0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Diagnosis FREE

Arch Surg. 2011;146(8):986. doi:10.1001/archsurg.2011.189-b.
Text Size: A A A
Published online

The metaiodobenzylguanidine scan (Figure 1) shows increased uptake in a small region adjacent to the junction of the abdominal aorta and the inferior mesenteric artery; computed tomographic scan (Figure 2) reveals a 2.5-cm mass in the same region. The preoperative diagnosis of paraganglioma was made and the patient opted for surgical resection of the mass. The patient underwent preoperative preparation by fluid volume expansion and α-blockade with phenoxybenzamine hydrochloride. An exploratory laparotomy was performed and the mass was dissected off the inferior mesenteric artery and aorta. A complete oncological resection was obtained. Pathology revealed evidence of positive staining of neuron-specific enolase, synaptophysin, chromogranin, and S100. His blood pressure normalized after the operation.

Paragangliomas, also known as extra-adrenal pheochromocytomas, are rare catecholamine-releasing neuroendocrine tumors. As with intra-adrenal pheochromocytomas, patients often present with nonspecific symptoms related to catecholamine excess, including episodic headache (80%), palpitations (64%), and diaphoresis (57%). This triad in a patient with hypertension has 90.9% sensitivity and 93.8% specificity for pheochromocytoma.1 In a prior study, 56% also experienced nausea and vomiting, 35% exhibited abdominal pain, and 8% noted constipation.2 Tumor size is positively correlated with secretory activity, with larger tumors usually secreting high levels of catecholamines.3

The vast majority of pheochromocytomas are located within the adrenal gland, but approximately 10% to 15% are extra-adrenal paragangliomas. Paragangliomas almost exclusively occur in the abdomen (98%), with the organ of Zuckerkandl being the predominant location.4 Functional secretory tumors make up 77% of paragangliomas of the organ of Zuckerkandl. Paragangliomas are of particular importance because of their rates of malignancy and recurrence. While approximately 10% of intra-adrenal pheochromocytomas are malignant, paragangliomas have a rate of malignancy approaching 50%.5,6

The preferred biochemical test for paragangliomas is the measurement of free plasma metanephrine levels (sensitivity 99%).79 Biopsy is contraindicated for suspected pheochromocytomas and paragangliomas because of the high rate of complications.10 Intra-adrenal pheochromocytomas generally show elevated plasma epinephrine levels while extra-adrenal paragangliomas generally produce elevated norepinephrine levels, although 10% of paragangliomas of the organ of Zuckerkandl produce epinephrine.6 By itself, metaiodobenzylguanidine scintigraphy is 80% to 90% sensitive in detecting paragangliomas,11 while computed tomography and magnetic resonance imaging are 95% and nearly 100% sensitive,6 respectively. Thus, if a pheochromocytoma is biochemically confirmed, the ideal algorithm is to conduct a metaiodobenzylguanidine scan to determine the location of the tumor, followed by high-resolution computed tomography or magnetic resonance imaging to determine proximity to and invasion of neighboring structures.

Surgical resection is the treatment of choice. Although laparoscopic adrenalectomy is the standard for intra-adrenal pheochromocytomas, paragangliomas often require open procedures because of the difficulty of the dissection and invasion into vital neighboring structures. Preoperative preparation via α-blockade with phenoxybenzamine is advised to prevent hypertensive crisis. Volume expansion via intravenous fluids is recommended to reduce the likelihood of cardiovascular collapse on removal of the tumor.

Lifelong follow-up of patients with paraganglioma is advised because recurrence of disease can occur decades after successful surgical resection.7 The 5-year survival of patients with paraganglioma after successful surgical resection is 75%. However, the 10-year disease-free survival is only 45%, suggesting that there is a strong likelihood for recurrence in more than half of patients successfully treated surgically.12

Return to Quiz Case.

Correspondence: Emad Kandil, MD, Department of Surgery, Tulane University School of Medicine, 1430 Tulane Ave, SL-22, New Orleans, LA 70112 (ekandil@tulane.edu).

Accepted for Publication: April 27, 2010.

Author Contributions:Study concept and design: Huan and Kandil. Acquisition of data: Huan and Kandil. Analysis and interpretation of data: Huan, Jaffe, and Kandil. Drafting of the manuscript: Huan, Jaffe, and Kandil. Critical revision of the manuscript for important intellectual content: Huan, Jaffe, and Kandil. Study supervision: Jaffe and Kandil.

Financial Disclosure: None reported.

