheer S, Bartlett EK, Fishbein L, Roses RE, Fraker DL, Cohen DL. Preoperative Metyrosine Improves Cardiovascular Outcomes for Patients Undergoing Surgery for Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2015; 22 Suppl 3:S646-54. [PMID: 26374407 DOI: 10.1245/s10434-015-4862-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Indexed: 01/24/2023]
Affiliation(s)
- Heather Wachtel
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Edward H Kennedy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Salman Zaheer
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Edmund K Bartlett
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren Fishbein
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Debbie L Cohen
- Division of Renal, Electrolytes, and Hypertension, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
10
|
Incidental Phaeochromocytoma on Staging PET-CT in a Patient with a Sigmoid Tumour and Situs Inversalis Totalis. Case Rep Surg 2014; 2014:645462. [PMID: 25110602 PMCID: PMC4119625 DOI: 10.1155/2014/645462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/17/2014] [Accepted: 06/19/2014] [Indexed: 11/30/2022] Open
Abstract
An adrenal “incidentaloma” is defined as an unexpected finding on radiological imaging performed for unrelated indications. Improvements in radiological technology have seen a dramatic increase in this phenomenon. We report the unique case of a 60-year-old female presenting with a 6-month history of abdominal pain, altered bowel habit, and rectal bleeding. Her past medical history included situs inversus totalis and a patent ductus arteriosus. Colonoscopy revealed an ulcerated tumour in her sigmoid colon. Staging PET-CT confirmed a sigmoid tumour and also identified a large heterogenous enhancing FDG-avid right adrenal mass. Biochemical testing/MIBG imaging confirmed a right adrenal phaeochromocytoma. Hypertension was controlled and excision was performed via a transperitoneal laparoscopic adrenalectomy, in the left lateral decubitus position. Uniquely, liver retraction was not required due to its position in the left hypochondrium. Histology confirmed a benign 46 mm phaeochromocytoma. Subsequent uncomplicated sigmoid colectomy/right salpingo-oophorectomy for a locally advanced colonic tumour was performed with adjuvant chemotherapy. This case highlights the importance of accurately identifying functioning adrenal tumours before elective surgery as undiagnosed phaeochromocytomas carry significant intraoperative morbidity/mortality. Right adrenalectomy was made easier in this patient by the liver's unique position. Uncomplicated colorectal resection was made possible by combined preoperative functional/anatomical imaging.
Collapse
|
11
|
Wachtel H, Cerullo I, Bartlett EK, Roses RE, Cohen DL, Kelz RR, Karakousis GC, Fraker DL. Clinicopathologic Characteristics of Incidentally Identified Pheochromocytoma. Ann Surg Oncol 2014; 22:132-8. [DOI: 10.1245/s10434-014-3933-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Indexed: 01/05/2023]
|
12
|
The Clinical Manifestations, Diagnosis, and Treatment of Adrenal Emergencies. Emerg Med Clin North Am 2014; 32:465-84. [DOI: 10.1016/j.emc.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
13
|
Agrawal R, Mishra SK, Bhatia E, Mishra A, Chand G, Agarwal G, Agarwal A, Verma AK. Prospective Study to Compare Peri-operative Hemodynamic Alterations following Preparation for Pheochromocytoma Surgery by Phenoxybenzamine or Prazosin. World J Surg 2013; 38:716-23. [DOI: 10.1007/s00268-013-2325-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
14
|
Jung JW, Park JK, Jeon SY, Kim YH, Nam SH, Choi YG, Bang SR. Dexmedetomidine and remifentanil in the perioperative management of an adolescent undergoing resection of pheochromocytoma -A case report-. Korean J Anesthesiol 2013; 63:555-8. [PMID: 23277819 PMCID: PMC3531537 DOI: 10.4097/kjae.2012.63.6.555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/07/2012] [Accepted: 02/10/2012] [Indexed: 01/23/2023] Open
Abstract
A 15-year-old adolescent with unilateral multiple adrenal pheochromocytoma had an episode of subcortical intracerebral hemorrhage and seizure 6 weeks before the surgery. He was pretreated with terazosin, losartan, atenolol and levetiracetam for 2 weeks. Dexmedetomidine was started in the preoperative waiting area, and a combination of dexmedetomidine and remifentanil was continuously infused for most of anesthetic time. To control blood pressure, bolus injection of remifentanil and low-dose infusion of sodium nitroprusside, nicardipine, and esmolol were administered during three adrenergic crises. There was minimal post-resection hypotension, and his trachea was extubated safely 20 min after the surgery. He was discharged without noticeable complication. His catecholamine levels showed the steadily decreasing pattern during the operation in this case. Though a combination of dexmedetomidine and remifentanil may not prevent the hemodynamic instability impeccably during the tumor manipulation, this combination seems to be the way of interrupting release of catecholamines and minimizing hemodynamic fluctuations.
