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Araujo-Castro M, García Sanz I, Mínguez Ojeda C, Hanzu F, Mora M, Vicente A, Blanco Carrera C, Miguel Novoa PD, López García MDC, Lamas C, Manjón-Miguélez L, Del Castillo Tous M, Rodríguez de Vera P, Barahona San Millán R, Recasens M, Fernández-Ladreda MT, Valdés N, Gracia Gimeno P, Robles Lazaro C, Michalopoulou T, Álvarez Escolá C, García Centeno R, Calatayud M. Risk factors for intraoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas. J Hypertens 2024; 42:252-259. [PMID: 37851004 DOI: 10.1097/hjh.0000000000003596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
PURPOSE To identify presurgical and surgical risk factors for intraoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas (PGLs) (PPGLs). METHODS Retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals. Intraoperative hypertensive crisis was defined as systolic blood pressure (SBP) greater than 200 mmHg lasting more than 1 min and postoperative hypertensive crisis as SBP greater than 180 mmHg or diastolic blood pressure (DBP) greater than 110 mmHg. RESULTS A total of 296 surgeries were included. Alpha presurgical blockade was employed in 93.2% of the cases and beta-adrenergic in 53.4%. Hypertensive crisis occurred in 20.3% ( n = 60) of the surgeries: intraoperative crisis in 56 and postoperative crisis in 6 cases (2 cases had both types of crises). We identified as risk factors of intraoperative hypertensive crisis, absence of presurgical glucocorticoid therapy (odds ratio [OR] 3.48; 95% confidence interval [CI] 1.19-10.12) higher presurgical SBP (OR 1.22 per each 10 mmHg, 95% CI 1.03-1.45), a larger tumor size (OR 1.09 per each 10 mm, 95% CI 1.00-1.19) and absence of oral sodium repletion (OR 2.59, 95% CI 1.25-5.35). Patients with hypertensive crisis had a higher rate of intraoperative bleeding ( P < 0.001), of intraoperative hemodynamic instability ( P < 0.001) and of intraoperative hypotensive episodes ( P < 0.001) than those without hypertensive crisis. CONCLUSION Intraoperative hypertensive crisis occurs in up to 20% of the PPGL resections. Patients not pretreated with glucocorticoid therapy before surgery, with larger tumors and higher presurgical SBP and who do not receive oral sodium repletion have a higher risk for developing hypertensive crisis during and after PPGL surgery.
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid
- University of Alcalá
| | - Iñigo García Sanz
- General & Digestive Surgery Department, Hospital Universitario de La Princesa
| | | | - Felicia Hanzu
- Endocrinology & Nutrition Department, Hospital Clinic, Barcelona
| | - Mireia Mora
- Endocrinology & Nutrition Department, Hospital Clinic, Barcelona
| | - Almudena Vicente
- Endocrinology & Nutrition Department, Hospital Universitario de Toledo, Toledo
| | | | | | | | - Cristina Lamas
- Endocrinology & Nutrition Department, Hospital Universitario de Albacete, Albacete
| | - Laura Manjón-Miguélez
- Endocrinology & Nutrition Department, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias. Oviedo
| | | | | | | | - Mónica Recasens
- Endocrinology & Nutrition Department, Institut Català de la Salut Girona, Girona
| | | | - Nuria Valdés
- Endocrinology & Nutrition Department, Hospital Universitario de Cabueñes, Asturias
| | | | | | | | | | | | - María Calatayud
- Endocrinology & Nutrition Department, Hospital Universitario Doce de Octubre, Madrid, Spain
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Aggarwal S, Prete A, Chortis V, Asia M, Sutcliffe RP, Arlt W, Ronchi CL, Karavitaki N, Ayuk J, Elhassan YS. Pheochromocytomas Most Commonly Present As Adrenal Incidentalomas: A Large Tertiary Center Experience. J Clin Endocrinol Metab 2023; 109:e389-e396. [PMID: 37417693 PMCID: PMC10735286 DOI: 10.1210/clinem/dgad401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/12/2023] [Accepted: 07/05/2023] [Indexed: 07/08/2023]
Abstract
CONTEXT Pheochromocytomas are increasingly diagnosed in incidentally detected adrenal masses. However, the characteristics of incidental pheochromocytomas are unclear. OBJECTIVE We aimed to assess the proportion and clinical, biochemical, radiological, genetic, histopathological, and follow-up characteristics of incidental pheochromocytomas. METHODS A retrospective review was conducted of patients with pheochromocytoma seen between January 2010 and October 2022 at a large UK tertiary care center. The diagnosis was confirmed histologically or by the combined presence of increased plasma and/or urinary metanephrines (MN), indeterminate adrenal mass on cross-sectional imaging, and metaiodobenzylguanidine avidity. RESULTS We identified 167 patients with pheochromocytoma; 144 (86.2%) underwent adrenalectomy, for 23 (13.8%) surgery was either awaited, deemed unsuitable due to frailty or other metastatic malignancy, or declined by the patients. Excluding pheochromocytomas diagnosed via screening genetically predisposed individuals (N = 20), 37 of 132 (28.0%) presented with adrenergic symptoms and/or uncontrolled hypertension, while 91 of 132 (69.0%) patients presented with an incidentally detected adrenal mass. Incidentally detected patients were older (median age 62 years) than those detected due to clinical suspicion (aged 42 years) or after genetic screening (aged 33 years) (all P < .05). Incidentally detected pheochromocytomas were smaller (median 42 mm) than tumors detected due to adrenergic symptoms/uncontrolled hypertension (60 mm), but larger than tumors identified by genetic screening (30 mm) (all P < .05). Increased MN excretion showed a similar pattern (symptomatic/uncontrolled hypertension > incidental > genetic screening) (all P < .05). Hereditary predisposition was detected in 20.4% of patients (incidental, 15.3%; symptomatic/uncontrolled hypertension, 42.9%). CONCLUSION The majority of pheochromocytomas are diagnosed incidentally and have distinct clinical, radiological, biochemical, and genetic features. Their detection at older age but smaller size may point to a different underlying tumor biology.
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Affiliation(s)
- Sunil Aggarwal
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | - Vasileios Chortis
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Miriam Asia
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Robert P Sutcliffe
- Department of Hepatobiliary Surgery, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Cristina L Ronchi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
| | - Yasir S Elhassan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham B15 2TT, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2GW, UK
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Liu Y, Liu C, Wang Y, Li S, Li X, Liu X, Wang B, Pei Z, Li L, Lin L, Qu J, Chen K, Zang L, Gu W, Mu Y, Lyu Z, Dou J, Gao Z. Nomogram for Predicting Intraoperative Hemodynamic Instability in Patients With Normotensive Pheochromocytoma. J Clin Endocrinol Metab 2023; 108:1657-1665. [PMID: 36655387 DOI: 10.1210/clinem/dgad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
CONTEXT Intraoperative hemodynamic instability (HI) deteriorates surgical outcomes of patients with normotensive pheochromocytoma (NP). OBJECTIVE To characterize the hemodynamics of NP and develop and externally validate a prediction model for intraoperative HI. METHODS Data on 117 patients with NP (derivation cohort) and 40 patients with normotensive adrenal myelolipoma (NAM) who underwent laparoscopic adrenalectomy from January 2011 to November 2021 were retrospectively collected. Data on 22 patients with NP (independent validation cohort) were collected from another hospital during the same period. The hemodynamic characteristics of patients with NP and NAM were compared. Machine learning models were used to identify risk factors associated with HI. The final model was visualized via a nomogram. RESULTS Forty-eight (41%) out of 117 patients experienced HI, which was significantly more than that for NAM. A multivariate logistic regression including age, tumor size, fasting plasma glucose, and preoperative systolic blood pressure showed good discrimination measured by area under curve (0.8286; 95% CI 0.6875-0.9696 and 0.7667; 95% CI 0.5386-0.9947) for predicting HI in internal and independent validation cohorts, respectively. The sensitivities and positive predictive values were 0.6667 and 0.7692 for the internal and 0.9167 and 0.6111 for the independent validations, respectively. The final model was visualized via a nomogram and yielded net benefits across a wide range of risk thresholds in decision curve analysis. CONCLUSION Patients with NP experienced HI during laparoscopic adrenalectomy. The nomogram can be used for individualized prediction of intraoperative HI in patients with NP.
