Endocrine Abstracts

A 42-year-old man from Colchester was referred to our endocrinology service in January 2023. He was having abdominal pain for a year, unresponsive to a trial of PPI. He was also found to have hypertension for one year which was controlled by Amlodipine. An ultrasound organised by his GP revealed gallstones and a substantial right supra-adrenal mass, leading to a referral to the local urology team. Subsequently, CT scan was performed which characterised as a likely phaeochromocytoma, measuring 9 × 8 cm. He has a history of well-controlled asthma and idiopathic Bell’s palsy. He has a family history of hypertension. He does not smoke but drinks occasionally. He experienced sporadic episodes of elevated blood pressure, palpitations, tremors, and anxiety. He was seen by local endocrinologist and checked urine normetadrenaline which was >49500 pmol/l, consistent with phaeochromocytoma. He was started on Doxazosin. Clinical examination was unremarkable and no evidence of other endocrine dysfunction. His plasma metanephrine results revealed metanephrine 490 pmol/l(0-510 pmol/l), normetanephrine 21220 pmol/l(0-1180 pmol/l), and 3-Methoxytyramine less than 75 pmol/l(0-180 pmol/l). He was initiated on phenoxybenzamine at St Bartholomew’s Hospital and the dose was titrated as an outpatient. He underwent a preoperative NM DMSA scan revealing normal divided renal function. While awaiting elective surgery, he faced recurrent episodes of high blood pressure, palpitations, and anxiety, necessitating local A&E visits. Phenoxybenzamine dose was up titrated gradually, along with cautious low-dose beta-blockade to control symptoms and blood pressure. He underwent an uneventful open right adrenalectomy in April 2023. Plasma metanephrines was normalised postoperatively and follow up MRI showed no residual or recurrent disease. Histological examination revealed a favourable tumour profile with Ki-67 less than 1%, and germ line testing for 13 key predisposition genes indicated no mutations.

Discussion: We present this case to highlight a careful titration of alpha and beta blockade in managing phaeochromocytoma and the significance of preoperative assessments in optimising surgical outcomes.