Medwave 2020;20(2):e7830 doi: 10.5867/medwave.2020.02.7830
Manejo perioperatorio de feocromocitoma y paraganglioma
Perioperative management of paragangliomas and pheochromocytomas
Magdalena Fermandois , Jaime Altamirano, Felipe Rojas , Cristóbal Román, Iván Pinto
Palabras clave: Neuroendocrine tumors, perioperative, pheochromocytoma, adrenal gland neoplasms; anesthesia.
Abstract
Pheochromocytomas and paragangliomas are rare neuroendocrine tumors, characterized by a high morbidity rate due to catecholamine excess. These high levels are independent of physiologic stressors. For the diagnosis, a biochemical workup is paramount. The most widely used are plasma-free metanephrines and urinary fractionated metanephrines. Imaging studies should be initiated once the biochemical diagnosis is established. Evaluation of the patient with pheochromocytomas and paragangliomas must be done taking into account the leading causes of perioperative morbidity and mortality. The two primary interventions that have reduced perioperative mortality are alpha-adrenergic blockade and intravascular volume normalization. Another significant advance has been the establishment of laparoscopic surgery as the gold standard for the surgical approach. No anesthetic technique has been found to be superior to another. Intraoperative hemodynamic instability has been correlated with poorer outcomes; thus one of the main intraoperative goals is maintaining hemodynamic stability. Lower morbidity and almost zero mortality rates due to preoperative and intraoperative management improvements have led to a focus on the immediate and long-term postoperative care. Anual lifelong follow-up is recommended to detect recurrent disease.
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Pheochromocytomas and paragangliomas are rare neuroendocrine tumors, characterized by a high morbidity rate due to catecholamine excess. These high levels are independent of physiologic stressors. For the diagnosis, a biochemical workup is paramount. The most widely used are plasma-free metanephrines and urinary fractionated metanephrines. Imaging studies should be initiated once the biochemical diagnosis is established. Evaluation of the patient with pheochromocytomas and paragangliomas must be done taking into account the leading causes of perioperative morbidity and mortality. The two primary interventions that have reduced perioperative mortality are alpha-adrenergic blockade and intravascular volume normalization. Another significant advance has been the establishment of laparoscopic surgery as the gold standard for the surgical approach. No anesthetic technique has been found to be superior to another. Intraoperative hemodynamic instability has been correlated with poorer outcomes; thus one of the main intraoperative goals is maintaining hemodynamic stability. Lower morbidity and almost zero mortality rates due to preoperative and intraoperative management improvements have led to a focus on the immediate and long-term postoperative care. Anual lifelong follow-up is recommended to detect recurrent disease.
Autores:
Magdalena Fermandois
[1], Jaime Altamirano
[2], Felipe Rojas
[1], Cristóbal Román
[3], Iván Pinto
[2]
Filiación:
[1] Departamento de Anestesiología, Facultad de Medicina, Universidad de los Andes, Santiago, Chile
[2] Instituto Oncológico Fundación Arturo López Pérez, Santiago, Chile
[3] Departamento de Urología, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
E-mail: fermandois@gmail.com
Correspondencia a:
[1] Cachapoal 7724
Las Condes
Santiago
Chile
Citación:
Fermandois M, Altamirano J, Rojas F, Román C, Pinto I.
Perioperative management of paragangliomas and pheochromocytomas. Medwave 2020;20(2):e7830 doi: 10.5867/medwave.2020.02.7830
Fecha de envío: 15/8/2019
Fecha de aceptación: 30/12/2019
Fecha de publicación: 4/3/2020
Origen: No solicitado.
Tipo de revisión: Con revisión externa por dos pares revisores, a doble ciego.
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- Fishbein L, Orlowski R, Cohen D. Pheochromocytoma/Paraganglioma: Review of
perioperative management of blood pressure and update on genetic mutations
associated with pheochromocytoma. J Clin Hypertens (Greenwich). 2013
Jun;15(6):428-34. | CrossRef | PubMed |
- Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, et al. Pheochromocytoma and
paraganglioma: an endocrine society clinical practice guideline. J Clin
Endocrinol Metab. 2014 Jun;99(6):1915-42. | CrossRef | PubMed |
- Fleisher LA. Anesthesia and Uncommon Diseases: Sixth Edition. Anesthesia and Uncommon Diseases: Sixth Edition. 2012; 424-426. | CrossRef |
- Wein AJ, Kavoussi LR, Partin AW, Peters CA. Campbell-Walsh Urology 11th Edition. Elsevier. 2015; 1528–1595.