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Affiliation(s)
- Yingshu Liu
- Dalian Medical University, Dalian, Liaoning 116044, China
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Chao Liu
- Yidu Cloud Technology Inc., Beijing 100083, China
| | - Yao Wang
- Yidu Cloud Technology Inc., Beijing 100083, China
| | - Shen Li
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Xinyu Li
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Xuhan Liu
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Bing Wang
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Zuowei Pei
- Department of Cardiology, Central Hospital of Dalian University of Technology, Dalian 116033, China
| | - Linfeng Li
- Yidu Cloud Technology Inc., Beijing 100083, China
| | - Lu Lin
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jianchang Qu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Kang Chen
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Li Zang
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Weijun Gu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yiming Mu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhaohui Lyu
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jingtao Dou
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhengnan Gao
- Dalian Medical University, Dalian, Liaoning 116044, China
- Department of Endocrinology, Central Hospital of Dalian University of Technology, Dalian 116033, China
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Ceccato F, Correa R, Livhits M, Falhammar H. Editorial: Predictive tools in pheochromocytoma and paraganglioma. Front Endocrinol (Lausanne) 2023; 14:1227543. [PMID: 37383393 PMCID: PMC10298152 DOI: 10.3389/fendo.2023.1227543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/30/2023] Open
Affiliation(s)
- Filippo Ceccato
- Department of Medicine DIMED, University of Padua, Padua, Italy
- Endocrine Disease Unit, University-Hospital of Padua, Padua, Italy
| | - Ricardo Correa
- Endocrinology, Diabetes and Metabolism, The University of Arizona College of Medicine Phoenix, Phoenix, AZ, United States
| | - Masha Livhits
- Department of General Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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5
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Araujo-Castro M, García Sanz I, Mínguez Ojeda C, Calatayud M, Hanzu F, Mora M, Vicente A, Blanco Carrera C, De Miguel Novoa P, López García MDC, Manjón-Miguélez L, Rodríguez de Vera P, Del Castillo Tous M, Barahona San Millán R, Recasens M, Tomé Fernández-Ladreda M, Valdés N, Gracia Gimeno P, Robles Lazaro C, Michalopoulou T, Álvarez Escolá C, García Centeno R, Lamas C. Differences in intraoperative and surgical outcomes between normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs) and hypertensive PPGLs: results from the PHEO-RISK STUDY. J Endocrinol Invest 2023; 46:805-814. [PMID: 36323983 DOI: 10.1007/s40618-022-01954-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/25/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE To compare the intraoperative and surgical outcomes of normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs), hypertensive PPGLs and non-PPGL adrenal lesions. METHODS This a retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals. A control group of histologically confirmed adrenocortical adenomas (non-PPGL group) was selected to compare intraoperative and surgical outcomes with of the normotensive PPGLs. RESULTS Two hundred and ninety-six surgeries performed in 289 patients with PPGLs were included. Before surgery, 209 patients were classified as hypertensive PPGLs (70.6%) and 87 as normotensive PPGLs. A higher proportion of normotensive PPGLs than hypertensive PPGLs did not receive alpha presurgical blockade (P = 0.009). When we only considered those patients who received presurgical alpha blockers (200 hypertensive PPGLs and 76 normotensive PPGLs), hypertensive PPGLs had a threefold higher risk of intraoperative hypertensive crisis (OR 3.0 [95% 1.3-7.0]) and of hypotensive episodes (OR 2.9 [95% CI 1.2-6.7]) than normotensive PPGLs. When we compared normotensive PPGLs (n = 76) and non-PPGLs (n = 58), normotensive PPGLs had a fivefold higher risk of intraoperative complications (OR 5.3 [95% CI 1.9-14.9]) and a six times higher risk of postoperative complications (OR 6.1 [95% CI 1.7-21.6]) than non-PPGLs. CONCLUSION Although the risk of intraoperative hypertensive and hypotensive episodes in normotensive PPGLs is significantly lower than in hypertensive PPGLs, normotensive PPGLs have a greater risk of intraoperative and postoperative complications than non-PPGL adrenal lesions. Therefore, it is recommended to follow the standard of care for presurgical and anesthetic management of PPGLs also in normotensive PPGLs.
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Affiliation(s)
- M Araujo-Castro
- Endocrinology and Nutrition Department, Hospital Universitario Ramón y Cajal, Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Colmenar Viejo Street Km 9, 28034, Madrid, Spain.
- University of Alcalá, Madrid, Spain.
