Phaeochromocytoma—views on current management

Aims: To evaluate the current investigation and management of phaeochromocytoma. Methods: Retrospective analysis of patients who underwent surgical excision of phaeochromocytoma in the Department of Endocrine Surgery at the University Hospital of Wales, Cardiff. Forty-seven patients (24 female and 23 males) were studied. Preoperative diagnosis was established by measurement of urinary catecholamines (HMMA, metadrenalines, and fractionated catecholamines). Tumour localisation was achieved by using ultrasound, CT, MRI and MIBG scintigraphy. Preoperative medical preparation and control of hypertension was achieved in the majority of cases by alpha adrenergic blockade with phenoxybenzamine and the beta blocker propranol. Surgery was performed by a variety of approaches which included laparotomy, posterior extraperitoneal and laparoscopic methods. All patients were followed up post-operatively in a surgical endocrine clinic. Results: Seventy percent of patients presented with hypertension but only 21.3% gave a history of paroxsmal hypertension. CT scanning and MRI proved to be the most sensitive localisation investigations. Excellent preoperative control of hypertension was achieved with alpha adrenergic blockade but induction of anaesthesia, rather than tumour handling was noted to be associated with most hypertensive surges of blood pressure. There was a zero 30 day post-operative mortality but 10 complications of surgery occurred in 8 patients (21.3%). Cure of hypertension was achieved in 80% of patients. Attempts to perform cortex sparing procedures in patients with familial disease and multiple tumours was not successful in the long term. Conclusions: Surgical excision of phaeochromocytoma is a procedure, which can be performed with zero mortality and a low morbidity resulting in a high cure rate for hypertension. Adequate preoperative pharmacological control of hypertension is mandatory. Localisation techniques permit a focussed approach with increasing use of laparoscopy. Those patients with familial disease and those with multiple tumours pose particular management challenges. For an optimum and satisfactory outcome a planned multidisciplinary approach is required.