Excision of an Extra-adrenal Pheochromocytoma after Pre-operative Treatment with Amlodipine and Lisinopril
Leif Dahleen, M.D., Steven Robicsek, M.D.,Ph.D.
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
Standard pre-operative treatment for pheochryocytoma excision has
historically consisted of 10-14 days of alpha-adrenergic blockade combined
with beta-adrenergic blockade if necessary. Several studies and case reports
have questioned the necessity of this pre-operative treatment regimen. This
case report describes the perioperative and intraoperative management of a
45 year old man with an extra-adrenal pheochromocytoma who received no alpha
or beta blockade prior to the day of surgery.
The patient, a 45 year old male, presented to his primary physician with
vague abdominal pain. His past medical history included hypertension,
hypercholesterolemia, and prostatitis. Review of systems revealed that the
patient suffered from headaches, hot flashes, night sweats and unstable
mood. After referral to a gastroenterologist, a CT scan was performed, and
the patient was diagnosed with a left renal hilum mass suspicious for
paraganglioma. Labaratory investigation included a 24 hour urine collection
which showed markedly elevated urine catecholamines. A needle aspirate
biopsy revealed a neuroendocrine tumor without atypia, consistent with an
extra-adrenal pheochromocytoma.
The patient was referred to our hospital for surgical treatment of this
mass. An MRI was done, showing a bilobed, left periaortic mass, partially
encasing the left renal vein and artery. The patient’s hypertension had been
treated for several years with the ACE inhibitor lisinopril, which was
continued. Ten days prior to surgery, the calcium channel blocker amlodipine
was added.
The patient was admitted to the hospital and evaluated by anesthesiology the
evening before surgery. Following discussion with the surgical team, and a
literature search, the decision was made to proceed with the operation.
The patient was premedicated with lorazepam and phentolamine and an arterial
line was placed prior to induction. Induction was achieved with sodium
thiopental, rocuronium, fentanyl and esmolol. Maintenance anesthesia
consisted of inhaled isoflurane, fentanyl and vecuronium. The patient’s
blood pressure was controlled by titrating nitroprusside and esmolol
infusions, with intermittent phentolamine boluses. The patient received
ample crystalloid, colloid fluids and the cell saver was utilized. The
patient tolerated the operation well, with moderate blood pressure lability
occurring only with significant tumor manipulation. The mass was excised,
along with the left kidney, which could not be salvaged. The patient was
admitted to a close observation unit for 24 hours, then transferred to the
general surgical ward. He had an uneventful post-operative course and was
discharged to home on post-operative day 7. He was normotensive and taking
no anti-hypertensive medications upon discharge.
Our experience in this case indicated that the standard preoperative alpha
blockade may not be necessary. While there is no strong evidence that
calcium channel blockade has advantages over alpha blockade as preoperative
therapy, literature exists to support it as a reasonable alternative.