| | - I García Sanz
- General and Digestive Surgery Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - C Mínguez Ojeda
- Urology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Calatayud
- Endocrinology and Nutrition Department, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - F Hanzu
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - M Mora
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - A Vicente
- Endocrinology and Nutrition Department, Hospital Universitario de Toledo, Toledo, Spain
| | - C Blanco Carrera
- Endocrinology and Nutrition Department, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - P De Miguel Novoa
- Endocrinology and Nutrition Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | - L Manjón-Miguélez
- Endocrinology and Nutrition Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - P Rodríguez de Vera
- Endocrinology and Nutrition Department, Hospital Universitario Virgen de La Macarena, Seville, Spain
| | - M Del Castillo Tous
- Endocrinology and Nutrition Department, Hospital Universitario Virgen de La Macarena, Seville, Spain
| | - R Barahona San Millán
- Endocrinology and Nutrition Department, Institut Català de la Salut Girona, Girona, Spain
| | - M Recasens
- Endocrinology and Nutrition Department, Institut Català de la Salut Girona, Girona, Spain
| | | | - N Valdés
- Endocrinology and Nutrition Department, Hospital Universitario de Cabueñes, Asturias, Spain
| | - P Gracia Gimeno
- Endocrinology and Nutrition Department, Hospital Royo Villanova, Zaragoza, Spain
| | - C Robles Lazaro
- Endocrinology and Nutrition Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | - T Michalopoulou
- Department of Endocrinology and Nutrition, Joan XXIII University Hospital, Tarragona, Spain
| | - C Álvarez Escolá
- Endocrinology and Nutrition Department, Hospital Universitario La Paz, Madrid, Spain
| | - R García Centeno
- Endocrinology and Nutrition Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - C Lamas
- Endocrinology and Nutrition Department, Hospital Universitario de Albacete, Albacete, Spain
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Castinetti F, De Freminville JB, Guerin C, Cornu E, Sarlon G, Amar L. Controversies about the systematic preoperative pharmacological treatment before pheochromocytoma or paraganglioma surgery. Eur J Endocrinol 2022; 186:D17-D24. [PMID: 35230260 DOI: 10.1530/eje-21-0692] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 02/28/2022] [Indexed: 11/08/2022]
Abstract
The question of systematic use of a pharmacological treatment before surgery in patients diagnosed with pheochromocytoma and paraganglioma (PPGL) remains highly controversial. While recent guidelines suggest that this should be used in all patients, some experienced teams consider it unnecessary in some cases, provided the surgery is performed in a dedicated center that has expert endocrinologists, cardiologists, surgeons, and anesthetists. This controversy is aimed at shedding light on the potential benefits and risks of such a treatment, focusing specifically on alpha blockers which are considered as the first-line medical treatments in patients with PPGL. After discussing the rationale for alpha blockers, hemodynamic instability, tolerance, and acute cardiac complications will then be discussed in the first part of the manuscript, defending a systematic use. The second section will focus on blood pressure control, tolerance of alpha blockers, and also the management of normotensive PPGL, examining the daily risks of PPGL and arguing against the systematic use of a preoperative pharmacological treatment before surgery. Finally, we will discuss the concept of expert centers and define the patients in whom the risk/benefit profile would favor the use of this preoperative treatment.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology, Aix Marseille Université, APHM, INSERM, Marseille Medical Genetics, Marmara Institute, La Conception Hospital, Marseille, France
| | - Jean-Baptiste De Freminville
- AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- Université de Paris, Paris, France
- PARCC, INSERM UMR970 and Reference Centre for Rare Adrenal Diseases, Paris, France
| | - Carole Guerin
- Department of Endocrine Surgery, APHM, La Conception Hospital, Marseille, France
| | - Erika Cornu
- AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- Université de Paris, Paris, France
- PARCC, INSERM UMR970 and Reference Centre for Rare Adrenal Diseases, Paris, France
| | - Gabrielle Sarlon
- Cardiology Department, APHM, HTA and Vascular Medicine University Hospital Timone, Marseille, France
| | - Laurence Amar
- AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- Université de Paris, Paris, France
- PARCC, INSERM UMR970 and Reference Centre for Rare Adrenal Diseases, Paris, France
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7
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Lopez AG, Duparc C, Renouf S, Machevin E, Le Guillou V, Sabourin JC, Defortescu G, Buffet A, Gimenez-Roqueplo AP, Dubessy C, Louiset E, Lefebvre H. Expression of LHCGR (Luteinizing Hormone/Chorionic Gonadotrophin Receptor) in Pheochromocytomas Unveils an Endocrine Mechanism Connecting Pregnancy and Epinephrine Overproduction. Hypertension 2022; 79:1006-1016. [PMID: 35189708 DOI: 10.1161/hypertensionaha.121.18864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanisms by which pregnancy may unmask pheochromocytomas and paragangliomas are not totally understood. We hypothesized that gestational hormones may participate in the pathophysiology of catecholamine excess during pregnancy. We report a case of silent pheochromocytoma revealed in a pregnant woman by life-threatening adrenergic myocarditis. METHODS In vitro studies were conducted to investigate the effect of estradiol and the pregnancy hormone hCG (human chorionic gonadotropin) on epinephrine secretion by cultured cells derived from the patient's tumor. Expression of LHCG (luteinizing hormone/chorionic gonadotropin) receptor was searched for in the patient's tumor, and a series of 12 additional pheochromocytoma by RT-Q-PCR and immunohistochemistry. LHCGR expression was also analyzed in silico in the pheochromocytomas and paragangliomas cohorts of the Cortico et Médullosurrénale: les Tumeurs Endocrines and The Cancer Genome Atlas databases. RESULTS hCG stimulated epinephrine secretion by cultured cells derived from the patient's pheochromocytoma. The patient's tumor expressed the LHCG receptor, which was colocalized with catecholamine-producing enzymes. A similar expression pattern of the LHCG receptor was also observed in 5 out of our series of pheochromocytoma. Moreover, in silico studies revealed that pheochromocytomas and paragangliomas display the highest expression levels of LHCG receptor mRNA among the 32 solid tumor types of The Cancer Genome Atlas cohort. CONCLUSIONS Pregnancy may thus favor surges in plasma catecholamine and hypertensive crises through hCG-induced stimulation of epinephrine production by pheochromocytomas.
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Affiliation(s)
- Antoine-Guy Lopez
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Endocrinology, Diabetes and Metabolic Diseases, Rouen University Hospital, France. (A.-G.L., H.L.)
| | - Céline Duparc
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Sylvie Renouf
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Elise Machevin
- Department of Gynaecology-Obstetrics, Evreux Hospital Centre, France (E.M.)
| | - Vincent Le Guillou
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital, France. (V.L.G.)
| | - Jean-Christophe Sabourin
- Department of Pathology and INSERM 1245, Rouen University Hospital, France. (J.-C.S,).,Tumor BioBank-Centre for Biological Resources, Rouen University Hospital, France. (J.-C.S., H.L.)
| | - Guillaume Defortescu
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Urology, Rouen University Hospital, France. (G.D.)
| | - Alexandre Buffet
- Université de Paris, PARCC, INSERM, Paris, France (A.B., A.-P.G.-R.).,Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges Pompidou, Paris, France (A.B., A.-P.G.-R.)
| | - Anne-Paule Gimenez-Roqueplo
- Université de Paris, PARCC, INSERM, Paris, France (A.B., A.-P.G.-R.).,Service de Génétique, Assistance Publique-Hôpitaux de Paris, Hôpital européen Georges Pompidou, Paris, France (A.B., A.-P.G.-R.)
| | - Christophe Dubessy
- Normandie University, UNIROUEN, INSERM, PRIMACEN, Rouen, France (C. Dubessy)
| | - Estelle Louiset
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.)
| | - Hervé Lefebvre
- Normandie University, UNIROUEN, INSERM U1239, NorDIC, Rouen, France (A.-G.L., C. Duparc, S.R., C. Dubessy, E.L., H.L.).,Department of Endocrinology, Diabetes and Metabolic Diseases, Rouen University Hospital, France. (A.-G.L., H.L.).,Tumor BioBank-Centre for Biological Resources, Rouen University Hospital, France. (J.-C.S., H.L.)
