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REVIEW Diagnosis of Pheochromocytoma

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REVIEW Diagnosis of Pheochromocytoma Clin. Lab. 2002;48:5-18 ÓCopyright REVIEW Diagnosis of Pheochromocytoma TOMAS LENZ, JAN GOSSMANN, KARL-LUDWIG SCHULTE*, LOTHAR SALEWSKI** AND HELMUT GEIGER Medical Clinic IV, Division of Nephrology, Johann Wolfgang Goethe University, Frankfurt am Main, Germany *Medical Clinic, Königin Elisabeth Herzberge Hospital, Berlin, Germany **Immnno Biological Laboratories, Hamburg, Germany SUMMARY The purpose of this article is to give an overview on recent advances in the diagnosis, localization by imaging and treatment of pheochromocytoma. Pheochromocytoma is a mostly benign tumor (malignancy rate 10 - 15%) which arises from chromaffin cells with excessive catecholamine production and secretion. Most tumors are localized in the adrenals but 15 - 18% of the lesions are found extraadrenally (paragangliomas). Pheochromocytoma is a rare form of secondary hypertension; it can also be found as a feature of familial disease (e.g. von Hippel-Lindau disease, MEN type II) due to genetic mutations of several genes that have been identified recently. In familial pheochromocytoma molecular genetic analysis has improved the diagnostic modalities. In such patients the tumor can occur bilaterally and patients often remain normotensive until the tumor produces sufficient catecholamines to have hemodynamic effects. The extreme importance of recognizing this tumor is evident from the fact that it can be successfully removed in about 90% of the cases, whereas if unrecognized the tumor poses great risk of death or devastating complications. Diagnostic screening includes measurement of catecholamines and their metabolites (metanephrines) in plasma and/or urine. Furthermore, pharmacological testing (e.g. clonidine suppression test) may be indicated in patients with moderately elevated catecholamines or when the diagnosis is still uncertain. Several imaging techniques are applied to localize the tumor. Abdominal CT scan is still considered the “gold standard” since about 98% of the tumors lie infradiaphragmatically. Magnetic resonance imaging (MRI) and MIBG-scanning are other useful methods. Recently, positron emission tomography (PET) based techniques have also been developed. After the diagnosis is made tumor removal following pharmacological pretreatment is the decisive therapeutic measure. (Clin. Lab. 2002;48:5-18) Abbreviations NA noradrenaline NMN normetanephrine A adrenaline NPY neuropeptide Y COMT catechol-O-methyltransferase PET positron emission tomography CT computed tomography PNMT phenylethanolamine-N-methyltransferase DHPG dihydroxyphenylglycol RIA Radioimmunoassay DOMA dihydroxymandelic acid SD Standard deviation DOPAC dihydroxyphenylacetic acid SPECT single photon emission computed tomography EDTA ethylenediaminetetraacetic acid VHL von Hippel-Lindau disease ELISA enzyme linked immunosorbent assay VMA vanillylmandelic acid HPLC high pressure liquid chromatography MAO monoaminooxidase MEN multiple endocrine neoplasia MIBG metaiodobenzylguanidine MN metanephrine MRI magnetic resonance imaging Manuscript accepted September 20, 2001 Clin. Lab. 1+2/2002 5 TOMAS LENZ et al. Figure 2: Adrenal tumor resectate from a 21-year-old wo- man with pheochromocytoma and von Hippel-Lindau dis- ease (with cerebellar hemangioblastoma and retinal angio- mas). grade systolic heart murmur at the apex. The renal sono- gram revealed normally sized kidneys without any abnormal finding. Her kidney function was normal (plasma creatinine 0.5 mg/dL) without albuminuria, and serum potassium was low normal (3.5 mmol/L). Urin- ary total catecholamines (198 µg/24 hrs) were 2-fold above the upper limit (100 µg/24 hrs); plasma noradren- aline (451 ng/L) was slightly above the upper limit (350 ng/L), whereas plasma adrenaline was normal (45 ng/L, Figure 1: MIBG-scintiscan with SPECT showing a small upper limit 50 ng/L). A MIBG-scintiscan with SPECT tumor in the left adrenal. The authors thank Professor (Figure 1) was then performed which revealed a small Grünwald, Frankfurt, for permission to show this picture. adrenal tumor on the left side. After pretreatment with phenoxybenzamine for 10 days left adrenalectomy was perfomed without complications. Three weeks after sur- gery her blood pressure decreased to 135/90 mm Hg Case report with a heart rate of 75/min; she was still taking a ß- blocker and a small dose of potassium-sparing diuretic. A 50-year-old woman was referred to our outpatient cli- This case demonstrates that pheochromocytoma may al- nic because of uncontrolled hypertension. She had a his- so occur in patients with long-standing essential hyper- tory of high blood pressure for 15 years which was well tension. controlled with antihypertensive monotherapy until about 9 months ago. At that