Collapse
Affiliation(s)
- Jae-Wook Jung
- Department of Anesthesiology and Pain Medicine, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | | | | | | | | | | | | |
Collapse
|
15
|
Därr R, Lenders JWM, Hofbauer LC, Naumann B, Bornstein SR, Eisenhofer G. Pheochromocytoma - update on disease management. Ther Adv Endocrinol Metab 2012; 3:11-26. [PMID: 23148191 PMCID: PMC3474647 DOI: 10.1177/2042018812437356] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pheochromocytomas are rare endocrine tumors that can present insidiously and remain undiagnosed until death or onset of clear manifestations of catecholamine excess. They are often referred to as one of the 'great mimics' in medicine. These tumors can no longer be regarded as a uniform disease entity, but rather as a highly heterogeneous group of chromaffin cell neoplasms with different ages of onset, secretory profiles, locations, and potential for malignancy according to underlying genetic mutations. These aspects all have to be considered when the tumor is encountered, thereby enabling optimal management for the patient. Referral to a center of specialized expertise for the disease should be considered wherever possible. This is not only important for surgical management of patients, but also for post-surgical follow up and screening of disease in patients with a hereditary predisposition to the tumor. While preoperative management has changed little over the last 20 years, surgical procedures have evolved so that laparoscopic resection is the standard of care and partial adrenalectomy should be considered in all patients with a hereditary condition. Follow-up testing is essential and should be recommended and ensured on a yearly basis. Managing such patients must now also take into account possible underlying mutations and the appropriate selection of genes for testing according to disease presentation. Patients and family members with identified mutations then require an individualized approach to management. This includes consideration of distinct patterns of biochemical test results during screening and the appropriate choice of imaging studies for tumor localization according to the mutation and associated differences in predisposition to adrenal, extra-adrenal and metastatic disease.
Collapse
|
16
|
Weingarten TN, Cata JP, O'Hara JF, Prybilla DJ, Pike TL, Thompson GB, Grant CS, Warner DO, Bravo E, Sprung J. Comparison of two preoperative medical management strategies for laparoscopic resection of pheochromocytoma. Urology 2010; 76:508.e6-11. [PMID: 20546874 DOI: 10.1016/j.urology.2010.03.032] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 03/09/2010] [Accepted: 03/12/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To compare the intraoperative and postoperative course of patients undergoing laparoscopic pheochromocytoma resection at 2 institutions (Mayo Clinic and Cleveland Clinic) with differing approaches to preoperative preparation. Patients undergoing adrenalectomy for pheochromocytoma typically undergo a preoperative preparation to normalize their blood pressure and intravascular volume. However, no consensus has been reached regarding the best preoperative preparation regimen. METHODS A retrospective chart review was performed of 50 Mayo Clinic patients and 37 Cleveland Clinic patients who had undergone laparoscopic pheochromocytoma resection. Mayo Clinic predominantly used the long-lasting nonselective alpha(1,2) antagonist phenoxybenzamine, and Cleveland Clinic predominately used selective alpha(1) blockade. Data regarding the intraoperative hemodynamics and postoperative complications were collected. RESULTS Almost all patients at Mayo Clinic received phenoxybenzamine (98%). At Cleveland Clinic, the predominant treatment (65%) was selective alpha(1) blockade (doxazosin, terazosin, or prazosin). Intraoperatively, patients at Cleveland Clinic had a greater maximal systolic blood pressure (209 +/- 44 mm Hg versus 187 +/- 30 mm Hg, P = .011) and had received a greater amount of intravenous crystalloid (median 5000, interquartile range 3400-6400, versus median 2977, interquartile range 2000-3139; P <.010) and colloid (median 1000, interquartile range 500-1000, versus median 0, interquartile range 0-0; P <.001). At Mayo Clinic, more patients had received phenylephrine (56.0% versus 27.0%, P = .009). No differences were found in the postoperative surgical outcomes, and the hospital stay was comparable between the 2 groups. CONCLUSIONS Differences in the preoperative preparation and intraoperative management were associated with differences in intraoperative hemodynamics but not with clinically significant outcomes in patients undergoing laparoscopic adrenalectomy for pheochromocytoma at 2 large tertiary care centers.