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Shah AN, Saikia UK, Chaudhary BK, Bhuyan AK. Adrenal Incidentaloma Needs thorough Biochemical Evaluation - An Institutional Experience. Indian J Endocrinol Metab 2022; 26:73-78. [PMID: 35662767 PMCID: PMC9162248 DOI: 10.4103/ijem.ijem_335_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/09/2022] [Accepted: 03/22/2022] [Indexed: 11/29/2022] Open
Abstract
CONTEXT Adrenal incidentalomas (AIs) are seen in around 2% of apparently healthy individuals. These require careful evaluation for the hormone excess state and the presence of malignancy prior to intervention. AIMS To study the clinical, biochemical, and imaging characteristics of the patients with AI and correlate the diagnosis with the histopathology findings in patients undergoing surgery. SETTINGS AND DESIGN Retrospective observational study. METHODS AND MATERIAL Patients with adrenal incidentaloma presenting between January 2017 and January 2021 were evaluated as per guidelines provided by the European Society of Endocrinology and the European Network for the Study of Adrenal Tumors. Patients were given final diagnosis on the basis of imaging impression, hormonal activity, and biopsy results (when applicable). RESULTS Forty-eight patients were evaluated, with 25 being male, the mean age being 40.9 years (8-71), and the mean size of the mass being 6.21 (1.4-13.7) cm. Thirty-five (72.9%) of them underwent surgical excision. The most common diagnosis was myelolipoma (16), followed by pheochromocytoma (10) and adenoma (9). Nineteen patients were found to have hormone-secreting masses. Two patients with pheochromocytoma were normotensive. There was discordance between imaging diagnosis and hormonal status in two patients, with final diagnosis of pheochromocytoma. One patient with extramedullary erythropoiesis of the adrenal gland was subsequently diagnosed with sickle cell anemia and adrenal insufficiency. CONCLUSIONS The study highlights the rare possibility of discrepancy between non-contrast CT diagnosis and functional status of AI. There is also a rare possibility of extramedullary erythropoiesis presenting as AI with adrenal insufficiency. Specific evaluation for such rare possibilities should be considered in AI cases as per clinical scenario.
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Affiliation(s)
- Akash N. Shah
- Department of Endocrinology, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Uma K. Saikia
- Department of Endocrinology, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Bipul K. Chaudhary
- Department of Endocrinology, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Ashok K. Bhuyan
- Department of Endocrinology, Gauhati Medical College and Hospital, Guwahati, Assam, India
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9
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Hallin Thompson L, Makay Ö, Brunaud L, Raffaelli M, Bergenfelz A. Adrenalectomy for incidental and symptomatic phaeochromocytoma: retrospective multicentre study based on the Eurocrine® database. Br J Surg 2021; 108:1199-1206. [PMID: 34270711 PMCID: PMC10364866 DOI: 10.1093/bjs/znab199] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/05/2021] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- L Hallin Thompson
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Ö Makay
- Department of General Surgery, Division of Endocrine Surgery, Ege University Hospital, Izmir, Turkey
| | - L Brunaud
- Department of Gastrointestinal, Metabolic and Surgical Oncology, Université de Lorraine, CHU Nancy, Hospital Brabois Adultes, Vandoevre les Nancy, France
| | - M Raffaelli
- Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Dipatimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A Bergenfelz
- Department of Surgery, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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10
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Voltan G, Boscaro M, Armanini D, Scaroni C, Ceccato F. A multidisciplinary approach to the management of adrenal incidentaloma. Expert Rev Endocrinol Metab 2021; 16:201-212. [PMID: 34240680 DOI: 10.1080/17446651.2021.1948327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/23/2021] [Indexed: 01/15/2023]
Abstract
An adrenal incidentaloma (AI) is an adrenal neoplasm incidentally discovered during an imaging unrelated to suspected adrenal disease. The aim of the present review is to offer practical guidance on the multidisciplinary approach of AIs.Areas covered:The prevalence of AI is high in the aging population (up to 5-8%); however, hormonally active or malignant conditions are rare. After the discovery of an AI, it is suggested to assess in parallel if the mass is potentially malignant and functionally active. The answer to the former question is mainly based on medical history (extra-adrenal malignancies, new-onset of signs or symptoms) and imaging (conventional radiology and/or nuclear medicine). The answer to the latter question is a complete endocrine evaluation of both cortical (glucocorticoids, mineralocorticoids) and medullary (catecholamines) secretion.Expert opinion:A multidisciplinary discussion is suggested for patients with adrenal disease, after the exclusion of nonfunctioning benign cortical adenoma, in order to plan a close and tailored follow-up for the suspected malignant or functioning forms. Surgery is advised for patients with malignant disease (adrenocortical cancer) or with clinically relevant secreting neoplasm (primary aldosteronism, Cushing's syndrome, and pheochromocytoma).
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Affiliation(s)
- Giacomo Voltan
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Decio Armanini
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
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11
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A Peculiar Phenotype Hindering Early Diagnosis: Multiple Endocrine Neoplasia 2B Syndrome. Am J Med 2020; 133:1411-1415. [PMID: 32277889 DOI: 10.1016/j.amjmed.2020.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 11/23/2022]
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12
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Patel D, Phay JE, Yen TWF, Dickson PV, Wang TS, Garcia R, Yang AD, Solórzano CC, Kim LT. Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine/Head and Neck Disease-Site Work Group. Part 1 of 2: Advances in Pathogenesis and Diagnosis of Pheochromocytoma and Paraganglioma. Ann Surg Oncol 2020; 27:1329-1337. [PMID: 32112212 PMCID: PMC8655649 DOI: 10.1245/s10434-020-08220-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 08/02/2023]
Abstract
This first part of a two-part review of pheochromocytoma and paragangliomas (PPGLs) addresses clinical presentation, diagnosis, management, treatment, and outcomes. In this first part, the epidemiology, prevalence, genetic etiology, clinical presentation, and biochemical and radiologic workup are discussed. In particular, recent advances in the genetics underlying PPGLs and the recommendation for genetic testing of all patients with PPGL are emphasized. Finally, the newer imaging methods for evaluating of PPGLs are discussed and highlighted.
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Affiliation(s)
- Dhaval Patel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John E Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paxton V Dickson
- Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Roberto Garcia
- Division of Surgical Oncology, National Cancer Institute of Panama/Paitilla Medical Center, Panama City, Panama
| | - Anthony D Yang
- Division of Surgical Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Carmen C Solórzano
- Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
| | - Lawrence T Kim
- Division of Surgical Oncology and Endocrine Surgery, University of North Carolina, Chapel Hill, NC, USA
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13
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Abstract
The European society of endocrinology, in association with the European network for the study of adrenal tumors, published recommendations for the diagnosis and treatment of adrenal incidentalomas in 2016. A thorough and critical analysis of the literature was performed to establish evidence-based recommendations and expert suggestions with the aim of avoiding 'over-diagnosis' and 'over-treatment' and to reduce unnecessary investigations, surgery and follow-up. The purpose of this review is to reconsider several recommendations that are open to debate, such as imaging of adrenal incidentalomas, diagnosis of pheochromocytoma, diagnosis and treatment of autonomous cortisol-secreting tumors, investigations of bilateral AI and follow-up of non-operated AIs, based on studies published after the release of the recommendations.
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Affiliation(s)
- Sophie Cambos
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, 33604 Pessac, France
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, 33604 Pessac, France; Inserm U1215, Neurocentre Magendie, University of Bordeaux, 146 Rue Leo Saignat, 33076 Bordeaux Cedex, France.
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14
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Haissaguerre M, Tabarin A. Letter to the Editor: "Pheochromocytoma Characteristics and Behavior Differ Depending on Method of Discovery". J Clin Endocrinol Metab 2020; 105:5589210. [PMID: 31624836 DOI: 10.1210/clinem/dgz080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/01/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Magalie Haissaguerre
- Dept of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Bordeaux, France
| | - Antoine Tabarin
- Dept of Endocrinology, Diabetes and Nutrition, University Hospital of Bordeaux, Bordeaux, France
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15
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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.
