Management of Patients with Treatment of Pheochromocytoma: A Critical Appraisal

A rare case of a composite phaeochromocytoma-ganglioneuroma in Australia

Composite phaeochromocytomas (CP) of the adrenal medulla are rare neuroendocrine tumours, comprising phaeochromocytoma and neurogenic components. They may present heterogeneously like ordinary phaeochromocytomas and are ideally managed surgically with a multidisciplinary approach. This report describes the case of a CP in Australia, which was cured by a surgical team in an unplanned two-staged left adrenalectomy over a 20-year period.

Intraoperative hemodynamic instability during laparoscopic adrenalectomy for pheochromocytoma without preoperative medical preparation compared with nonsecreting tumor

BACKGROUND

Control of hemodynamic features during adrenalectomy for pheochromocytoma is recommended to minimize perioperative cardiovascular complications. However, episodes of intraoperative hemodynamic instability have been observed during adrenalectomies with other indications than pheochromocytoma. The objective of this study was to compare the hemodynamic instability score assessed during unilateral adrenalectomy for pheochromocytoma without preoperative medical preparation to hemodynamic instability score in nonsecreting tumor.

METHODS

This was an observational study with prospective intraoperative hemodynamic data collection (every 20 seconds) and retrospective analysis.

RESULTS

During the study period, 60 consecutive patients (30 pheochromocytomas vs 30 nonsecreting tumors) were included with a median number of data collections during total procedure time of 318 (interquartile range, 257-388). Mean cumulative intraoperative time outside the target blood pressure range expressed as a percentage of total procedure time was 13.3% vs 6.8% for systolic blood pressure >160 mm Hg (P = .01) and 2.4% vs 2.8% for mean arterial pressure <60 mm Hg (P = ns), respectively. The median hemodynamic instability score during total procedure time was 33 (interquartile range, 27-43) and 20 (interquartile range, 11-26) in the pheochromocytoma and nonsecreting tumor group, respectively (P < .01). Hemodynamic instability score were similar in patients with compared with without long-term antihypertensive treatment in each patient group (P = ns). The mean length of hospital stay was 2.0 ± 1.5 days, and 30-day morbidity rate was 6.6% (4/60) with no significant difference observed between both groups.

CONCLUSION

Although intraoperative hemodynamic instability remains greater in the pheochromocytoma group without preoperative medical preparation, both groups have similar hypotensive episodes. These data highlight the need to better understand the role of preoperative medical preparation in pheochromocytoma patients.

Retrospective evaluation of the influence of phenoxybenzamine pretreatment on intraoperative cardiovascular variables in dogs with pheochromocytoma

Objective

To compare cardiovascular outcomes in dogs undergoing adrenalectomy for pheochromocytoma with and without phenoxybenzamine pretreatment.

Animals

A total of 65 medical records from dogs at 5 veterinary hospitals.

Procedure

Records from January 2004 to December 2021 were evaluated for systolic, mean, and diastolic arterial pressures; numbers of hypertensive and hypotensive episodes; highest and lowest systolic arterial pressure differences; dose and duration of phenoxybenzamine; and presence of intraoperative arrhythmias. Phenoxybenzamine-pretreated dogs (Group PT, n = 33) and dogs not receiving phenoxybenzamine (Group N, n = 31) were compared. The Shapiro-Wilk test was used to test for normality, Student's t-test was used for normally distributed data, and Fisher's exact test was used for ordinal and categorical data. Multivariable logistic regression was used to assess effect of pretreatment with phenoxybenzamine on occurrence of hypotension and hypertension, allowing for adjustment for confounding variables (P < 0.05).

Results

Median (range) phenoxybenzamine dose was 0.46 (0.08 to 2.0) mg/kg, PO, q12h. Peak systolic and mean arterial pressures, lowest systolic and mean arterial pressures, duration of hypertension, duration of sinus tachycardia, number of hypotensive episodes, and duration of hypotension were not different between groups. More hypertensive episodes (P = 0.01) and anesthetic events involving hypertension (P = 0.02) were recorded in Group PT than in Group N.

