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Al-Ward R, Brondani VB, Sawani S, Potter CL, Xu G, Waguespack SG, Varghese J, Habra MA, Lu Y, Jimenez C. High-Specific-Activity 131 I-MIBG for the Treatment of Advanced Pheochromocytoma and Paraganglioma. Clin Nucl Med 2024; 49:610-620. [PMID: 38630996 DOI: 10.1097/rlu.0000000000005184] [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: 04/19/2024]
Abstract
PATIENTS AND METHODS The primary endpoints were objective response rate (ORR) and disease control rate (DCR). Secondary endpoints were duration of response, blood pressure control, safety, overall and progression-free survival rates, MIBG uptake, and correlations with genetic background. RESULTS The study included 25 patients. Twenty-four patients had distant metastases, 17 (68%) had hormonally active tumors, and 13 (52%) had previously received antineoplastic treatment. In 24 evaluable patients, the ORR was 38%, including 2 patients with complete response, and the DCR was 83%; median time to response was 12.5 months (95% confidence interval, 4.6-25.1). Twelve patients had sporadic disease, among whom the ORR was 25% and DCR was 83%. Twelve patients had hereditary disease ( SDHB , VHL , RET ); among these, the ORR was 50%, and DCR was 83%. Plasma metanephrines normalized in 30% of patients and improved by greater than 50% in 46%. Sixteen patients had hormonally active tumors and hypertension; in 9 (56%) of these, blood pressure normalized, leading to discontinuation of antihypertensive therapy.The most common adverse events were grades 1-2 nausea/vomiting and transient bone marrow suppression. One patient developed premature ovarian failure. Reversible grades 3-4 myelosuppression were seen in 7 patients (28%). One patient had fatal pneumonitis. CONCLUSIONS HSA- 131 I-MIBG is associated with a high DCR in patients with MPPGL, regardless of underlying genetic mutation.
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Affiliation(s)
| | - Vania Balderrama Brondani
- From the Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center
| | | | - Cheryl L Potter
- From the Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center
| | - Guofan Xu
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven G Waguespack
- From the Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center
| | - Jeena Varghese
- From the Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center
| | - Mouhammed Amir Habra
- From the Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center
| | - Yang Lu
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Camilo Jimenez
- From the Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center
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Mustafa K, Zadeh S, Culver SA. Dopamine-Secreting Carotid Body Paraganglioma in a Patient With SDHB Mutation. AACE Clin Case Rep 2024; 10:109-112. [PMID: 38799041 PMCID: PMC11127581 DOI: 10.1016/j.aace.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 05/29/2024] Open
Abstract
Background/Objective Exclusively dopamine-secreting paragangliomas (PGLs) are rare, and the majority of head and neck PGLs are nonsecretory. Here, we describe a patient with succinate dehydrogenase subunit B (SDHB) mutation and a dopamine-secreting carotid body PGL to highlight the potential importance of screening for dopamine excess in patients with suspected PGL. Case Report We report a 34-year-old patient who presented with cranial nerve palsy and was found to have a cerebellopontine PGL. Biochemical testing demonstrated increased circulating dopamine levels with normal levels of other catecholamines. Dopamine excess improved with resection of the PGL, and subsequent genetic testing revealed an SDHB mutation. Discussion Secretory head and neck PGLs and exclusively dopamine-secreting PGLs are both uncommon and rarely present together, although PGLs in patients with SDHB mutations often do produce dopamine. Although current guidelines do not recommend routine evaluation of the dopamine levels in patients at risk for PGL, dopamine-secreting PGLs are frequently locally invasive or metastatic. Conclusion Screening for dopamine excess in patients with a predisposition to PGL or with suspected PGL may aid in diagnosis and as a marker of successful treatment.
