Giant left pheochromocytoma with vascular anomalies and pelvic horseshoe kidney: a case report

BACKGROUND

Pheochromocytoma is a neuroendocrine tumor, and its treatment is dependent on surgical resection. Due to the wide availability of cross-sectional imaging, pheochromocytomas are commonly seen as small tumors less than 10 cm in size and are mostly treated with minimally invasive surgery. Their concomitant presence with horseshoe kidney or other anatomical and vascular anomalies is rare. Herein, we present a surgically complex giant pheochromocytoma case who underwent an open left radical adrenalectomy.

CASE PRESENTATION

A 41-year-old Hispanic female presented with a 12 × 8 cm left hypervascular adrenal mass, pelvic horseshoe kidney, and severely dilated large left retro-aortic renal vein which branched into a left adrenal vein, congested left ovarian vein, and left uterine plexus. She was managed with insulin and metformin for uncontrolled diabetes with an A1c level of 9% and doxazosin for persistent hypertension. Clinical diagnosis of pheochromocytoma was confirmed with elevated urine and serum metanephrine and normetanephrine. The pre-operative ACTH was within normal range with a normal dexamethasone suppression test and 24-hour urine free cortisol. The adrenalectomy of the highly aggressive adrenal mass was performed via open approach to obtain adequate surgical exposure. Due to the large size of the tumor and its significant involvement with multiple adjacent structures, coordination with multiple surgical teams and close hemodynamic monitoring by anesthesiology was required for successful patient outcomes including preservation of blood supply to the pelvic horseshoe kidney. The histopathological diagnosis was pheochromocytoma with negative surgical margins. The patient was followed at 1, 4, 12, and 24 weeks postoperatively. She had a normal postoperative eGFR and was able to discontinue antihypertensive and antidiabetic medications at four weeks. She had transient adrenal insufficiency, which resolved at five months. The horseshoe kidney was intact except for a minimal area of hypo-enhancement in the left superior renal moiety due to infarction, which was significantly improved at six months.

CONCLUSION

Our patient had a giant pheochromocytoma with anatomical variations complicating an already surgically challenging procedure. Nonetheless, with multiple provider collaboration, detailed pre-operative surgical planning, and meticulous perioperative monitoring, radical resection of the giant pheochromocytoma was safe and feasible with successful postoperative outcomes.

BH3 Inhibitor Sensitivity and Bcl-2 Dependence in Primary Acute Lymphoblastic Leukemia Cells

BH3 mimetic drugs may be useful to treat acute lymphoblastic leukemia (ALL) but the sensitivity of primary tumor cells has not been fully evaluated. Here, B-lineage ALL cell cultures derived from a set of primary tumors were studied with respect to sensitivity to the BH3 mimetics ABT-263 and ABT-199 and to Bcl-2 dependence and function. These ALL cells each expressed high levels of Bcl-2 and exhibited great sensitivity to ABT-263 and ABT-199, which induced rapid apoptotic cell death. BH3 profiling indicated that the ALL cultures were Bcl-2 dependent. Coimmunoprecipitation studies revealed a multifaceted role for Bcl-2 in binding proapoptotic partners including Bax, Bak, Bik, and Bim. ABT-263 disrupted Bcl-2:Bim interaction in cells. Mcl-1 overexpression rendered ALL cells resistant to ABT-263 and ABT-199, with Mcl-1 assuming the role of Bcl-2 in binding Bim. Freshly isolated pediatric ALL blasts also expressed high levels of Bcl-2 and exhibited high sensitivity to Bcl-2 inhibition by the BH3 mimetic compounds. Overall, our results showed that primary ALL cultures were both more sensitive to BH3 mimetics and more uniform in their response than established ALL cell lines that have been evaluated previously. Furthermore, the primary cell model characterized here offers a powerful system for preclinical testing of novel drugs and drug combinations to treat ALL.

Cyclin B1 overexpression induces cell death independent of mitotic arrest

Microtubule inhibitors are widely used in cancer chemotherapy. These drugs characteristically induce mitotic arrest and cell death but the mechanisms linking the two are not firmly established. One of the problems is that cancer cells vary widely in their sensitivity to these agents, and thus comparison of data from different systems is difficult. To alleviate this problem we sought to molecularly induce mitotic death and study its mechanisms, by expressing non-degradable cyclin B (R42A) in HeLa cells. However, this approach failed to induce significant mitotic arrest, Cdk1 activation, or phosphorylation of anti-apoptotic Bcl-2 proteins, all characteristics of cells treated with microtubule inhibitors. Furthermore, cyclin B1-R42A induced rapid cell death, and when expressed in synchronized cells, cell death occurred in G1 phase. Decreasing the plasmid concentration reduced transfection efficiency but restored mitotic arrest and eliminated non-specific death. These results show that inappropriate overexpression of cyclin B1 causes non-specific cell death and suggest caution in its use for the study of mitotic events.

Identification of a mitotic death signature in cancer cell lines

This study examined the molecular mechanism of action of anti-mitotic drugs. The hypothesis was tested that death in mitosis occurs through sustained mitotic arrest with robust Cdk1 signaling causing complete phosphorylation of Mcl-1 and Bcl-xL, and conversely, that mitotic slippage is associated with incomplete phosphorylation of Mcl-1/Bcl-xL. The results, obtained from studying six different cancer cell lines, strongly support the hypothesis and identify for the first time a unique molecular signature for mitotic death. The findings represent an important advance in understanding anti-mitotic drug action and provide insight into cancer cell susceptibility to such drugs which has important clinical implications.

