Anaesthetic Management of Recurrent extra-adrenal Pheochromocytoma

Abstract

A 47 year old female, presented with uncontrolled hypertension while evaluvating for elective myomectomy for fibroid uterus. She gave a past history of pheochromocytoma for which she underwent right adrenalectomy.Now,she was diagnosed of recurrent   para-aortic pheochromocytoma and optimized with T.propranolol,T.prasozin and T.amlodipine.After adequate preoptimization was taken up forsurgery.Haemodynamically stable during tumor manipulation and following tumor ligation.She was extubated immediately following surgery and shifted to post anaesthesia care unit for observation.

Keywords:Pheochromocytoma,para-aorticpheochromocytoma,recurrent pheochromocytoma,anaesthesia management.

Introduction

Pheochromocytoma is a rare neuroendocrine tumour arising from chromaffin cells of adrenal medulla or paraganglions  of the sympathetic nervous system.They cause uncontrolled catecholamine release that result in malignant hypertension, cerebrovascular accident and myocardial infarction.Intraoperative goals include avoidance of drugs or manoeuvres that may provoke catecholamine release or potentiate catecholamine actions and  maintenance of  cardiovascular stability, preferably with short acting drugs.

Case Report

            A47 year old female, presented with uncontrolled hypertension while evaluvating for elective myomectomy for fibroid uterus.

 She had a past history of pheochromocytoma and right adrenalectomy done. Now, diagnosed of  para-aortic        pheochromocytoma.

 24hours urine Nor-epinephrine 104 micrograms (<90microgram)

24 hours urine  Nor-metanephrine 806 micrograms (600micrograms)

Nor-meta nephrinecreatinine ratio 918micrograms (86-236)

PET-CT showed a hot nodule in para-aortic region.

Other routine investigations were:

Hb-10.6gms,RBS-151mg/dl, B.Urea-10mg/dl,S.Creatinine-0.5mg/dl, S.Electrolytes Na+ - 131meq/L, K+- 4.5meq/L, Platelets-4.36 Lakhs.

ECG and Echocardiography was normal.Her thyroid profile was

Free T3- 2.3pg/ml (Normal - 2.3 to 4.2 pg/ml)

Free T4- 1.36ng/dl (Nromal- 0.8 to 1.8mg/dl)

TSH- 0.95 U/ml (Normal – 0.3 to 5 U/ml).

Her pulse rate was 92/min and supine blood pressure was 160/90mmHg. She was optimized with T.Propranolol 10mg OD, T.Prasozin 5mg BD and T.Amlodipine 5mg BD.

 After that blood pressure was in the range of 130/90-140/86 mmhg.

On examination patient was conscious, oriented, moderately built and nourished. Patient was afebrile, no pallor , no cyanosis,       no icterus, and no generalized lymphadenopathy.

The examination of cardiovascular, respiratory and central     nervous system showed no obvious abnormality.

Previous laparotomy scar was present in the abdomen. Weight -55kg, Height-153cm.