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Affiliation(s)
- Katherine Mustafa
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Sara Zadeh
- Department of Pathology, University of Virginia Health System, Charlottesville, Virginia
| | - Silas A. Culver
- Division of Endocrinology, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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Ceccato GHW, Borba LAB. Jugular Foramen Paragangliomas. Adv Tech Stand Neurosurg 2024; 49:201-229. [PMID: 38700686 DOI: 10.1007/978-3-031-42398-7_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Paragangliomas are the most common tumors at jugular foramen and pose a great surgical challenge. Careful clinical history and physical examination must be performed to adequately evaluate neurological deficits and its chronologic evolution, also to delineate an overview of the patient performance status. Complete imaging evaluation including MRI and CT scans should be performed, and angiography is a must to depict tumor blood supply and sigmoid sinus/internal jugular vein patency. Screening for multifocal paragangliomas is advisable, with a whole-body imaging. Laboratory investigation of endocrine function of the tumor is necessary, and adrenergic tumors may be associated with synchronous lesions. Preoperative prepare with alpha-blockage is advisable in norepinephrine/epinephrine-secreting tumors; however, it is not advisable in exclusively dopamine-secreting neoplasms. Best surgical candidates are young otherwise healthy patients with smaller lesions; however, treatment should be individualized each case. Variations of infratemporal fossa approach are employed depending on extensions of the mass. Regarding facial nerve management, we avoid to expose or reroute it if there is preoperative function preservation and prefer to work around facial canal in way of a fallopian bridge technique. If there is preoperative facial nerve compromise, the mastoid segment of the nerve is exposed, and it may be grafted if invaded or just decompressed. A key point is to preserve the anteromedial wall of internal jugular vein if there is preoperative preservation of lower cranial nerves. Careful multilayer closure is essential to avoid at most cerebrospinal fluid leakage. Residual tumors may be reoperated if growing and presenting mass effect or be candidate for adjuvant stereotactic radiosurgery.
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Affiliation(s)
- Guilherme H W Ceccato
- Department of Neurosurgery, Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil
| | - Luis A B Borba
- Department of Neurosurgery, Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil
- Department of Neurosurgery, Federal University of Paraná, Curitiba, PR, Brazil
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4
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Sharma S, Fishbein L. Diagnosis and Management of Pheochromocytomas and Paragangliomas: A Guide for the Clinician. Endocr Pract 2023; 29:999-1006. [PMID: 37586639 DOI: 10.1016/j.eprac.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE The aim of this review was to provide a practical approach for clinicians regarding the diagnosis and management of pheochromocytomas and paragangliomas (PPGLs). METHODS A literature search of PubMed was carried out using key words, including pheochromocytoma, paraganglioma, treatment, diagnosis, screening, and management. The discussion of diagnosis and management of PPGL is based on the evidence available from prospective studies when available and mostly from cohort studies, cross-sectional studies, and expert consensus. RESULTS PPGL are neuroendocrine tumors arising from the chromaffin cells of adrenal medulla and sympathetic and parasympathetic ganglia, respectively. PPGL can be localized or metastatic, and they may secrete catecholamines, causing a variety of symptoms and potentially catastrophic and lethal complications if left untreated. The rarity of these tumors along with heterogeneous clinical presentation often poses challenges for the diagnosis and management. PPGL can be associated with several familial syndromes which are important to recognize. CONCLUSION The last few years have witnessed an exponential growth in the knowledge around PPGL. This review aims at providing a comprehensive discussion of current concepts for clinicians regarding clinical presentation, diagnostic tools, and management strategies for PPGL.
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Affiliation(s)
- Sona Sharma
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Duke University, Durham, North Carolina
| | - Lauren Fishbein
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism and Rocky Mountain Regional Veteran's Administration Medical Center, Endocrinology Section, University of Colorado School of Medicine, Aurora, Colorado.