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16
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Abstract
Pheochromocytomas and extra-adrenal paragangliomas are rare neuroendocrine neoplasms with characteristic histologic and immunohistochemical features. These tumors can arise in several anatomic locations, necessitating that their diagnostic recognition extends beyond the realm of endocrine disorders. A practical and reproducible risk stratification system for these tumors is still in development. In this rapidly evolving era of molecular medicine, it is essential for pathologists to equip themselves with a framework for understanding the classification of paragangliomas and pheochromocytomas and be informed of how they might advise their colleagues with regard to prognostication and appropriate follow-up.
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Affiliation(s)
- Julie Guilmette
- Department of Pathology, Charles-Lemoyne Hospital, Sherbrooke University Affiliated Health Care Center, 3120 Boulevard Taschereau, Greenfield Park, Quebec J4V 2H1, Canada
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114-2696, USA.
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17
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Lopez AG, Fraissinet F, Lefebvre H, Brunel V, Ziegler F. Pharmacological and analytical interference in hormone assays for diagnosis of adrenal incidentaloma. ANNALES D'ENDOCRINOLOGIE 2019; 80:250-258. [DOI: 10.1016/j.ando.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/27/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
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18
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Normotensive, Oversized Pheochromocytoma in Twin-Pregnancy: Analysis of Therapeutic Challenges in a Rare Case. Case Rep Urol 2019; 2019:7141060. [PMID: 31249716 PMCID: PMC6556236 DOI: 10.1155/2019/7141060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/15/2019] [Indexed: 11/30/2022] Open
Abstract
An asymptomatic, normotensive 36-year-old woman in the second trimester of a twin-gestation was diagnosed with a 11 cm adrenal pheochromocytoma. Considering the hemodynamic stability of the patient, tumor size, and gestational age, the therapeutic decision of a multidisciplinary team ensued open surgical excision without any preoperative antihypertensive preparation. Following successful removal of pheochromocytoma, the patient had a normal subsequent course of pregnancy and cesarean section delivery of healthy twins at term. This unique case of a normotensive, incidental, large-sized pheochromocytoma in a twin-pregnancy illustrates that the decisions of management in such a rare occurrence should be based on individual features of the patient. Our experience supports that α-adrenergic blockade may not be essential in normotensive pheochromocytoma in pregnancy and open-surgery remains as a safe approach in the management of large adrenal tumors in twin-pregnant patients following a multidisciplinary consultation.
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19
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Kolasinska-Ćwikła A, Pęczkowska M, Ćwikła JB, Michałowska I, Pałucki JM, Bodei L, Lewczuk-Myślicka A, Januszewicz A. A Clinical Efficacy of PRRT in Patients with Advanced, Nonresectable, Paraganglioma-Pheochromocytoma, Related to SDHx Gene Mutation. J Clin Med 2019; 8:jcm8070952. [PMID: 31262070 PMCID: PMC6678858 DOI: 10.3390/jcm8070952] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/19/2022] Open
Abstract
Paragangliomas and pheochromytomas (PPGLs) exhibit variable malignancy, advanced/hormonally active/progressive need therapy. PRRT (Peptide Receptor Radionuclide Therapy) could be an option for these patients. To evaluate the effectiveness of PRRT (90Y DOTATATE), based on overall survival (OS) and progression-free survival (PFS), in patients with PPGLs, related to SDHx gene mutation, we conducted a prospective open-label, single-center, phase II study. Thirteen patients were observed, eight PGL1 and five PGL4, all with advanced, non-resectable tumors, and eight had metastases. All were treated with 90Y DOTATATE. Efficacy was based on OS and PFS, and radiological response was based on RECIST. Hormonal activity was evaluated using serum-fractionated free catecholamines. Eight subjects had a clinical response, three were stable, and two exhibited disease progression. Among four patients with hormonally-active PPGLs, three showed a reduction and one showed normalization. OS for all was 68.0 months; PFS was 35.0 months. OS in PGL4 = 25.0 vs. N.R. (not reached) in PGL1. PFS in PGL4 = 12.0 vs. N.R. in PGL1. A difference was seen in the OS and PFS in patients who did not respond clinically, compared to those who did, OS = 22.0 vs. N.R. PFS = 7.0 vs. N.R. A difference in the OS and PFS was noted in patients with liver and bone involvement compared to those without. PRRT is an effective therapy in selected population of patients with SDHx, in those with locally-advanced, non-resectable tumors. Furthermore, it is effective regardless of the secretory status.
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Affiliation(s)
- Agnieszka Kolasinska-Ćwikła
- Department of Oncology and Radiotherapy and Department of Radiology, Maria Skłodowska-Curie Memorial Cancer Center, 02-034 Warsaw, Poland
| | - Mariola Pęczkowska
- Department of Hypertension and Department of Radiology Institute of Cardiology, 04-628 Warsaw, Poland
| | - Jarosław B Ćwikła
- Department of Cardiology and Cardiosurgery, School of Medicine; University of Warmia and Mazury, 10-082 Olsztyn, Poland.
| | - Ilona Michałowska
- Department of Hypertension and Department of Radiology Institute of Cardiology, 04-628 Warsaw, Poland
| | - Jakub M Pałucki
- Department of Oncology and Radiotherapy and Department of Radiology, Maria Skłodowska-Curie Memorial Cancer Center, 02-034 Warsaw, Poland
| | - Lisa Bodei
- Molecular Imaging and Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Anna Lewczuk-Myślicka
- Department of Internal Medicine and Endocrinology, Medical University of Gdansk, 80-211 Gdansk, Poland
| | - Andrzej Januszewicz
- Department of Hypertension and Department of Radiology Institute of Cardiology, 04-628 Warsaw, Poland
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20
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Performance of plasma free metanephrines in diagnosis of pheochromocytomas and paragangliomas in the population of Asturias. ENDOCRINOLOGÍA, DIABETES Y NUTRICIÓN (ENGLISH ED.) 2019. [DOI: 10.1016/j.endien.2018.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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21
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Martínez-Morillo E, Valdés Gallego N, Eguia Ángeles E, Fernández Fernández JC, Prieto García B, Álvarez FV. Rendimiento de las metanefrinas libres plasmáticas en el diagnóstico de los feocromocitomas y paragangliomas en la población asturiana. ENDOCRINOL DIAB NUTR 2019; 66:312-319. [DOI: 10.1016/j.endinu.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/14/2018] [Accepted: 08/18/2018] [Indexed: 11/30/2022]
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Ohara N, Kaneko M, Yaguchi Y, Ishiguro H, Ishizaki F, Maruyama R, Suzuki K, Komeyama T, Usuda H, Yamazaki Y, Sasano H, Kaneko K, Kamoi K. A case of normotensive incidentally discovered adrenal pheochromocytoma. Clin Case Rep 2018; 6:2303-2308. [PMID: 30564317 PMCID: PMC6293157 DOI: 10.1002/ccr3.1772] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 07/03/2018] [Accepted: 07/29/2018] [Indexed: 11/28/2022] Open
Abstract
Pheochromocytomas are catecholamine-producing neuroendocrine tumors that arise from the adrenal medulla. The clinical presentation includes headache, palpitation, and hypertension, but pheochromocytomas are sometimes clinically silent. The present case highlights the importance of biochemical testing for pheochromocytoma in patients with adrenal incidentaloma, even if they are completely normotensive and asymptomatic.
