Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 68, Num. 3, 2006, pp. 163-164

Indian Journal of Surgery, Vol. 68, No. 3, May-June, 2006, pp. 163-164

Case Report

Pheochromocytoma: A composite resection

Sharma PradeepP

Bharati Vidyapeeth Medical College and Hospital (Deemed University), Dhankawadi, Pune - 411 040, Maharashtra
Correspondence Address:Pradeep P. Sharma, 6 and 7, Pramila Apartments, 93, Sahaney Sujan Park, Lullanagar, Pune - 411043, Maharashtra, India. E-mail: geetanjali-ip@eth.net

Code Number: is06045

Abstract

Keywords: Benign, composite resection, sporadic pheochromocytoma

Pheochromocytoma are rare adrenal tumors, with an incidence of about 1-2 cases per lakh population.[1] They account for 0.1 to 0.2% of all cases of hypertension.[2] Ten percent of these are malignant, 10% are bilateral, and 10% are found at extra-adrenal sites. They can occur sporadically, or are found as a part of familial multiple endocrine neoplasia (MEN syndrome).

I present herewith, a case of sporadic benign pheochromocytoma, which was resected completely by composite resection.

CASE REPORT

A 55 year old male patient presented to us with a mass in the right subcostal region. He carried a scar of previous surgery, which was performed in another hospital [Figure - 1].

Going through the records of the previous surgery, it was found that he was a case of sporadic pheochromocytoma in whom surgery was attempted. The lesion could not be resected due to large size, proximity to the IVC, and extremes of fluctuations in the BP intra-operatively. A biopsy was taken, and the surgery was terminated. He was then referred for MIBG (I-131- meta iodo benzyl guanidine) therapy. He underwent MIBG therapy, which obviously did not regress the tumor due to its large volume. He was then referred to us for the feasibility of surgery.

On examination, he was found to have a large mass in the right hypochondrium and the lumbar region. He was found to be persistently normotensive. There was no orthostatic hypotension. His urinary VMA levels were 24.5 units (our normal value is upto 7 units). Appropriate imaging by the CECT (contrast enhanced computerized tomography) was done, and the resectability was confirmed. He was prepared only with crystalloids for 72 hrs. No alpha or beta blockers were used, as he was found to be normotensive by his BP records.

Re-exploration was carried out through the old subcostal scar with extension on either sides. At laparotomy, he was found to have a large mass, which was densely adherent to the right kidney, fundus, and body of the gall bladder, and the inferior aspect of the right lobe of the liver. It was also densely adherent to the 2nd part of the duodenum. It was separated carefully from the IVC. Due to dense adhesions, it was only possible to separate it from the duodenum by subserosal dissection. Attempts to have a clear margin and dense adhesions made us resect it enbloc with the kidney, gall bladder, and non-anatomical resection of the inferior art of the right liver. There were no major fluctuations in the blood pressure throughout the surgery.

The specimen after removal, measured 17 x12 cms and weighed 850 gms. [Figure - 2]. The post-operative course was uneventful except hypotension which required Dopamine drip for 6 days. The final histopathology was Benign Pheochromocytoma. It is more than a year since surgery, and the patient is doing well, which goes in favor of its benign nature. His recent urinary VMA is well within normal range (4.3 mg per 24 hrs), and so are the recent scans of the renal bed.

DISCUSSION

Pheochromocytoma are catecholamine-secreting neoplasms with a clinical pattern, which can vary from completely asymptomatic (10%) to a sustained stable hypertension (50%), or to frequent life-threatening hypertensive crises (30%). Most of the patients present with the classical symptom triad of episodic headache, palpitations, diaphoresis, and a feeling of impending doom. Several series have reported that 19-76% of Pheochromocytomas are not diagnosed until after death.[3] The incidence of asymptomatic Pheochromocytoma as Incidentaloma, is 4.4 to 17 %.[1] Inability to noninvasively determine the malignant potential of the pheochromocytoma, crisis due to spontaneous hemorrhage / necrosis, and anesthesia- induction coupled with availability of potent alpha and beta blocker drugs to achieve a better hemodynamic control, have all shifted the trend towards surgical extirpation rather than expectant follow-up, once it is diagnosed. Advent of laparoscopy has added the element of minimal invasiveness, and can be used in some selected cases.[4]

This case was interesting due to the following reasons:

1. Large asymptomatic (normotensive) pheochromocytoma. 17 x 12 cms and weighed 850 gms. Usual Pheochromocytomas measure 5 to 6 cms and weigh upto 200 gms.
2. Required a composite resection due to dense adhesions with the contiguous organs like kidney, duodenum, gall bladder and the liver. These adhesions could be due to previous attempts at removal, and partly due to the radiation fibrosis as result of the MIBG therapy he received 6 month prior to this surgery.
3. Surgery after MIBG therapy.
4. No pre-operative blocker as the patient was normotensive, though the literature mentions the use of the alpha and beta adrenergic blockers.[5]

References

Copyright 2006 - Indian Journal of Surgery

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