pituitrin and Pheochromocytoma

The perioperative management of pheochromocytomas requires meticulous anesthetic care. There has been considerable progress in its management, recently 3 agents that may be particularly advantageous to the anesthetic team have been identified. Magnesium sulfate is readily available, cheap, safe, and effective for hemodynamic control before tumor resection. It has demonstrated efficacy in adults, children, and in rarer scenarios, such as pheochromocytoma resection in pregnancy and in pheochromocytoma crises. Although only recently entering clinical practice, clevidipine exhibits a pharmacologic profile of great interest, showing efficacy in the management of hypertensive crisis and providing rapid titration and precise hemodynamic control. Its application in the perioperative management of pheochromocytoma before tumor resection recently has been described and likely will expand in the near future. Vasopressin has demonstrated utility in the management of catecholamine-resistant shock after tumor resection. A familiarity with these 3 agents offers anesthesia providers further effective pharmacologic options for managing the hemodynamic challenges inherent to this population before and after tumor resection.

Topics: Adrenal Gland Neoplasms; Anti-Arrhythmia Agents; Combined Modality Therapy; Hemodynamics; Humans; Magnesium Sulfate; Perioperative Care; Pheochromocytoma; Postoperative Complications; Pyridines; Vasoconstrictor Agents; Vasopressins

Topics: Adrenal Gland Neoplasms; Aldosterone; Angiotensin II; Catecholamines; Diagnosis, Differential; Humans; Hyperaldosteronism; Hypertension; Kinins; Natriuretic Agents; Pheochromocytoma; Potassium; Prostaglandins; Renin; Serotonin; Vasopressins

The effects of clonidine on renal hemodynamics and renal function make it a particularly useful antihypertensive agent. During treatment of hypertensive patients with clonidine, renal blood flow and glomerular filtration rate are well maintained, and renin secretion is reduced. Early in therapy, a slight tendency to retain salt and water may be seen as blood pressure is lowered. This effect on salt and water excretion is usually transient and may be avoided if a diuretic is used concomitantly. No deterioration of renal function was noted in patients with primary hypertension who were treated with clonidine for periods from 6 months to at least 5 years. The drug is effective in patients with renal hypertension with or without renal failure and well tolerated. Clonidine is also effective in hypertensive patients undergoing chronic hemodialysis, but doses may have to be reduced because the drug is excreted chiefly by the kidney.

Topics: Adrenal Gland Neoplasms; Aldosterone; Antihypertensive Agents; Catecholamines; Clonidine; Humans; Hypertension; Kidney; Kidney Diseases; Pheochromocytoma; Renal Artery Obstruction; Sympathetic Nervous System; Vasopressins; Water-Electrolyte Balance

A variety of cells found in the pituitary and pineal glands, sympathetic nervous system and adrenal glands, the gut, pancreas, thyroid (C-cells), chemoreceptors (type I-Cells), lungs (P-cells), skin (melanocytes) and the urogenital tract have a common origin from the neural crest. These cells are programmed for neuro-endocrine function and, as a group, can be regarded as one of the physiological control systems. They secrete a variety of amine and peptide hormones and have common cytochemical characteristics from which the term APUD cell is derived. Tumours of these cells are referred to as 'apudomas' and may synthesise not only their own hormones but also those which are normally produced by other APUD cells. The relevant physiological properties of some of the peptides which have been described relatively recently are discussed and the principal clinical syndromes produced by the APUDomas are described.

Topics: Adenoma, Islet Cell; APUD Cells; Apudoma; Cushing Syndrome; Endocrine System Diseases; Gastrointestinal Neoplasms; Hormones; Humans; Malignant Carcinoid Syndrome; Neoplasms, Nerve Tissue; Pancreatic Neoplasms; Paraneoplastic Endocrine Syndromes; Pheochromocytoma; Pituitary Neoplasms; Thyroid Neoplasms; Vasopressins; Zollinger-Ellison Syndrome

A patient presented with multiple unrelated tumors and was found to have a small but functional adrenal pheochromocytoma. After pheochromocytoma resection, shock developed unresponsive to vasopressin in recommended doses (0.04 U/min infusion plus repeated 1-U boluses) but responded dramatically to an angiotensin II infusion (20 ng/kg/min) with a mean arterial pressure >100 mm Hg. The patient's blood pressure was maintained for 42 hours postoperatively with an infusion rate that ranged from 2 to 38 ng/kg/min. Because vasopressin may not always be effective for postresection shock in people with pheochromocytomas, angiotensin II may prove to be an effective alternative.