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Affiliation(s)
- Nobumasa Ohara
- Department of Endocrinology and MetabolismNagaoka Red Cross HospitalNiigataJapan
- Department of Endocrinology and MetabolismUonuma Institute of Community MedicineNiigata University Medical and Dental HospitalNiigataJapan
| | - Masanori Kaneko
- Department of Endocrinology and MetabolismNagaoka Red Cross HospitalNiigataJapan
| | - Yuta Yaguchi
- Department of Endocrinology and MetabolismNagaoka Red Cross HospitalNiigataJapan
| | - Hajime Ishiguro
- Department of Endocrinology and MetabolismNagaoka Red Cross HospitalNiigataJapan
| | - Fumio Ishizaki
- Department of UrologyNagaoka Red Cross HospitalNiigataJapan
| | - Ryo Maruyama
- Department of UrologyNagaoka Red Cross HospitalNiigataJapan
| | - Kazuya Suzuki
- Department of UrologyNagaoka Red Cross HospitalNiigataJapan
| | | | - Hiroyuki Usuda
- Department of PathologyNagaoka Red Cross HospitalNiigataJapan
| | - Yuto Yamazaki
- Department of PathologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Hironobu Sasano
- Department of PathologyTohoku University Graduate School of MedicineMiyagiJapan
| | - Kenzo Kaneko
- Department of Endocrinology and MetabolismNagaoka Red Cross HospitalNiigataJapan
| | - Kyuzi Kamoi
- Department of Internal MedicineOjiya General HospitalNiigataJapan
- Center of Diabetes, Endocrinology and MetabolismJoetsu General HospitalNiigataJapan
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23
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Pheochromocytoma as a reversible cause of cardiomyopathy: Analysis and review of the literature. Int J Cardiol 2018; 249:319-323. [PMID: 29121733 DOI: 10.1016/j.ijcard.2017.07.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/12/2017] [Accepted: 07/06/2017] [Indexed: 12/20/2022]
Abstract
CONTEXT Pheochromocytoma and paraganglioma are rare neuroendocrine tumors which overproduce catecholamines and arise from the adrenal gland or extra-adrenal chromaffin cells of the sympathetic and parasympathetic ganglia (1). Excessive catecholamine-induced stimulation of cardiac myocytes leads to damage which manifests in several forms ranging from Takotsubo to dilated cardiomyopathy. Diagnosis of pheochromocytoma-related cardiomyopathies is often delayed due to the atypical presentation associated with many cases. OBJECTIVE Limited data exists on the presentation and outcomes of the various forms of pheochromocytoma-induced cardiomyopathies. We performed a literature review to assess the association of pheochromocytoma and cardiomyopathy to aide in further understanding this clinical entity. DESIGN 163 cases from 150 articles published between 1991 and November 2016 were included from a PubMed search. RESULTS There were 163 occurrences of pheochromocytoma and cardiomyopathy (63 dilated cardiomyopathy, 38 Takotsubo cardiomyopathy, 30 inverted Takotsubo cardiomyopathy, 10 HOCM, 8 myocarditis, and 14 unspecified cardiomyopathy). Many patients lacked classic signs or symptoms of pheochromocytoma with hypertension as a presenting symptom in 65% and the triad of headache, palpitations, and diaphoresis only in 4%. Resection of the pheochromocytoma led to improvement of the cardiomyopathy in 96% while lack of resection was associated with death or cardiac transplantation in 44%. CONCLUSION Pheochromocytoma should be considered in the evaluation of non-ischemic, non-valvular cardiomyopathy even in the absence of symptoms of catecholamine excess. Our study highlights the importance of early suspicion and diagnosis of pheochromocytoma in cases of idiopathic heart failure as early resection may prevent progression to irreversible myocardial remodeling and death.
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Marty M, Gaye D, Perez P, Auder C, Nunes ML, Ferriere A, Haissaguerre M, Tabarin A. Diagnostic accuracy of computed tomography to identify adenomas among adrenal incidentalomas in an endocrinological population. Eur J Endocrinol 2018; 178:439-446. [PMID: 29467231 DOI: 10.1530/eje-17-1056] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/20/2018] [Indexed: 11/08/2022]
Abstract
CONTEXT The recent recommendations of the European Endocrine Society states that the performance of computed tomography (CT) to characterize 'true' adrenal incidentalomas (AIs) remains debatable. OBJECTIVE To determine relevant thresholds for usual CT parameters for the diagnosis of benign tumors using robust reference standard among a large series of 'true' AIs recruited in an endocrinological setting. DESIGN Retrospective study of 253 AIs in 233 consecutive patients explored in a single university hospital: 183 adenomas, 33 pheochromocytomas, 23 adrenocortical carcinomas, 5 other malignant tumors and 9 other benign tumors. Reference standard was histopathology in 118 AIs, biological diagnosis of pheochromocytoma in 2 AIs and size stability after at least 1 year of follow-up in 133 AIs. METHODS Sensitivity, specificity and positive and negative predictive values were estimated for various thresholds of size, unenhanced attenuation (UA), relative and absolute wash-out (RPW, APW) of contrast media. 197 scans were reviewed independently in a blinded fashion by two expert radiologists to assess inter-observer reproducibility of measurements. RESULTS Criteria associated with a 100% positive predictive value for the diagnosis of benign AI were: a combination of size and UA: 30 mm and 20 HU or 40 mm and 15 HU, respectively; RPW >53%; and APW >78%. Non-adenomatous AIs with rapid contrast wash-out were exclusively benign pseudocysts and pheochromocytomas, suggesting that classical thresholds of 60% and 40% for APW and RPW, respectively, can be safely used for patients with normal metanephrine values. Inter-observer reproducibility of all parameters was excellent (intra-class correlation coefficients: 0.96-0.99). CONCLUSIONS Our study, the largest conducted in AIs recruited in an endocrinological setting, suggests safe thresholds for quantitative CT parameters to avoid false diagnoses of benignity.
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Affiliation(s)
- M Marty
- Departments of EndocrinologyDiabetes and Nutrition
| | - D Gaye
- Departments of RadiologyCHU Haut-Leveque and University of Bordeaux, Bordeaux, France
| | - P Perez
- Public Health DepartmentClinical Epidemiology Unit INSERM, CIC 1401 and Bordeaux University Hospital, Bordeaux, France
| | - C Auder
- Departments of RadiologyCHU Haut-Leveque and University of Bordeaux, Bordeaux, France
| | - M L Nunes
- Departments of EndocrinologyDiabetes and Nutrition
| | - A Ferriere
- Departments of EndocrinologyDiabetes and Nutrition
| | | | - A Tabarin
- Departments of EndocrinologyDiabetes and Nutrition
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25
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Crona J, Taïeb D, Pacak K. New Perspectives on Pheochromocytoma and Paraganglioma: Toward a Molecular Classification. Endocr Rev 2017; 38:489-515. [PMID: 28938417 PMCID: PMC5716829 DOI: 10.1210/er.2017-00062] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/01/2017] [Indexed: 02/07/2023]
Abstract
A molecular biology-based taxonomy has been proposed for pheochromocytoma and paraganglioma (PPGL). Data from the Cancer Genome Atlas revealed clinically relevant prognostic and predictive biomarkers and stratified PPGLs into three main clusters. Each subgroup has a distinct molecular-biochemical-imaging signature. Concurrently, new methods for biochemical analysis, functional imaging, and medical therapies have also become available. The research community now strives to match the cluster biomarkers with the best intervention. The concept of precision medicine has been long awaited and holds great promise for improved care. Here, we review the current and future PPGL classifications, with a focus on hereditary syndromes. We discuss the current strengths and shortcomings of precision medicine and suggest a condensed manual for diagnosis and treatment of both adult and pediatric patients with PPGL. Finally, we consider the future direction of this field, with a particular focus on how advanced molecular characterization of PPGL can improve a patient's outcome, including cures and, ultimately, disease prevention.
