Pheochromocytoma: state-of-the-art and future prospects

Chromogranin A as a diagnostic marker of pheochromocytoma and paraganglioma: A systematic review and meta-analysis

OBJECTIVES

This work aims to assess the diagnostic value of chromogranin A (CgA) in the laboratory diagnosis of neuroendocrine tumors classified as pheochromocytoma and paraganglioma (PPGL).

METHODS

A comprehensive search was performed in PubMed, Embase, the Cochrane Library, and Web of Science databases to obtain relevant studies reporting the diagnostic accuracy of CgA in patients with PPGL. The search involved studies written in English between the time of library inception and May 1, 2023. We computed the pooled sensitivity, specificity, and diagnostic odds ratio (DOR). Additionally, the receiver operating characteristic curve and area under the curve (AUC) were determined. The heterogeneity was assessed using the Chi-square test and the I2 test. The subgroup analyses were performed to investigate the origins of heterogeneity. Stata 15.1 statistical software was used in all data analyses.

RESULTS

This meta-analysis included 13 studies involving 1470 patients. CgA had a pooled diagnostic sensitivity of 0.86 (95% CI 0.81-0.91), a specificity of 0.90 (95% CI 0.81-0.95), and a DOR of 57 (95% CI 23-142). CgA had an AUC of 0.93. The studies did not reveal any threshold effect (r = -0.165; p > 0.05). The subgroup analyses revealed that the control group category and the detection method caused the overall heterogeneity.

CONCLUSIONS

Our study suggests that CgA is a helpful PPGL biomarker. However, relying solely on CgA for diagnosis is not advisable. A comprehensive approach is essential for accurate diagnosis. Future large-scale research is needed to refine CgA's clinical application.

Pheochromocytoma-induced cardiogenic shock

BACKGROUND

Pheochromocytoma is a rare catecholamine-secreting tumor of neuroendocrine origin. It has a prevalence of <1% in adults with hypertension. In some cases, hypertension is associated with the classical triad of headache, sweating, and tachycardia. Cardiogenic shock due to stress-induced cardiomyopathy caused by catecholamine excess may rarely be the initial symptom of pheochromocytoma, mimicking Takotsubo Syndrome.

METHODS

We report the case of a 58-year-old female patient with pheochromocytoma-induced cardiogenic shock (PICS) in the early postoperative period after thyroidectomy.

RESULTS

PICS is caused by a catecholamine storm, which induces myocardial stress and cardiac dysfunction. In such cases, early management with mechanical circulatory assistance may be promptly considered, given the increased risk of mortality.

CONCLUSION

PICS is a rare and serious condition. Prompt diagnosis and adequate resuscitation measures are necessary to avoid high mortality.

Pheochromocytoma: A Troublesome Tumor

This report presents the case of a 45-year-old man with a history of episodic headaches, palpitations, and sweating for the past six months. His blood pressure on admission was 170/100 mmHg. The patient was diagnosed with pheochromocytoma confirmed by elevated levels of plasma catecholamines and metanephrines. CT imaging revealed a 3 cm mass in the left adrenal gland with evidence of local invasion into the surrounding tissues. The patient underwent a laparoscopic adrenalectomy and was discharged on the third postoperative day with normal blood pressure. Histopathological examination confirmed the diagnosis of pheochromocytoma. The patient was followed for six months postoperatively with the resolution of symptoms and no evidence of tumor recurrence on imaging. Recurrence involves complex environment-gene interactions that are poorly understood. The diagnosis of pheochromocytoma could take several weeks to several years mainly because the symptoms are nonspecific and episodic. Although sudden death is rare, the debilitations associated with pheochromocytoma are often multisystemic with cardiovascular, emotional, and metabolic components. This case report highlights the importance of early diagnosis, appropriate management, and follow-up for pheochromocytoma.

A bioinspired copper-based coordination polymer for the detection of pheochromocytoma biomarkers

Oxidase-mimicking (catechol oxidase/laccase) nanozymes provide outstanding specificity in the detection of epinephrine (Epi) for the assessment of pheochromocytoma; however, epinephrine (Epi) and norepinephrine (NE) co-existing in the same systems will reduce the selectivity of the biosensor. In the current study, we synthesized copper-based coordination polymer (Cu-CP) nanozymes capable of accelerating the oxidation of Epi with high specificity. Furthermore, the Cu-CP is able to detect Epi over a wide linear range of 0.5-100 μM with a low detection limit of 0.36 μM while providing excellent stability and recyclability. Furthermore, we employed colorimetric and fluorescence signals for sequential detection of the coexistence of Epi and NE for use in tracking the treatment outcomes of patients with pheochromocytoma. Experiments using artificial urine further confirmed the efficacy of the proposed system.

Minimally Invasive Management of Hemorrhagic Pheochromocytoma—A Rare Case Report

Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. The diagnosis is usually suggested by its classic history, presence of a strong family history, or discovery of an incidental mass on imaging in an asymptomatic patient. Hemorrhage into an occult pheochromocytoma is a rare complication with ∼1 to 2 per 100,000 individuals diagnosed annually. We report a case of a 29-year-old woman, who presented with abdominal pain (with no other significant history) due to a right hemorrhagic pheochromocytoma. Computed tomographic imaging and magnetic resonance imaging revealed the source of retroperitoneal hemorrhage as the right adrenal mass. They lacked the typical features of a pheochromocytoma which was eventually proven by the biochemical tests. The patient underwent preoperative stabilization with α and β adrenergic receptor blockers for 7 days following which laparoscopic adrenalectomy was performed successfully with an uneventful postoperative period. This is the eighth reported case in literature managed laparoscopically. Histopathology confirmed it as pheochromocytoma. The treacherous and deceptive nature of pheochromocytomas and its hemorrhage make it crucial to detect and treat it promptly; otherwise, it will almost certainly be fatal from cardiovascular complications or metastasis.