Topics: Adrenal Gland Neoplasms; Angiotensin II; Blood Pressure; Female; Humans; Middle Aged; Pheochromocytoma; Shock, Surgical; Treatment Outcome; Vasopressins

The perioperative management of pheochromocytoma is challenging for anesthesiologists and persistent hypotension secondary to cathecholamine depletion after tumor resection can be refractory to treatment. A 64-year-old man underwent right adrenalectomy for treatment of massive pheochromocytoma. Doxazosin administration was started and increased gradually to 12 mg daily. He was premedicated with doxazosin on the day of the surgery. Induction was uneventful but there was a sudden increase of blood pressure with tachycardia on handling of tumor which was controlled by intravenous remifentanil, landiolol, diltiazem, and magnesium sulfate. With dissection of the tumor, the blood pressure dropped to 65/40 mmHg, which was resistant to fluid and cathecholamine treatment. After commencement of low dose vasopressin administration (two boluses of 0.08 U followed by 1.6 U x hr(-1)), blood pressure gradually recovered to normal ranges. Low dose vasopressin can be safely used to treat postadrenalectomy hypotension and also can reduce the cathecholamine dose.

Topics: Adrenal Gland Neoplasms; Adrenalectomy; Catecholamines; Drug Resistance; Humans; Hypotension; Male; Middle Aged; Pheochromocytoma; Postoperative Complications; Vasopressins

Topics: Adrenal Gland Neoplasms; Catecholamines; Child; Humans; Hypotension; Intraoperative Complications; Male; Pheochromocytoma; Vasoconstrictor Agents; Vasopressins

Topics: Adrenal Gland Neoplasms; Humans; Hypotension; Male; Middle Aged; Norepinephrine; Pheochromocytoma; Vasopressins

Topics: Adrenal Gland Neoplasms; Child; Humans; Hypotension; Male; Phenoxybenzamine; Pheochromocytoma; Vasopressins

Topics: Adrenal Gland Neoplasms; Catecholamines; Humans; Male; Middle Aged; Pheochromocytoma; Shock; Vascular Diseases; Vascular Resistance; Vasopressins

A patient undergoing excision of phaeochromocytoma developed refractory hypotension which was complicated by significant intraoperative blood loss. Cardiovascular support with fluids, blood and noradrenaline failed to reverse the hypotension. Introduction of vasopressin successfully reversed the hypotension. The experience with this case suggests that vasopressin may be a useful adjunct in the treatment of catecholamine-resistant hypotension after phaeochromocytoma excision.

Topics: Adrenal Gland Neoplasms; Aged; Humans; Hypotension; Intraoperative Complications; Male; Norepinephrine; Pheochromocytoma; Postoperative Complications; Vasoconstrictor Agents; Vasopressins

Topics: Adrenal Gland Neoplasms; Child; Humans; Male; Pheochromocytoma; Vasopressins

We describe a case of Cushing's syndrome caused by a phaeochromocytoma secreting corticotrophin-releasing hormone (CRH) and corticotrophin (ACTH). A 49-year-old white woman presented with a 1-month history of lower limb oedema, polydipsia and polyuria. Physical examination revealed a patient with plethoric facies, lanugo-type facial hair, central obesity, red abdominal striae, lower limb oedema, and blood pressure of 210/115 mmHg. Laboratory studies showed high plasma ACTH and markedly elevated urinary cortisol excretion that suppressed more than 50% with high-dose dexamethasone administration. Computed tomographic scan of the abdomen showed a 4-cm left adrenal tumour. Catecholamines and metabolites were markedly increased in a 24-hour urine collection. Results of venous catheterization studies showed that CRH and ACTH were secreted by the tumour. In addition, with ovine CRH administration, inferior petrosal sinus sampling showed pituitary secretion of ACTH. Left adrenalectomy resulted in complete remission of Cushing's syndrome. Light microscopic and immunohistochemical studies revealed a phaeochromocytoma that produced CRH, ACTH and vasopressin. RNA studies showed that this tumour, in contrast to normal adrenal and other reported phaeochromocytomas, transcribed a lone pituitary-sized (1200 nucleotide) pro-opiomelanocortin mRNA. This is the second reported case of a CRH-secreting phaeochromocytoma.