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Affiliation(s)
- Joakim Crona
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health.,Department of Medical Sciences, Uppsala University, Sweden
| | - David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, European Center for Research in Medical Imaging, Aix Marseille Université, France
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health
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26
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Davison AS, Jones DM, Ruthven S, Helliwell T, Shore SL. Clinical evaluation and treatment of phaeochromocytoma. Ann Clin Biochem 2017; 55:34-48. [DOI: 10.1177/0004563217739931] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Phaeochromocytoma and extra adrenal paraganglioma are rare neuroendocrine tumours and have the potential to secrete adrenaline, noradrenaline and dopamine causing a myriad of clinical symptoms. Prompt diagnosis is essential for clinicians and requires a multidisciplinary specialist approach for the clinical and laboratory investigation, diagnosis, treatment and follow-up of patients. This paper is an integrated review of the clinical and laboratory evaluation and treatment of patients suspected to have phaeochromocytoma or paraganglioma, highlighting recent developments and best practices from recent published clinical guidelines.
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Affiliation(s)
- Andrew S Davison
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Danielle M Jones
- Department of Clinical Biochemistry and Metabolic Medicine, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Stuart Ruthven
- Department of Cellular Pathology, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Timothy Helliwell
- Department of Cellular Pathology, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
| | - Susannah L Shore
- Department of Endocrine Surgery, Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK
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27
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Isaacs M, Lee P. Preoperative alpha-blockade in phaeochromocytoma and paraganglioma: is it always necessary? Clin Endocrinol (Oxf) 2017; 86:309-314. [PMID: 27864838 DOI: 10.1111/cen.13284] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/17/2016] [Accepted: 11/15/2016] [Indexed: 11/27/2022]
Abstract
Resection of phaeochromocytoma and paraganglioma (PPGL) is traditionally preceded by alpha-blockade to prevent complications of haemodynamic instability intraoperatively. While there is general agreement on preoperative alpha-blockade for classic PPGLs presenting with hypertension, it is less clear whether alpha-blockade is necessary in predominantly dopamine-secreting tumours, normotensive PPGLs, as well as tumours that appear to be biochemically 'silent'. Preoperative management of these 'atypical' PPGLs is challenging and the treatment approach must be individualized, carefully weighing the risk of intraoperative hypertension against the possibility of orthostatic and prolonged postoperative hypotension. Consideration of antihypertensive medication pharmacology in the light of catecholamine physiology and PPGL secretory profile will facilitate the formulation of individualized preoperative preparatory strategies.
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Affiliation(s)
- Michelle Isaacs
- Department of Endocrinology, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Paul Lee
- Department of Endocrinology, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St Vincent's Hospital and Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
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28
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Képénékian L, Mognetti T, Lifante JC, Giraudet AL, Houzard C, Pinson S, Borson-Chazot F, Combemale P. Interest of systematic screening of pheochromocytoma in patients with neurofibromatosis type 1. Eur J Endocrinol 2016; 175:335-44. [PMID: 27450695 DOI: 10.1530/eje-16-0233] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/22/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Pheochromocytoma (PHEO) may occur in 0.1-5.7% of patients presenting with a neurofibromatosis type 1 (NF1). Current recommendations are to explore only symptomatic patients. The objective of the study is to evaluate the prevalence and the interest of a systematic PHEO screening in this population. DESIGN A prospective study in a French tertiary center including consecutive NF1 patients older than 18 years. METHODS A systematic screening combining abdominal imaging and urinary fractionated metanephrines was proposed. In case of positivity of one or both exams, (123)I-metaiodobenzylguanidine scintigraphy or [(18)F]-fluoro-dihydroxyphenylalanine PET imaging was performed. The diagnosis of secreting PHEO was retained in case of elevated urinary metanephrines associated with positive scintigraphy and non-secreting PHEO when urinary metanephrines were normal with a positive scintigraphy. RESULTS Between January 2014 and August 2015, 234 patients were included and 156 patients (66.7%) completed both exams. In these 156 patients, 12 PHEOs were diagnosed, representing a prevalence of 7.7%. Of these, six PHEOs were secreting, with only two symptomatic patients. The tumor size of these PHEOs were bigger than that of non-secreting PHEO (25.2 ± 6.6 vs 14 ± 6.9 mm, P = 0.0165). One lesion was bilateral. Mean metanephrine and normetanephrine levels were 3.2 ± 2.6N and 2.8 ± 1N respectively. Three patients underwent surgery. The six patients with non-secreting PHEO were asymptomatic. One of them had bilateral lesion and one underwent surgery. CONCLUSIONS PHEO in NF1, whether or not secreting, are mostly asymptomatic. The current strategy to explore only symptomatic patients leads to an underestimation of prevalence with the risks inherent to the existence of an unrecognized PHEO.
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Affiliation(s)
- Lori Képénékian
- Department of Endocrinology and DiabetologyHospices Civils de Lyon, Groupement Hospitalier Est, Hôpital Louis Pradel, Bron Cedex, France
| | - Thomas Mognetti
- Department of Nuclear MedicineLéon Bérard Comprehensive Cancer Center, Lyon, France
| | - Jean-Christophe Lifante
- Department of GeneralDigestive and Endocrine Surgery, Centre Hospitalier Lyon Sud, Université Claude Bernard Lyon 1, Pierre Bénite, France
| | - Anne-Laure Giraudet
- Department of Nuclear MedicineLéon Bérard Comprehensive Cancer Center, Lyon, France
| | - Claire Houzard
- Nuclear Medicine UnitImaging Department, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Stéphane Pinson
- Molecular Genetics LaboratoryHôpital Edouard Herriot, Bâtiment E, Lyon, France
| | - Françoise Borson-Chazot
- Department of Endocrinology and DiabetologyHospices Civils de Lyon, Groupement Hospitalier Est, Hôpital Louis Pradel, Bron Cedex, France
| | - Patrick Combemale
- Rhône-Alpes Auvergne Competence Center for the treatment of Neurofibromatosis type 1Léon Bérard Comprehensive Cancer Center, Lyon, France
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Cho YY, Song KH, Kim YN, Ahn SH, Kim H, Park S, Suh S, Kim BJ, Lee SY, Chun S, Koh JM, Lee SH, Kim JH. Symptom-dependent cut-offs of urine metanephrines improve diagnostic accuracy for detecting pheochromocytomas in two separate cohorts, compared to symptom-independent cut-offs. Endocrine 2016; 54:206-216. [PMID: 27481364 DOI: 10.1007/s12020-016-1049-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/04/2016] [Indexed: 12/30/2022]
Abstract
The development of advanced imaging techniques has increased the detection of subclinical pheochromocytomas. Because of the substantial proportions of subclinical pheochromocytomas, measurement of urine metanephrine concentrations is crucial due to detect or exclude pheochromocytoma. Although urine metanephrines are elevated in symptomatic subjects, diagnostic cut-offs according to the presence of adrenergic symptoms have not been studied. Pheochromocytomas patients who underwent adrenalectomy at Samsung Medical Center and a control group were compared to determine cut-off concentrations of urine metanephrines. An independent population was analyzed for urine metanephrines with different kits to validate the improvement in diagnostic accuracy using adjusted cut-offs. Symptom-dependent cut-offs of urine metanephrines were higher for symptomatic patients (307 μg/day in males, 235 μg/day in females for urine metanephrine, and 1,045 μg/day in males and 457 μg/day in females for urine normetanephrine) than for asymptomatic patients (206 μg/day in males, 199 μg/day in females for urine metanephrine, and 489 μg/day in males and 442 μg/day in females for urine normetanephrine). Symptom-dependent cut-offs of urine metanephrines improved a specificity from 92.7 % to 96.3 % and a high sensitivity of 97.8 % was maintained. Using the Symptom-dependent cut-offs raised diagnostic accuracy by 5.5 % (p <0.001). Similar trend was also observed in an independent population using different hormone kits. Using symptom-dependent cut-offs of urine metanephrines in symptomatic patients for pheochromocytomas resulted in a significant improvement in diagnostic accuracy in two separate cohorts.
