Histopathological Analysis of Tumor Microenvironment and Angiogenesis in Pheochromocytoma.

Pheochromocytomas (PHEOs) are relatively rare catecholamine-producing tumors derived from adrenal medulla. Tumor microenvironment (TME) including neoangiogenesis has been explored in many human neoplasms but not necessarily in PHEOs. Therefore, in this study, we examined tumor infiltrating lymphocytes (CD4 and CD8), tumor associated macrophages (CD68 and CD163), sustentacular cells (S100p), and angiogenic markers (CD31 and areas of intratumoral hemorrhage) in 39 cases of PHEOs in the quantitative fashion. We then compared the results with pheochromocytoma of the adrenal gland scaled score (PASS), grading system for pheochromocytoma and paraganglioma (GAPP) and the status of intra-tumoral catecholamine-synthesizing enzymes (TH, DDC, and PNMT) as well as their clinicopathological factors. Intratumoral CD8 (p = 0.0256), CD31 (p = 0.0400), and PNMT (p = 0.0498) status was significantly higher in PHEOs with PASS <4 than PASS ≧4. In addition, intratumoral CD8+ lymphocytes were also significantly more abundant in well-than moderately differentiated PHEO according to GAPP score (p = 0.0108) and inversely correlated with tumor size (p = 0.0257). Intratumoral CD68+ cells were significantly higher in PHEOs with regular or normal histological patterns than those not (p = 0.0370) and inversely correlated with tumor size (p = 0.0457). The status of CD163 was significantly positively correlated with that of CD8 positive cells (p = 0.0032). The proportion of intratumoral hemorrhage areas was significantly higher in PHEOs with PASS ≧4 (p = 0.0172). DDC immunoreactivity in tumor cells was significantly positively correlated with PASS score (p = 0.0356) and TH status was significantly higher in PHEOs harboring normal histological patterns (p = 0.0236) and cellular monotony (p = 0.0219) than those not. Results of our present study did demonstrate that abundant CD8+ and CD68+ cells could represent a histologically low-scored tumor. In particular, PHEOs with increased intratumoral hemorrhage should be considered rather malignant. In addition, abnormal catecholamine-producing status of tumor cells such as deficient PNMT and TH and increased DDC could also represent more aggressive PHEOs.

From clinic to mechanism: Proteomics-based assessment of angiogenesis in adrenal pheochromocytoma.

Adrenal pheochromocytoma (PCC) is a very rare tumor that stems from chromaffin cells, which can develop into malignant tumor. During the operation, abundant blood vessels were often observed in PCC than other adrenal tumors, which increases the difficulty and risk of the surgery. Therefore, it is important to investigate the mechanism of PCC angiogenesis. Twelve surgical specimens of PCC from Ruijin Hospital, Shanghai Jiaotong University were grouped into high and low microvessel density (MVD) group. They were also divided into rich blood supply and nonenriched blood supply group, according to computed tomography (CT) manifestation. Comparative proteomic analysis based on liquid chromatography-tandem mass spectrometry (LC-MS/MS) and bioinformatics analysis revealed that 206 proteins differentially regulated in the high MVD group compared with low MVD group (p < 0.05). Besides, 61 proteins were discovered to be significantly changed when the 12 samples were grouped according to CT manifestation. By intersecting the differentially changed protein from MVD and CT grouping, 25 proteins were filtered out, with pathological function. COX4I2 was verified to be increased gradually with angiogenesis with increasing severity, and PLAT was shown to be decreased with angiogenesis in PCC, by quantitative reverse-transcription polymerase chain reaction and immunohistochemistry. The quantitative proteomics result indicated that the tumor angiogenesis in PCC is associated with hypoxia. COX4I2 and PLAT were highly correlated with blood supply in PCC which contribute to angiogenesis in PCC, which could be used as biomarkers to better indicate tumor angiogenesis, or targets to regress tumor angiogenesis as treatment.