Topics: Adrenal Gland Neoplasms; Adrenocorticotropic Hormone; Blotting, Northern; Corticotropin-Releasing Hormone; Cushing Syndrome; Female; Humans; Middle Aged; Pheochromocytoma; Pro-Opiomelanocortin; RNA; Vasopressins

Ten patients with pheochromocytoma were examined before operation, 8 were examined 2-4 weeks after surgical treatment, and 30 in the long-term periods after elimination of hypercatecholaminemia. The patients with pheochromocytoma manifested activation of the renin-aldosterone system and inhibition of PGE2 secretion. In the long-term postoperative period, the level of aldosterone in the blood plasma was increased and that of PGE2 was reduced. In the patients with pheochromocytoma, the interrelation was discovered between the magnitude of arterial blood pressure and secretion of catecholamines, deoxycorticosterone, depressor prostaglandins. At different times after surgical treatment the central hemodynamics was found to be related to the level of mineralocorticoid hormones.

Topics: Adrenal Gland Neoplasms; Aldosterone; Blood Pressure; Catecholamines; Desoxycorticosterone; Hemodynamics; Hormones; Humans; Mineralocorticoids; Pheochromocytoma; Prostaglandins; Vasopressins

The presence of functional receptors for human atrial natriuretic hormone in human pheochromocytomas was recently reported. The present study reports the binding of hANH as measured by Scatchard analysis in 4 human adrenal glands and in 5 human pheochromocytomas. Binding assays using [3H]ANH revealed a single class of high-affinity binding sites for hANH in both tissues. Human pheochromocytomas present a lower number of binding sites than normal human adrenal gland (Bmax of 7.1 +/- 2.1 vs 33.6 +/- 6.9 fmol/mg protein, respectively). However, the decreased number of ANH receptors was not paralleled by modifications of tissular cyclic GMP (cGMP). Moreover, plasma hANH concentrations in 7 patients with pheochromocytomas (20.2 +/- 2.7 pmol/l) were statistically higher than those obtained in 25 normal control humans (8.1 +/- 0.6 pmol/l, p less than 0.001). We also demonstrated the presence of immunoreactive ANH in the tumour itself.

Topics: Adrenal Gland Neoplasms; Adrenal Glands; Aldosterone; Angiotensin II; Atrial Natriuretic Factor; Binding, Competitive; Chromatography, Ion Exchange; Cyclic GMP; Desoxycorticosterone; Dopamine; Humans; Neuropeptide Y; Pheochromocytoma; Receptors, Atrial Natriuretic Factor; Receptors, Cell Surface; Vasopressins

Topics: Abdominal Neoplasms; Angiotensin II; Blood Pressure; Child; Humans; Hypertension, Renal; Hypertension, Renovascular; Male; Nephrectomy; Pheochromocytoma; Saralasin; Vasopressins

Ectopic production of polypeptide hormones by tumors of nonendocrine tissues can serve as a clue to diagnosis of the tumor and as a focus for management of the patient with cancer. In the differential diagnosis of syndromes of endocrine hyperfunction, the ectopic hormone syndromes have achieved an increasingly prominent position. Available evidence on the properties of ectopic ACTH, MSH, parathyroid hormone, erythropoietin, gonadotropins, and thyrotropin is consistent with the unifying hypothesis of genetic derepression.

Topics: Abdominal Neoplasms; Adenocarcinoma; Adrenocortical Hyperfunction; Brain Neoplasms; Carcinoma, Bronchogenic; Carcinoma, Hepatocellular; Carcinoma, Small Cell; Cysts; Diagnosis, Differential; Fibroma; Hemangiosarcoma; Humans; Hyperparathyroidism; Hypoglycemia; Kidney Diseases; Kidney Neoplasms; Liver Neoplasms; Lung Neoplasms; Paraneoplastic Endocrine Syndromes; Pheochromocytoma; Polycythemia; Sarcoma; Thoracic Neoplasms; Vasopressins

Topics: Carcinoid Tumor; Cushing Syndrome; Humans; Hyperthyroidism; Hypoglycemia; Neoplasms; Pheochromocytoma; Polycythemia; Puberty; Puberty, Precocious; Sexual Maturation; Vasopressins