Difficulties in the diagnosis of pheochromocytoma in children]

Pheochromocytoma was the cause of arterial hypertension observed in 0.9% of children treated in 1982-1989. Out of clinical features the most characteristic was sustained hypertension often complicated by the accelerated phase of malignant hypertension and encephalopathy. Sustained tachycardia was also found in all patients. Increased urinary excretion of catecholamines and its metabolites confirmed the diagnosis in all cases. The most sensitive and specific methods for tumor diagnosis were ultrasonography and computer tomography of the adrenals while scintigraphy with meta-iodobenzylguanidine+ labelled with iodine-131 radioisotope gave a high percentage of false negative results.     

Serum chromogranin-alpha immunoradiometric assay in the diagnosis of pheochromocytoma

BACKGROUND: The diagnosis of pheochromocytoma is based on laboratory tests that demonstrate an increase in urinary excretion of catecholamines or their metabolites. Chromogranin A (CgA) is a member of the granin family and is widely distributed in neuroendocrine cells and particularly in chromaffin adrenal cells. Consequently, serum CgA increases in patients affected by pheochromocytoma and other diseases of the chromaffin system. AIM: This study investigated the performance of serum CgA assay in the diagnosis of pheochromocytoma and compared serum CgA with 24-hour urinary epinephrine (E), norepinephrine (NE), vanillylmandelic acid (VMA) and metanephrines (MNs). METHODS: We enrolled 15 patients with histologically proven pheochromocytoma; 100 healthy blood donors and 148 patients with essential hypertension were enrolled as controls. Serum CgA was assayed by a specific immunoradiometric method (IRMA). Urinary tests were done with high performance liquid chromatography (HPLC). RESULTS: Circulating CgA showed a higher sensitivity (1.00), specificity (0.96) and accuracy (0.96) than all other tests. Serum levels of CgA clearly increased from blood donors and patients with essential hypertension to patients with pheochromocytoma (p<0.0001). Furthermore, a strong relationship between serum CgA and tumor mass was found (p<0.0001). In conclusion, our data suggest that the CgA assay might be used as a single test for the diagnosis of pheochromocytoma.     

Localization of pheochromocytoma by selective venous catheterization and assay of plasma catecholamines.

The diagnosis of pheochromocytoma rests primarily on determination of the 24-hour urinary excretion of catecholamines and their metabolites. In most cases nephrotomography and selective arteriography or venography, or both, are sufficient to localize the tumour. Selective venous catheterization and the assay of plasma catecholamines should be considered for pheochromocytoma localization in: (a) patients in whom standard techniques fail to localize the tumour; (b) patients who exhibit idiosyncratic reactions to the angiographic contrast materials; (c) young patients or patients with familial pheochromocytoma, including those with multiple neurofibromatosis or multiple endocrine adenomatosis, type 2; (d) patients with recurrent, malignant, or suspected multicentric or extra-adrenal tumours; and (e) patients excreting only norepinephrine in the urine. The validity of the results is particularly dependent on the skill with which venous catheterization is carried out.     

A systematic review of the literature examining the diagnostic efficacy of measurement of fractionated plasma free metanephrines in the biochemical diagnosis of pheochromocytoma

BACKGROUND: Fractionated plasma metanephrine measurements are commonly used in biochemical testing in search of pheochromocytoma. METHODS: We aimed to critically appraise the diagnostic efficacy of fractionated plasma free metanephrine measurements in detecting pheochromocytoma. Nine electronic databases, meeting abstracts, and the Science Citation Index were searched and supplemented with previously unpublished data. Methodologic and reporting quality was independently assessed by two endocrinologists using a checklist developed by the Standards for Reporting of Diagnostic Studies Accuracy Group and data were independently abstracted. RESULTS: Limitations in methodologic quality were noted in all studies. In all subjects (including those with genetic predisposition): the sensitivities for detection of pheochromocytoma were 96%-100% (95% CI ranged from 82% to 100%), whereas the specificities were 85%-100% (95% CI ranged from 78% to 100%). Statistical heterogeneity was noted upon pooling positive likelihood ratios when those with predisposition to disease were included (p < 0.001). However, upon pooling the positive or negative likelihood ratios for patients with sporadic pheochromocytoma (n = 191) or those at risk for sporadic pheochromocytoma (n = 718), no statistical heterogeneity was noted (p = 0.4). For sporadic subjects, the pooled positive likelihood ratio was 5.77 (95% CI = 4.90, 6.81) and the pooled negative likelihood ratio was 0.02 (95% CI = 0.01, 0.07). CONCLUSION: Negative plasma fractionated free metanephrine measurements are effective in ruling out pheochromocytoma. However, a positive test result only moderately increases suspicion of disease, particularly when screening for sporadic pheochromocytoma.     

Use of plasma catecholamines in diagnosing pheochromocytoma and neuroblastoma

The diagnosis in two cases of neural crest tumours was confirmed by the measurement of concentration of plasma catecholamines. A histamine provocative test monitored by values of plasma catecholamines provided support for a diagnosis of pheochromocytoma in a patient with normal blood pressure and elevated values of urinary amines. In the second case the presence of a ganglioneuroblastoma secreting abnormal amounts of catecholamines was detected by plasma epinephrine and norepinephrine measurements when values of urinary free catecholamines were normal.     

Nuclear medicine: metaiodobenzylguanidine in the diagnosis of pheochromocytoma and neuroblastoma

The Scientific Board of the California Medical Association presents the following inventory of items of progress in nuclear medicine. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in nuclear medicine that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Nuclear Medicine of the California Medical Association and the summaries were prepared under its direction.     