Etiology and Management of Treatment-Resistant Hypertension in African American Adults ≥18 Years: A Literature Review

Treatment-resistant hypertension (TRH) is defined as blood pressure levels that remain above the therapeutic goal despite concurrent use of three or more antihypertensive medications taken at maximally tolerated doses, one of which should be a diuretic. Additionally, individuals on four or more antihypertensive agents regardless of blood pressure are also considered to have TRH. Amongst people diagnosed with TRH, African American adults face a huge management gap, resulting in increased cardiovascular disease risk. The primary objective of this review was to identify the commonly encountered etiologies and extensively discuss the current management strategies of TRH with a particular focus on African Americans. Relevant studies were identified by analyzing scientific databases and journals such as PubMed, Cochrane, MEDLINE, Cureus, and American Heart Association (AHA). The studies identified and examined common causes of TRH, describing their pathophysiology and highlighting different treatment options for the respective etiologies. The most prevalent etiologies of TRH amongst African Americans were chronic kidney disease (CKD), renal artery stenosis (RAS), fibromuscular dysplasia, obstructive sleep apnea (OSA), endocrine causes (Conn syndrome, Cushing syndrome, etc.), sympathetic nervous system overactivity, lifestyle factors, inaccurate blood pressure measurement, and inappropriate treatment. Of the etiologies reviewed, OSA, lifestyle factors, and CKD exhibited a striking prevalence among the subpopulation studied. Unfortunately, there was a paucity of articles addressing this topic amongst African Americans, and therefore there was not a substantial appreciation of the prevalence of some of the identified etiologies in the population of interest. Thorough diagnostic testing for associated or underlying conditions provides a basis for successful management. This review brought to the fore the need for doctors and patients to collaborate in order to improve TRH management and help patients lead healthier lives.

Role of Chromogranin A in the Diagnosis and Follow-up of Neuroendocrine Tumors: Real-World Experience

OBJECTIVE

The aim of this study was to assess the utility of serum chromogranin A (CgA) along the clinical pathway of patients with neuroendocrine tumors (NETs).

METHODS

A retrospective review of medical records was conducted of patients with NET who had at least 1 measurement of CgA between January 2015 and April 2021 at a large metropolitan Australian hospital. Chromogranin A was classified as increased or decreased if there was at least a 25% change in sequential levels and was compared with disease response by anatomical or functional imaging if within 6 weeks (considered concurrent).

RESULTS

Of 102 patients with NETs, 67 had at least 1 serum CgA level: 50 had been ordered during diagnostic workup, of which 33 were elevated (sensitivity: 66%; 95% confidence interval, 51%-79%). Of 129 CgA results concurrent with imaging, the sensitivity for detecting progressive disease was 28% (95% confidence interval, 15%-44%).

CONCLUSIONS

Our findings support previous concerns that CgA adds little value in clinical decision-making.

Subclinical phaeochromocytoma: a diagnostic and management challenge

There is a paradigm shift in the detection of phaeochromocytomas with more being identified as adrenal 'incidentalomas'. While majority of these individuals are asymptomatic, they are nevertheless at risk of subtle cardiovascular dysfunction and phaeochromocytoma crises. Therefore, early resection of phaeochromocytomas, even if subclinical, is recommended. However, the perioperative management can be challenging as the normotension can limit the initiation and titration of alpha-blockade. We present a man in his 60s with a subclinical phaeochromocytoma, discuss the evaluation of an incidentally discovered adrenal nodule, as well as the practical considerations in the perioperative management.

Development of a radiomics model to diagnose pheochromocytoma preoperatively: a multicenter study with prospective validation

Background

Preoperative diagnosis of pheochromocytoma (PHEO) accurately impacts preoperative preparation and surgical outcome in PHEO patients. Highly reliable model to diagnose PHEO is lacking. We aimed to develop a magnetic resonance imaging (MRI)-based radiomic-clinical model to distinguish PHEO from adrenal lesions.

Methods

In total, 305 patients with 309 adrenal lesions were included and divided into different sets. The least absolute shrinkage and selection operator (LASSO) regression model was used for data dimension reduction, feature selection, and radiomics signature building. In addition, a nomogram incorporating the obtained radiomics signature and selected clinical predictors was developed by using multivariable logistic regression analysis. The performance of the radiomic-clinical model was assessed with respect to its discrimination, calibration, and clinical usefulness.

Results

Seven radiomics features were selected among the 1301 features obtained as they could differentiate PHEOs from other adrenal lesions in the training (area under the curve [AUC], 0.887), internal validation (AUC, 0.880), and external validation cohorts (AUC, 0.807). Predictors contained in the individualized prediction nomogram included the radiomics signature and symptom number (symptoms include headache, palpitation, and diaphoresis). The training set yielded an AUC of 0.893 for the nomogram, which was confirmed in the internal and external validation sets with AUCs of 0.906 and 0.844, respectively. Decision curve analyses indicated the nomogram was clinically useful. In addition, 25 patients with 25 lesions were recruited for prospective validation, which yielded an AUC of 0.917 for the nomogram.

Conclusion

We propose a radiomic-based nomogram incorporating clinically useful signatures as an easy-to-use, predictive and individualized tool for PHEO diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03233-w.

Management and outcome of metastatic pheochromocytomas/paragangliomas: a monocentric experience

BACKGROUND

Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors releasing catecholamines. Metastatic pheochromocytomas/paragangliomas (PPGLs) occur in about 5-26% of cases. To date, the management of patients affected by metastatic disease is a challenge in the absence of guidelines.

AIM

The aim of this study was to evaluate the overall survival (OS) and the progression-free survival (PFS) in metastatic PPGLs.

METHODS

Clinical data of 20 patients referred to the Careggi University Hospital (Florence, Italy) were retrospectively collected. Follow-up ranged from 1989 to 2019. Site and size of primary tumor, biochemical activity, genetic analysis and employed therapies were considered. Data were analyzed with SPSS version 27.

RESULTS

Nine PHEOs (45%) and 11 PGLs (55%) were enrolled. Median age at diagnosis was 43.5 years [30-55]. Mean follow-up was 104.6 ± 89.3 months. Catecholamines were released in 70% of cases. An inherited disease was reported in 50% of patients. OS from the initial diagnosis (OSpt) and from the metastatic appearance (OSmtx) were lower in older patients (OSpt p = 0.028; OSmtx p < 0.001), abdominal PGLs (OSpt p = 0.007; OSmtx p = 0.041), larger tumors (OSpt p = 0.008; OSmtx p = 0.025) and sporadic disease (OSpt p = 0.013; OSmtx p = 0.008).

