Pheochromocytoma during Pregnancy: Laparoscopic and Conventional Surgical Treatment of Two Cases

Abstract

Pheochromocytoma is a rare entity. When it presents during pregnancy, rapid recognition and diagnosis are crucial in order to avoid the maternal and fetal morbidity and mortality associated with severe, uncontrolled hypertension. Difficulties arise from the differential diagnosis of pre-eclampsia. We report two patients operated on for pheochromocytoma during pregnancy. The first patient developed new-onset hypertension in early pregnancy. Prior to presentation, there had been non-specific signs of endocrine disorder, namely a mild diabetes, but no hypertension requiring medication. The second patient sought medical care for irregular heartbeat, shortness of breath, and fatigue during the 6th week of pregnancy. She was found to be hypertensive; diagnostic evaluation revealed substantially increased catecholamine levels. The diagnosis was made by elevated urinary catecholamines and by MRI scan as well as ultrasonography, both of which demonstrated an adrenal mass.

Both patients underwent surgical extirpation of the affected adrenal gland. The procedure was performed laparoscopically in the case of the second patient. Pre-operatively, both patients were pre-treated with α-blockade followed by secondary β-blockade. Patient two also received methyldopa for control of hypertension. Both patients were readily weaned from antihypertensive medications post-operatively, with complete resolution of hypertension within a few hours. Each pregnancy progressed normally to term.

Key words

Pheochromocytoma - pregnancy - pre-eclampsia - laparoscopy

References

• 1 Bailit J, Neerhof M. Diagnosis and managment of pheochromocytoma in pregnancy: A case report.  Am J Perinatol. 1998;  15 259-262
• 2 Botchan A, Hauser R, Kupfermine M, Grisaru D, Reuben Payser M, Lessing J B. Pheochromocytoma in pregnancy: Case report and review of the literature.  Obstet Gynecol Surv. 1995;  56 321-327
• 3 Demeure M J, Carlsen B, Traul D, Budney C, Lalande B, Lipinski A, Cruikshank D, Kotchen T, Wilson S. Laparoscopic removal of a right adrenal pheochromocytoma in a pregnant woman.  J Laparoendosc Adv Surg Tech A. 1998;  8 315-319
• 4 Fernandez-Cruz L, Taura P, Saenz A, Benarroch G, Sabater L. Laparoscopic approach to pheochromocytoma: Haemodynamic changes and catecholamine secretion.  World J Surg. 1996;  20 762-768
• 5 Finkenstedt G, Gasser R W, Hofle G, Lhotta K, Kolle D, Gschwendtner A, Janetschek G. Pheochromocytoma and subclinical Cushing's Syndrome during pregnancy: diagnosis, medical pre-treatment and cure by laparoscopic unilateral adrenalectomy.  J Endocrinol Invest. 1999;  22 551-557
• 6 Greene J P, Guay A T. New perspectives in pheochromocytoma. (Review).  Urol Clin North Am. 1989;  16 487-503
• 7 Harper M A, Murnaghan G A, Kennedy L, Hadden D R, Atkinson A B. Pheochromocytoma in Pregnancy. Five cases and a review of the literature.  Br J Obset Gynaecol. 1989;  96 594-606
• 8 Inabnet W B, Pitre J, Bernard D, Chapuis Y. Comparison of the hemodynamic parameters of open and laparoscopic adrenalectomy for pheochromocytoma.  World J Surg. 2000;  24 574-578
• 9 Janetschek G, Finkenstedt G, Gasser R, Waibel U G, Peschel R, Bartsch G, Neumann H PH. Laparoscopic surgery for pheochromocytoma: Adrenalectomy, partial resection, excision of paragangliomas.  J Urol. 1998;  160 330-334
• 10 Keely E. Pheochromocytoma in Pregnancy. Lee RV, Garner, PR, Barron WM et al. Current Obstetrics Medicine. Vol. 3. St Louis, MO, USA; Mosby-Year Book 1995: 73-94
• 11 Keely E. Enocrine causes of hypertension in pregnancy - when start locking for zebras.  Semin Perinatol. 1998;  22 471-484
• 12 Landsberg L, Young J B. Catecholamines and the adrenal medulla. Wilson JD, Foster DW Williams Textbook of Endocinology. 8th ed. Philadelphia, USA; Saunders 1992: 891-965
• 13 Lyons C W, Colmorgen G H. Medical management of pheochromocytoma in pregnancy.  Obstet Gynecol. 1988;  72 420-451
• 14 Manger T, Piatek S, Klose S, Kopf D, Kunz D, Lehnert H, Lippert H. Bilaterale laparoskopische transperitoneale Adrenalektomie beim Phaeochromocytom.  Langenbecks Arch Chir. 1997;  382 37-42
• 15 Mannelli M, Lanzillotti R, Ianni L, Pupilli C, Serio M. Dopaminergic modulation of human adrenal medulla: indirect evidence for the involvement of DA-2 receptors located on the chromaffin cells.  J Auton Pharmacol. 1990;  10 79-84
• 24 Martinez Brocca M A, Acosta Delgado D, Quijada D, Navarro Gonzalez E, Soto Moreno A, Gonzales Duarte D, del Valle Lopez de Ayala A, Astorga Jimenez R. Pheochromocytoma in a pregnant woman with multiple endocrine neoplasia type 2a.  Gynecol Endocrinol. 2001;  15 439-442
• 23 Neumann H P, Hoegerle S, Manz T, Brenner K, Iliopoulos O. How many pathways to pheochromocytoma?.  Semin Nephrol. 2002;  22 89-99
• 25 Pace D E, Chiasson P M, Schlachta C M, Mamazza J, Cadeddu M O, Poulin E C. Minimally invasive adrenalectomy for pheochromocytoma during pregancy.  Surg Laparosc Endosc Percutan Tech. 2002;  12 122-125
• 16 Potts J M, Larrimer J. Pheochromocytoma in a pregnant patient.  J Fam Pract. 1994;  22 1-10
• 17 Schenker J G, Granat M. Pheochromocytoma and pregnancy - an updated appraisal.  NZ J Obstet Gynaecol. 1982;  22 1-10
• 18 Sheps S G, Jiang N S, Klee G C. Diagnostic evaluation of pheochromocytoma.  Endocrinol Metab Clin North Am. 1988;  17 397-415
• 19 Simon D, Dotzenrath C, Röher H D. Endokrine Chirurgie in der Schwangerschaft.  Gynäkologe. 1990;  23 104-107
• 20 Takai Y, Seki H, Kinoshita K. Pheochromocytoma in pregnancy manifesting hypertensive crisis induced by metoclopramide.  Int J Gynecol Obstet. 1997;  59 133-137
• 21 Walz M K, Peitgen K, Walz M V, Hoermann R, Saller B, Giebler R M, Jockenhovel F. Posterior retroperitoneoscopic adrenalectomy: lessons learned within five years.  World J Surg. 2001;  25 728-734
• 22 Zuspan F P. Catecholamines. Their role in pregnancy and the development of pregnancy-induced hypertension.  J Reprod Med. 1979;  23 143-150