time the patient started to have blood pressure values around 165/105 mm Hg INTRODUCTION with systolic peak values of 210 mm Hg and she did not feel well. To rule out secondary causes of hyperten- Pheochromocytoma is a mostly benign tumor arising sion, diagnostic work-up was initiated including renal from neuroectodermal chromaffin cells, which belong scintiscan, magnetic resonance imaging of the kidneys to the adrenergic (sympathoadrenal system); if unrecog- and adrenals without revealing any abnormality; routine nized, it poses an enormous risk of death or serious laboratory tests were also unremarkable, except for complications (1). Especially, patients undergoing sur- urinary catecholamines which were slightly elevated. gical procedures and pregnant women are at very high When we first saw the patient she was taking standard risk (2). In turn, surgical removal of the tumor is cura- doses of an ACE inhibitor, a diuretic, a ß-blocker and a tive in up to 90% of cases. However, if it is not cor- calcium antagonist; despite this therapy her blood pres- rectly diagnosed, the tumor is invariably fatal. The aver- sure was 180/95 mm Hg, with a regular heart rate of age pheochromocytoma is about 5 cm in diameter and 78/min. Her weight was 71 kg at a height of 165 cm. 70% weigh less than 70 gms; some of them are very Years ago lumbar spondylodesis had been performed small or weigh as much as 4000 gms. Tumors are usu- resulting in reduced spine mobility. The physical exa- ally encapsulated and vascular and can be cystic (Figure mination was otherwise unremarkable except for a 1/6 2) (3). The incidence of pheochromocytoma in Cau- 6 Clin. Lab. 1+2/2002 DIAGNOSIS OF PHEOCHROMOCYTOMA Figure 3: Principle pathways of synthesis and metabolism of catecholamines; only metabolites which are important for diagnostic purposes are shown (redrawn from 11). COMT = catechol-O-methyltransferase, DOMA = dihydroxymandelic acid, DOPAC = dihydroxyphenylacetic acid, MAO = monoaminooxidase, PNMT = phenylethanolamine-N-methyltransferase casians is about one case per 100,000 inhabitants and beta (b1, b2) and dopaminergic receptors. As with other year, quite rare a disease altogether (4). Among un- receptors, classification of these receptors and their selected hypertensives, the prevalence ranges from 0.05 subtypes is based on the rank order of potency of their to 0.2%, so that pheochromocytoma is the underlying responses to agonists and antagonists. Due to the vary- disorder in hypertension almost as frequently as primary ing pattern of excess catecholamines and their different hyperaldosteronism (approx. 0.5%) (5, 6). In patients effects on adrenoreceptors the resulting clinical picture with adrenal incidentaloma the prevalence is 4% (7). A may also be quite variable. Adrenaline causes hyper- peak is found between the second and fifth decade of metabolism and tachycardia (via b-receptors) whereas life, but the disease is not uncommon among the elderly noradrenaline induces peripheral vasoconstriction (via (3, 6). a-receptors). Dopamine enhances myocardial contracti- These tumors produce an excess of the catecholamines lity and has some diuretic and natriuretic action. adrenaline, noradrenaline, dopamine, metanephrines In sympathetic nerve endings, parts of the brain and in and vanillylmandelic acid which are released into the chromaffin cells catecholamines are synthesized from circulation. Release can occur permanently or periodi- the precursor tyrosine through enzymatic degradation. cally. Most tumors produce both noradrenaline and ad- The rate limiting enzyme is tyrosine hydroxylase which renaline, less often solely noradrenaline. Exclusively at first generates dopa, which is a substrate for the ubi- adrenaline or dopamine producing tumors seem to be quitous enzyme dopa-decarboxylase, generating dop- rare; however, contradictory results have been reported amine. Dopamine-b-hydroxylase then catalyses the pro- in the literature. In one series of 19 patients with pheo- duction of noradrenaline, which in the adrenal medulla - chromocytoma 6 were found to exclusively secrete but not in peripheral nerve endings - is converted to adrenaline (8). Catecholamines exert their effects by sti- adrenaline by phenylethanolamine-N-methyltransferase mulating specific cellular sites, namely alpha (a1, a2), (PNMT) (Figure 3). In normals the relative contribution Clin. Lab. 1+2/2002 7 TOMAS LENZ et al. to the total catecholamine level in blood is 73% for noradrenaline, 14% for adrenaline and about l3% is dopamine (3). In the tumor tissue the same biosynthetic pathway is operative; however, the activity of the enzymes in- volved may differ; thus, the distribution and secretion of the various catecholamines may also differ from tumor to tumor. Very rarely an exclusively dopamine-produc- ing pheochromocytoma may occur, which
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