- Azadeh N, Ramakrishna H, Bhatia NL, Charles JC, Mookadam F. Therapeutic goals
in patients with pheochromocytoma: a guide to perioperative management. Ir J Med Sci. 2016 Feb;185(1):43-9. | CrossRef | PubMed |
- Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N
Engl J Med. 2007 Feb 8;356(6):601-10. | PubMed |
- Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas:
European Society of Endocrinology Clinical Practice Guideline in collaboration
with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016
Aug;175(2):G1-G34. | CrossRef | PubMed |
- Brunaud L, Nguyen-Thi PL, Mirallie E, Raffaelli M, Vriens M, Theveniaud PE,
et al. Predictive factors for postoperative morbidity
after laparoscopic adrenalectomy for pheochromocytoma: a multicenter
retrospective analysis in 225 patients. Surg Endosc. 2016 Mar;30(3):1051-9. | CrossRef | PubMed |
- Farrugia FA, Martikos G, Surgeon C, Tzanetis P, Misiakos E, Zavras N,
et al. Radiology of the adrenal incidentalomas. Review of the
literature. Endocr Regul. 2017 Jan 1;51(1):35-51. | CrossRef | PubMed |
- Maurea S, Klain M, Mainolfi C, Ziviello M, Salvatore M. The diagnostic role of
radionuclide imaging in evaluation of patients with nonhypersecreting adrenal
masses. J Nucl Med. 2001 Jun;42(6):884-92. | PubMed |
- Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions:
principles, techniques, and algorithms for imaging characterization. Radiology.
2008 Dec;249(3):756-75. | CrossRef | PubMed |
- Kim SJ, Lee SW, Pak K, Kim IJ, Kim K. Diagnostic accuracy of (18)F-FDG PET or
PET/CT for the characterization of adrenal masses: a systematic review and
meta-analysis. Br J Radiol. 2018 Jun;91(1086):20170520. | CrossRef | PubMed |
- Boland GW, Dwamena BA, Jagtiani Sangwaiya M, Goehler AG, Blake MA, et al. Characterization of adrenal masses by using FDG PET: a
systematic review and meta-analysis of diagnostic test performance. Radiology.
2011 Apr;259(1):117-26. | CrossRef | PubMed |
- Ramakrishna H. Pheochromocytoma resection: Current concepts in anesthetic
management. J Anaesthesiol Clin Pharmacol. 2015 Jul-Sep;31(3):317-23. | CrossRef | PubMed |
- Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, et al.
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and
management: The Joint Task Force on non-cardiac surgery: cardiovascular
assessment and management of the European Society of Cardiology (ESC) and the
European Society of Anaesthesiology (ESA). Eur Heart J. 2014 Sep
14;35(35):2383-431. | CrossRef | PubMed |
- Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B,
et al. 2014 ACC/AHA
guideline on perioperative cardiovascular evaluation and management of patients
undergoing noncardiac surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014 Dec 9;130(24):e278-333. | CrossRef | PubMed |
- Roizen MF, Schreider BD, Hassan SZ. Anesthesia for patients with pheochromocytoma. Anesthesiol Clin North America. 1987;5:269-75.
- Smith J, Howards S, Preminger G, Dmochowski R. Hinman's Atlas of Urologic Surgery 4th Edition. Elsevier. 2012; 1097-1101.
- Thornton JK. Abdominal nephrectomy for large sarcoma of the left suprarenal capsule: recovery. Trans Clin Soc Lond. 1890;23:150–3.
- Mayo CH. Paroxysmal hypertension with tumor of retroperitoneal nerve: report of case. J Am Med Assoc. 1927;89:1047-1050
- Gagner M, Lacroix A, Bolté E. Laparoscopic adrenalectomy in Cushing's syndrome
and pheochromocytoma. N Engl J Med. 1992 Oct 1;327(14):1033. | PubMed |
- Piazza L, Caragliano P, Scardilli M, Sgroi AV, Marino G, Giannone G.
Laparoscopic robot-assisted right adrenalectomy and left ovariectomy (case
reports). Chir Ital. 1999 Nov-Dec;51(6):465-6. | PubMed |
- Porpiglia F, Miller BS, Manfredi M, Fiori C, Doherty GM. A debate on
laparoscopic versus open adrenalectomy for adrenocortical carcinoma. Horm Cancer.
2011 Dec;2(6):372-7. | CrossRef | PubMed |
- Brunt LM. The positive impact of laparoscopic adrenalectomy on complications
of adrenal surgery. Surg Endosc. 2002 Feb;16(2):252-7. | PubMed |
- Lee J, El-Tamer M, Schifftner T, Turrentine FE, Henderson WG, Khuri S, et al. Open and laparoscopic adrenalectomy: analysis of the National
Surgical Quality Improvement Program. J Am Coll Surg. 2008 May;206(5):953-9;
discussion 959-61. | CrossRef | PubMed |
- Arezzo A, Bullano A, Cochetti G, Cirocchi R, Randolph J, Mearini E,
et al. Transperitoneal versus
retroperitoneal laparoscopic adrenalectomy for adrenal tumours in adults.
Cochrane Database Syst Rev. 2018 Dec 30;12:CD011668. | CrossRef | PubMed |
- Morino M, Benincà G, Giraudo G, Del Genio GM, Rebecchi F, Garrone C.
Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled
trial. Surg Endosc. 2004 Dec;18(12):1742-6. | PubMed |
- Brunaud L, Bresler L, Zarnegar R, Ayav A, Cormier L, Tretou S, et al. Does
robotic adrenalectomy improve patient quality of life when compared to
laparoscopic adrenalectomy? World J Surg. 2004 Nov;28(11):1180-5. | PubMed |
- Castillo O, Cortés O, Kerkebe M, Pinto P, ArellanoL, Russo M. Adrenalectomía laparoscópica: lecciones aprendidas en 110 procedimientos consecutivos. Rev Chil Cir. 2006;58(3):175-180.
Fishbein L, Orlowski R, Cohen D. Pheochromocytoma/Paraganglioma: Review of
perioperative management of blood pressure and update on genetic mutations
associated with pheochromocytoma. J Clin Hypertens (Greenwich). 2013
Jun;15(6):428-34. |
CrossRef |
PubMed |
Lenders JW, Duh QY, Eisenhofer G, Gimenez-Roqueplo AP, Grebe SK, Murad MH, et al. Pheochromocytoma and
paraganglioma: an endocrine society clinical practice guideline. J Clin
Endocrinol Metab. 2014 Jun;99(6):1915-42. |
CrossRef |
PubMed |
Fleisher LA. Anesthesia and Uncommon Diseases: Sixth Edition. Anesthesia and Uncommon Diseases: Sixth Edition. 2012; 424-426. |
CrossRef |
Wein AJ, Kavoussi LR, Partin AW, Peters CA. Campbell-Walsh Urology 11th Edition. Elsevier. 2015; 1528–1595.
Azadeh N, Ramakrishna H, Bhatia NL, Charles JC, Mookadam F. Therapeutic goals
in patients with pheochromocytoma: a guide to perioperative management. Ir J Med Sci. 2016 Feb;185(1):43-9. |
CrossRef |
PubMed |
Young WF Jr. Clinical practice. The incidentally discovered adrenal mass. N
Engl J Med. 2007 Feb 8;356(6):601-10. |
PubMed |
Fassnacht M, Arlt W, Bancos I, Dralle H, Newell-Price J, Sahdev A, et al. Management of adrenal incidentalomas:
European Society of Endocrinology Clinical Practice Guideline in collaboration
with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016
Aug;175(2):G1-G34. |
CrossRef |
PubMed |
Brunaud L, Nguyen-Thi PL, Mirallie E, Raffaelli M, Vriens M, Theveniaud PE,
et al. Predictive factors for postoperative morbidity
after laparoscopic adrenalectomy for pheochromocytoma: a multicenter
retrospective analysis in 225 patients. Surg Endosc. 2016 Mar;30(3):1051-9. |
CrossRef |
PubMed |
Farrugia FA, Martikos G, Surgeon C, Tzanetis P, Misiakos E, Zavras N,
et al. Radiology of the adrenal incidentalomas. Review of the
literature. Endocr Regul. 2017 Jan 1;51(1):35-51. |
CrossRef |
PubMed |
Maurea S, Klain M, Mainolfi C, Ziviello M, Salvatore M. The diagnostic role of
radionuclide imaging in evaluation of patients with nonhypersecreting adrenal
masses. J Nucl Med. 2001 Jun;42(6):884-92. |
PubMed |
Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions:
principles, techniques, and algorithms for imaging characterization. Radiology.
