Pheochromocytoma
Here's a tip.
If you see a patient with paroxysmal spells of syncope, palpitations, headaches, and you image him and find a 3 cm enhancing adrenal mass on CT, please bloody have the sense to check his metanephrines and catecholamines before you decide to stick a needle into that goomba*.
I imagine that medical team (from another hospital before the patient transferred here) darn near shit and pissed in their Pagoda undies and panties when the pathology report read 'pheochromocytoma'.
They're farking lucky that patient didn't die on the table during the biopsy (no alpha and beta blockade).
You don't need to be an endocrinologist to know. Maybe just a brain larger than the size of a pea.
Idiots. Can you spell L-A-W-S-U-I-T ? (which reminds me. Piff, you need to give me your business card).
*Goomba (noun): Technical term describing a surprising find of a mass on radiologic imaging. Often used with objectionable phrases or words describing the genitalia. Example: "WTF?? What the KKC is that Goomba on his left upper lung field??" May also be used to hide ignorance about the pathology of a lesion. Example: "This is a 78 year old male with a right cerebral Goomba..."
posted by vagus at 10:19 PM
20 Comments:
i know this is a stupid question, but where is the lesion on the ct?
this wasn't my patient's, obviously. stole the image from google :P
but this one is on the left (patient's left, so the viewer's right). that honkin' mass beside the kidney. looks like it's extending inferiorly cos it's usually most prominent more superior than that relative to the kidney. these things tend to look inhomogenous, cystic, sometimes hemorrhagic even. in this case you can tell it has a heterogenous, partially cystic appearance.
hard to tell since this is a single slice and i can't scroll up and down, but looking at the right side i wonder if that's a generous-looking adrenal, or if that's something else (remember can be bilateral in 10%).
MRI T2 weighted images would be better than a CT though.
all this is greek to me. ;P no namecard for the time being, my dear... on a breakie, remember? =)
Can I also hand u my name card.. haha.. a bit far though.
It is certainly not uncommon to obtain biopsies of adrenal masses. In fact, pheos are so rare and metastatic carcinomas to the adrenals are so common that the cost benefit analysis of checking metanephrines for every patient is extremely unreasonable and lays a tremendous burden on the already ailing healthcare system of the United States of America. Let's not even mention if this recommendation of your is instituted in Canada or worse, Malaysia.
true, it unreasonable to measure metanephrines for all patients, allcomers.
but, it is not only reasonable, but certainly indicated, to measure this in a patient with an adrenal incidentaloma. there is sufficient evidence to suggest this. 5.1% of incidentalomas here prove to be pheos.
Pheos may be rare but they're certainly around. i've seen 3 in the last 6 months.
This comment has been removed by a blog administrator.
In reply to Anonymous' comment (I deleted the original comment becoz an institution's name was mention)(for privacy reasons):
i said i've seen 3 in the last 6 months. This is not my 3rd case.
and i certainly don't think my view represents the world's view of pheo. but i do stand by my view (based on published data) that an adrenal incidentaloma probably warrants biochemical screening for pheo. especially in a clinical context of paroxyxms. certainly warrants this more than a CT guided biopsy (are you implying that it's more cost effective to FNA patients than to check metanephrines?). Especially since the FNA itself can kill if it IS indeed a pheo.
Agreed we see a lot of unicorns. I've seen a lot of weird case report stuff in the last year. So perhaps my views are biased.
p/s: no i'm not a board-certified endocrinologist. i'm an endo fellow.
In your interest to point out the ignorance of other physician who do not work at the "mothership", may I humbly remind you that the NIH consensus statement on clinically inapparent adrenal masses states that the clinical evaluation should also include a dexamethasone suppression test.
Wah! All you doctor so smart one. I am soooooo impressed.
YS
yup, definitely agree.
either an overnight 1mg dex suppression or 24 hour urinary free cortisol.
although the cushing wouldn't kill you on the operating table (well, i guess it could if you're not given stress doses) as a pheo would if you stuck it with a needle.
what's your background, anonymous, if you don't mind my asking?
thanks for stopping by.
YP: All this doctor-talk just rubbish lar. Meant to impress (and fool) cute single girls.
P/S: Are you impressed? ;)
YP or YS?
Vagus: you're both anon and vagus just to fool us izzit? lol
oooh. YS ar? soli soli. misread. tot it was YP up to her usual cheekiness :)
It is certainly impressive to non-medical people observing our jargon being thrown about. I hope that this is not a way for you to impress cute single girl. For your information, cute single girls do work in the medical profession too.
nope it's not.
hasn't worked yet :)
I did come up with my own pheo diagnose, since doctors had no clue for seven years.
I had all symptoms like a thyroidstorm, but could not be hyperthyroid, because I had a thyroidectomy. So I started to put the puzzloe together and urged a doctor to test the catecholamines..and boy was I right.
Now I have to find the nasty pheo, mri is sceduled and I just think it's in my right adrenal..there has been a stabbing pain in that region for years and during pheo episodes..it feels like I am willing to cut it out with a kitchenknife right then and there.
Of course they labeled me having a panic dissorder..wauw with a bp going 220/160..and all the other nice vommiting.
Living under a fan for years..sweating.
I am from europe, so my spelling may be odd;)
The beginning of my piuzzle was my surgeon in bangkok who said my bp went absurd high on the operating table for my thyroidectomy..he said...something must be very wrong.
Thank you for your beautiful spicy log and I wish there were more doctors like you, honest and direct.
Greets from holland.
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