Hipertensión arterial mal controlada secundaria a quiste vascular suprarenal / Vascular adrenal cyst causing difficult to control high blood pressure

La hipertensión arterial supone un importante problema de salud pública en los países desarrollados. Las masas suprarrenales pueden pasar desapercibidas, ya que no son lesiones frecuentes y no producen síntomas o no se les atribuyen directamente. Estas circunstancias hacen que sea fundamental la actuación médica multidisciplinar. Comunicamos el caso de una mujer de 72 años, hipertensa mal controlada de años de evolución (3 fármacos antihipertensivos, sin alcanzar la tensión arterial en rango de normalidad), remitida por hallazgo incidental de lesión retroperitoneal derecha. Se diagnostica de quiste de origen suprarrenal posiblemente responsable del cuadro hipertensivo. Realizamos revisión de la literatura analizando diferentes actitudes diagnósticas y terapéuticas. Tras adrenalectomía por abordaje laparoscópico, conseguimos estabilizar a la paciente en cifras de tensión arterial dentro de la normalidad. La integración coordinada de servicios médicos y quirúrgicos es clave para el manejo de situaciones clínicas poco frecuentes. La cirugía laparoscópica constituye el tratamiento de elección en la enfermedad retroperitoneal (AU)

Hypertension is a prevalent disease in developed countries. Adrenal masses, and especially adrenal cysts, are a rare and usually asymptomatic finding, which can go unnoticed or be detected as incidental findings in imaging tests. These circumstances make the multidisciplinary approach mandatory. The case is presented on a 72 year-old woman with uncontrolled high blood pressure referred to the Urology Department due to the incidental finding of a right retroperitoneal mass. A functional and imaging study was performed, establishing a diagnosis of adrenal cyst causing hypertensive symptoms. A literature search was performed in order to assess diagnostic and therapeutic approaches. With the diagnosis of adrenal cyst causing uncontrolled high blood pressure, a right laparoscopic adrenalectomy was performed. After surgery the patient has maintained blood pressure within the normal range. A multidisciplinary approach is necessary for the management of rare diseases. The surgical approach, if possible, should be laparoscopic (AU)

Preoperative adrenal artery embolization followed by surgical excision of giant hypervascular adrenal masses: report of three cases.

BACKGROUND: Transcatheter arterial embolization (TAE) is an effective minimally invasive adjunct to surgery for the management and/or palliation of adrenal tumors. METHODS: In this case study, we reported three patients who underwent preoperative TAE before adrenalectomy for large hypervascular adrenal tumors. All patients underwent preoperative embolization 24 h before the operation and were then followed up at the intensive care unit surgery. RESULTS: The largest diameter of the adrenal lesions ranged between 8 and 17 cm. Hypertensive attack occurred in one patient with pheochromocytoma during embolization. No other complications associated with the procedure was noted. The adrenal tumors were totally excised in all patients. The major intraoperative findings associated with preoperative embolization were marked reduction in hypervascularity and the decrease in the size of collateral vessels. No major hemorrhage necessitating blood transfusion were noted during surgery. CONCLUSIONS: Preoperative embolization of large hypervascular adrenal masses could reduce perioperative blood loss by reducing tumor vascularity.

Prevalence and clinical characteristics of adrenal incidentalomas in potential kidney donors.

BACKGROUND: The prevalence of adrenal incidentalomas (AIs) in asymptomatic individuals is unknown. This study evaluated the prevalence of AIs in healthy kidney donors in whom pre-operative computed tomography (CT) is performed routinely. METHODS: All potential kidney donors evaluated at the Rabin Medical Center who had routine abdominal CT were identified and their medical records were retrospectively reviewed. Subjects who had normal CT scans were compared with those with a finding of an AI, evaluating demographic (age, body mass index, systolic and diastolic blood pressure) and laboratory variables (glucose, sodium, potassium, calcium, phosphorus, albumin and creatinine). In addition, prevalence of hypertension, rate of donation and surgical mortality were compared between the two groups. RESULTS: CT was performed in 673 potential kidney donors. Of these, 645 had a normal CT and 28 (4.2%) had evidence of an AI. Those with AIs had a similar prevalence of hypertension, kidney donation and surgical mortality as those with a normal CT. Those with AIs were older (50.93 ± 11.1 versus 43.76 ± 11.1 years) but other demographic variables were similar; laboratory variables were also similar except for slightly lower albumin and creatinine in those with AIs. CONCLUSIONS: The prevalence of AIs is high even in healthy asymptomatic individuals.

