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Case Report

Case Report: A giant but silent adrenal pheochromocytoma – a rare entity

[version 1; peer review: 2 approved]
PUBLISHED 07 Mar 2016
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Abstract

Herein we report a rare entity of a giant adrenal pheochromocytoma in a fifty-year-old male presenting with a vague abdominal pain. A computerised tomogram of the abdomen revealed a well-defined  left supraadrenal giant lesion with no evidence of invasion to surrounding structures.The patient underwent surgical excision without any untoward postoperative events. Histopathological study revealed a benign pheochromocytoma. This report highlights the importance of acknowledging the fact that sometimes a giant adrenal pheochromocytoma can present with paucity of clinical  signs and symptoms.Thorough investigations and a multidisciplinary team approach may lead  to a better outcome in these patients.

Keywords

Giant, benign, silent, pheochromocytoma

Introduction

Giant pheochromocytomas (> 7 cm in size) are rare entities with around 20 cases reported in the literature16. They do not present with the classical symptoms of pheochromocytomas6. Most patients present with vague discomfort while others may complain of a palpable abdominal mass. Operative surgery is the ideal management option7. There needs to be a multidisciplinary approach while managing such cases. Stringent preparation to combat crisis due to catecholamine surge (during tumor manipulation) and sudden decrease in peripheral vascular resistance (following lesional excision) need to be emphasized8,9. Presence of chromaffin cells in the extra-adrenal tissue is the only confirmative method of distinguishing the malignant variant from its benign counterpart10. Herein we highlight and discuss the management algorithm taken while managing one such case.

Case report

A fifty-year-old male from Dhahran, Nepal presented to the surgical outpatient clinic with a vague symptom of abdominal discomfort. He had no history of trauma, persistent vomiting, altered bowel habits, change in the color of the stool or abdominal distension. There were no significant past medical or surgical illnesses. Family history of similar symptoms was also absent. Examination of the abdomen was normal except for slight discomfort during palpation in his left upper quadrant. Ultrasound examination of the abdomen revealed a huge left suprarenal mass. Computerised tomogram (CT) of the abdomen confirmed a giant mass of approximately 12×8 cm2 in the left suprarenal region showing rim enhancement and areas of low attenuation within it. The left renal vein was normal and the lesion was slightly abutting the spleen (Figure 1).

42adf53c-0337-489e-a70e-a104d137b725_figure1.gif

Figure 1. CT images showing the giant suprarenal lesion abutting the spleen but with no invasion of the kidney or the renal vein.

The patient denied attacks of headache, cheat pain, palpitation and sweating. The serum and urinary catecholamine levels were within normal range. The patient was kept for observation with 24 hour electrocardiography (ECG) and blood pressure monitoring (BP) which was normal.

The patient and his relatives were explained of the disease entity and were advised for surgery. With written consent, he was prepared for surgery. The anesthesiologists prepared medication (Intravenous (i.v.) Phentolamine (1 mg injection), Nitroprusside (4 mg drip) and Esmolol (30 mg injection) for potential intra-operative crisis pertaining to catecholamine surge during surgical manipulation. Vasoactive agents were also made available for combating sudden loss of peripheral vascular resistance following tumor removal. Early vascular control was secured. There was a well demarcated plane to dissect the tumor from the surrounding structures (Figure 2).

42adf53c-0337-489e-a70e-a104d137b725_figure2.gif

Figure 2. Cut specimen of the excised lesion showing areas of scattered hemorrhages.

The patient was extubated and was kept in the intensive care unit (ICU) for 48 hours. There were no untoward events in the post-operative period and the patient was discharged home on the 10th day. Histopathological study revealed zellballen nests of chromaffin cells with no invasion of the capsule (Figure 3), which is highly suggestive of a benign pheochromocytoma.

42adf53c-0337-489e-a70e-a104d137b725_figure3.gif

Figure 3. Histopathology revealing characteristic zellballen nests of cells separated by fibro vascular stroma.