CONCLUSION

Our data showed that older age at the initial diagnosis, sympathetic extra-adrenal localization, larger tumors and wild-type neoplasms are related to worse prognosis. Notably, the employed therapies do not seem to influence the survival of our patients. At present, effective treatments for metastatic PPGLs are missing and a multidisciplinary approach is indispensably required.

Adrenal pheochromocytoma with involvement of aorta and left renal artery: salvaged with adrenalectomy and nephrectomy

Large adrenal pheochromocytomas encasing the renal artery are a rare entity. The management of such challenging cases is surgical resection. The involvement of renal tissue and renal artery may necessitate meticulous dissection and concomitant nephrectomy. Here, we present a case of 41-year-old man diagnosed with left adrenal pheochromocytoma with complete encasement of left renal artery and partial encasement of aorta. Open left adrenalectomy and nephrectomy was performed after adequate preoperative optimisation. The patient is doing well at 6-month follow-up. Large adrenal pheochromocytoma with renal involvement is a rare presentation and requires optimal preoperative imaging, adequate preoperative alpha and beta blockade and meticulous surgical technique.

The inferior vena cava: anatomical variants and acquired pathologies

The inferior vena cava (IVC) is the largest vein in the body, draining blood from the abdomen, pelvis and lower extremities. This pictorial review summarises normal anatomy and embryological development of the IVC. In addition, we highlight a wide range of anatomical variants, acquired pathologies and a common pitfall in imaging of the IVC. This information is essential for clinical decision making and to reduce misdiagnosis.

Adrenalectomy for incidental and symptomatic phaeochromocytoma: retrospective multicentre study based on the Eurocrine® database

BACKGROUND

Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative α-blockade.

METHODS

This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in Eurocrine®, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed.

RESULTS

Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative α-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P = 0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative α-blockade or not.

CONCLUSION

Subclinical phaeochromocytoma detected incidentally is common. A significantproportion of patients with phaeochromocytoma did not have α-blockade before surgery, without an apparent effect on complications.

Malignant pheochromocytoma: A diagnostic and therapeutic dilemma

Introduction

Malignant pheochromocytomas are rare endocrine tumors that develop within chromaffin tissue. The diagnosis of malignancy is based on neoplastic recurrence or the presence of metastasis in organs that lack chromaffin tissue. We report a series of four cases because of their diagnostic and therapeutic particularities.

Presentation of case

we describe four clinical cases of patients with malignant pheochromocytoma whose Menard triad “headache-palpitations-sweating” was present in three out of four patients, the methoxylated derivatives were measured in 4 patients, 3 of which had high values, all of our patients carried out a CT scan which objectified signs of malignancy, MRI was performed on a single patient; presenting with a neoplastic recurrence; looking for a locoregional invasion.

Discussion

Pheochromocytoma (PC) is a rare neuroendocrine tumor derived from the chromaffin cells of the adrenal medulla. Its annual incidence is 2 to 8 per million adults. A peak frequency is observed between 30 and 40 years of age. Approximately 10% of pheochromocytomas are malignant and in 10% of cases, bilateral localization is observed. Criteria for malignancy include the invasion of neighboring organs, a large tumor, the presence of lymphadenopathy on imaging, or fixation on scintigraphy. Surgery for MAP is not always curative. In the case of multiple liver metastases, treatment is based on adrenalectomy, which can be effectively combined with chemoembolization, cryoablation, or radiofrequency techniques.

Conclusion

The main prognostic factors of the malignant pheochromocytomas are a large tumor volume, the existence or number of visceral metastases, and the presence of a mutation in the SDHB (Succinate dehydrogenase B) gene.

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Malignant pheochromocytomas are rare endocrine tumors that develop within chromaffin tissue.

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A very large part of pheochromocytomas are of genetic origin which can be part of hereditary syndromes.

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Criteria for malignancy include the invasion of neighboring organs, a large tumor, the presence of lymphadenopathy on imaging, or fixation on scintigraphy.

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Adequate management of this pathology requires a multidisciplinary consultation meeting

Management and outcome of metastatic pheochromocytomas/paragangliomas: an overview

BACKGROUND

Metastatic pheochromocytomas and paragangliomas (PPGLs) occur in about 5-26% of cases and are characterized by a heterogeneous prognosis. Metastases can be synchronous at the initial diagnosis, but they can occur also many years after surgery for the primary tumor. To date, the treatment of patients affected by metastatic PPGLs represents a clinical challenge because of the lack of guidelines.

AIM

The aim of this article is to review the available management options and their impact on the outcomes of patients with metastatic PPGLs.

RESULTS

Generally, treatments are not curative. Surgery, when possible, can be used to reduce hormonal symptoms and cardiovascular morbidity. Chemotherapy plays a role in patients with high burden tumor and rapid disease progression. Tyrosine kinases inhibitors (TKIs) might be considered for their ability to block the angiogenesis and cell growth. Radiation therapy and interventional radiology techniques can help in the management of local metastases to control symptoms and avoid tumor progression. On the other hand, peptide receptor radionuclide therapy (PRRT), using ⁹⁰Y or ¹⁷⁷Lu-DOTATATE, could be a promising therapy. In addition, high specific ¹³¹I-MIBG was approved by the Food and Drug Administration (FDA) in the US for the treatment of patients affected by metastatic and unresectable ¹³¹I-MIBG positive PPGLs. Considering the different pathways involved in the pathogenesis of PPGLs, several target therapies have been proposed and are under evaluation in clinical trials.

CONCLUSIONS

The choice of the appropriate treatment should be based on multidisciplinary and personalized approach taking into account the rarity and the variability of these tumors.

Genetics, diagnosis, management and future directions of research of phaeochromocytoma and paraganglioma: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension

: Phaeochromocytoma and paraganglioma (PPGL) are chromaffin cell tumours that require timely diagnosis because of their potentially serious cardiovascular and sometimes life- threatening sequelae. Tremendous progress in biochemical testing, imaging, genetics and pathophysiological understanding of the tumours has far-reaching implications for physicians dealing with hypertension and more importantly affected patients. Because hypertension is a classical clinical clue for PPGL, physicians involved in hypertension care are those who are often the first to consider this diagnosis. However, there have been profound changes in how PPGLs are discovered; this is often now based on incidental findings of adrenal or other masses during imaging and increasingly during surveillance based on rapidly emerging new hereditary causes of PPGL. We therefore address the relevant genetic causes of PPGLs and outline how genetic testing can be incorporated within clinical care. In addition to conventional imaging (computed tomography, MRI), new functional imaging approaches are evaluated. The novel knowledge of genotype-phenotype relationships, linking distinct genetic causes of disease to clinical behaviour and biochemical phenotype, provides the rationale for patient-tailored strategies for diagnosis, follow-up and surveillance. Most appropriate preoperative evaluation and preparation of patients are reviewed, as is minimally invasive surgery. Finally, we discuss risk factors for developing metastatic disease and how they may facilitate personalised follow-up. Experts from the European Society of Hypertension have prepared this position document that summarizes the current knowledge in epidemiology, genetics, diagnosis, treatment and surveillance of PPGL.