Radiofrequency Ablation of Functioning Adrenal Adenomas: Preliminary Clinical and Laboratory Findings.

PURPOSE: To evaluate clinical and laboratory findings in patients undergoing radiofrequency (RF) ablation for functioning adrenal adenomas. MATERIALS AND METHODS: Eleven adult patients, nine with Conn syndrome and two with Cushing syndrome, underwent percutaneous computed tomography-guided RF ablation for benign adrenal neoplasms. Systolic, diastolic, and mean blood pressure and the number of classes of antihypertensive drugs used by each patient were analyzed before and 1, 4, and 12 weeks after the procedure. Serum hormone levels were analyzed within 30 days before and 12 weeks after the procedure. RESULTS: Of the nine patients with Conn syndrome, eight showed normal serum aldosterone levels after the procedure and one patient had a nodule located very close to the inferior vena cava, resulting in incomplete ablation. The two patients with Cushing syndrome had normal serum and salivary cortisol levels after the procedure. Mean aldosterone concentration at baseline was 63.3 ng/dL ± 28.0 and decreased to 13.3 ng/dL ± 13.5 at 12 weeks postoperatively (P = .008). Systolic, diastolic, and mean blood pressures decreased significantly in the first week after the procedure (P < .001) and remained stable during further follow-up. CONCLUSIONS: In patients with Conn syndrome or Cushing syndrome, percutaneous RF ablation of functioning adrenal adenomas may result in normalization of hormone secretion, improvement in blood pressure, and reduced need for antihypertensive drugs.

Reversing the established order: Should adrenal venous sampling precede cross-sectional imaging in the evaluation of primary aldosteronism?

BACKGROUND: Adrenal venous sampling (AVS) is the definitive evaluation for primary aldosteronism (PA). Pre-AVS cross-sectional imaging does not reduce the need for AVS. The goal of this study was to examine whether performing AVS prior to imaging could decrease the use of imaging in the evaluation of PA at a high volume, experienced center. METHODS: We performed a retrospective analysis of all AVS procedures (n = 337) done for PA from 2001-2013. Patients whose cross-sectional imaging reports were unavailable (n = 90) or AVS was non-diagnostic (n = 12) were excluded. AVS was performed using modified Mayo technique. Univariate analysis utilized the χ² test and fisher's exact test. RESULTS: Of the 235 patients analyzed, 63% (n = 148) were male. The mean age was 55 ± 11 years. AVS was non-lateralizing in 43% (n = 101); these patients might have avoided imaging with an AVS-first approach. Imaging and AVS were concordant in 52% (n = 123). In patients ≤40yo (n = 23), 35% (n = 8) had no lateralization on AVS, and might have avoided imaging in an AVS-first approach. Imaging and AVS were concordant in 52% (n = 12) of patients ≤ 40yo, versus 52% (n = 111) of patients > 40 yo (P = 0.987). CONCLUSION: An AVS-first, imaging-second approach could have avoided CT/MRI in 43% of patients. At a high volume, experienced center, performing AVS first on patients with PA may reduce unnecessary cross-sectional imaging studies.

Vascular pattern analysis for the prediction of clinical behaviour in pheochromocytomas and paragangliomas.