Collapse
Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Abstract
ABSTRACT
The anesthetic management of pheochromocytoma is complicated and challenging. However, preoperative pharmacologic preparation has greatly improved perioperative outcome, and modern anesthetic drugs combined with advanced monitoring contribute to intraoperative stability. There is great regional and international variation in which intraoperative anesthetic technique is employed and there are little data to suggest one approach over another. Nevertheless, most management principles are universal. Progress lies in improved data collection that is increasingly available with electronic anesthesia information systems.
Collapse
|
18
|
Herrera M, Mehl M, Kass P, Pascoe P, Feldman E, Nelson R. Predictive Factors and the Effect of Phenoxybenzamine on Outcome in Dogs Undergoing Adrenalectomy for Pheochromocytoma. J Vet Intern Med 2008; 22:1333-9. [DOI: 10.1111/j.1939-1676.2008.0182.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
19
|
|
20
|
|
21
|
Abstract
Pheochromocytomas are rare neuroendocrine tumors with a highly variable clinical presentation, but they most commonly present as spells of headaches, sweating, palpitations, and hypertension. Patients with pheochromocytoma may develop complicated and potentially lethal cardiovascular and other complications, especially in the setting of diagnostic or interventional procedures (e.g. upon induction of anesthesia or during surgery). The serious and potentially lethal nature of such complications is due to the potent effect of paroxysmal release of catecholamines. Because this warrants prompt diagnosis and treatment, the physician should be aware of the clinical manifestations and complications of catecholamine excess and be able to provide proper preoperative management to minimize catecholamine-related pre-, intra-, and postoperative adverse events. The following clinical scenario and discussion aim to enhance the knowledge of the physician regarding the behavior of pheochromocytoma and to outline current approaches to comprehensive preoperative management of patients suffering from this tumor.
Collapse
Affiliation(s)
- Karel Pacak
- Section on Medical Neuroendocrinology, National Institute of Child Health and Human Development, National Institutes of Health, Building 10, CRC, Room 1E-3140, 10 Center Drive MSC-1109, Bethesda, Maryland 20892-1109, USA.
| |
Collapse
|
22
|
Wu GY, Doshi AA, Haas GJ. Pheochromocytoma induced cardiogenic shock with rapid recovery of ventricular function. Eur J Heart Fail 2006; 9:212-4. [PMID: 16890484 DOI: 10.1016/j.ejheart.2006.05.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 05/02/2006] [Accepted: 05/15/2006] [Indexed: 10/24/2022] Open
Abstract
Pheochromocytoma is a rare cause of secondary hypertension. It may present atypically as cardiogenic shock with significant morbidity and mortality. We present a patient in cardiogenic shock dependent on an intra-aortic balloon pump and vasopressor support who completely recovered cardiac function within 96 h of hospitalization.