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Eisenhofer G, Pamporaki C, Lenders JWM. Biochemical Assessment of Pheochromocytoma and Paraganglioma. Endocr Rev 2023; 44:862-909. [PMID: 36996131 DOI: 10.1210/endrev/bnad011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/24/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
Pheochromocytoma and paraganglioma (PPGL) require prompt consideration and efficient diagnosis and treatment to minimize associated morbidity and mortality. Once considered, appropriate biochemical testing is key to diagnosis. Advances in understanding catecholamine metabolism have clarified why measurements of the O-methylated catecholamine metabolites rather than the catecholamines themselves are important for effective diagnosis. These metabolites, normetanephrine and metanephrine, produced respectively from norepinephrine and epinephrine, can be measured in plasma or urine, with choice according to available methods or presentation of patients. For patients with signs and symptoms of catecholamine excess, either test will invariably establish the diagnosis, whereas the plasma test provides higher sensitivity than urinary metanephrines for patients screened due to an incidentaloma or genetic predisposition, particularly for small tumors or in patients with an asymptomatic presentation. Additional measurements of plasma methoxytyramine can be important for some tumors, such as paragangliomas, and for surveillance of patients at risk of metastatic disease. Avoidance of false-positive test results is best achieved by plasma measurements with appropriate reference intervals and preanalytical precautions, including sampling blood in the fully supine position. Follow-up of positive results, including optimization of preanalytics for repeat tests or whether to proceed directly to anatomic imaging or confirmatory clonidine tests, depends on the test results, which can also suggest likely size, adrenal vs extra-adrenal location, underlying biology, or even metastatic involvement of a suspected tumor. Modern biochemical testing now makes diagnosis of PPGL relatively simple. Integration of artificial intelligence into the process should make it possible to fine-tune these advances.
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Affiliation(s)
- Graeme Eisenhofer
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Christina Pamporaki
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Jacques W M Lenders
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, 6500 HB Nijmegen, The Netherlands
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Nezu M, Hirotsu Y, Amemiya K, Tateno T, Takizawa S, Inoue M, Mochizuki H, Hosaka K, Chik C, Oyama T, Omata M. Paraganglioma with High Levels of Dopamine, Dopa Decarboxylase Suppression, Dopamine β-hydroxylase Upregulation and Intra-tumoral Melanin Accumulation: A Case Report with a Literature Review. Intern Med 2023; 62:1895-1905. [PMID: 36384901 PMCID: PMC10372287 DOI: 10.2169/internalmedicine.0743-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Object Exclusively dopamine-producing pheochromocytoma/paraganglioma (PPGL) is an extremely rare subtype. In this condition, intratumoral dopamine β-hydroxylase (DBH), which controls the conversion of norepinephrine from dopamine, is impaired, resulting in suppressed norepinephrine and epinephrine production. However, the rarity of this type of PPGL hampers the understanding of its pathophysiology. We therefore conducted genetic and immunohistological analyses of a patient with an exclusively dopamine-producing paraganglioma. Methods Paraganglioma samples from a 52-year-old woman who presented with a 29.6- and 41.5-fold increase in plasma and 24-h urinary dopamine, respectively, but only a minor elevation in the plasma norepinephrine level was subjected to immunohistological and gene expression analyses of catecholamine synthases. Three tumors carrying known somatic PPGL-related gene variants (HRAS, EPAS1) were used as controls. Whole-exome sequencing (WES) was also performed using the patient's blood and tumor tissue. Results Surprisingly, the protein expression of DBH was not suppressed, and its mRNA expression was clearly higher in the patient than in the controls. Furthermore, dopa decarboxylase (DDC), which governs the conversion of 3,4-dihydroxyphenyl-L-alanine (L-DOPA) to dopamine, was downregulated at the protein and gene levels. In addition, melanin, which is synthesized by L-DOPA, accumulated in the tumor. WES revealed no PPGL-associated pathogenic germline variants, but a missense somatic variant (c.1798G>T) in CSDE1 was identified. Conclusion Although pre-operative plasma L-DOPA was not measured, our histological and gene expression analyses suggest that L-DOPA, rather than dopamine, might have been overproduced in the tumor. This raises the possibility of pathophysiological heterogeneity in exclusively dopamine-producing PPGL.