Catecholamines in plasma and erythrocytes of rats with transplantable pheochromocytoma

Accumulation of catecholamines in erythrocytes (RBC) was compared to rising plasma levels of catecholamines at weekly intervals following transplantation of pheochromocytoma (line P-259) in the New England Deaconess Hospital rat strain. Additionally changes were investigated during a 12 hour interval after tumor was established in PHEO rats. Starting 2 weeks after tumor implant, the concentrations of norepinephrine (NE) and dopamine (DA) in RBC paralleled and correlated strongly with rising levels of plasma NE and DA which were maximum by 4 weeks. Four to 6 weeks after implant, the RBC to plasma (L/P) concentration ratio of NE was 30% higher in PHEO rats than controls (p less than 0.05) indicating a shift in distribution of NE between the 2 circulating pools. Three measurements, 6 hours apart, showed that mean arterial pressure, plasma and RBC NE and DA concentrations were highest in AM in both PHEO and control groups. Shifts in DA were smaller and did not rise in PM as did NE suggesting DA may reflect tumor secretion and NE, tumor secretion plus sympathetic neuronal activity.     

Usefulness of determining conjugated amine catecholamines in blood platelets for diagnosis of pheochromocytoma]

The studies included 14 patients with pheochromocytoma (mean age 39.5 years), 32 patients with arterial hypertension (mean age 39.5 years), and 9 healthy volunteers (mean age 39.5 years). Free and conjugated noradrenaline and adrenaline in blood platelets have been assayed with RIA technique. It was shown that mean concentrations of conjugated noradrenaline and adrenaline in blood platelets are significantly higher in patients with pheochromocytoma than those in hypertensive patients and healthy individuals. However, such test may be used with limitations as there is high percentage of increased values in patients with the primary arterial hypertension. A decreased noradrenaline inactivation in blood platelets of patients with pheochromocytoma has also been observed. This may exert some effect on the diversified clinical course of this type of arterial hypertension.     

Evaluation of the usefulness of certain localization methods in diagnosis of pheochromocytoma]

Localization tests including TC-scans, scintigraphy with 131I-radiolabelled metaiodobenzylguanidine and ultrasound have been performed in 68 patients with diagnosed pheochromocytoma. Diagnosis was based on clinical symptoms and increased catecholamines and/or their metabolites excretion with the urine. Proper diagnosis with CT-scans was 97%, scintigraphy--92%, and ultrasound--93%; false negative results in scintigraphy amounted to 8% (3 patients) and 5% (3 patients) in case of ultrasound. CT-scans were free of such errors. False positive diagnosis was made in 2 (3%) patients with CT-scans and in 1 (2%) patient tested with ultrasound. These results suggest that pheochromocytoma may be precisely localized with non-invasive techniques, especially CT-scans.     

Biochemical tests for diagnosis of phaeochromocytoma: urinary versus plasma determinations.

Fifteen patients with hypertension due to phaeochromocytoma and 35 controls with essential hypertension were studied to assess the diagnostic value of urinary and plasma biochemical determinations in phaeochromocytoma. In every case of phaeochromocytoma the urinary concentration of vanillylmandelate, metanephrines, or adrenaline plus noradrenaline was diagnostic of the disease irrespective of whether the patient was normotensive or hypertensive at the time. Plasma determinations of adrenaline and noradrenaline, however, gave falsely negative results on three occasions. These findings suggest that urinary biochemical determinations--particularly of metanephrines--are more reliable than plasma catecholamine measurements as a test for phaeochromocytoma. The test is particularly useful in patients with intermittent hypertension.     

Measurement of plasma acetate kinetics using high-performance liquid chromatography.

Previous studies suggest that plasma acetate may be an important fuel in man, accounting for approximately 10% of energy expenditure. Available methods for the determination of plasma acetate kinetics are difficult and time consuming. We describe here a procedure for the determination of plasma acetate concentration and specific activity using automated high-performance liquid chromatography that is precise and sensitive and accommodates large numbers of samples. The procedure involves extraction from plasma with diethyl ether, derivatization with bromoacetophenone, and separation on a C-18 reversed-phase column. The specific activities of D-beta-hydroxybutyrate and lactate can also be determined. Acetate turnover was measured in four dogs and was similar to that previously reported in sheep and humans. Transport of [14C]acetate into red blood cells was negligible.     

Hypoglycemia following excision of pheochromocytoma.

In two patients hypoglycemia developed in the immediate postoperative period after removal of a pheochromocytoma. In one patient the serum insulin value was elevated when he was hypoglycemic. Preoperative preparation of patients with pheochromocytoma requires use of an alpha-adrenergic blocking agent to decrease blood pressure and allow the plasma volume to expand; in the two patients referred to phenoxybenzamine was given orally. It is difficult to recognize hypoglycemia postoperatively because of the altered consciousness associated with a major operation, analgesics, anesthetic agents and the effects of adrenergic blocking medications; hence the physician must watch closely for this complication.     

Management of pheochromocytoma during pregnancy.

To reduce the high maternal and fetal mortality in pheochromocytoma of pregnancy, therapy is advocated with phenoxybenzamine and propranolol to obtain adequate alpha- and beta-adrenergic receptor blockade. In early pregnancy control of symptoms may be difficult, but the patient may be carried to term with such medical therapy. Delivery should be by cesarean section before the onset of labour, with, if possible, simultaneous removal of the tumour. Additional preoperative preparation with phenoxybenzamine and propranolol and careful intraoperative management are essential. During her third pregnancy a 29-year-old woman was found to have a pheochromocytoma of the left adrenal gland. After the medical therapy and preparation described, the infant was delivered by cesarean section and the mother''s left adrenal gland excised. Eight-year follow-up, including during a fourth pregnancy, showed no recurrence of tumour in the mother and only mild hypertension. The infant developed normally.