Refractory shock during the anesthetic and surgical management of an intrahepatic tumor arising from the adrenal cortex: A case report

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With adrenocortical carcinoma, tumoral secretion is present in 25 to 75% of the cases.

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In the absence of excessive hormonal production, the diagnosis is often delayed.

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Isolated liver metastatic lesion may develop after several years of follow-up.

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Resection of a large intrahepatic malignant lesion may be complicated by a secondary capillary leak syndrome.

Introduction

Adrenocortical carcinoma is a rare type of malignant adrenal tumor with a possibility of delayed metastases. Diagnosis may be delayed with a non-secreting tumor or metastasis, and even in this case, surgical management may be complicate.

Presentation of case

A 55-year-old man underwent elective surgery for the resection of a large intra-hepatic mass from an undetermined type according to a recent liver biopsy. He had a previous history of a non-secreting adrenal tumor that was operated ten years before. Pre-operatively, he was poorly symptomatic, with a normal arterial blood pressure. Anesthesia induction was uneventful, but at the time of tumor resection and removal, he developed extreme vasoplegia and shock with anuric renal failure, lactic acidosis, four-limb and abdominal compartment syndrome. The patient died on day 9 from delayed septic complications. According to the pathological findings, the tumor was a non-secreting adrenocortical carcinoma.

Discussion

Adrenocortical carcinoma (ACC) is rare condition with diverse clinical manifestations due to excessive hormonal production when the tumor is secreting and mimicking pheochromocytoma. Our patient underwent the resection a large intrahepatic non-secreting metastasis more than ten years after the initial lesion. Peri-operative and post-operative management was complicated by a refractory shock with the characteristics of a secondary systemic capillary leak syndrome. The role of endothelial lesions may be discussed.

Conclusion

Surgery of metastatic adrenocortical carcinoma may be complicated by severe hemodynamic complications, even in the absence of hormonal secretion.

Role of Preoperative Adrenergic Blockade with Doxazosin on Hemodynamic Control during the Surgical Treatment of Pheochromocytoma: A Retrospective Study of 48 Cases

Authors evaluated the effects of selective adrenergic blockade by means of doxazosin on blood pressure in 48 patients operated on for pheochromocytoma by a multicenter retrospective study. Age, tumor size, surgical approach, and operative time were analyzed as predictive factors of intraoperative hypertensive crises. Forty-eight patients underwent adrenalectomy—four open surgery and 44 laparoscopic surgery—for pheochromocytoma of adrenal glands from 1998 to 2008 after preoperative administration of doxazosin. Perioperative cardiovascular status modifications and surgical medium- and long-term outcomes were analyzed. There was no mortality, conversion rate was 4.5 per cent, and morbidity rate was 8.3 per cent. Intraoperative hypertensive crises (180/ 90 mmHg or higher) were observed in 14.5 per cent (seven of 48) of patients and were treated pharmacologically with no aftermath. None of the examined variables influenced the occurrence of intraoperative hypertensive episodes. Postoperative hypotension (lower than 90/60 mmHg) was observed in four of 48 patients (8.3%) and was treated by crystalloids and hydrocortisone. In the surgical treatment of pheochromocytoma, the preoperative adrenergic blockade by doxazosin does not prevent intraoperative hypertensive crises. Nevertheless, in our series, they were of short duration and were not associated with major cardiovascular complications. Perioperative hemodynamic instability was managed bypreoperative pharmacological treatment, allowing low morbidity.

The case series of functional adrenal tumors: Experience of two tertiary hospitals in Yaoundé, Cameroon

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This is a case series of functional adrenal tumors and treatment outcomes.

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A diversity of cases is presented with clinical, medical imaging, macroscopic and microscopic features included.

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Successful management of two cases of adrenal insufficiency following classic adrenalectomy in a low resource community is reported.

Introduction

Adrenal tumors are often found incidentally during abdominal imaging. Functioning adrenal tumors are less frequent than these incidentalomas discovered unexpectedly. We report treatment outcomes (major complications) of 7 cases of symptomatic adrenal masses from 2009 to 2019.

Presentation of the cases

Seven cases of functioning adrenal tumors: four adenomas presenting with Cushing’s syndrome, two adrenal carcinomas, and one pheochromocytoma are described. The preoperative diagnoses were made through clinical manifestations, an increase in urinary free cortisol with normal ACTH, elevated metanephrine and enlarged masses on CT. The diagnoses were established on histopathology of adrenalectomy specimens. Adrenal insufficiency in two patients following surgery was corrected with corticoid replacement therapy. One patient died of hypovolemia the day of surgery and another from anaphylactic shock (allergy) late in the post-operative period.

Discussion

Pre, intra and post-operative complications from vascular instability often complicate surgery in functioning adrenal tumors. Adrenal adenomas manifest as Cushing’s syndrome in 10–15 % of patients. They are the most common adrenal tumor although the diagnosis is most often coincidental to abdominal imaging. The incidence of adrenal adenoma increases with age, up to 7 % in the seventh decade. Laparoscopic adrenalectomy, which was not available in our hospitals then, is standard treatment for most tumors. It is alleged to have better outcomes in trained and tested hands.

Conclusion

Surgery of functioning adrenal tumors demands close collaboration of multiple clinical disciplines to manage vascular instability and adrenal insufficiency, especially in resource strapped communities.

Pheochromocytoma: An approach to diagnosis

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.

Changing pattern of pheochromocytoma and paraganglioma in a stable UK population

Context

Pheochromocytomas and paragangliomas (PCC/PGLs) are diagnosed variously with increasing incidence and changing clinical and pathology pattern.

Objective

The aim was to further characterize PCC/PGLs in a stable population.

Methods

A retrospective, single institution study analysed adrenalectomies for PCC/PGLs between January 2010 - January 2019. Demographics, symptoms, blood pressure, preoperative hormones, imaging, histology, hospital stay, complications and three subgroups [based on the modality of diagnosis - incidentaloma group (IG), genetic group (GG) and symptomatic group (SG)] were noted.

Results

86 patients included IG 51 (59.3%), GG 10 (11.62%) and SG 25 patients (29.06%). Incidence was 5.30 cases/1 million population. 33.34% of the IG had a delayed diagnosis with a mean interval of 22.95 months (4-120 months). Females presented more often with paroxysmal symptoms (PS) (p=0.011). Patients with PS and classic symptoms were younger (p=0.0087, p=0.0004) and those with PS required more inotropes postoperatively (p=0.014). SG had higher preoperative hormone levels (p=0.0048), larger tumors (p=0.0169) and more likely females. GG are younger compared with those from the IG (p=0.0001) or SG (p= 0.178).

Conclusion

Majority of patients had an incidental and delayed diagnosis. If symptomatic, patients are more likely to be young females with higher hormone levels and larger tumors.

Preoperative Management of Pheochromocytoma and Paraganglioma

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.

A Novel MAX Gene Mutation Variant in a Patient With Multiple and "Composite" Neuroendocrine-Neuroblastic Tumors

Introduction: Pheochromocytomas (PCCs), paragangliomas (PGLs), ganglioneuroblastomas (GNBs), and ganglioneuromas (GNs) are neuroendocrine neoplasms (NENs) that were thought to share a common embryologic origin from neural crest cells. However, they rarely occur concurrently and recurrently. We describe the case of a 40-years-old woman with "composite PCC-GN" and multiple NENs and neuroblastic tumors. Case presentation: The patient was first referred to our department at the age of 15 years for paroxysmal hypertension, headache, sweating, and watery diarrhea. Her personal history included the diagnosis of a pelvic GNB with lumbar-aortic lymph node metastases at 11 months. Her family history was positive for cerebral glioblastoma multiforme (father). An abdominal ultrasound showed a right adrenal mass that histologically was a "composite adrenal PCC-GN." The symptoms disappeared after surgery. At the age of 20 years, the symptoms returned: computed tomography (CT) and 131I-metaiodobenzylguanidine (MIBG) scintigraphy showed an inter-aortocaval mass, found histologically to be an inter-aortocaval PGL. Her symptoms reappeared again at 28 years: CT and magnetic resonance imaging revealed four left adrenal gland nodules, found histologically to be multifocal PCCs with some atypia. Genetic screening for VHL, RET, NF1, Tp53, SDHD, SDHB, SDHC, SDHAF2, SDHAF3, SDHA, and TMEM127 was negative. Mutational analysis of the MAX gene revealed the presence of a novel heterozygous variant, c299G>C (p.Arg100Pro, NM_002382.5) that the bioinformatics prediction programs defined as noxious and causative of pathology. Conclusion: This report represents the first description of a co-occurrence of multiple composite PCC-GN and neuroblastic tumors. The long timeline of the presentation of the NENs/neuroblastic tumors from infancy to adulthood requires a lifelong follow-up for this patient. Moreover, the importance of this case lies in the presence of a novel MAX gene variant deleterious, harmful, and causative of pathology, confirmed by Sanger sequencing and never been associated before with multiple composite PCC-GN. The present case underlines the importance of precision medicine and molecular diagnoses for hereditary pheochromocytomas and paragangliomas, suggesting that when they occur in early childhood, it is necessary to perform an extensive genetic investigation and a lifelong follow-up.

Pheochromocytomas and Paragangliomas

Pheochromocytomas are rare neuroendocrine tumors. Extra-adrenal lesions arising from the autonomic neural ganglia are termed paraganglioma. Clinical symptoms are common between the adrenal and extra-adrenal forms and are determined by excess secretion of catecholamines. Hypertension is a critical and often dramatic feature of pheochromocytoma/paraganglioma, and its most prevalent reported symptom. However, given the rare occurrence of this cancer, in patients undergoing screening for hypertension, the prevalence ranges from 0.1% to 0.6%. Still, patients frequently come to the attention of endocrinologist when pheochromocytoma/paraganglioma is suspected as a secondary cause of hypertension. This article summarizes current clinical approaches in patients with pheochromocytoma/paraganglioma.

Adverse Events of Diagnostic Radiopharmaceuticals: A Systematic Review

Diagnostic radiopharmaceuticals used in nuclear medicine can cause adverse events. Information on these adverse events is available in case reports and databases but may not be readily accessible to healthcare professionals. This systematic review provides an overview of adverse events of diagnostical radiopharmaceuticals and their characteristics. A median frequency for adverse events in diagnostical radiopharmaceuticals of 1.63 (interquartile range: 1.09-2.29) per 100,000 is reported. Most common are skin and subcutaneous tissue disorders, and general disorders and administration site conditions. Many adverse events reported are minor in severity, although 6.7% can be classified as important. In rare cases, adverse events are serious and potentially life-threatening. With the introduction of new radiopharmaceuticals and the increasing use of positron emission tomography-computed tomography, previously unknown adverse events may be detected in daily practice. Future work should cover the experience of the patient with adverse events from diagnostic radiopharmaceuticals.

A high rate of modestly elevated plasma normetanephrine in a population referred for suspected PPGL when measured in a seated position

OBJECTIVE

Determine rate of high plasma normetanephrine or metanephrine (PNM-PMN) in a large sample of patients according to PNM-PMN posture and age-adjusted references.

DESIGN

Retrospective re-analysis of PNM-PMN from a Canadian reference laboratory (n = 5452), 2011-2015; most were in seated position (n = 5112) rather than supine (n = 340). An international PPGL database demonstrated expected distribution of supine PNM-PMN in PPGL patients.

METHODS

All PNM-PMN from a tertiary referral laboratory were reviewed. Any PNM-PMN result greater than 2× upper reference limit (URL) was considered likely true PPGL. Results 1-2× URL were uncertain, requiring additional testing/follow-up despite most being false positive given the rarity of PPGL. The rate of results in the 1-2× URL category were calculated for each group according to collection posture and differing published URL: seated, supine or supine age adjusted.