Conclusion

In dogs undergoing adrenalectomy for pheochromocytoma, phenoxybenzamine pretreatment as administered did not offer any cardiovascular benefits based on the measured variables, and may be associated with more intraoperative hypertensive episodes.

Clinical relevance

Intraoperative changes in cardiovascular variables are prevalent in dogs with pheochromocytoma undergoing adrenalectomy. Further evaluation of pretreatment with phenoxybenzamine is needed to determine its role in these cases.

Surgery for phaeochromocytomas and paragangliomas: Current practice in the United Kingdom

INTRODUCTION

There is wide variability in the perioperative management of phaeochromocytoma and paraganglioma (PPGL) in different centres. This study aimed to summarise the management of PPGLs as reported in the United Kingdom Registry for Endocrine and Thyroid Surgery (UKRETS) database and to determine current perioperative management of PPGLs by surveying UK clinicians.

METHODS

Data recorded on UKRETS from 2005 to 2021 were subjected to descriptive analyses. British Association of Endocrine and Thyroid Surgeons members were invited to participate in an open survey relating to the perioperative management of patients with PPGLs.

RESULTS

A total of 2,007 operations for PPGL from 49 participating centres were included. The median annual workload in each centre was four cases. Operations were performed predominantly laparoscopically (69%). The median length of stay (4 days) was the same in groups of surgeons stratified by volume. The survey had 29 respondents from 22 centres across the UK, and a formal protocol for perioperative management exists in 48% of the centres. Phenoxybenzamine (72%) was preferred for alpha-blockade. The practice of admitting patients for optimisation from 1 to 7 days before the day of surgery was common (62%). Central venous pressure and blood glucose monitoring were mentioned as routine intraoperative adjuncts by 72% of the responders.

CONCLUSIONS

There is significant variation in the workload and perioperative management of PPGLs in the UK. This is potentially detrimental to patient outcomes and a consensus document might be beneficial to harmonise practice across the UK.

Risk factors for intraoperative hypertensive crisis in patients with pheochromocytomas and sympathetic paragangliomas

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.

[Surgical treatment of pheochromocytoma]

This review article contains a summary of modern aspects of preoperative preparation, surgical treatment, and follow-up of patients with adrenal pheochromocytomas. The main component of preoperative preparation is the use of alpha-blockers. The need to prescribe them to all patients is increasingly disputed, especially for patients without severe hypertension. An increasing number of publications demonstrate positive results of treatment without the use of alpha-blockers, advocating an individual approach and the use of the drug according to certain indications. Minimally invasive endoscopic techniques of adrenalectomy have become widespread in surgical treatment. They are represented by laparoscopic and retroperitonescopic technic, including using their single-port modifications. The earliest possible intersection of the central vein in the past was considered the most important aspect of adrenalectomy for pheochromocytoma, currently, due to the development of surgical techniques and anesthesiological manuals, this has ceased to be a mandatory rule of successful surgery. Despite the significant influence of the intersection of this vessel on intraoperative hemodynamics, surgical tactics with its later intersection have their own justifications and do not lead to a deterioration in treatment results. The standard volume of surgical intervention for pheochromocytomas is total adrenalectomy, however, in the presence of hereditary syndromes, such as multiple endocrine neoplasia type 2 syndrome, neurofibomatosis type 1, von Hippel-Lindau syndrome, it is possible to perform cortical-sparing adrenalectomy.

Hemodynamic parameters in patients undergoing surgery for pheochromocytoma/paraganglioma: a retrospective study

BACKGROUND

Pheochromocytoma (PHEO) and paraganglioma (PGL) are rare neuroendocrine tumors characterized by hemodynamic instability, caused by the paroxysmal release of catecholamines. Patients may develop cardiovascular complications in the perioperative phase due to the massive release of catecholamines, particularly during anesthetic induction and surgical manipulation of the tumor. The aim of this retrospective study was to evaluate the risk factors involved in perioperative hemodynamic instability in patients who underwent surgery for chromaffin tumors.

