It Is Not a Metastasis; It Is Phaeochromocytoma

Abstract

Phaeochromocytoma has diverse clinical manifestations and in some cases can be asymptomatic. We report a case of intraoperative hypertensive crisis in a patient with ovarian carcinoma. An adrenal mass was identified by computed tomography scan but not investigated further; it was assumed that to be a metastatic lesion from the ovarian cancer. The patient was normotensive. The only diagnostic clue was left ventricular hypertrophy on electrocardiography. Biochemical screening for phaeochromocytoma should always be performed for any adrenal mass and attention should be paid to any diagnostic clues. Key Words: phaeochromocytoma, hypertensive crisis, adrenal metastasis, left ventricular hypertrophy, electrocardiography (The Endocrinologist 2005;15: 279 -280) P haeochromocytoma can be clinically silent during life with up to 50% diagnosed postmortem. 1 Some patients can present with complications of hypertension, eg, stroke, myocardial infarction, or left ventricular failure. 2,3 Trauma, surgery, and pharmacologic agents can provoke phaeochromocytoma and cause hypertensive crisis (Table 1). CASE REPORTAn 81-year-old woman suspected of having bilateral ovarian neoplasms was admitted to the hospital for elective laparotomy. Preoperative computed tomography (CT) imaging showed bilateral ovarian neoplasms and a 6-cm right adrenal mass. The patient was previously well without symptoms or signs that indicated a possible catecholamine-secreting tumor. The only positive finding was electrocardiographic evidence of left ventricular hypertrophy (LVH). The patient was not investigated further, and the adrenal mass was assumed to be a metastatic lesion from the ovarian neoplasm. The patient developed cardiovascular crisis peri-and postoperatively with blood pressure levels exceeding 289/140 mm Hg, necessitating intravenous clonidine, labetalol, and nitroprusside. She recovered postoperatively and her blood pressure remained within normal limits. Investigations into a possible phaeochromocytoma were instigated. No adrenoblocking regimes were initiated because her blood pressure was now within normal limits and stable. She was discharged. However, she was readmitted 4 days later through the emergency department with a simple mechanical fall and radialulnar fracture. She underwent internal fixation under general anesthesia and experienced another hypertensive crisis. Postoperative recovery was stormy with acute renal failure and frequent and severe hypertensive episodes. Biochemical diagnosis of phaeochromocytoma was confirmed. Twenty-fourhour urinary-free catecholamine excretion was markedly elevated, and she was started on phenoxybenzamine and proprandol. She improved quickly and her blood pressure was controlled. The patient declined further investigations and surgical removal of the adrenal tumor. She remained stable on medical treatment.