Collapse
Affiliation(s)
- Grace Y Wu
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, OH 43210, USA
| | | | | |
Collapse
|
23
|
Khorram-Manesh A, Ahlman H, Nilsson O, Friberg P, Odén A, Stenström G, Hansson G, Stenquist O, Wängberg B, Tisell LE, Jansson S. Long-term outcome of a large series of patients surgically treated for pheochromocytoma. J Intern Med 2005; 258:55-66. [PMID: 15953133 DOI: 10.1111/j.1365-2796.2005.01504.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To analyse the morbidity, mortality and long-term outcome in a consecutive series of surgically treated patients with pheochromocytoma (PC), or paraganglioma (PG), from the western region of Sweden between 1950 and 1997. PATIENTS All patients (n = 121) who had been hospitalized and treated for PC/PG over 47 years. DESIGN Retrospective review of patients with PC/PG regarding presenting symptoms, tumour characteristics, clinical management and long-term outcome after treatment. SETTING One referral centre for all patients from the western region of Sweden. RESULTS During an observation of 15 +/- 6 years, 42 patients died vs. 23.6 expected in the general population (P < 0.001). There was no intra- or post-operative mortality. Four patients with sporadic disease died of malignant PC and six with hereditary disease of associated neuroectodermal tumours. Five patients died of other malignancies, 20 of cardiovascular disease and seven of other causes. Besides older age at primary surgery, elevated urinary excretion of methoxy-catecholamines was the only observed risk factor for death (P = 0.02). At diagnosis 85% of the patients were hypertensive; one year after surgery more than half were still hypertensive. However, pre- and post-operative hypertension did not influence the risk for death versus controls. CONCLUSION Pheochromocytoma/PG can be safely treated by surgery. Death of malignant PC/PG was unusual, but the patients as a group had an increased risk of death. We recommend life-long follow-up of patients treated for PC/PG with screening for recurrent tumour in sporadic cases and for associated tumours in hereditary cases. This strategy would also be helpful in diagnosing cardiovascular disease at an early stage.
Collapse
Affiliation(s)
- A Khorram-Manesh
- Lundberg Laboratory for Cancer Research, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
The basic principles of treatment for phaeochromocytomas and paragangliomas are to block the effects of high catecholamines and make the patient safe for surgical removal of the tumour. The traditional preoperative medical preparation uses the non-selective alpha-adrenoceptor blocker phenoxybenzamine and a beta-adrenoceptor blocker, propranolol. Other agents have been used effectively, including selective alpha-adrenoceptor blockers, doxazosin and prazosin, and calcium channel antagonists. There have been no trial comparing regimens and there is some controversy as to the best regimen. Major advances have been made in laparoscopic and laparoscopic-assisted surgery. Cortical-sparing adrenalectomy has been used in some centres for familial phaeochromocytomas. High-dose [(131)I]-metaiodobenzylguanidine therapy and combined [(131)I]-metaiodobenzylguanidine and chemotherapy are promising new developments for the malignant disease. All patients should be followed indefinitely because the recurrence or malignancy rate is >or= 10% over a prolonged follow up.
Collapse
Affiliation(s)
- Shern L Chew
- St Bartholomew's Hospital, London, EC1A 7BE, UK.
| |
Collapse
|
25
|
Pulcrano M, Palmieri EA, Pagano L, Tauchmanova L, Rossi A, Fazio S, Lombardi G, Biondi B. Long-term efficacy of doxazosin plus atenolol in the management of severe and sustained arterial hypertension and reversibility of the cardiac damage induced by chronic cathecolamine excess. A case report in a young girl with recurrent, functioning paraganglioma. J Endocrinol Invest 2004; 27:774-7. [PMID: 15636433 DOI: 10.1007/bf03347522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Herein we report on a young girl with recurrent, functioning paraganglioma of the organ of Zuckerkandl and severe and sustained arterial hypertension (systolic pressure >200, diastolic pressure >120 mmHg); with evidence of cardiac damage induced by chronic cathecolamine excess. She promptly and steadily improved after the institution of doxazosin (6 mg/day) plus atenolol (50 mg bid) treatment. This case demonstrates that a correct therapeutic strategy in the long-term management of patients with inoperable catecholamine-producing neuroendocrine tumors (pheochromocytomas and paragangliomas) can maintain arterial pressure in the normal range and reverse the cardiac damage induced by chronic cathecolamine excess.