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Affiliation(s)
- Masahiro Nezu
- Department of Endocrinology and Diabetes, Yamanashi Central Hospital, Japan
- Genome Analysis Center, Yamanashi Central Hospital, Japan
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Canada
| | - Yosuke Hirotsu
- Genome Analysis Center, Yamanashi Central Hospital, Japan
| | - Kenji Amemiya
- Genome Analysis Center, Yamanashi Central Hospital, Japan
| | - Toru Tateno
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Canada
| | - Soichi Takizawa
- Department of Endocrinology and Diabetes, Yamanashi Central Hospital, Japan
| | - Masaharu Inoue
- Department of Endocrinology and Diabetes, Yamanashi Central Hospital, Japan
| | | | - Kyoko Hosaka
- Department of Urology, Yamanashi Central Hospital, Japan
| | - Constance Chik
- Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Canada
| | - Toshio Oyama
- Department of Pathology, Yamanashi Central Hospital, Japan
| | - Masao Omata
- Genome Analysis Center, Yamanashi Central Hospital, Japan
- The University of Tokyo, Japan
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7
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Kumar S, Wu K, Rodrigo N, Glover A. Massive Biochemically Silent Pheochromocytoma Masquerading as Nonfunctioning Adrenocortical Cancer. JCEM CASE REPORTS 2023; 1:luad061. [PMID: 37908587 PMCID: PMC10580479 DOI: 10.1210/jcemcr/luad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Indexed: 11/02/2023]
Abstract
Pheochromocytomas are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla chromaffin cells, usually associated with features of catecholamine excess. Clinically and biochemically silent pheochromocytoma without adrenergic symptoms or elevated catecholamine concentrations are rare. A 71-year-old female presented with acute right flank pain with abdominal computed tomography (CT) scan revealing a hemorrhagic right adrenal mass. She had no preceding adrenergic symptoms, and normal serum electrolytes, on a background of well-controlled hypertension on amlodipine monotherapy. After conservative management and discharge, an outpatient CT adrenal scan confirmed an 88 × 64 mm right adrenal mass demonstrating intense avidity (maximum standardized uptake value, 20.2) on fluorodeoxyglucose F 18-positron emission tomography (FDG-PET)/CT scan. Biochemical screening supported a nonfunctional adrenal lesion with normal-range plasma normetanephrines and metanephrines. She underwent a right adrenalectomy for presumed nonfunctioning adrenocortical cancer; however, histopathology demonstrated a 120-mm pheochromocytoma. Succinate dehydrogenase subunit B (SDHB) and fumarate hydratase (FH) staining were retained; however, weakly positive 2SC staining raised concerns for FH-deficient pheochromocytoma. Germline DNA sequencing was negative for pathogenic RET, VHL, SDHB, SDHD, or FH variants. Tumor cells stained positive for tyrosine hydroxylase and negative for dopamine β hydroxylase. Four months postoperatively, progress FDG-PET/CT scan demonstrated no focal avidity. Massive biochemically silent pheochromocytomas are exceedingly rare, and we discuss various mechanisms that may predispose patients to this phenomenon.
