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Incidentally detected inoperable malignant pheochromocytoma with hepatic metastasis treated by transcatheter arterial chemoembolization.

Kim JK, Kim BH, Baek SM, Shin DH, Kim WJ, Jeon YK, Kim SS, Kim IJ - Endocrinol Metab (Seoul) (2014)

Bottom Line: He had undergone right adrenalectomy in May 2005 and PCC had been confirmed on the basis of histopathological findings.Thus, TACE was performed instead.After TACE, symptoms including dizziness and cold sweating improved, and the patient's serum catecholamine levels decreased.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.

ABSTRACT
Malignant pheochromocytoma (PCC) is a rare condition. Although the liver is the second most frequent site of metastasis in malignant PCC, no definite treatments have been established. Herein, we report a case of liver metastasis of PCC that was successfully treated by transcatheter arterial chemoembolization (TACE). A 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. He had undergone right adrenalectomy in May 2005 and PCC had been confirmed on the basis of histopathological findings. Liver biopsy was performed, and metastatic PCC was diagnosed. The lesion appeared inoperable because of invasion of the portal vein and metastases in the lymph nodes along the hepatoduodenal ligament. Thus, TACE was performed instead. After TACE, symptoms including dizziness and cold sweating improved, and the patient's serum catecholamine levels decreased. On the basis of this case, we believe that TACE may be a useful treatment for liver metastasis in malignant PCC.

No MeSH data available.


Related in: MedlinePlus

Transcatheter arterial chemoembolization (TACE). (A) The hepatic mass was stained in the celiac angiogram. An emulsion of 10 mL of lipiodol and 50 mg of doxorubicin was injected. (B) The tumor was well lipiodolized, as observed by post-TACE imaging. Abdominal computed tomography scans taken (C) 2 weeks and (D) 7 months after TACE revealed partial lipiodol uptake and necrotic changes in the center of the liver mass. The size of the mass (white arrow) had decreased to 8.3 cm.
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Figure 3: Transcatheter arterial chemoembolization (TACE). (A) The hepatic mass was stained in the celiac angiogram. An emulsion of 10 mL of lipiodol and 50 mg of doxorubicin was injected. (B) The tumor was well lipiodolized, as observed by post-TACE imaging. Abdominal computed tomography scans taken (C) 2 weeks and (D) 7 months after TACE revealed partial lipiodol uptake and necrotic changes in the center of the liver mass. The size of the mass (white arrow) had decreased to 8.3 cm.

Mentions: A 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. In 2005, he had been admitted to the Department of Endocrinology because of cold sweating, facial flushing, and uncontrolled blood pressure. A ~7 cm right adrenal mass had been observed on computed tomography (CT) and there had been no distant metastasis on an MIBG scan. The patient had undergone laparoscopic right adrenalectomy due to PCC. After surgery, he had been followed up in the outpatient clinic until 2007. During that period, there was no evidence of metastasis in abdominal CT. The patient had also been treated for hypertension and type 2 diabetes mellitus for 3 years and had a history of coronary stent insertion for non-ST-elevation myocardial infarction in March 2012. At admission to the Department of Gastroenterology, he experienced dizziness, diaphoresis, general weakness, and poor oral intake; his blood pressure was 130/80 mm Hg and his heart rate was 78 bpm. Contrast-enhanced abdominal CT and magnetic resonance imaging (MRI) were performed. They revealed a ~10 cm hepatic mass in the right lobe of the liver that had a high signal intensity on T2-weighted images and early arterial enhancement and delayed washout on dynamic contrast-enhanced images. Also, it had a low signal intensity on the hepatobiliary phase and high cellularity on the diffusion phase (Fig. 1). The hepatic mass was considered to be hepatocellular carcinoma rather than malignant PCC. For these reasons, liver biopsy was performed to evaluate the incidental hepatic mass. The patient was given the α-adrenergic antagonist phenoxybenzamine to prevent a hypertensive crisis before biopsy because we could not completely rule out the possibility of metastatic PCC. However, during and after the liver biopsy, his vital signs were stable. PCC was finally confirmed on the basis of morphological and immunohistochemical findings, with the specimens staining positive for chromogranin A and synaptophysin. Laboratory tests revealed the following serum metabolite levels on the day of admission: aspartate aminotransferase, 29 IU/L (normal, 10 to 40); alanine aminotransferase, 24 IU/L (normal, 6 to 40); alkaline phosphatase, 97 IU/L (normal, 40 to 129); total bilirubin, 0.42 mg/dL (normal, 0.1 to 1.2); direct bilirubin, 0.16 mg/dL (normal, 0.09 to 0.30); and γ-glutamyltranspeptidase (GGT), 150 IU/L (normal, 11 to 73). These levels, obtained by performing a liver function test, were all in the normal ranges, except for the mild elevation of GGT. Hepatitis virus markers were negative and tumor markers for hepatocellular carcinoma (α-fetoprotein and protein induced by vitamin K absence or antagonist II) were in the normal ranges. Furthermore, at admission we measured the patient's serum/urine levels of catecholamines, which were as follows: serum epinephrine, 0.078 pg/mL (normal, <50); serum norepinephrine, 1.473 pg/mL (normal, 110 to 410); serum metanephrine, 2.47 nmol/L (normal, <0.5); serum normetanephrine, 44.97 nmol/L (normal, <0.5); 24-hour urine epinephrine, 43.8 µg (normal, 0 to 20 µg/day); 24-hour urine norepinephrine, 339 µg (normal, 12.1 to 85.5 µg/day); 24-hour urine metanephrine, 35.931 mg (normal, 0.0 to 1.3 mg/day); and 24-hour urine vanillylmandelic acid, 120 mg (normal, 1.20 to 6.52 mg/day). The total urine volume collected in one day was 1,900 mL, and contained 1,171.16 mg of creatinine. The serum and 24-hour urine catecholamine levels were high. An 131I-MIBG scan revealed increased uptake of 131I-MIBG in the right adrenal gland bed and adjacent liver parenchyma (Fig. 2). Surgical resection was impossible because the tumor had invaded the portal vein and the adjacent lymph nodes. Therefore, we planned radionuclide therapy. However, the isolated ward needed for that was not available for at least 6 weeks. Finally, TACE was performed for the liver metastasis. Celiac angiography showed a large mass in the right lobe of the liver. An emulsion of 10 mL of lipiodol and 50 mg of doxorubicin (an anticancer drug) was injected (Fig. 3A). The tumor was well lipiodolized, as observed by post-TACE imaging (Fig. 3B).


Incidentally detected inoperable malignant pheochromocytoma with hepatic metastasis treated by transcatheter arterial chemoembolization.

Kim JK, Kim BH, Baek SM, Shin DH, Kim WJ, Jeon YK, Kim SS, Kim IJ - Endocrinol Metab (Seoul) (2014)

Transcatheter arterial chemoembolization (TACE). (A) The hepatic mass was stained in the celiac angiogram. An emulsion of 10 mL of lipiodol and 50 mg of doxorubicin was injected. (B) The tumor was well lipiodolized, as observed by post-TACE imaging. Abdominal computed tomography scans taken (C) 2 weeks and (D) 7 months after TACE revealed partial lipiodol uptake and necrotic changes in the center of the liver mass. The size of the mass (white arrow) had decreased to 8.3 cm.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4285037&req=5