Pheochromocytomas (PCCs) are neuroendocrine tumors arising from chromaffin cells of the adrenal medulla. Related tumors that arise from the paraganglia outside the adrenal medulla are called paragangliomas (PGLs). PCC/PGLs are usually benign, but approximately 17% of these tumors are malignant, as defined by the development of metastases. Currently, there are no generally accepted markers for identifying a primary PCC or PGL as malignant. In 2002, Favier et al. described the use of vascular architecture for the distinction between benign and malignant primary PCC/PGLs. The aim of this study was to validate the use of vascular pattern analysis as a test for malignancy in a large series of primary PCC/PGLs. Six independent observers scored a series of 184 genetically well-characterized PCCs and PGLs for the CD34 immunolabeled vascular pattern and these findings were correlated to the clinical outcome. Tumors were scored as malignant if an irregular vascular pattern was observed, including vascular arcs, parallels and networks, while tumors with a regular pattern of short straight capillaries were scored as benign. Mean sensitivity and specificity of vascular architecture, as a predictor of malignancy was 59.7% and 72.9%, respectively. There was significant agreement between the 6 observers (mean κ = 0.796). Mean sensitivity of vascular pattern analysis was higher in tumors >5 cm (63.2%) and in genotype cluster 2 tumors (100%). In conclusion, vascular pattern analysis cannot be used in a stand-alone manner as a prognostic tool for the distinction between benign and malignant PCC, but could be used as an indicator of malignancy and might be a useful tool in combination with other morphological characteristics.

[FIRST EXPERIENCE OF APPLICATION OF TECHNOLOGY OF A TWO-STREAM LOW-FREQUENCY ULTRASOUND TECHNOLOGY IN ABDOMINAL SURGERY].

Biophysical peculiarities of action on tissues of a two-strem low-frequency ultrasound (TSLFU) technology, elaborated by "Arobella Medical LLC" (USA) firm, were studied. Capacity of ultrasound to separate a pathologically-changed and healthy tissues, to divide the structures in accordance to their bioacoustical parameters constitutes the technology peculiarities. The presence of such a biophysical effect permits to achieve high resectability (R0) in patients with oncological diseases. Antibacterial effect and stimulation of intraorgan microcirculation with ultrasound irradiation were noted. Biophysical peculiarities of TSLFU were successfully applied in surgical treatment of 48 patients, suffering inflammatory and oncological diseases of the abdominal cavity organs.

Both sunitinib and sorafenib are effective treatments for pheochromocytoma in a xenograft model.

Pheochromocytomas and paragangliomas are rare neuroendocrine tumors which develop from chromaffin cells of the adrenal medulla and extra-adrenal sites, leading to excess catecholamine release and hypertension. Many of the tumors are characterized by a high vascularity, suggesting the possible implementation of anti-angiogenic therapies for patients. Here, the efficacy of the tyrosine kinase inhibitors sunitinib and sorafenib was investigated in vivo and in vitro. Oral treatment with either sunitinib or sorafenib (40mg/kg/day) for 14days induced a marked reduction in the volume and weight of PC12 pheochromocytoma cell tumor xenografts in mice. Assessment of tumoral neo-angiogenesis, assessed by morphometric analysis of the vascular network after CD31 immunolabeling, showed that both sunitinib and sorafenib reduced the microvessel area (-85% and -80%, respectively) and length (-80% and -78%, respectively) in treated compared to control tumors. In addition, the number of vessel nodes was significantly lower in treated tumors (-95% and -84%, respectively). Furthermore, cleaved caspase 3 immunolabeling revealed a marked increase in the number of apoptotic cells in tumors from treated animals. Sunitinib and sorafenib could exert a direct effect on PC12 cell viability in vitro. While sunitinib induced a rapid (4h) and pronounced (5-fold) increase in caspase-3/7-dependent apoptosis, sorafenib seems to exert its cytotoxic activity through a different mechanism. Altogether, our data demonstrate that sunitinib and sorafenib have the ability to impair pheochromocytoma development by inhibiting angiogenesis and reducing tumor cell viability. These results strongly suggest that both sunitinib and sorafenib could represent valuable therapeutic tools for pheochromocytoma.