Roman S. Pheochromocytoma and functional paraganglioma.  Curr Opin Oncol. 2004;16(1):8-12
PubMed   |  Link to Article
Hume DM. Pheochromocytoma in the adult and in the child.  Am J Surg. 1960;99:458-496
PubMed   |  Link to Article
Guerrero MA, Schreinemakers JM, Vriens MR,  et al.  Clinical spectrum of pheochromocytoma.  J Am Coll Surg. 2009;209(6):727-732
PubMed   |  Link to Article
Donahue J, Sahani D, Tso L, Cusack JC Jr. Extra-adrenal pheochromocytoma involving the organ of Zuckerkandl.  Surgery. 2008;143(6):830-832
PubMed   |  Link to Article
Clarke MR, Weyant RJ, Watson CG, Carty SE. Prognostic markers in pheochromocytoma.  Hum Pathol. 1998;29(5):522-526
PubMed   |  Link to Article
Grant S. Pheochromocytoma. In: Clark O, Duh Q-Y, Kebebow E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005:621-633
Van Slycke S, Caiazzo R, Pigny P,  et al.  Local-regional recurrence of sporadic or syndromic abdominal extra-adrenal paraganglioma: incidence, characteristics, and outcome.  Surgery. 2009;146(6):986-992
PubMed   |  Link to Article
Lenders JW, Pacak K, Walther MM,  et al.  Biochemical diagnosis of pheochromocytoma: which test is best?  JAMA. 2002;287(11):1427-1434
PubMed   |  Link to Article
Hickman PE, Leong M, Chang J, Wilson SR, McWhinney B. Plasma free metanephrines are superior to urine and plasma catecholamines and urine catecholamine metabolites for the investigation of phaeochromocytoma.  Pathology. 2009;41(2):173-177
PubMed   |  Link to Article
Vanderveen KA, Thompson SM, Callstrom MR,  et al.  Biopsy of pheochromocytomas and paragangliomas.  Surgery. 2009;146(6):1158-1166
PubMed   |  Link to Article
Subramanian A, Maker VK. Organs of Zuckerkandl: their surgical significance and a review of a century of literature.  Am J Surg. 2006;192(2):224-234
PubMed   |  Link to Article
Shen WT, Sturgeon C, Clark OH, Duh QY, Kebebew E. Should pheochromocytoma size influence surgical approach?  Surgery. 2004;136(6):1129-1137
PubMed   |  Link to Article

Figures

Tables

References

Roman S. Pheochromocytoma and functional paraganglioma.  Curr Opin Oncol. 2004;16(1):8-12
PubMed   |  Link to Article
Hume DM. Pheochromocytoma in the adult and in the child.  Am J Surg. 1960;99:458-496
PubMed   |  Link to Article
Guerrero MA, Schreinemakers JM, Vriens MR,  et al.  Clinical spectrum of pheochromocytoma.  J Am Coll Surg. 2009;209(6):727-732
PubMed   |  Link to Article
Donahue J, Sahani D, Tso L, Cusack JC Jr. Extra-adrenal pheochromocytoma involving the organ of Zuckerkandl.  Surgery. 2008;143(6):830-832
PubMed   |  Link to Article
Clarke MR, Weyant RJ, Watson CG, Carty SE. Prognostic markers in pheochromocytoma.  Hum Pathol. 1998;29(5):522-526
PubMed   |  Link to Article
Grant S. Pheochromocytoma. In: Clark O, Duh Q-Y, Kebebow E, eds. Textbook of Endocrine Surgery. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2005:621-633
Van Slycke S, Caiazzo R, Pigny P,  et al.  Local-regional recurrence of sporadic or syndromic abdominal extra-adrenal paraganglioma: incidence, characteristics, and outcome.  Surgery. 2009;146(6):986-992
PubMed   |  Link to Article
Lenders JW, Pacak K, Walther MM,  et al.  Biochemical diagnosis of pheochromocytoma: which test is best?  JAMA. 2002;287(11):1427-1434
PubMed   |  Link to Article
Hickman PE, Leong M, Chang J, Wilson SR, McWhinney B. Plasma free metanephrines are superior to urine and plasma catecholamines and urine catecholamine metabolites for the investigation of phaeochromocytoma.  Pathology. 2009;41(2):173-177
PubMed   |  Link to Article
Vanderveen KA, Thompson SM, Callstrom MR,  et al.  Biopsy of pheochromocytomas and paragangliomas.  Surgery. 2009;146(6):1158-1166
PubMed   |  Link to Article
Subramanian A, Maker VK. Organs of Zuckerkandl: their surgical significance and a review of a century of literature.  Am J Surg. 2006;192(2):224-234
PubMed   |  Link to Article
Shen WT, Sturgeon C, Clark OH, Duh QY, Kebebew E. Should pheochromocytoma size influence surgical approach?  Surgery. 2004;136(6):1129-1137
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles