Diagnosis And Treatment Of 40 Cases Of Pheochromocytoma

ObjectiveTo improve the understanding of pheochromocytoma and provide references for the diagnosis and treatment of this disease through retrospective analysising of Clinical data of 40 cases of pheochromocytoma.MethodsRetrospective analysis of 40 patients of pheochromocytoma in the Department of Urology of the people’s Hospital of Zhengzhou University from August 2013 to February 2016. Among them,17 were male and 23 were female. Ages range from 19 to 72 years old, average 42.4±10.2 years old. Tumors of 37 cases are inside adrenal glands, including 20 cases of left side (54.1%),15 cases of right (40.5%),2 cases of bilateral (5.4%). The other 3 cases (7.5%) are Outside adrenal glands (1 cases of bladder wall,1 cases of posterior renal pedicle,1 cases of abdominal aorta). Tumor diameter ranged from 2.5 to 12cm, with an average of 5.64+3.02cm.The participants have a history of hypertension from 3 to 18 years, what’s more, routine examination of hematuria, liver and renal function, electrolyte, related hormone and bilateral adrenal ultrasonography, CT and magnetic resonance imaging were performed preoperation. All the surgeries were successfully completed, including laparoscopic surgery in 33 cases (82.5%), open surgery in 7 cases (17.5%). Preoperative preparation time was 12.01+3.43 days. The clinical features, diagnosis, preoperative preparation, surgical procedures, operative time, intraoperative blood loss, postoperative pathology were summarized and analyzed in our institution.Results(1) Hypertension is the most common clinical manifestation of pheochromocytoma, and symptoms like paroxysmal risen of blood pressure and heart palpitations, sudation, headache and so on should be given to the possibility of pheochromocytoma. Typical "triad" (palpitations, sweating, headache) in 4 cases (10%). Asymptomatic pheochromocytoma in 3 cases, were found out by accident as a physical examination.18 cases (45%) were complicated with diabetes or hyperglycemia. Serum creatine kinase isoenzyme (CKMB) was increased in 6 cases (15%). Preoperative underwent electrocardiogram, appear arrhythmia (including bradycardia tachycardia, arrhythmia, such as atrial fibrillation) in 16 cases (40%) and ST-T change in 13 cases (32.5%).(2) Free 3-methoxy-norepinephrine in plasma (NMN) higher than normal in 38 patients (95%),3-methoxy-epinephrine (MN) higher than normal in 26 patients (65%). Reviews were returned to nomal after one week of surgery. NMN normal reference value<160ng/L, MN normal reference value<90ng/L(3)40 cases were performed CT examination before operation, of which 10 cases were examined by MRI, the positive rate was 100%. Another 8 cases were examined by 131I-metaiodobenzylguanidine (131I-MIBG) and the results are all positive.(4)38 cases of patients were preoperatively prepared by the treatment of blood pressure of decompression and expansion and the time was 6～20 days, with an average of 11 days.2 patients without clinical symptoms and abnormal plasma NMN, MN preoperatively misdiagnosised as adrenal adenomas, without preoperative preparation of drugs, while the other 38 patients had different preoperative drug preparation according to the time sequence. The schema of first 20 cases (group A):2 ～6mg, oral, QN, Succinylated Gelatin Injection 500ml,0.9% Sodium Chloride Solution 500ml, intravenous drip, QD. The program of subsequent 18 cases (group B): 2～6mg, oral, QN. About 20% of the patients is not ideal due to blood pressure control, combined use of Nifedipine Controlled Release Tablets 30mg, oral, QD. Combined using of beta blockers when heart rate greater than 100 times/min. There were no significant differences in preoperative blood pressure levels, blood pressure fluctuation amplitude and postoperative blood pressure levels between A and B in two groups (P> 0.05). According to the presence or absence of intraoperative blood pressure fluctuations and volatility 40 cases of patients were divided into group C and D, which in group C (n= 22) in patients with blood pressure fluctuations or volatility is less than or equal to 20 mmHg; group D 18 cases of intraoperative blood pressure fluctuations> 20 mmHg. A comparative analysis of the factors affecting blood pressure fluctuations, including hypertension duration, tumor size and plasma NMN, MN levels are factors that affect blood pressure fluctuations.(5) The operations above were all successfully completed, of which 33 cases (82.5%) underwent laparoscopic surgery (26 cases retroperitoneal,7 cases of abdominal cavity),7 cases (17.5%) underwent open surgery. The 29 cases of tumor diameter< 6cm were performed in laparoscopic surgery, the 4 of the 11 cases of tumor diameter> 6cm were in laparoscopic operation.(6)Immunohistochemistry after operation:Adrenomedullin (ADM) has a positive rate of 60%(24/40); The positive rate of CgA was 82.5%(33/40), Syn positive rate was 70%(28/40), and the positive rate of S-100 protein was 52.5%(21/40).(7)The patients were followed up after operation for 3-24 months, with an average of 18 months. In 37 cases with hypertension,32 cases (86.5%) recovered to the normal level or significantly decreased above the normal level in 6 months after operation.In 18 cases with abnormal blood glucose,11 cases of which(61.1%)returned to normal after 6 months. Free NMN, MN in plasma were returned to normal 2 months after surgery. Recurrence occurred in 3 cases after 1 years, and two cases of them were malignant, the tumor volume was> 6cm.Conclusions(1) Hypertension is the most common clinical manifestation of pheochromocytoma, followed by is headaches, palpitations, sweating, elevated blood glucose, arrhythmia and ST-T changes in electrocardiogram, the typical triad occurred rate is very low, therefore, high blood pressure should be considered as pheochromocytoma, especially with headaches, palpitations, sweating, elevated blood glucose, arrhythmia and ST-T changes.(2) The clinical manifestations combining with plasma NMN, MN and CT, MRI 131I-MIBG examination are the main basis for diagnosis of pheochromocytoma; diagnostic doubts or suspected ectopic pheochromocytoma may be considered 131I-MIBG check,131I-MTBG re-examination is the main basis of qualitative and positional diagnosis for pheochromocytoma.(3)Alpha receptor blocking agent has a good effect of reducing blood pressure, and it is the basic medicine preparation before operation. Duration of hypertension, tumor size and plasma NMN, MN levels were the factors that affect the fluctuation of blood pressure during operation.(4) Surgery is the most effective treatment of pheochromocytoma, laparoscopic surgery has an obviously advantages in indicators concluding operative time, bleeding volume, postoperative drainage volume, operative hospitalization stay and so on compared with open surgery.(5) There is the possibility of malignant pheochromocytoma, for patients with tumor volume larger (diameter> 6cm) must be alert to and close follow-up, and tissue slice staining for benign and malignant tumors had no help.