RESULTS

When collected and interpreted by seated URL, 19.6% of PNM required additional testing; only 4.6% being >2× URL. For patients over age 50 years, the abnormal rate was 24.9%. When collected supine, interpreted by supine age-adjusted URL, only 5.3% of PNM were mildly elevated. Possible false positives may be even lower when considering PMN or plasma methoxytyramine which were commonly high in true PPGL despite mild PNM elevations.

CONCLUSIONS

In a general medical population, seated PNM has a high rate of abnormal results, far exceeding expected prevalence. Supine measurement with supine, age-adjusted interpretation is strongly preferred prior to costly or invasive PPGL investigations.

SUMMARY

Review of 5452 plasma normetanephrine measurements showed 20% to be high, likely false positives for most. Supine, age-adjusted measures were half as likely to be elevated.

Pheochromocytoma- and paraganglioma-triggered Takotsubo syndrome

Takotsubo syndrome (TS), also known as neurogenic stunned myocardium or broken heart syndrome, is a recognized acute cardiac syndrome. In about 70% of cases, the syndrome is preceded by an emotional or a physical stressor. Among the innumerable physical trigger factors that may induce TS are pheochromocytomas and paragangliomas (PPGLs). PPGL-associated cardiovascular complications as "myocarditis", "myocardial infarction", "reversible cardiomyopathies", and "transient repolarization electrocardiographic changes" have been described since more than 70 years. During the last two decades, dozens of cases of PPGL-induced TS have been reported. PPGLs display increased catecholamine levels, sometimes massively elevated, which may trigger TS, most likely through hyperactivation of sympathetic nervous system including the cardiac sympathetic nerve terminal disruption with norepinephrine seethe and spillover. PPGL-induced TS is characterized by a dramatic clinical presentation with hemodynamic compromise and high complication rates. The prevalence of global and apical sparing pattern of TS in PPGL-induced TS is significantly higher than in other TS populations. In this report, the associations of PPGL-induced cardiovascular complications are analyzed, and clinical features, complications, outcome and treatment of PPGL-induced TS are reviewed.

Adrenal disorders in pregnancy, labour and postpartum - an overview

Adrenal disorders may manifest during pregnancy for the first time, or present from before pregnancy as either undiagnosed or diagnosed and treated. They may present as hormonal hypofunction or hyperfunction, or with mass effects or other non-endocrine effects. Adrenal disorders such as Cushing's syndrome, Addison's disease, pheochromocytoma, primary hyper-aldosteronism and adreno-cortical carcinoma are rare in pregnancy. Pregnancy presents special problems in the evaluation of the hypothalamic-pituitary-adrenal and renin-angiotensin-aldosterone axis as these undergoe major changes during pregnancy. Diagnosis is challenging as symptoms associated with pregnancy are also seen in adrenal diseases. A timely diagnosis and treatment is critical as these disorders can cause maternal and foetal morbidity and mortality. A high index of suspicion must be maintained as they can go unrecognised and untreated. An early diagnosis and treatment often improves outcomes. The aim of this article is to review the patho-physiology, clinical manifestation, diagnosis and management of various adrenal disorders during pregnancy.

A simple and robust liquid chromatography tandem mass spectrometry assay for determination of plasma free metanephrines and its application to routine clinical testing for diagnosis of pheochromocytoma

Plasma free metanephrines (PFMs) have high sensitivity for detecting pheochromocytoma (PCC). Herein, we developed a simple and reliable liquid chromatography tandem mass spectrometry assay for PFMs determination in Chinese population. PFMs were enriched by SPE without requiring extract evaporation or the use of buffers containing nonvolatile salts. The analytes were analyzed in multiple reaction monitoring mode. Inter- and intra-assay precisions were ≤4.3% and ≤ 6.3%. The lower limits of quantification were 0.07 nmol/L for metanephrine and 0.06 nmol/L for normetanephrine. Recoveries of PFMs were in the range of 89.3-113%. The method was free from significant matrix effect, carryover and interference. Owing to its fast analysis time, more than 150 samples/day could be easily performed by a single operator. With the established reference intervals of PFMs in the Chinese population, this simple and robust LC-MS/MS method could be valuable for use in routine clinical laboratories. It is noted that the combined tests of PFMs with urinary catecholamines or urinary vanillylmandelic acid could improve specificity.

The adrenal cortex: Physiology and diseases in human pregnancy

Pregnancy is characterized by marked alterations in the hypothalamic-pituitary-adrenal axis and in the function of the adrenal gland. Some of those alterations have clinical characteristics that are similar to those of adrenal gland disorders. While adrenal disorders are rare among pregnant women, they harbor the potential for significant morbidity if they remain unrecognized and untreated. As the majority of patients with adrenal disorders present with clinical features that are typical of normal pregnancy - diagnosis during pregnancy is not uncommonly delayed. A high index of suspicion must be practiced for these disorders as they might carry severe obstetrical negative outcomes. In this review we will survey the normal function of adrenal glands in pregnancy and the role of adrenal hormones in pregnancy. We will outline the adrenal disorders that commonly present during pregnancy and review the literature on treatment modalities.

Genetic Profile of Indian Pheochromocytoma and Paraganglioma Patients - A Single Institutional Study

BACKGROUND AND AIMS

Pheochromocytomas (PCCs) and Paragangliomas (PGL) are rare catecholamine producing tumors that may present in sporadic or familial settings. Despite vast strides in understanding of PCC/PGL genetics in the last two decades, there is a dearth of information from India. The aim here is to study the prevalence of genetic mutations in Indian PCC/PGL patients.

SETTINGS AND DESIGN

Tertiary care academic hospital; prospective study.

METHODS

50 histopathologically diagnosed PCC/PGL patients formed the study group. Clinical, biochemical, pathological attributes and outcomes were documented and the phenotype was compared to the genotype. Succinyl dehydrogenase (SDH), Re-Arranged during Transfection (RET), Von-Hippel-Lindau (VHL) and NeuroFibromatosis-1 (NF1) mutations were studied. Additionally, immunohistochemisty for SDHB was also done, and the results compared to mutational analysis of SDH by MLPA (Multiplex Ligation-dependent Probe Activation).

