Endocrine Abstracts

Introduction: Pheochromocytoma is a rare catecholamine-secreting tumour that commonly arises from the adrenal medulla. In addition to the episodic cardiovascular complications leading to severe hemodynamic disturbances perioperatively, it has been increasingly recognised that catecholamine-related cardiomyopathy is a life-threatening condition. Our case highlights the complexities and risks involved in the perioperative management of adrenalectomy.

Case Report: A 60-year-old man had a finding of a large mass with central cystic necrosis measuring 9.0/8.4/8.2 cm involving the left adrenal gland after presenting with a CAP. Further investigations showed raised plasma metanephrines (metanephrine at a maximum of 12707 pmol/l and normetanephrine at 48024 pmol/l) to confirm the diagnosis of pheochromocytoma. During preparation for surgery, the patient suffered an acute embolic infarct in the right temporoparietal region and subsequent haemorrhagic transformation. He was then readmitted with shortness of breath, ankle swelling and pulmonary oedema. An echocardiogram showed severe left ventricular dysfunction with an EF of 18%; his BNP was 604pg/ml. A diagnosis of catecholamine induced cardiomyopathy (CICMP) with severe left ventricular failure was made.

Discussion: Surgical excision was deemed the only option and co-ordinated efforts between specialities were made to prepare the patient for surgery. His predicted P-POSSUM scores for mortality and morbidity were 10.2% and 77.9% respectively. Pharmacological preparation required a fine balance between pheochromocytoma, LVF and stroke management as an inpatient. Once optimised, the patient had a successful open left adrenalectomy. Since surgery, the patient has remained symptom free and repeat plasma metanephrines eight weeks post operatively showed normal levels.

Conclusion: Whilst surgery remains the definitive treatment for pheochromocytoma, it is accompanied by significant risks, particularly in the presence of CICMP, LVF and recent stroke. Careful pre-operative assessment and preparation by multi-disciplinary teams prior to theatre are essential to reduce the incidence of mortality and morbidity associated with this challenging condition.