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Affiliation(s)
- Shejil Kumar
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Katherine Wu
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Natassia Rodrigo
- Department of Diabetes, Endocrinology & Metabolism, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Northern Sydney Clinical School, Faculty of Medicine, University of Sydney, Sydney, NSW 2065, Australia
| | - Anthony Glover
- Endocrine Surgical Unit, Royal North Shore Hospital & Northern Clinical School, Sydney, Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2065, Australia
- The Kinghorn Cancer Centre, Garvan Institute of Medical Research, St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Darlinghurst, NSW 2010, Australia
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Eremina OE, Kapitanova OO, Medved'ko AV, Zelenetskaya AS, Egorova BV, Shekhovtsova TN, Vatsadze SZ, Veselova IA. Plier Ligands for Trapping Neurotransmitters into Complexes for Sensitive Analysis by SERS Spectroscopy. BIOSENSORS 2023; 13:bios13010124. [PMID: 36671959 PMCID: PMC9856153 DOI: 10.3390/bios13010124] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 05/28/2023]
Abstract
Catecholamines-dopamine, noradrenaline and adrenaline are important biomarkers of neurotransmitter metabolism, indicating neuroendocrine tumors and neurodegenerative diseases. Surface-enhanced Raman spectroscopy (SERS) is a promising analytical technique with unprecedented multiplexing capabilities. However, not all important analytes exhibit strong SERS signals on stable and robust nanostructured substrates. In this work, we propose a novel indicator system based on the formation of mixed ligand complexes with bispidine-based bis-azole ligands which can serve as pliers to trap Cu(II) ions and stabilize its complexes with catecholamines. Four synthesized ligands with different functional groups: carboxyl, amino, benzyl, and methoxybenzyl, were applied for forming stable complexes to shift maximum absorbance of catecholamines from the ultraviolet region to 570-600 nm. A new absorbance band in the visible range resonates with the local surface plasmon resonance (LSPR) band of metal nanoparticles and most used laser wavelengths. This match allowed use of Molecular Immobilization and Resonant Raman Amplification by Complex-Loaded Enhancers (MIRRACLE) methodology to measure intense Raman signals on a nanostructured silver-based SERS-active substrate. The synthesized plier-like ligands fixed and stabilized catecholamine complexes with Cu(II) on the SERS sensor surface, which facilitated the determination of dopamine in a 3.2 × 10-12-1 × 10-8 M concentration range.
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Affiliation(s)
- Olga E. Eremina
- Chemistry Department, Moscow State University, Moscow 119991, Russia
| | | | - Alexei V. Medved'ko
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Moscow 119991, Russia
| | | | | | | | - Sergey Z. Vatsadze
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Moscow 119991, Russia
| | - Irina A. Veselova
- Chemistry Department, Moscow State University, Moscow 119991, Russia
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9
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Zhao L, Zhang X, Meng X, Zhang T, Fan H, Zhang Q, Liu Y, Zhou X, Zhu H. The Clinical Characteristics of Pheochromocytomas and Paragangliomas with Negative Catecholamines. J Clin Med 2022; 11:jcm11195583. [PMID: 36233451 PMCID: PMC9572258 DOI: 10.3390/jcm11195583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) associated with negative catecholamines are not uncommon. However, few studies have examined clinical features of patients with these tumors. In the absence of available data, it is difficult to identify characteristics of patients with potential PPGLs and normal serum and urine screens. Therefore, an analysis of patients with PPGLs was conducted retrospectively to compare the clinical features of patients with positive and negative catecholamines. This study included 214 patients, including 69 patients with negative catecholamines. Prevalence rates of diabetes (p < 0.001) and hypertension (p < 0.001) were lower and tumor diameter (p < 0.001) was smaller in the negative-catecholamine group compared with the positive-catecholamine group. Multivariable logistic regression analysis showed that extra-adrenal PPGLs were independently positively associated with negative catecholamines (p = 0.004); hypertension (p = 0.001) and tumor diameter (p = 0.016) were independently negatively associated with negative catecholamines. There was no significant difference in tumor recurrence between the two groups (mean follow-up, 20.54 ± 11.83 months) (p = 0.44). The results demonstrated that PPGL patients with negative catecholamines were more likely to have extra-adrenal tumors and less likely to have comorbidities, and these patients should also be closely monitored for tumor recurrence.
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Affiliation(s)
- Lin Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xiaoran Zhang
- Department of Emergency Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Xu Meng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Ting Zhang
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
- Department of Family Medicine & Division of General Internal Medicine, Department of Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hua Fan
- Department of Urology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
| | - Qiongyu Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yecheng Liu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
- Correspondence: (Y.L.); (X.Z.)
| | - Xianliang Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Correspondence: (Y.L.); (X.Z.)