Cyclin-dependent kinase-1 (Cdk1)/cyclin B1 dictates cell fate after mitotic arrest via phosphoregulation of antiapoptotic Bcl-2 proteins

The prevailing model suggests that cell fate after mitotic arrest depends on two independent and competing networks that control cyclin B1 degradation and the generation of death signals. However, recent evidence for Cdk1/cyclin B1-mediated phosphorylation and inactivation of antiapoptotic Bcl-2 proteins suggests the existence of significant cross-talk and interdependence between these pathways. Further, the nature of the mitotic death signals has remained elusive. In this study, we sought to test the hypothesis that fate after mitotic arrest is dictated by the robustness of Cdk1/cyclin B1 signaling to Bcl-2 proteins and to identify signals that may represent a mitotic death signature. We show that when treated with Taxol, slippage-resistant HT29 colon carcinoma cells display robust Cdk1 activity and extensive Mcl-1/Bcl-x(L) phosphorylation and die in mitosis, whereas slippage-prone DLD-1 colon carcinoma cells display weak Cdk1 activity and partial and transient Mcl-1/Bcl-x(L) phosphorylation and die in subsequent interphase or survive. Furthermore, modulation of this signaling axis, either by inhibition of Cdk1 in slippage-resistant HT29 or by enforcing mitotic arrest in slippage-prone DLD-1 cells, evokes a switch in fate, indicating that the strength of Cdk1 signaling to Bcl-2 proteins is a key determinant of outcome. These findings provide novel insight into the pathways that regulate mitotic death, suggest that the robustness of these signaling events may be useful as a marker to define susceptibility to antimitotic drugs, and encourage a revision in the current model describing fate after mitotic arrest.

Effects of breed type and restricted versus ad libitum feeding on fatty acid composition and cholesterol content of muscle and adipose tissue from mature bovine females

Fatty acid composition and cholesterol content of muscle and adipose tissue from mature cows (N = 101) representing 15 breeds and crosses were determined. An initial group of cows was slaughtered after being fed slightly above the maintenance level for 2 wk; the remaining cows were fed either at the maintenance level or ad libitum for 84 d, then slaughtered. Samples of triceps brachii and longissimus muscle and subcutaneous and perinephric adipose tissue were obtained from each carcass. In addition, phospholipid and triacylglycerol fatty acids from total lipid extracts of triceps brachii muscle and subcutaneous adipose tissue were analyzed for 24 cows that were fed ad libitum or at the maintenance level for 84 d. Breed type effects on fatty acid composition were more pronounced in adipose tissue than in muscle tissue. Total lipid extracts of both triceps brachii and longissimus muscle from animals fed a maintenance diet for 84 d contained higher (P less than .01) percentages (3 to 8%) of polyunsaturated fatty acids (PUFA) and lower percentages (2 to 3%) of saturated fatty acids (SFA) than those from animals fed ad libitum for 84 d. This reflected significant variation in the fatty acids C14:0, C16:0, C18:2, C18:3 and C20:4 for both longissimus and triceps brachii muscle. Fatty acid composition within phospholipid and triacylglycerol fractions was similar regardless of maintenance or ad libitum feeding. Much of the variation in total lipid fatty acid composition appeared to be the result of differences in triacylglycerol:phospholipid ratios. Adipose tissue contained about twice as much cholesterol (mg/100 g wet weight) as muscle tissue. Both breed type and feeding group effects on cholesterol content of muscle tissue were nonsignificant. Values for cholesterol content of adipose tissue from cows fed restricted diets were higher than those from cows fed ad libitum (approximately 55 mg/100 g higher for subcutaneous and 25 mg/100 g for perinephric). The results show that changes in fatty acid composition of bovine tissues can be made genetically and by varying the energy level in the diet. Alteration of the cholesterol content of muscle tissue by these methods does not appear to be feasible.

Fatty acid composition of muscle and adipose tissue from crossbred bulls and steers

Fatty acid composition of total lipid extracts of muscle and adipose samples from crossbred bulls (N = 34) and steers (N = 35) was determined by gas-liquid chromatography. Samples of semitendinosus, triceps brachii and longissimus muscle and of subcutaneous and perinephric adipose tissue were excised from the right side of each carcass. In addition, thin-layer chromatography was utilized to obtain phospholipid and triacylglycerol fractions from total lipid extracts of semitendinosus and longissimus muscle and subcutaneous adipose tissue from 10 bull and steer cohorts (N = 20). The most prominent sex condition effect was in percentage of total poly-unsaturated fatty acids (PUFA). Bull tissues contained higher (P less than .01) percentages of PUFA than those of steers at all sampling sites. This reflected higher percentages of linoleate (C18:2), linolenate (C18:3) and arachidonate (C20:4) in bull tissues. Most of the PUFA were present as phospholipids in muscle samples. The fatty acid composition of muscle phospholipids was similar regardless of sex condition or muscle sampled. Total lipid extracts of semitendinosus and triceps brachii muscles of both bulls and steers contained from 6 to 10% more unsaturated fatty acids (UFA) compared with M. longissimus. Muscle triacylglycerols contained relatively high percentages of saturated fatty acids (SFA). Semitendinosus and longissimus samples from steers contained higher (P less than .05 and P less than .01, respectively) percentages of total SFA than those from bulls. Steer samples contained slightly higher percentages of palmitic acid (C16:0) compared with bulls at all sampling sites, and this difference was significant for M. longissimus. The fat:lean ratio of muscle tissue is the major factor that determines fatty acid composition.