Collapse
Affiliation(s)
- M Pulcrano
- Department of Clinical and Molecular Endocrinology and Oncology, Federico II University School of Medicine, Naples, Italy
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Baraka A, Siddik-Sayyid S, Jalbout M, Yaacoub C. Variable hemodynamic fluctuations during resection of multicentric extraadrenal pheochromocytomas. Can J Anaesth 2002; 49:682-6. [PMID: 12193485 DOI: 10.1007/bf03017445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To report the perioperative management and the serious hemodynamic fluctuations during manipulation of an organ of Zuckerkandl tumour in a patient undergoing resection of multicentric extraadrenal pheochromocytomas. CLINICAL FINDINGS A 28-yr-old man who had undergone at age 12 a laparotomy for excision of an extraadrenal pheochromocytoma complained of paroxysmal headache, occasional sweating and palpitations. The arterial blood pressure (BP) was 200/100 mmHg. A 24-hr-urine collection showed catecholamines 5076 microg x 24 hr(-1) (normal < 25 microg x 24 hr(-1)). Computed tomography of the abdomen revealed two retroperitoneal masses, one adjacent to the lower pole of the right kidney and a second larger mass located at the aortic bifurcation in the region of the organ of Zuckerkandl. The patient was scheduled for excision of multiple extraadrenal pheochromocytomas. He was prepared preoperatively for two weeks with prazosin 1 mg po q six hours and propranolol 10 mg tid. Manipulation of the infrarenal tumour was uneventful but manipulation of the Zuckerkandl tumour resulted in severe hypertensive episodes with BP ranging from 200/100 to 320/120 mmHg. Surgery was interrupted temporarily; the hypertensive crisis was controlled by the infusion of sodium nitroprusside and by iv phentolamine and esmolol. CONCLUSION In a patient undergoing resection of recurrent multicentric extraadrenal pheochromoctyomas, severe hypertensive episodes occurred during manipulation of one tumour but not during manipulation of the other. This may be attributed to inadequate preparation of the patient, difficult surgical dissection of the large Zuckerkandl pheochromocytoma, and/or secondary to an excessive and different pattern of release of catecholamines during manipulation of the Zuckerkandl tumour.
Collapse
Affiliation(s)
- Anis Baraka
- Department of Anesthesiology, American University of Beirut-Medical Center, Beirut, Lebanon.
| | | | | | | |
Collapse
|
27
|
Abstract
Phaeochromocytoma is uncommonly associated with myocardial infarction. We present a patient who, despite established alpha adrenoceptor blockade, sustained an acute myocardial infarction and was found to have coronary artery disease. Indications for coronary revascularization were not met, and adrenalectomy was successfully performed four weeks later. Factors contributing to the myocardial infarction, the role of beta adrenoceptor blockade, the timing of adrenalectomy and the place of coronary revascularization are discussed.