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Affiliation(s)
- Yoon Young Cho
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Kee-Ho Song
- Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Young Nam Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hee Ahn
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Endocrinology, Inha University School of Medicine, Incheon, Korea
| | - Hyeonmok Kim
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sooyoun Park
- Division of Endocrinology and Metabolism, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sunghwan Suh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Dong-A University Medical Center, Dong-A University College of Medicine, Busan, Korea
| | - Beom-Jun Kim
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sail Chun
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Koh
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
- Samsung Biomedical Research Institute, Seoul, Korea.
- Department of Health Sciences & Technology, SAIHST, Sungkyunkwan University, Seoul, Korea.
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30
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Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, Tabarin A, Terzolo M, Tsagarakis S, Dekkers OM. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2016; 175:G1-G34. [PMID: 27390021 DOI: 10.1530/eje-16-0467] [Citation(s) in RCA: 908] [Impact Index Per Article: 113.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022]
Abstract
: By definition, an adrenal incidentaloma is an asymptomatic adrenal mass detected on imaging not performed for suspected adrenal disease. In most cases, adrenal incidentalomas are nonfunctioning adrenocortical adenomas, but may also represent conditions requiring therapeutic intervention (e.g. adrenocortical carcinoma, pheochromocytoma, hormone-producing adenoma or metastasis). The purpose of this guideline is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with adrenal incidentalomas based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions crucial for the management of adrenal incidentaloma patients, addressing these four with systematic literature searches: (A) How to assess risk of malignancy?; (B) How to define and manage low-level autonomous cortisol secretion, formerly called 'subclinical' Cushing's syndrome?; (C) Who should have surgical treatment and how should it be performed?; (D) What follow-up is indicated if the adrenal incidentaloma is not surgically removed? SELECTED RECOMMENDATIONS: (i) At the time of initial detection of an adrenal mass establishing whether the mass is benign or malignant is an important aim to avoid cumbersome and expensive follow-up imaging in those with benign disease. (ii) To exclude cortisol excess, a 1mg overnight dexamethasone suppression test should be performed (applying a cut-off value of serum cortisol ≤50nmol/L (1.8µg/dL)). (iii) For patients without clinical signs of overt Cushing's syndrome but serum cortisol levels post 1mg dexamethasone >138nmol/L (>5µg/dL), we propose the term 'autonomous cortisol secretion'. (iv) All patients with '(possible) autonomous cortisol' secretion should be screened for hypertension and type 2 diabetes mellitus, to ensure these are appropriately treated. (v) Surgical treatment should be considered in an individualized approach in patients with 'autonomous cortisol secretion' who also have comorbidities that are potentially related to cortisol excess. (vi) In principle, the appropriateness of surgical intervention should be guided by the likelihood of malignancy, the presence and degree of hormone excess, age, general health and patient preference. (vii) Surgery is not usually indicated in patients with an asymptomatic, nonfunctioning unilateral adrenal mass and obvious benign features on imaging studies. We provide guidance on which surgical approach should be considered for adrenal masses with radiological findings suspicious of malignancy. Furthermore, we offer recommendations for the follow-up of patients with adrenal incidentaloma who do not undergo adrenal surgery, for those with bilateral incidentalomas, for patients with extra-adrenal malignancy and adrenal masses and for young and elderly patients with adrenal incidentalomas.
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Affiliation(s)
- Martin Fassnacht
- Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany Comprehensive Cancer Center MainfrankenUniversity of Würzburg, Würzburg, Germany
| | - Wiebke Arlt
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism & Systems ResearchUniversity of Birmingham, Birmingham, UK Centre for EndocrinologyDiabetes and Metabolism, Birmingham Health Partners, Birmingham, UK Division of EndocrinologyMetabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, Minnesota, USA
| | - Henning Dralle
- Department of GeneralVisceral, and Vascular Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - John Newell-Price
- Department of Oncology and MetabolismMedical School, University of Sheffield, Sheffield, UK Endocrine UnitRoyal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anju Sahdev
- Department of ImagingSt Bartholomew's Hospital, Barts Health, London, UK
| | - Antoine Tabarin
- Department of Endocrinology and INSERM U862University and CHU of Bordeaux, Pessac, France
| | - Massimo Terzolo
- Internal Medicine 1Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Stylianos Tsagarakis
- Department of EndocrinologyDiabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Olaf M Dekkers
- Departments of Clinical Epidemiology and Internal MedicineLeiden University Medical Centre, Leiden, The Netherlands Department of Clinical EpidemiologyAarhus University, Aarhus, Denmark
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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]
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32
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Tabarin A. [Adrenal incidentalomas]. Presse Med 2014; 43:393-400. [PMID: 24613315 DOI: 10.1016/j.lpm.2014.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 01/20/2014] [Accepted: 01/28/2014] [Indexed: 11/30/2022] Open
Abstract
Adrenal incidentalomas are found in approximately 2-3% of abdominal CT-scan examinations. A key issue is to determine whether the incidentaloma is neoplastic or responsible for endocrine hypersecretion, two situations in which surgical excision is recommended. Candidate incidentalomas for surgery include hypersecreting tumors (pheochromocytomas, Cushing's adenoma, Conn's adenoma) and adrenocortical carcinomas. The majority of adrenal incidentalomas are non-secreting cortical adenomas and lesions to remove account for less than 5% of adrenal incidentalomes. The pathological consequences of "subclinical" cortisol-secreting adenomas responsible for mild hypercortisolism and whether or not these tumors should be removed remain debatable.
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Affiliation(s)
- Antoine Tabarin
- CHU de Bordeaux, USN Haut-Levêque, service d'endocrinologie, diabète et nutrition, 1, avenue Magellan, 33604 Pessac cedex, France.
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