Pheochromocytoma: an updated scoping review from clinical presentation to management and treatment

Locally advanced pheochromocytoma/paraganglioma exhibit high metastatic recurrence and disease specific mortality rates: long-term follow-up of 283 patients

IMPORTANCE

Data on locally advanced (LAP) pheochromocytoma/paraganglioma (PPGL), based on capsular, vascular or periadrenal fat invasion, tumor emboli and extra-adrenal extension, are scarce.

OBJECTIVE

To compare outcomes of patients with LAP and without (nLAP).

DESIGN

Retrospective cohort study, 1981-2024, prospectively supplemented 2020-2024.

SETTING

Referral center.

OUTCOMES

Overall, metastatic and nonmetastatic recurrence, overall (OAS) and disease-specific survival (DSS).

RESULTS

Of 283 patients followed for 11.3 ± 8.8 (mean ± SD) years, 79 (27.9%) had LAP. Compared to patients with nLAP (n = 204), patients with LAP had more overall (n = 17 vs. 31, hazard ratio 2.4, 95% CI 1.4-5.0) and metastatic (11 vs. 9, HR 6.8, 2.2-20.6) and similar (6 vs. 22, HR 1.2, 0.5-3.0) nonmetastatic recurrences. OAS was comparable (12 vs. 42 nonsurvivors, HR 1.2, 0.6-2.3), but mortality from metastatic disease was higher with LAP (2 vs. 4 deaths, HR 12.2, 1.8-82.8). Extra-adrenal tumor location was predictive of metastatic and nonmetastatic recurrence but not of OAS or DSS, tumor size of metastatic recurrence and of DSS, cluster 1 and 2 pathogenic variants of overall and nonmetastatic recurrence but not of OAS or DSS. LAP with tumor emboli and extra-adrenal extension predicted overall (HR 4.5, 1.3-14.2 and 5.0, 1.4-13.7) and metastatic recurrence (HR 24.6, 6.4-91.8 and 6.5, 1.6-23.4), OAS (HR 21.2, 2.8-108, tumor emboli only) and DSS (HR 22.6, 3.5-183 and 13.1, 1.7-120), LAP with vessel invasion nonmetastatic recurrence (HR 3.6, 1.2-10.0).

CONCLUSION

Patients with LAP vs. nLAP have higher metastatic recurrences and worse DSS. Tumor emboli and extra-adrenal extension indicated lower DSS, warranting a close follow-up.

A Case Report of Pheochromocytoma Presenting With a Tongue Sign Indicative of Blood Deficiency

Pheochromocytoma is a rare neuroendocrine tumor presenting with varied clinical symptoms. We present a unique case of pheochromocytoma in a 46-year-old male who developed paroxysmal palpitations, headaches, and elevated blood pressure. Notably, his tongue showed atypical signs of blood deficiency (pale white, thin, and emaciated appearance), which we attributed to peripheral vasoconstriction from sympathetic hyperactivity. His pulse and abdominal findings aligned with qi counterflow in Kampo medicine (traditional Japanese herbal medicine). Despite treatment with Saikokaryukotsuboreito, a traditional herbal formula prescribed to address qi counterflow, only partial improvement of neuropsychiatric symptoms was observed. Further evaluation by an endocrinology specialist confirmed the diagnosis of pheochromocytoma through advanced diagnostic modalities, including scintigraphy. Pheochromocytoma is known to induce sympathetic hyperactivity via excessive catecholamine production, resulting in peripheral vasoconstriction and compromised blood flow, particularly in distal areas such as the tongue.  This case illustrates that sympathetic hyperactivity can produce tongue signs mimicking blood deficiency patterns. Recognition of this discrepancy between tongue signs and other clinical findings prompted further investigation, leading to the diagnosis of pheochromocytoma through modern diagnostic methods. Our experience demonstrates how the integration of Kampo and Western diagnostic approaches enables accurate diagnosis of underlying conditions.

Paraneoplastic Pemphigus in a Patient With Pheochromocytoma: A Report of a Rare Case

This report details a rare case of paraneoplastic pemphigus (PNP) associated with pheochromocytoma. The patient presented with prominent dermatological manifestations, including erythema, vesicles, and erosions. During hospitalization, diagnostic imaging revealed a retroperitoneal mass, which was subsequently surgically removed. A comprehensive diagnostic workup, including CT, MRI, histopathological analysis, and direct immunofluorescence examination, was conducted. Postoperative management combined with pharmacological intervention led to significant clinical improvement. This case highlights the critical importance of considering PNP in the differential diagnosis of pheochromocytoma, particularly in patients presenting with complex autoimmune manifestations. The findings underscore the necessity for early diagnosis and prompt therapeutic intervention in such cases. Additionally, this report emphasizes the need for further investigation into the clinical spectrum, genetic associations, and underlying mechanisms of this rare disease association to enhance diagnostic accuracy and therapeutic outcomes.