Extraadrenal Pheochromocytoma: A Rare Cause of Tachycardia and Hypertension During Percutaneous Biopsy

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Extraadrenal Pheochromocytoma: A Rare Cause of Tachycardia and Hypertension During Percutaneous Biopsy

Tejas Dalal, Michael M. Maher, Mannudeep K. Kalra and Peter R. Mueller

Massachusetts General Hospital and Harvard Medical School Boston, MA 02114

We report the case of a 75-year-old man who presented to thehospital with a 2-month history of slurred speech, right handincoordination, and gait instability. His medical history wasnotable for hypertension, myocardial infarction, and congestiveheart failure, with an ejection fraction of 16%. Contrast-enhancedCT of the head on admission revealed enhancing left parietal,right cerebellopontine angle, and temporoparietal masses, findings thatwere consistent with metastatic disease. CT scans of the chest,abdomen, and pelvis were obtained in an attempt to identifythe primary tumor. Chest CT showed multiple lung nodules, consistentwith metastatic disease. An enhancing 2.0 x 1.5 cm right retrocavallesion was seen and was assumed to be a lymph node (Fig. 1A).In addition, abdominal CT showed a 6.8 x 6.4 cm cystic massabutting the left lobe of the liver, consistent with a duplicationcyst of the duodenum.

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Fig. 1A —75-year-old man who underwent biopsy and was subsequently found to have unsuspected retroperitoneal extraadrenal pheochromocytoma. Abdominal CT scan shows enhancing 2.0 x 1.5 cm right retrocaval lesion (arrow).

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Fig. 1B —75-year-old man who underwent biopsy and was subsequently found to have unsuspected retroperitoneal extraadrenal pheochromocytoma. Scan obtained during CT-guided biopsy performed with patient in right lateral decubitus position confirms satisfactory needle position in lesion.

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Fig. 1C —75-year-old man who underwent biopsy and was subsequently found to have unsuspected retroperitoneal extraadrenal pheochromocytoma. Graph shows patient's mean arterial pressure ( ${blacksquare}$ ) and heart rate ( ${diamondsuit}$ ) during biopsy procedure.

Interventional radiology was consulted regarding percutaneousbiopsy. Review of the abdominopelvic and chest CT scans suggestedthat the retrocaval lesion was most accessible for percutaneousbiopsy, with the lowest risk for procedural complications. CT-guidedretroperitoneal biopsy was performed with the patient in theright lateral decubitus position under conscious sedation withmidazolam (2 mg) and fentanyl (150 µg). A 17-gauge Temnoneedle (Coaxial Temno Biopsy System, Allegiance Healthcare)was introduced in increments into the lesion. Once CT confirmedthe needle tip to be in the lesion, fine-needle aspirates wereobtained through the Temno needle using a 22-gauge Chiba needle(Cook). Subsequently, 18-gauge core biopsies were taken (Fig. 1B).After the initial fine-needle aspiration, the patient immediatelybecame hypertensive and tachycardic (Fig. 1C). During this time,he was optimally sedated and was not experiencing proceduralpain, chest pain, shortness of breath, or dizziness. The tachycardiaand hypertension persisted, and the procedure was terminatedafter the second core biopsy. The cause of sudden onset of hypertensionin a patient who was optimally sedated was unclear, but a possiblecause was thought to be that the biopsied lesion representedan extraadrenal pheochromocytoma rather than a lymph node.

The location of the lesion made an extraadrenal pheochromocytomaunlikely because most are located in the organ of Zuckerkandl.However, the enhancement of the retrocaval lesion on the preproceduralCT scan supported our clinical suspicions of extraadrenal pheochromocytoma.The patient was taken to the recovery area, where his tachycardiaand hypertension persisted, and a cardiologist was consulted.Hypertension settled after the administration of oral metoprolol(25 mg). Pathology showed a paraganglioma with atypia.

To our knowledge, this is the first reported case of a hypertensiveepisode occurring during biopsy of an unsuspected retroperitonealextraadrenal pheochromocytoma. When patients become hypertensiveand tachycardic during a biopsy procedure, the usual cause ispain resulting from inadequate sedation [1]. When the patientis adequately sedated, other causes such as pheochromocytomashould be considered. Consideration of an extraadrenal pheochromocytomaas the cause of this event precipitated early termination ofthe procedure and appropriate medical consultation. Moreover,this case illustrates the importance of close monitoring ofthe blood pressure in all patients during and after interventionalradiology procedures [2].

References

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References

Casola G, Nicolet V, vanSonnenberg E, et al. Unsuspected pheochromocytoma: risk of blood pressure alterations during percutaneous adrenal biopsy. Radiology 1986;159 : 733–735[Abstract/Free Full Text]
Mueller PR, Wittenberg KH, Kaufman JK, Lee MJ. Patterns of anesthesia and nursing care for interventional radiology procedures: a national survey of physician practices and preferences. Radiology 1997;202 : 339–343[Abstract/Free Full Text]