Samejima et al. reported a 45‐year‐old male case of giant pheochromocytoma who experienced acute hypotension during suction of intratumoral fluid. The acute hypotension was observed twice reproducibly and concentration of catecholamines in the fluid was very high (norepinephrine 814 500 pg/mL and epinephrine 23 825 pg/mL; aspirated total fluid volume 2450 mL). In a similar case report, acute hypotension was not observed during adrenalectomy for pheochromocytoma; aspirated fluid volume was 180 mL with high concentration of catecholamines (norepinephrine 3 700 000 pg/mL, epinephrine 800 000 pg/mL, and dopamine 20 000 pg/mL).2 Physicians need to ask anesthesiologists to prepare for hemodynamic instability before aspiration of cystic lesion fluid for pheochromocytoma, considering the possibility of acute hypotension or hypertension.
Aspiration of intratumoral fluid is useful procedure to mobilize the tumor from adjacent structures; however, physicians should pay attention to avoid dissemination of the fluid because all pheochromocytoma has malignant potential.3 Although needle aspiration of intratumoral fluid is a time‐spending manner, I think the procedure is more safety for minimizing the risk of dissemination of malignant tumor cells and more useful to ready for preparation of hemodynamic instability during the procedure than tube aspiration.
The current WHO Classification of Tumours of Endocrine Organs3 states that all pheochromocytomas have malignant potential and should be risk stratified using one or both of the established algorithms: the Pheochromocytoma of the Adrenal Gland Scaled Score (PASS)4 and the Grading System for Adrenal Pheochromocytoma and Paraganglioma (GAPP).5 Kimura et al. had demonstrated the ability of GAPP classification to differentiate low‐grade malignancies from moderate‐ to high‐grade malignancies with different rates of metastasis.5 The Clinical Practice Guideline of Pheochromocytoma/Paraganglioma 2018 released by the Japan Endocrine Society recommended the use of GAPP but not PASS for judging a malignant grade of pheochromocytoma/paraganglioma because it is significantly associated with overall survival (http://www.shindan.co.jp/books/index.php?menu=10&cd=236200&kbn=1). I also have an interest for the GAPP score and prognosis of this patient.
The Japanese Urological Association has started an operation of the National Clinical Database in Japan (NCD) from April 2018. If we will input data of rare tumors including pheochromocytoma/paraganglioma with patients’ characteristics, PASS/GAPP scores, and prognosis into the NCD, we might improve understanding feature of the rare urological tumors and prognosis of the patients.
Conflict of interest
The author declares no conflict of interest.
References
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