Vascular skeletalization: a new concept to improve the resection rate in childhood neuroblastoma.

AIM: The surgical resection rate in childhood neuroblastoma (Stage III and IV) is relatively low and influences the prognosis greatly. This study analyzes the primary resection rate neuroblastoma in children. METHODS: The tumors are shrunk with pre-operative chemotherapy and surgical resection beginning from the iliac vessels is performed to skeletalize the large retroperitoneal vascular. Using this method, 22 cases of childhood neuroblastoma received resections and the outcomes were analyzed. RESULTS: The tumors were completely removed in 21 out of the 22 cases (95.45% in total). There were no serious complications and perioperative deaths. CONCLUSION: Using proper surgical methods and skeletalizing the large retroperitoneal vessels significantly increases the resection rate.

Role of VEGF-A and its receptors in sporadic and MEN2-associated pheochromocytoma.

Pheochromocytoma (PHEO), a rare catecholamine producing tumor arising from the chromaffin cells, may occurs sporadically (76%-80%) or as part of inherited syndromes (20%-24%). Angiogenesis is a fundamental step in tumor proliferation and vascular endothelial growth factor (VEGF-A) is the most well-characterized angiogenic factor. The role of angiogenic markers in PHEO is not fully understood; investigations were therefore made to evaluate the expression of VEGF-A and its receptors in PHEO and correlate to clinical parameters. Twenty-nine samples of PHEO were evaluated for VEGF-A, VEGF receptor-1 (VEGFR-1) VEGFR-2 expression and microvessel density (MVD) by immunohistochemistry. Clinical data were reviewed in medical records. The mean age of patients was 38±14 years, and 69% were woman. VEGF-A, VEGFR-1 and VEGFR-2 staining were detected in nearly all PHEO samples. No significant correlation was observed between VEGF-A, VEGFR-1, VEGFR-2 expression or MVD and age at diagnosis, tumor size or sporadic and hereditary PHEO. However, the levels of expression of these molecules were significantly higher in malignant PHEO samples (p=0.027, p=0.003 and p=0.026, respectively).VEGF-A and its receptors were shown to be up-regulated in malignant PHEO, suggesting that these molecules might be considered as therapeutic targets for unresectable or metastatic tumors.

Interferon alpha and rapamycin inhibit the growth of pheochromocytoma PC12 line in vitro.

INTRODUCTION: Pheochromocytomas are benign or malignant neuroendocrine tumours. The unsatisfactory efficacy of the traditional therapeutic methods for patients with metastatic disease results in a continuing search for more effective and targeted agents. Due to the increased vascularisation of these tumours, inhibitors of angiogenesis could be potentially a new group of drugs in pheochromocytoma/paraganglioma therapy. MATERIAL AND METHODS: The aim of this study was to evaluate the influence of angiomodulators: VEGF (vascular endothelial growth factor) and five endogenous and exogenous antiangiogenic compounds (endostatin; IFN-alpha [interferon alpha]; rapamycin - mTOR [mammalian target of rapamycin] inhibitor; JV1-36 and SU5416 (semaxinib]) on the growth of rat pheochromocytoma PC12 cell line. RESULTS: IFN-alpha (10(5) U/mL) strongly inhibited PC12 growth in a 72 h culture, increasing apoptosis and arresting the cell cycle. Rapamycin in a wide range of concentrations (10(-5) to 10(-8) M) induced a slight inhibitory effect on PC12 viability and decreased cell proliferation at the concentration of 10(-5) M. VEGF, endostatin and JV1-36 did not influence the growth of PC12. CONCLUSIONS: The study has shown for the first time that IFN-a inhibited the growth of pheochromocytoma PC12 line and confirmed the inhibitory action of rapamycin on these cells. The results suggest that IFN-alpha and mTOR inhibitors could be potentially effective in the therapy of malignant pheochromocytoma, and encourage further study in this field.

Embolization of anomalous vessels in tumor formation.