| | - Huadong Zhu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
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Kubo H, Tsurutani Y, Sunouchi T, Hoshino Y, Hirose R, Katsuragawa S, Kimura N, Saito J, Nishikawa T. A Case of 123I-Metaiodobenzylguanidine Scintigraphy-Negative Pheochromocytoma with a Tumor-Developing Mutation in the RET Gene. J Clin Med 2022; 11:jcm11154624. [PMID: 35956242 PMCID: PMC9369916 DOI: 10.3390/jcm11154624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Pheochromocytoma (PCC) is rare catecholamine-producing endocrine tumor that metastasizes in approximately 10% of cases. As a functional imaging of PCC, 123I-metaiodobenzylguanidine (MIBG) scintigraphy was established, and some cases of PCC exhibit negative accumulation on MIBG scintigraphy, indicating a high risk of metastasis. Additionally, germline genetic variants of PCC are evident in approximately 30% of cases, although the genotype-phenotype correlation in PCC, especially the association between genetic mutations and MIBG scintigraphy, remains unclear. A 33-year-old man was admitted to our hospital for further examination for hypertension. He was diagnosed with sporadic PCC, and left adrenalectomy was performed. The adrenal tumor was negative on MIBG scintigraphy. Histology of the tumor revealed a moderately differentiated PCC. Target gene testing revealed a mutation in RET (c.2071G > A). This mutation has been reported to be a tumor-developing gene involved in the pathogenesis of PCC. Moreover, the RET mutation is the only gene mutation reported in a previous study of PCC with negative results on MIBG scintigraphy, except for the SDHB gene mutation, which is a common mutation in metastatic PCC. Correctively, the present RET gene mutation may be associated to MIBG-scintigraphy negative PCC and its pathophysiology. Clinicians should follow such cases more cautiously in clinical practice.
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Affiliation(s)
- Haremaru Kubo
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
| | - Yuya Tsurutani
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
- Correspondence:
| | - Takashi Sunouchi
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
| | - Yoshitomo Hoshino
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
| | - Rei Hirose
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
| | - Sho Katsuragawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
| | - Noriko Kimura
- Division of Clinical Research, Pathology Section, National Hospital Organization, Hakodate Hospital, Hakodate 041-8512, Japan
| | - Jun Saito
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
| | - Tetsuo Nishikawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Yokohama 222-0036, Japan
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Mete O, Asa SL, Gill AJ, Kimura N, de Krijger RR, Tischler A. Overview of the 2022 WHO Classification of Paragangliomas and Pheochromocytomas. Endocr Pathol 2022; 33:90-114. [PMID: 35285002 DOI: 10.1007/s12022-022-09704-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2022] [Indexed: 12/12/2022]
Abstract
This review summarizes the classification of tumors of the adrenal medulla and extra-adrenal paraganglia as outlined in the 5th series of the WHO Classification of Endocrine and Neuroendocrine Tumors. The non-epithelial neuroendocrine neoplasms (NENs) known as paragangliomas produce predominantly catecholamines and secrete them into the bloodstream like hormones, and they represent a group of NENs that have exceptionally high genetic predisposition. This classification discusses the embryologic derivation of the cells that give rise to these lesions and the historical evolution of the terminology used to classify their tumors; paragangliomas can be sympathetic or parasympathetic and the term pheochromocytoma is used specifically for intra-adrenal paragangliomas that represent the classical sympathetic form. In addition to the general neuroendocrine cell biomarkers INSM1, synaptophysin, and chromogranins, these tumors are typically negative for keratins and instead have highly specific biomarkers, including the GATA3 transcription factor and enzymes involved in catecholamine biosynthesis: tyrosine hydroxylase that converts L-tyrosine to L-DOPA as the rate-limiting step in catecholamine biosynthesis, dopamine beta-hydroxylase that is present in cells expressing norepinephrine, and phenylethanolamine N-methyltransferase, which converts norepinephrine to epinephrine and therefore can be used to distinguish tumors that make epinephrine. In addition to these important tools that can be used to confirm the diagnosis of a paraganglioma, new tools are recommended to determine genetic predisposition syndromes; in addition to the identification of precursor lesions, molecular immunohistochemistry can serve to identify associations with SDHx, VHL, FH, MAX, and MEN1 mutations, as well as pseudohypoxia-related pathogenesis. Paragangliomas have a well-formed network of sustentacular cells that express SOX10 and S100, but this is not a distinctive feature, as other epithelial NENs also have sustentacular cells. Indeed, it is the presence of such cells and the association with ganglion cells that led to a misinterpretation of several