STATISTICAL ANALYSIS

Independent samples t-test and Fisher's exact test were used as appropriate. P values ≤0.05 were considered statistically significant.

RESULTS

The mean age was 34.3 years. Of the 50 patients, 27 were males and 23 females. 10 patients (20%) in all were detected to have a genetic mutation. 6 patients possessed a RET mutation, while two had VHL mutations. No patient presented with a NF1 mutation. 2 patients had a SDH mutation, and Immunohistochemistry for SDHB correlated with mutational analysis for these patients.

CONCLUSIONS

The proportion of patients with a familial variant of PCC/PGL is more than what the historic "Rule of Ten" suggests. Our study found that one in five patients have a genetic mutation. PCC/PGL patients with genetic mutations not only require more stringent follow-up, but also screening of family members.

Paraganglioma in pregnancy: interdisciplinary management during pregnancy

Paragangliomas are tumors that originate from the extra-adrenal neural crest, the incidence of which during pregnancy is not more than two to eight cases per million people per year and are known to be highly morbid. The purpose of this report is to describe the experience and results obtained during management of a primigravida diagnosed with paraganglioma on week 21.2 and received both medical and surgical management with good maternal and perinatal outcomes. This case report evidences the importance of practicing interdisciplinary management of patients with clinical suspicion of paragangliomas or pheochromocytomas during pregnancy at high-complexity centers even in a medium-income country.

Malignant Pheochromocytomas/Paragangliomas and Ectopic Hormonal Secretion: A Case Series and Review of the Literature

Malignant pheochromocytomas (PCs) and paragangliomas (PGLs) are rare neuroendocrine neoplasms defined by the presence of distant metastases. There is currently a relatively paucity of data regarding the natural history of PCs/PGLs and the optimal approach to their treatment. We retrospectively analyzed the clinical, biochemical, imaging, genetic and histopathological characteristics of fourteen patients with metastatic PCs/PGLs diagnosed over 15 years, along with their response to treatment. Patients were followed-up for a median of six years (range: 1–14 years). Six patients had synchronous metastases and the remaining developed metastases after a median of four years (range 2–10 years). Genetic analysis of seven patients revealed that three harbored succinate dehydrogenase subunit B/D gene (SDHB/D) mutations. Hormonal hypersecretion occurred in 70% of patients; normetanephrine, either alone or with other concomitant hormones, was the most frequent secretory component. Patients were administered multiple first and subsequent treatments including surgery (n = 12), chemotherapy (n = 7), radionuclide therapy (n = 2) and radiopeptides (n = 5). Seven patients had stable disease, four had progressive disease and three died. Ectopic hormonal secretion is rare and commonly encountered in benign PCs. Ectopic secretion of interleukin-6 in one of our patients, prompted a literature review of ectopic hormonal secretion, particularly from metastatic PCs/PGLs. Only four cases of metastatic PC/PGLs with confirmed ectopic secretion of hormones or peptides have been described so far.

Analysis of Short-term Blood Pressure Variability in Pheochromocytoma/Paraganglioma Patients

Data on short-term blood pressure variability (BPV), which is a well-established cardiovascular prognostic tool, in pheochromocytoma and paraganglioma (PPGL) patients is still lack and conflicting. We retrospectively evaluated 23 PPGL patients referred to our unit from 2010 to 2019 to analyze 24 h ambulatory blood pressure monitoring (24-h ABPM)-derived markers of short-term BPV, before and after surgical treatment. PPGL diagnosis was assessed according to guidelines and confirmed by histologic examination. The 24-h ABPM-derived markers of short-term BPV included: circadian pressure rhythm; standard deviation (SD) and weighted SD (wSD) of 24-h, daytime, and night-time systolic and diastolic blood pressure (BP); average real variability (ARV) of 24-h, daytime, and night-time systolic and diastolic BP. 7 males and 16 females of 53 ± 18 years old were evaluated. After surgical resection of PPGL we found a significant decrease in 24-h systolic BP ARV (8.8 ± 1.6 vs. 7.6 ± 1.3 mmHg, p < 0.001), in 24-h diastolic BP ARV (7.5 ± 1.6 vs. 6.9 ± 1.4 mmHg, p = 0.031), and in wSD of 24-h diastolic BP (9.7 ± 2.0 vs 8.8 ± 2.1 mmHg, p = 0.050) comparing to baseline measurements. Moreover, baseline 24-h urinary metanephrines significantly correlated with wSD of both 24-h systolic and diastolic BP. Our study highlights as PPGL patients, after proper treatment, show a significant decrease in some short-term BPV markers, which might represent a further cardiovascular risk factor.

Changes in blood pressure, blood sugar, and quality of life in patients undergoing pheochromocytoma surgery: a prospective cohort study

Introduction:

Pheochromocytoma surgery is associated with significant hemodynamic and metabolic changes that require post-operative monitoring. We prospectively evaluated the trends of blood pressure, blood sugar, body mass index (BMI), and quality of life (QoL) changes in a cohort of patients undergoing pheochromocytoma surgery to determine the minimum duration of monitoring and assess factors that could predict these changes.

Materials and Methods:

Consecutive patients undergoing surgery for pheochromocytoma over a 20-month period were included in this ethics review board-approved, prospective cohort study. Blood pressure and sugar levels were serially monitored using a fixed protocol in the perioperative period and subsequently at 3 months after surgery. BMI and QoL (using World Health Organization Quality of Life [WHOQOL-BREF] questionnaire) were recorded at baseline and 3 months. Changes were compared and assessed for the predictive factors.

Results:

Twenty-six patients undergoing 31 procedures were included in the study of whom 8 (30%) developed hypotension and 4 (15%) developed hypoglycemia after surgery. All hypotension episodes occurred within 6 hours of surgery. However, while 3 of the 4 patients who developed hypoglycemia manifest in the first 4 h after surgery, one occurred after 12 h. Occurrence of hypotension correlated with preoperative 24-h urinary vanillylmandelic acid (VMA) levels (P = 0.02) and the total daily dose of prazosin (P = 0.04). Out of 21 hypertensive patients, 7 (33%) had persistent hypertension (HTN) at 3 months and this was associated with age (P = 0.04) and diabetes mellitus (DM) at presentation (P = 0.04). Among six diabetic patients, 1 (16%) had persistent DM. There was significant increase in the BMI (P < 0.0001) and in WHOQOL-BREF scores postoperatively.