The patient is asymptomatic 4 years following surgery, and has been advised to follow up periodically in order to rule out early recurrence.

Discussion

Pheochromocytomas typically present with the characteristic triad of paroxysmal attacks of headache, sweating and palpitation11. However giant lesions paradoxically may lack these symptoms6. The reasons for the same can be due of the presence of tumoral necrosis, high loads of interstitial tissue compared to chromaffin cells or the paucity of the release of the catecholamines due to encapsulation by the connective tissues6. This may also cause normal catecholamine values during their serum and urinary assays2.

CT scan is the image modality of choice to diagnose the condition4. However, in cases of giant lesions, there may be difficulties indetermining the organ of origin o leading to mis-diagnosis of the entity2.

Open surgical removal is the therapeutic target7. Laparoscopic removal is reserved only for smaller lesions12,13. Some authors have suggested preoperative embolisation of theses lesion14. However, it may be tenacious due to major arterio-venous connections within the lesion6. The key to a successful outcome is the fine tuning between the surgeons and the anesthesist in the peri-operative period8,9. There needs to be minimal handling of the lesion and an early control of the adrenal vein so as to limit crisis due catecholamine surge6.

Pheochromocytoma of the adrenal gland scaled score (PASS) score has been described to differentiate between the benign and the malignant lesions15. But the hallmark of the malignant counterpart is the presence of the ectopic chromaffin cells in the extra-adrenal sites10.

The patients need to be on a periodic follow up so as to exclude the risk of recurrence16. There are still no set therapeutic guidelines in the management of the malignant lesions due to paucity of cases. Long term prognosis is dismal with five year survival of around 50% only17.

Conclusion

Though benign, surgery is advocated for giant pheochromocytomas. Early vascular control, minimal handling of the tumor and a multidisciplinary approach to combat potential intra-operative crisis are the cornerstones in managing such cases. Malignant counterparts need to be excluded histologically. Patients require regular follow up to rule out recurrence.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images and/or other details that could potentially reveal the patient’s identity.

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how to cite this article
Munakomi S, Rajbanshi S and Adhikary PS. Case Report: A giant but silent adrenal pheochromocytoma – a rare entity [version 1; peer review: 2 approved]. F1000Research 2016, 5:290 (https://doi.org/10.12688/f1000research.8168.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 07 Mar 2016
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Reviewer Report 12 Sep 2016
Prasanna Kumar Reddy, Department of Minimal Access Surgery, Apollo Hospitals, Chennai, India 
Nadeem Mushtaque, Department of Minimal Access Surgery, Apollo Hospitals, Chennai, India 
Vimalkumar Dhaduk, Department of Minimal Access Surgery, Apollo Hospitals, Chennai, India 
Approved
VIEWS 4
The format of the paper and the language are good. Giant adrenal tumors are not that rare, but always pose a diagnostic dilemma.

The CT pictures are informative and remaining diagnostic work up was done well. Even though it ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Reddy PK, Mushtaque N and Dhaduk V. Reviewer Report For: Case Report: A giant but silent adrenal pheochromocytoma – a rare entity [version 1; peer review: 2 approved]. F1000Research 2016, 5:290 (https://doi.org/10.5256/f1000research.8785.r16138)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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10
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Reviewer Report 22 Apr 2016
Venugopal Sarveswaran, Department of General Surgery, Sri Ramakrishna Hospital, Coimbatore, India 
Approved
VIEWS 10
I feel the case report seems to be an original one, though such cases have been published previously.
 
It provides sufficient details for others to learn, like it emphasizes that such clinical condition must be kept in mind and adequate safety precautions ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Sarveswaran V. Reviewer Report For: Case Report: A giant but silent adrenal pheochromocytoma – a rare entity [version 1; peer review: 2 approved]. F1000Research 2016, 5:290 (https://doi.org/10.5256/f1000research.8785.r13171)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 07 Mar 2016
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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