Figure 3: Transcatheter arterial chemoembolization (TACE). (A) The hepatic mass was stained in the celiac angiogram. An emulsion of 10 mL of lipiodol and 50 mg of doxorubicin was injected. (B) The tumor was well lipiodolized, as observed by post-TACE imaging. Abdominal computed tomography scans taken (C) 2 weeks and (D) 7 months after TACE revealed partial lipiodol uptake and necrotic changes in the center of the liver mass. The size of the mass (white arrow) had decreased to 8.3 cm.
Mentions: A 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. In 2005, he had been admitted to the Department of Endocrinology because of cold sweating, facial flushing, and uncontrolled blood pressure. A ~7 cm right adrenal mass had been observed on computed tomography (CT) and there had been no distant metastasis on an MIBG scan. The patient had undergone laparoscopic right adrenalectomy due to PCC. After surgery, he had been followed up in the outpatient clinic until 2007. During that period, there was no evidence of metastasis in abdominal CT. The patient had also been treated for hypertension and type 2 diabetes mellitus for 3 years and had a history of coronary stent insertion for non-ST-elevation myocardial infarction in March 2012. At admission to the Department of Gastroenterology, he experienced dizziness, diaphoresis, general weakness, and poor oral intake; his blood pressure was 130/80 mm Hg and his heart rate was 78 bpm. Contrast-enhanced abdominal CT and magnetic resonance imaging (MRI) were performed. They revealed a ~10 cm hepatic mass in the right lobe of the liver that had a high signal intensity on T2-weighted images and early arterial enhancement and delayed washout on dynamic contrast-enhanced images. Also, it had a low signal intensity on the hepatobiliary phase and high cellularity on the diffusion phase (Fig. 1). The hepatic mass was considered to be hepatocellular carcinoma rather than malignant PCC. For these reasons, liver biopsy was performed to evaluate the incidental hepatic mass. The patient was given the α-adrenergic antagonist phenoxybenzamine to prevent a hypertensive crisis before biopsy because we could not completely rule out the possibility of metastatic PCC. However, during and after the liver biopsy, his vital signs were stable. PCC was finally confirmed on the basis of morphological and immunohistochemical findings, with the specimens staining positive for chromogranin A and synaptophysin. Laboratory tests revealed the following serum metabolite levels on the day of admission: aspartate aminotransferase, 29 IU/L (normal, 10 to 40); alanine aminotransferase, 24 IU/L (normal, 6 to 40); alkaline phosphatase, 97 IU/L (normal, 40 to 129); total bilirubin, 0.42 mg/dL (normal, 0.1 to 1.2); direct bilirubin, 0.16 mg/dL (normal, 0.09 to 0.30); and γ-glutamyltranspeptidase (GGT), 150 IU/L (normal, 11 to 73). These levels, obtained by performing a liver function test, were all in the normal ranges, except for the mild elevation of GGT. Hepatitis virus markers were negative and tumor markers for hepatocellular carcinoma (α-fetoprotein and protein induced by vitamin K absence or antagonist II) were in the normal ranges. Furthermore, at admission we measured the patient's serum/urine levels of catecholamines, which were as follows: serum epinephrine, 0.078 pg/mL (normal, <50); serum norepinephrine, 1.473 pg/mL (normal, 110 to 410); serum metanephrine, 2.47 nmol/L (normal, <0.5); serum normetanephrine, 44.97 nmol/L (normal, <0.5); 24-hour urine epinephrine, 43.8 µg (normal, 0 to 20 µg/day); 24-hour urine norepinephrine, 339 µg (normal, 12.1 to 85.5 µg/day); 24-hour urine metanephrine, 35.931 mg (normal, 0.0 to 1.3 mg/day); and 24-hour urine vanillylmandelic acid, 120 mg (normal, 1.20 to 6.52 mg/day). The total urine volume collected in one day was 1,900 mL, and contained 1,171.16 mg of creatinine. The serum and 24-hour urine catecholamine levels were high. An 131I-MIBG scan revealed increased uptake of 131I-MIBG in the right adrenal gland bed and adjacent liver parenchyma (Fig. 2). Surgical resection was impossible because the tumor had invaded the portal vein and the adjacent lymph nodes. Therefore, we planned radionuclide therapy. However, the isolated ward needed for that was not available for at least 6 weeks. Finally, TACE was performed for the liver metastasis. Celiac angiography showed a large mass in the right lobe of the liver. An emulsion of 10 mL of lipiodol and 50 mg of doxorubicin (an anticancer drug) was injected (Fig. 3A). The tumor was well lipiodolized, as observed by post-TACE imaging (Fig. 3B).

Bottom Line: He had undergone right adrenalectomy in May 2005 and PCC had been confirmed on the basis of histopathological findings.Thus, TACE was performed instead.After TACE, symptoms including dizziness and cold sweating improved, and the patient's serum catecholamine levels decreased.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea.

ABSTRACT
Malignant pheochromocytoma (PCC) is a rare condition. Although the liver is the second most frequent site of metastasis in malignant PCC, no definite treatments have been established. Herein, we report a case of liver metastasis of PCC that was successfully treated by transcatheter arterial chemoembolization (TACE). A 69-year-old man was admitted to the Department of Gastroenterology for evaluation of an incidental hepatic mass in August 2013. He had undergone right adrenalectomy in May 2005 and PCC had been confirmed on the basis of histopathological findings. Liver biopsy was performed, and metastatic PCC was diagnosed. The lesion appeared inoperable because of invasion of the portal vein and metastases in the lymph nodes along the hepatoduodenal ligament. Thus, TACE was performed instead. After TACE, symptoms including dizziness and cold sweating improved, and the patient's serum catecholamine levels decreased. On the basis of this case, we believe that TACE may be a useful treatment for liver metastasis in malignant PCC.

No MeSH data available.


Related in: MedlinePlus