Embolotherapy or embolization has rapidly developed in recent years and now represents an integral part of interventional radiology practice. Embolotherapy is defined as the percutaneous endovascular application of one or more of a variety of agents or materials to accomplish vascular occlusion. Embolization has grown dramatically in scope and complexity over the past three decades, and with this growth, there is now a need to define standards for those practicing in this field, including: appropriate training with monitoring of outcomes; provision of pre-, intra-, and postprocedure patient care; and performance of the technical aspects of the procedure. We present 58 patients from clinic of Vascular Surgery and Angiology at "St. Ekaterina" University Hospital. After four abnormal nutrition artery embolization in two consecutive procedure due to recurrences formation of adrenal tumor.

Clinical outcomes in children with adrenal neuroblastoma undergoing open versus laparoscopic adrenalectomy.

BACKGROUND: Laparoscopic resection of adrenal neuroblastoma has become a common alternative to open surgery. Prior reports have largely focused on short-term operative complications. This study compares long-term oncologic outcomes in children undergoing laparoscopic or open adrenalectomy for neuroblastoma. METHODS: Seventy-nine patients at a single center met inclusion criteria for having adrenal neuroblastoma and undergoing operative resection. Patients were assigned to high or low/intermediate (L/I) risk groups based upon Children's Oncology Group (COG) trial enrollment. Criteria for laparoscopic resection were absence of vascular encasement and size ≤ 5 cm in greatest dimension. Comparison between open versus laparoscopic groups was performed by Wilcoxon ranked-sum and Fisher's exact test. Multivariate Cox proportional hazard models analyzed the primary outcomes of mortality and recurrence. RESULTS: In the L/I risk category (N=30) there was one non-neuroblastoma related death in the open cohort. Six of 7 patients in the High risk Group who underwent laparoscopic resection had favorable outcomes. Only higher tumor stage (Hazard Ratio 8.455, P=0.01) and earlier tumor recurrence were associated with increased mortality (Hazards Ratio 0.932, P=0.0002). Among patients who met selection criteria for laparoscopic surgery there was no difference in mortality or recurrence rates between High risk and L/I risk. CONCLUSIONS: Laparoscopic resection of adrenal neuroblastoma is feasible and can be performed with equivalent recurrence and mortality rates in L/I risk patients and selected High risk patients. These data suggest that laparoscopic resection of adrenal neuroblastoma should be considered in patients who meet selection criteria, irrespective of risk group categorization.

Adrenal venous catecholamine concentrations in patients with adrenal masses other than pheochromocytoma.

The aim of this study was to retrospectively examine adrenal venous catecholamine concentrations and related indices in non-pheochromocytoma patients and to estimate from the obtained results whether measurements of adrenal venous catecholamine concentrations by adrenal venous sampling (AVS) are useful for localizing adrenal pheochromocytoma. The study population comprised 15 patients in whom AVS was performed for evaluation of adrenal non-pheochromocytoma masses (primary aldosteronism, n = 8; Cushing syndrome, n = 5; non-hyperfunctioning tumor, n = 2) without hormonal intervention and was successful in bilaterally judging adrenal vein to infra-renal inferior vena cava cortisol ratios as >3.0. Wide ranges of catecholamine concentrations were seen for both right (epinephrine, 35-175,821 pg/ml; norepinephrine, 115-32,102 pg/ml; dopamine, 9-232 pg/ml) and left (epinephrine, 16-27,251 pg/ml; norepinephrine, 155-9,267 pg/ml; dopamine, 5-234 pg/ml) adrenal veins. High- to low-side adrenal vein concentration ratios also showed wide ranges of up to 779 for epinephrine, 22.5 for norepinephrine, and 7.8 for dopamine. Adrenal venous catecholamine concentrations obtained by AVS and simple comparisons between bilateral adrenal veins might not be useful to localize adrenal pheochromocytoma, as wide variations in concentrations and high- to low-side adrenal vein concentration ratios were noted in patients with adrenal non-pheochromocytoma.