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What initial medical treatment would you start ? and why ?

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  1. 1. pheochromocytoma Kholoud Alharbi King Faisal University
  2. 2. Case B 36 year old woman is seen at the outpatient clinic because of intermittent high blood pressure. She complains about periodic sweating and panic attacks. there is intermittent tremor, palpitation and elevated blood pressure. During these attacks blood pressure is 210/110
  3. 3. Objective What initial medical treatment would you start ? and why
  4. 4. Treatment is surgical excision of the tumor, following preoperative treatment of hypertension, which is usually curative (unless metastatic)
  5. 5. Treatment Options for Patients With Pheochromocytoma Pheochromocytoma Standard Treatment Options Localized Pheochromocytoma Surgery Regional Pheochromocytoma Surgery Metastatic Pheochromocytoma Surgery Palliative therapy Recurrent Pheochromocytoma Surgery Palliative therapy
  6. 6. Preoperative Medical Preparation • Alpha-adrenergic blockade • should be initiated at the time of diagnosis and maximized preoperatively to prevent potentially life-threatening cardiovascular complications, which can occur as a result of excess catecholamine secretion during surgery.  Complications may include the following: • Hypertensive crisis. • Arrhythmia. • Myocardial infarction. • Pulmonary edema.
  7. 7. Phenoxybenzamine (a nonselective alpha-antagonist) is the usual drug of choice prazosin, terazosin, and doxazosin (selective alpha-1- antagonists) are alternative choices Prazosin, terazosin, and doxazosin are shorter acting than phenoxybenzamine The duration of postoperative hypotension is theoretically less than with phenoxybenzamine • A preoperative treatment period of 1 to 3 weeks is usually sufficient
  8. 8. • If tachycardia develops or if blood pressure control is not optimal with alpha-adrenergic blockade • a beta-adrenergic blocker (e.g., metoprolol or propranolol) can be added but only after alpha-blockade. • Beta-adrenergic blockade must never be initiated before alpha-adrenergic blockade
  9. 9. Sodium nitroprusside and phentolamine ( rapid acting alpha blocker ) should be available in cases sudden sever hypertension develops. Propranolol 120-240 mg daily Treatment Phenoxybenzamine ( 20 -80 mg daily initially in divide doses ) Common side effects include headache, palpitation, orthostatic hypotension and tachycardia
  10. 10. surgery • Laparoscopic surgery is being used more often for tumors smaller than 6 than 6 cm but for larger tumors, an an open operation is probably safer. safer. • Both anterior transabdominal laparoscopic adrenalectomy as well well as posterior retroperitoneoscopic retroperitoneoscopic adrenalectomy adrenalectomy have been demonstrated to be safe for the majority of patients with a modestly modestly sized.
  11. 11. Surgical outcome and post-operative follow-up  Following surgical removal of Pheochromocytoma 80% of patients are expected to become normotensive.  Around 20% of patients will remain hypertensive without biochemical evidence of residual tumor, however, due to associated essential hypertension or due to acquired renovascular changes.  Plasma catecholamine or urinary metanephrines should be measured two weeks after surgery. If the biochemical tests are still diagnostically high, residual or metastatic tumor should be suspected.  Plasma catecholamines or urinary metanephrines should be measured every three months for the first year and then annually even in normotensive patients.
  12. 12. Summary:  Alpha blockade with phenoxybenzamine is started at least 7 to 10 days before operation to allow for expansion of blood volume.  Only once this is achieved is beta blockade considered. If beta blockade is started too soon, unopposed alpha stimulation can precipitate a hypertensive crisis.  Laparoscopic surgery is being used more often for tumors smaller than 6 cm but for larger tumors, an open operation is probably safer.
  13. 13. References http://www.cancer.gov/cancertopics/pdq/treatment/pheochromocytoma/HealthProfessional/page 4 http://emedicine.medscape.com/article/124059-medication http://www.ncbi.nlm.nih.gov/books/NBK7002/ Clinical medicine KUMAR book