Feocromocitoma

0021-972X/07/$15.00/0 Printed in U.S.A.

The Journal of Clinical Endocrinology & Metabolism 92(11):4069 – 4079 Copyright © 2007 by The Endocrine Society doi: 10.1210/jc.2007-1720

APPROACH TO THE PATIENT
Preoperative Management of the Pheochromocytoma Patient
Karel Pacak
Section on Medical Neuroendocrinology, Reproductive and Adult Endocrinology Program, National Institute of Child Healthand Human Development, National Institutes of Health, National Institutes of Health, Bethesda, Maryland 20892-1109
Pheochromocytomas are rare neuroendocrine tumors with a highly variable clinical presentation, but they most commonly present as spells of headaches, sweating, palpitations, and hypertension. Patients with pheochromocytoma may develop complicated and potentially lethal cardiovascularand other complications, especially in the setting of diagnostic or interventional procedures (e.g. upon induction of anesthesia or during surgery). The serious and potentially lethal nature of such complications is due to the potent effect of paroxysmal release of catecholamines. Because this warrants prompt diagnosis and treatment, the physician should be aware of the clinical manifestationsand complications of catecholamine excess and be able to provide proper preoperative management to minimize catecholamine-related pre-, intra-, and postoperative adverse events. The following clinical scenario and discussion aim to enhance the knowledge of the physician regarding the behavior of pheochromocytoma and to outline current approaches to comprehensive preoperative management of patientssuffering from this tumor. (J Clin Endocrinol Metab 92: 4069 – 4079, 2007)

A Patient’s Presentation

A 57-yr-old white male presented to the community hospital emergency room with a 3-wk history of presyncopal and syncopal episodes, as well as abdominal pain with intermittent nausea. The patient had reported brief feelings of light-headedness and fainting upon standing on three separateoccasions before his admission. The third episode resulted in an injury to his head. At the emergency room, he also complained of abdominal pain associated with nausea. In the past, other symptoms and problems included episodes of sweating lasting 1–2 min, palpitations, and dizziness (all three usually occurring once every 1–2 wk for the past 6 months), and blurred vision for the last 2–3 months. Pastmedical history was also significant for labile and difficultto-control hypertension [treated with amlodipine (Norvasc) 10 mg and metoprolol (Toprol XL) 50 mg once a day] for the past 5 yr. He also had a history of severe weight gain (over 110 pounds) during the last 2 yr, compounded by low energy level. A few months before hospitalization, the patient was put on a diet and a weight loss medication(phentermine, 30 mg once a day for 2 months) resulting in a 70-pound weight loss; however, he continued to be hypertensive. In addition, he was previously diagnosed to have uncomplicated umbilical hernia, benign prostate hypertrophy, and bilateral knee osteoarthritis. At the emergency room, in view of the recurrent episodes of syncope and recent history of abdominal pain associated with nausea, awork-up for cardio- and cerebrovascular events and a possible small bowel obstruction was initiated.
Abbreviations: CT, Computed tomography; ECG, electrocardiogram; EPI, epinephrine; MIBG, metaiodobenzylguanidine; NE, norepinephrine. JCEM is published monthly by The Endocrine Society (http://www. endo-society.org), the foremost professional society serving the endocrine community.

Computedtomography (CT) of the abdomen revealed a 6.4-cm left adrenal gland mass, in addition to a small umbilical hernia with partial small bowel obstruction. Magnetic resonance imaging confirmed the diagnosis of the left adrenal mass that appeared heterogeneous with a bright signal on T2-weighted images. It also showed moderately distended loops of the small bowel. Electrocardiogram (ECG) did not show...