METHODS

Forty patients (median age 55 [36.50-64.50]) undergone surgery for PHEO/abdominal PGL from January 2011 to December 2016 at the AOU Careggi (Florence, Italy) were retrospectively evaluated. Systolic, diastolic, and mean blood pressure were considered at baseline and during surgery. Patients with blood pressure steadily < 140/90 mmHg before surgery were considered "adequately prepared". A preoperative therapy with doxazosin, a selective alpha-1 blocker, was started in all patients for at least 14 days prior to the surgery. The presence of hemodynamic instability was reported.

RESULTS

Comparing males and females, a significant difference in doxazosin daily dose (p = 0.018), systolic blood pressure (p = 0.048), and in the proportion of adequately prepared patients (p = 0.031) emerged. A positive correlation between preoperative daily dose of doxazosin, tumor size (B = 0.60, p < 0.001), and urinary normetanephrine levels (B = 0.64, p < 0.001) was also observed. Hemodynamic instability occurred in 30.0% of patients. The absence of adequate preparation (p = 0.012) before surgery, urinary normetanephrine levels (NMNur p = 0.039), and surgery time (minutes) (p = 0.021) resulted as risk factors of hemodynamic instability in our series. The use of intraoperative drugs was higher in patients with hemodynamic instability (p < 0.001). A pre-surgical SBP level of > 133 mmHg (OR = 6 CI95% 1.37-26.20, p = 0.017) and an intraoperative SBP and MBP levels of > 127 mmHg (OR = 28.80 CI95% 2.23-371.0, p = 0.010) and > 90 mmHg (OR = 18.90 CI95% 1.82-196.0, p = 0.014), respectively, were identified as effective thresholds to recognize patients at higher risk of HI.

CONCLUSIONS

A preoperative therapy with alpha-blockers is useful, but not sufficient to avoid surgical risks. Patients with higher pre-surgical levels of NMNur, pre-surgical SBP > 133 mmHg, and/or intraoperative SBP > 127 mmHg and MBP > 90 mmHg, should be carefully monitored. A multidisciplinary approach is indispensable to optimize the management of PHEOs/abdominal PGLs in order to reduce surgical complications.

Abandonment of intravenous volume expansion after preoperative receipt of α-blockers in patients with adrenal pheochromocytoma was not an independent risk factor for intraoperative hemodynamic instability

Background

There is no consensus on whether intravenous rehydration must be added after preoperative phenoxybenzamine (PXB) administration for pheochromocytoma. The aim of this study is to investigate whether abandonment of intravenous volume expansion after PXB administration is associated with intraoperative hemodynamic instability.

Methods

83 Patients with pheochromocytoma received surgical treatment in the Department of Urology, Handan First Hospital, between October 2014 and July 2022. All patients were subclassified into either the hemodynamic stability group (HS group) or the hemodynamic instability group (HU group) according to whether intraoperative hemodynamic instability occurred, with 51 cases in HS group and 32 cases in HU group. Differences in data between the two groups were examined, and the risk factors for intraoperative hemodynamic instability were analyzed using logistic regression.

Results

The results of the analysis showed no statistically significant differences in age, sex, location of the tumor, surgical method, body mass index (BMI) ≥ 24 kg/m², blood and urine catecholamine test results, preoperative oral PXB followed by combined intravenous volume expansion, proportion of patients with hypertension or diabetes mellitus or coronary heart disease between the two groups (P>0.05). The size of the tumor in the HS group was smaller than that in the HU group (5.3 ± 1.9 cm vs 6.2 ± 2.4 cm P=0.010). Multivariate analyses demonstrated that abandonment of intravenous volume expansion after preoperative receipt of α-blockers in patients with adrenal pheochromocytoma was not an independent risk factor for intraoperative hemodynamic instability. Only the tumor size (P=0.025) was an independent risk factor for intraoperative hemodynamic instability.

Conclusion

The purpose of general preoperative intravenous fluid expansion is to prevent hypotension after the tumor has been resected. In the current study, we indicated that preoperative management of pheochromocytomas using the α-blocker PXB in combination with intravenous volume expansion does not further reduce the risk of intraoperative hemodynamic instability or postoperative complications compared with oral PXB alone. Therefore, our study supports preoperative management of pheochromocytoma with a single α-blocker, PXB, as sufficient.