unusual lesions as paragangliomas; in the 2022 WHO classification, the tumor formerly known as cauda equina paraganglioma is now classified as cauda equina neuroendocrine tumor and the lesion known as gangliocytic paraganglioma has been renamed composite gangliocytoma/neuroma and neuroendocrine tumor (CoGNET). Since the 4th edition of the WHO, paragangliomas have no longer been classified as benign and malignant, as any lesion can have metastatic potential and there are no clear-cut features that can predict metastatic behavior. Moreover, some tumors are lethal without metastatic spread, by nature of local invasion involving critical structures. Nevertheless, there are features that can be used to identify more aggressive lesions; the WHO does not endorse the various scoring systems that are reviewed but also does not discourage their use. The identification of metastases is also complex, particularly in patients with germline predisposition syndromes, since multiple lesions may represent multifocal primary tumors rather than metastatic spread; the identification of paragangliomas in unusual locations such as lung or liver is not diagnostic of metastasis, since these may be primary sites. The value of sustentacular cells and Ki67 labeling as prognostic features is also discussed in this new classification. A staging system for pheochromocytoma and extra-adrenal sympathetic PGLs, introduced in the 8th Edition AJCC Cancer Staging Manual, is now included. This paper also provides a summary of the criteria for the diagnosis of a composite paragangliomas and summarizes the classification of neuroblastic tumors. This review adopts a practical question-answer framework to provide members of the multidisciplinary endocrine oncology team with a most up-to-date approach to tumors of the adrenal medulla and extra-adrenal paraganglia.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network, Toronto, ON, Canada.
- Endocrine Oncology Site, Princess Margaret Cancer Centre, Toronto, ON, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
| | - Sylvia L Asa
- Department of Pathology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Anthony J Gill
- Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Royal North Shore Hospital, St Leonards, NSW, Sydney, Australia
| | - Noriko Kimura
- Department of Clinical Research, Division of Diagnostic Pathology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
| | - Ronald R de Krijger
- Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arthur Tischler
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
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Constantinescu G, Preda C, Constantinescu V, Siepmann T, Bornstein SR, Lenders JWM, Eisenhofer G, Pamporaki C. Silent pheochromocytoma and paraganglioma: Systematic review and proposed definitions for standardized terminology. Front Endocrinol (Lausanne) 2022; 13:1021420. [PMID: 36325453 PMCID: PMC9618947 DOI: 10.3389/fendo.2022.1021420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors with heterogeneous clinical presentations and potential lethal outcomes. The diagnosis is based on clinical suspicion, biochemical testing, imaging and histopathological confirmation. Increasingly widespread use of imaging studies and surveillance of patients at risk of PPGL due to a hereditary background or a previous tumor is leading to the diagnosis of these tumors at an early stage. This has resulted in an increasing use of the term "silent" PPGL. This term and other variants are now commonly found in the literature without any clear or unified definition. Among the various terms, "clinically silent" is often used to describe the lack of signs and symptoms associated with catecholamine excess. Confusion arises when these and other terms are used to define the tumors according to their ability to synthesize and/or release catecholamines in relation to biochemical test results. In such cases the term "silent" and other variants are often inappropriately and misleadingly used. In the present analysis we provide an overview of the literature and propose standardized terminology in an attempt at harmonization to facilitate scientific communication.
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Affiliation(s)
- Georgiana Constantinescu
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
| | - Cristina Preda
- Department of Endocrinology, Grigore T. Popa University, Iasi, Romania
| | - Victor Constantinescu
- Center of Clinical Neuroscience, University Clinic Carl-Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Timo Siepmann
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden Inter-national University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan R. Bornstein
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Dresden, Germany
- Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Jacques W. M. Lenders
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Graeme Eisenhofer
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University of Dresden, Dresden, Germany
| | - Christina Pamporaki
- Department of Endocrinology and Diabetes, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Christina Pamporaki, ; Georgiana Constantinescu,
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