Perioperative hemodynamics and outcomes of patients on metyrosine undergoing resection of pheochromocytoma or paraganglioma

Butz, James J; Weingarten, Toby N.; Cavalcante, Alexandre N.; Bancos, Irina; Young, William F.; McKenzie, Travis J.; Schroeder, Darrell R.; Martin, David P.; Šprung, Juraj

doi:10.1016/j.ijsu.2017.08.026

Cited by 22 publications

(23 citation statements)

References 16 publications

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“…The majority of our patients were pretreated with α-adrenergic blockade, but despite that we still observed large hemodynamic oscillations during ablations. This is consistent with previous observations that preoperative adrenergic blockade cannot entirely eliminate intraoperative hemodynamic oscillations in these patients [ 13 , 15 , 16 ]. In our series, 1 patient was admitted to the ICU after ablation for treatment of severe hypertension despite the fact that he received comprehensive preoperative adrenergic blockade (Table 5 ).…”

Section: Discussionsupporting

confidence: 93%

“…Exceptions to the use of blockade are nonsecretory parasympathetic-derived skull base and neck PPGLs [ 18 ]. The details of our protocol used before surgical resection have been previously reported [ 13 , 15 , 16 ]. Our practice for preablation preparation of patients with metastatic PPGL lesions includes administering the same adrenergic blocking agents that are used for the surgical resection of a primary PPGL [ 19 ].…”

Section: Methodsmentioning

confidence: 99%

“…However, despite adrenergic receptor blockade, hemodynamic volatility is still frequently observed [ 13 , 14 ]. We recently reported hemodynamic oscillations during open and laparoscopic operations of PPGL [ 15 , 16 ]; however, we lack the knowledge regarding the extent of hemodynamic fluctuations during ablation of extra-adrenal PPGL metastases. In this study, we aim to describe intraprocedural hemodynamics for patients with nonfunctional and functional metastatic PPGL lesions, and their periprocedural outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Hemodynamic instability during percutaneous ablation of extra-adrenal metastases of pheochromocytoma and paragangliomas: a case series

et al. 2018

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BackgroundSurgical manipulation of pheochromocytomas and paragangliomas (PPGLs) may induce large hemodynamic oscillations due to catecholamine release. Little is known regarding hemodynamic instability during percutaneous ablation of PPGLs. We examined intraprocedural hemodynamic variability and postoperative complications related to percutaneous ablation of extra-adrenal metastases of PPGL.MethodsFrom institutional PPGL registry we identified patients undergoing ablation of extra-adrenal PPGL metastases from January 1, 2000, through December 31, 2016. We reviewed medical records for clinical characteristics and hospital outcomes. Tumors were categorized as functional or nonfunctional based on preprocedural fractionated catecholamine and metanephrine profiles.ResultsTwenty-one patients (14 female [67%]) underwent 38 ablations. Twenty-four ablations were performed in patients with functional metastatic lesions, and 14 were in nonfunctional lesions. Intraprocedural use of potent vasodilators for hypertension was higher for patients with functional tumors (P = 0.02); use of vasopressors for hypotension was similar for functional and nonfunctional tumors (P = 0.74). Mean (±SD) intraprocedural blood pressure range (maximum–minimum blood pressure) during 38 procedures was greater for functional than nonfunctional tumors [systolic: 106 (±48) vs 64 (±30) mm Hg, P = 0.005; diastolic: 58 (±22) vs 35 (±14) mm Hg, P = 0.002; mean arterial: 84 (±43) vs 47 (±29) mm Hg, P = 0.007]. Complications included 5 unplanned intensive care unit admissions (3 for precautionary monitoring, 1 for recalcitrant hypotension, and 1 for hypertensive crisis), 1 case of postoperative bleeding, and 1 death.ConclusionsSubstantial hemodynamic instability may develop during ablation of functional and nonfunctional PPGL metastases. When anesthesia is provided for ablation of metastatic PPGLs in radiology suites, preparation for hemodynamic management should match standards used for surgical resection.

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Section: Discussionsupporting

confidence: 93%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Hemodynamic instability during percutaneous ablation of extra-adrenal metastases of pheochromocytoma and paragangliomas: a case series

et al. 2018

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“…It was shown that urine MNs have been reduced for at least 50% from baseline after the administration of metyrosine ( 45 , 46 ). Although Butz et al reported that patients treated with metyrosine and pheoxybenzamine had wider range of intraoperative blood pressure variations than phenoxybenzamine-only patients ( 47 ), it has been reported by most studies that the combination of metyrosine and α-AR antagonists lead to better blood pressure control, decreased intraoperative blood loss, and reduced volume replacement during operation compared with the classical method of monotherapy of α-AR blockade ( 45 , 46 , 48 , 49 ). In a case report of a patient with PPGL, the administration of metyrosine alone was unable to satisfactorily control intraoperative blood pressure ( 50 ), which was probably due to the incomplete depletion of CA stores no matter what dose used.…”

Section: Ca Synthesis Inhibitormentioning

confidence: 99%

Preoperative Management of Pheochromocytoma and Paraganglioma

Fang

Ding

et al. 2020

Front. Endocrinol.

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Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, characterized by excessive release of catecholamines (CAs), and manifested as the classic triad of headaches, palpitations, profuse sweating, and a variety of other signs and symptoms. The diagnosis of PPGL requires both evidence of excessive release of CAs and anatomical localization of CA-secreting tumor. Surgery is the mainstay of treatment for all patients with PPGL unless contraindicated. However, without proper preparation, the release of excessive CAs, especially during surgery, can result in lethal cardiovascular complications. Herein, we briefly reviewed the pathogenesis of this disease, discussed the current approaches and evidence available for preoperative management, summarizing the results of the latest studies which compared the efficacies of preoperative management with or without a adrenergic-receptor antagonists, aiming to facilitate better understanding of the preoperative management of PPGL for the physicians.

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“…This results in a reduction of circulating catecholamine levels by 50% to 80% (53). The initial oral dose is usually 250 mg 3 times a day, which may gradually be increased to a maximum daily dose of 4 g. In general, metyrosine is prescribed in combination with an α-adrenergic receptor blocker, in particular phenoxybenzamine [54][55][56]. A few case reports suggested that monotherapy with metyrosine is less effective (57,58).…”

Section: Alternatives To α-Adrenergic Receptor Blockersmentioning

confidence: 99%

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

Berends

Kerstens

Lenders

et al. 2020

The Journal of Clinical Endocrinology &Amp; Metabolism

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Abstract Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally the areas of uncertainty and controversies in this field are addressed.

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Perioperative hemodynamics and outcomes of patients on metyrosine undergoing resection of pheochromocytoma or paraganglioma

Cited by 22 publications

References 16 publications

Hemodynamic instability during percutaneous ablation of extra-adrenal metastases of pheochromocytoma and paragangliomas: a case series

Hemodynamic instability during percutaneous ablation of extra-adrenal metastases of pheochromocytoma and paragangliomas: a case series

Preoperative Management of Pheochromocytoma and Paraganglioma

Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma

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