2008 Dec;249(3):756-75. |
CrossRef |
PubMed |
Kim SJ, Lee SW, Pak K, Kim IJ, Kim K. Diagnostic accuracy of (18)F-FDG PET or
PET/CT for the characterization of adrenal masses: a systematic review and
meta-analysis. Br J Radiol. 2018 Jun;91(1086):20170520. |
CrossRef |
PubMed |
Boland GW, Dwamena BA, Jagtiani Sangwaiya M, Goehler AG, Blake MA, et al. Characterization of adrenal masses by using FDG PET: a
systematic review and meta-analysis of diagnostic test performance. Radiology.
2011 Apr;259(1):117-26. |
CrossRef |
PubMed |
Ramakrishna H. Pheochromocytoma resection: Current concepts in anesthetic
management. J Anaesthesiol Clin Pharmacol. 2015 Jul-Sep;31(3):317-23. |
CrossRef |
PubMed |
Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, et al.
2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and
management: The Joint Task Force on non-cardiac surgery: cardiovascular
assessment and management of the European Society of Cardiology (ESC) and the
European Society of Anaesthesiology (ESA). Eur Heart J. 2014 Sep
14;35(35):2383-431. |
CrossRef |
PubMed |
Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B,
et al. 2014 ACC/AHA
guideline on perioperative cardiovascular evaluation and management of patients
undergoing noncardiac surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014 Dec 9;130(24):e278-333. |
CrossRef |
PubMed |
Roizen MF, Schreider BD, Hassan SZ. Anesthesia for patients with pheochromocytoma. Anesthesiol Clin North America. 1987;5:269-75.
Smith J, Howards S, Preminger G, Dmochowski R. Hinman's Atlas of Urologic Surgery 4th Edition. Elsevier. 2012; 1097-1101.
Thornton JK. Abdominal nephrectomy for large sarcoma of the left suprarenal capsule: recovery. Trans Clin Soc Lond. 1890;23:150–3.
Mayo CH. Paroxysmal hypertension with tumor of retroperitoneal nerve: report of case. J Am Med Assoc. 1927;89:1047-1050
Gagner M, Lacroix A, Bolté E. Laparoscopic adrenalectomy in Cushing's syndrome
and pheochromocytoma. N Engl J Med. 1992 Oct 1;327(14):1033. |
PubMed |
Piazza L, Caragliano P, Scardilli M, Sgroi AV, Marino G, Giannone G.
Laparoscopic robot-assisted right adrenalectomy and left ovariectomy (case
reports). Chir Ital. 1999 Nov-Dec;51(6):465-6. |
PubMed |
Porpiglia F, Miller BS, Manfredi M, Fiori C, Doherty GM. A debate on
laparoscopic versus open adrenalectomy for adrenocortical carcinoma. Horm Cancer.
2011 Dec;2(6):372-7. |
CrossRef |
PubMed |
Brunt LM. The positive impact of laparoscopic adrenalectomy on complications
of adrenal surgery. Surg Endosc. 2002 Feb;16(2):252-7. |
PubMed |
Lee J, El-Tamer M, Schifftner T, Turrentine FE, Henderson WG, Khuri S, et al. Open and laparoscopic adrenalectomy: analysis of the National
Surgical Quality Improvement Program. J Am Coll Surg. 2008 May;206(5):953-9;
discussion 959-61. |
CrossRef |
PubMed |
Arezzo A, Bullano A, Cochetti G, Cirocchi R, Randolph J, Mearini E,
et al. Transperitoneal versus
retroperitoneal laparoscopic adrenalectomy for adrenal tumours in adults.
Cochrane Database Syst Rev. 2018 Dec 30;12:CD011668. |
CrossRef |
PubMed |
Morino M, Benincà G, Giraudo G, Del Genio GM, Rebecchi F, Garrone C.
Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled
trial. Surg Endosc. 2004 Dec;18(12):1742-6. |
PubMed |
Brunaud L, Bresler L, Zarnegar R, Ayav A, Cormier L, Tretou S, et al. Does
robotic adrenalectomy improve patient quality of life when compared to
laparoscopic adrenalectomy? World J Surg. 2004 Nov;28(11):1180-5. |
PubMed |
Castillo O, Cortés O, Kerkebe M, Pinto P, ArellanoL, Russo M. Adrenalectomía laparoscópica: lecciones aprendidas en 110 procedimientos consecutivos. Rev Chil Cir. 2006;58(3):175-180.