Collapse
Affiliation(s)
- B M Biccard
- Department of Anaesthetics, University of Natal, Congella, South Africa
| | | |
Collapse
|
28
|
Poopalalingam R, Chin EY. Rapid preparation of a patient with pheochromocytoma with labetolol and magnesium sulfate. Can J Anaesth 2001; 48:876-80. [PMID: 11606344 DOI: 10.1007/bf03017353] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To describe the rapid perioperative optimization and control of blood pressure in a young patient who presented with pheochromocytoma. He was non-compliant with phenoxybenzamine but insisted on early surgery. He was scheduled for laparoscopic resection of the tumour. CLINICAL FEATURES This 32-yr-old man presented with uncontrolled hypertension for a few years for which he was treated with nifedipine. He subsequently defaulted follow-up. The patient presented again approximately three months from the day of surgery and was diagnosed to have a pheochromocytoma. The endocrinologist prescribed phenoxybenzamine and propanolol in addition to the nifedipine but the patient stopped taking both drugs six weeks prior to surgery due to their side effects. The patient was admitted the evening before surgery to the intensive care unit for rapid control of his blood pressure. Blood pressure was optimized with an infusion of labetolol and volume expansion titrated under central venous catheter and intraarterial blood pressure guidance throughout the night. On the morning of surgery, a magnesium sulfate infusion was started. The laparoscopic surgery proceeded uneventfully and the patient was hemodynamically stable. There were two transient periods of hypotension after induction and at removal of tumour respectively which were corrected with a brief adrenaline infusion. No adverse outcome was noted. CONCLUSION This case highlights the possibility of a more rapid perioperative control of pheochromocytoma using high doses of labetolol and a magnesium sulfate infusion to achieve stable intraoperative hemodynamics during laparoscopic resection of pheochromocytoma.
Collapse
Affiliation(s)
- R Poopalalingam
- Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital, Singapore.
| | | |
Collapse
|
29
|
Abstract
Anesthesiologists routinely encounter patients with endocrine disorders. Good perioperative outcome depends on preoperative identification, risk stratification and optimization of the patients' endocrinopathies and their sequelae; intraoperative control of metabolic and physiological parameters; and appropriate postoperative pain management, stress modulation, and evaluation of neurological, cardiovascular, and renal function.
Collapse
Affiliation(s)
- G W Graham
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, Madison 53792, USA
| | | | | |
Collapse
|
30
|
Abstract
The safe anaesthetic management of a child with a phaeochromocytoma requires an understanding of the pathophysiology of the disease, together with a thorough knowledge of its pharmacology, in order to avoid or minimize the potentially harmful cardiovascular changes that may occur during anaesthesia. Although there is a considerable amount of information on the management of the adult with phaeochromocytoma, much less has been written concerning children with the disease. Children differ significantly from adults in the incidence, location, presentation and management of this condition and these differences are discussed here together with some of the more controversial issues of management.
Collapse
Affiliation(s)
- H A Hack
- Royal Children's Hospital, Flemington Road, Parkville 3052, Victoria, Australia
| |
Collapse
|
31
|
Abstract
Pheochromocytoma is a rare but important tumor in children. Appropriate evaluation and management are essential for a favorable outcome. Pheochromocytomas are more often multifocal and extra-adrenal in children when compared with adults. This pattern makes the diagnosis, localization, and surgical management more challenging. Nonetheless, the standard biochemical evaluation is usually diagnostic, and MR imaging is currently the best tool for tumor localization. The possibility of a familial syndrome must always be considered and should always be thoroughly evaluated when children present with a pheochromocytoma. Conversely, children with a familial syndrome should undergo annual screening for pheochromocytoma from a young age. Given the greater likelihood of a metachronous recurrence in children, consideration should be given to adrenal-sparing surgery in selected patients. When managed appropriately, the outlook for pheochromocytoma in children is excellent. Unfortunately, the uncommon malignant tumors are still difficult to treat. Perhaps the unique genetic characteristics of pheochromocytoma will ultimately be exploited in the management of the aggressive forms of this disease.
Collapse
Affiliation(s)
- J H Ross
- Section of Pediatric Urology, Cleveland Clinic Foundation, Ohio, USA
| |
Collapse
|
32
|
Affiliation(s)
- C Prys-Roberts
- Sir Humphry Davy Department of Anaesthesia, Bristol Royal Infirmary, UK
| |
Collapse
|
33
|
Harioka T, Nomura K, Hosoi S, Mukaida K. Laparoscopic Resection of Unsuspected Pheochromocytoma. Anesth Analg 1999. [DOI: 10.1213/00000539-199910000-00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|