Conclusions:

Hypotension occurs in 30% patients and hypoglycemia in 15% after pheochromocytoma surgery. Hypotension occurs immediately but hypoglycemia may manifest upto 12h after surgery. Older, diabetic patients are more likely to have persistent HTN. Surgery results in increase in BMI and improvement in QoL.

Transcriptome Analysis Reveals Significant Differences in Gene Expression of Malignant Pheochromocytoma or Paraganglioma

Prediction of malignant behavior of pheochromocytoma (PC) or paraganglioma (PG) is of limited value. The Cancer Genome Atlas (TCGA) and the French 'Cortico et Médullosurrénale: les Tumeurs Endocrines' (COMETE) network in Paris (France) facilitate accurate differentiation of malignant PC/PG based on genetic information. Therefore, the objective of this transcriptome analysis is to identify the prognostic genes underlying the differentiation of malignant PC/PG in the TCGA and COMETE databases. TCGA carries data pertaining to multigenomic analysis of 173 PC/PG surgical resection samples while the COMETE cohort contains data involving 188 PC/PG surgical resection samples. Clinical information and mRNA expression datasets were downloaded from TCGA and COMETE databases. Based on eligibility criteria, 58 of 173 PC/PG samples in TCGA and 171 of 188 PC/PG samples collected by the COMETE network were selected. Using Ingenuity Pathway Analysis, the mRNA expression of malignant and benign PC/PG was compared. The 58 samples in TCGA included 11 malignant and 47 benign cases. Among the 171 samples obtained from the COMETE cohort, 19 were malignant and 152 were benign. A comparative analysis of the mRNA expression data of the two databases revealed that 11 up/downregulated pathways involved in malignant PC/PG were related to cancer signaling, metabolic alteration, and prominent mitosis, whereas 6 upregulated genes and 1 downregulated gene were significantly enriched in the functional annotation pathways. The TCGA and COMETE databases showed differences in mRNA expression associated with malignant and benign PC/PG. Improved recognition of prognostic genes facilitates the diagnosis and treatment of PC/PG.

Retroperitoneal paraganglioma: a chameleon masquerading as an adrenal pheochromocytoma

Retroperitoneal paragangliomas are rare tumours arising from neural crest cells located near or in the autonomic nervous system; right from the skull bass to the pelvic floor. Often called the great masqueraders, their diagnosis and treatment is often difficult and fraught with danger, considering the close proximity of these tumours to important retroperitoneal organs. A 29-year-old woman presented to the outpatient department with complaints of paroxysms of headache, sweating and palpitations for one year. She was found to have elevated urinary metadrenalines (metanephrines) and a suprarenal mass on contrast-enhanced computed tomography of the abdomen, which demonstrated increased tracer activity on I-131 iodine-123 meta-iodobenzylguanidine scintigraphy. Adrenal pheochromocytoma was diagnosed and she underwent laparoscopic adrenalectomy after stabilisation of her blood pressure. Laparoscopy revealed a large suprarenal mass with dense adhesions to the inferior vena cava that was carefully separated from the vein and surrounding structures. The cut section revealed a heterogeneous mass encasing a normal adrenal gland and histopathology confirmed the same, confirming the final diagnosis of retroperitoneal paraganglioma.

Adipokine and cytokine levels in non-functioning adrenal incidentalomas (NFAI)

Due to the fact that overweight or obesity is accompanied by hormonally active adrenal tumors: Cushing Syndrome-(CS) and Subclinical Cushing Syndrome (SCS), it is of high interest the correlation between different adipokines and cytokines secreted by adipose tissue, with metabolic disorders and hormonal activity in this group. Even in non-functioning adrenal incidentalomas (NFAI) elevated risk for cardiovascular disease and metabolic syndrome was demonstrated. The aim of the study was to investigate plasma adiponectin, leptin, resistin, tumor necrosis factor α (TNFα), interleukin 6 (IL6) and monocyte chemoattractant protein 1 (MCP1) levels in patients with NFAIs and healthy subjects. The study included 18 NFAI patients and 18 healthy subjects. The groups were homogeneous in terms of age, sex and body mass index (BMI). Patients with NFAI showed significantly higher circulating levels of pro-inflammatory cytokines compared to healthy controls (MCP 1: p < 0.001; TNFα p = 0.021; IL6 p = 0.012). On the other hand, adiponectin concentration was significantly lower in the NFAI group (p = 0.034). The serum leptin and resistin concentrations did not differ significantly between the two groups. Acquired results were not dependent on glucocorticoid and catecholamine secretion in NFAI patients. Also, there were no clear correlations between BMI and cytokine levels. It is possible that increased risk for cardiovascular and metabolic diseases reported in NFAI patients is at least partially dependent on adipose tissue activity.

Successful Management of Pheochromocytoma Detected in Pregnancy by Interval Adrenalectomy in a VHL Patient

A 34-year-old mother with diabetes mellitus for 6 years presented in the late second trimester of her third pregnancy with new onset hypertension and characteristic hyperadrenergic spells. Clinical examination was unremarkable except a blood pressure of 170/110 mmhg. She had an elevated 24 hour urinary normetanephrine level with ultrasonic evidence of a hyperechoic hypervascular well-defined right supra renal mass of 6 x 5 cm in size which was very suggestive of a pheochromocytoma. Her management decisions were made by a multidisciplinary team which decided to deliver the baby by lower segment cesarean section (LSCS) as the pregnancy was advanced and to proceed with interval adrenalectomy after contrast enhanced computer tomography (CECT) of the abdomen with adrenal protocol. As a result a healthy baby was delivered by an uncomplicated elective LSCS at 36 weeks of POA. CECT abdomen with adrenal protocol confirmed a right-sided pheochromocytoma without any evidence of metastasis. Uncomplicated laparoscopic right adrenalectomy led to a clinical and biochemical recovery of the patient while histology confirmed the pheochromocytoma without any evidence of invasion. Subsequent follow up revealed cerebellar hemangioblastomas and retinal angioma in the right eye which led to a clinical diagnosis of Von Hippel Lindau disease (VHL). Even though clinical criteria for Von Hippel Lindau disease were fulfilled, her VHL genetic test was negative. At present she and her family are under surveillance of the endocrine team.