Endocrine Abstracts

Malignant pheochromocytomas (MP) are rare form of catecholamine-producing tumours that are usually associated with tachycardia, hypertension and diaphoresis. MP are typically diagnosed by symptoms, elevated catecholamine levels and characteristic radiological imagining. Metastases to the vertebrae are extremely rare and usually appear at late stage of the disease, sometimes years after the diagnosis. Backpain as a first manifestation of MP is unusual, especially with history of stable adrenal mass described as adenoma. A 44-year-old male patient was admitted to endocrinology clinic in November 2023 because of backpain since March 2023. Previously patient sought help at least 3 times at neurologists because of increasing backpain (VAS 9/10) and paraesthesia. He was treated for sciatica. The lumbar spine MRI was prescribed in October – in L1 vertebrae large pathological mass causing spinal canal narrowing with nerve compression and pathological mass of right adrenal gland 64x50mm. Patient was scheduled for neurosurgical decompression, which was cancelled due to pheochromocytoma suspicion, eventually confirmed in vertebral mass biopsy. One-day clinic endocrinological assessment proved elevated chromogranin, catecholamines in evaluation. Patient had a history of stable 15mm right adrenal gland tumour described as adenoma. Due to the backpain worsening and being bedridden the patient was admitted to our endocrinology clinic. He negated any pheochromocytoma symptoms. Elevation of serum normetanephrine was confirmed. In FDG-PET scan – right adrenal gland tumour with infiltration of inferior vena cava (IVC) and metastases to L1 vertebrae, sacrum, left VII rib, Th1 vertebrae and IV liver segment. Somatostatin analogue (SSA) scintigraphy described primary tumour 84x56mm with metastases in previously found sites and at least 9 more lytic lesions in bones – ribs, vertebrae, skull and pelvic bones, which were not visible in FDG-PET scan. SSA was administered. Patient was transferred to neurosurgery clinic – decompression with carbon implant placement was performed. Then, the patient was admitted to general surgery department –right adrenalectomy with a 130mm-tumour infiltrating the IVC and liver metastasectomy was conducted. The PRRT is scheduled for January 2024. For the time being the patient is walking and without severe pain. The clinical presentation of MP might be atypical and not associated with catecholamine overproduction. It should be remembered that first symptoms might derive from the mass of the metastasis. The treatment of patients with MP needs to be multidisciplinary and requires various and sometimes not standardized approaches. The patient’s quality of life must be the most important goal during planning all diagnostic and therapeutic procedures.