Novel Method in Performing PTH Washout for Localizing Parathyroid Adenoma: Case Report & an Institute Experience in Qatar

Abstract Introduction: Primary hyperparathyroidism (PHPT) is a common cause of hypercalcemia and mostly caused by benign solitary benign adenoma (80 to 85 %). Definite treatment is the surgical removal. The most commonly used diagnostic modalities are Sestamibi scan and neck ultrasound (US) which can be inconclusive in some cases. Parathyroid hormone (PTH) washout obtained with ultrasound guided FNA may be useful to accurately localize the adenoma. In our study we describe a novel method for PTH washout. Methods: First, blood samples are drawn from the patient’s peripheral vein and placed in two yellow top tubes (3 ml of blood in each tube). 1 ml of normal saline (NS) will be add to Tube # 1 (Control tube). The suspected parathyroid lesion aspirate is obtained via US guided FNA. It is washed in 1 ml of NS and added to tube #2 (PTH washout tube). Both tubes are sent to our local laboratory for PTH assay. The ratio of PTH in PTH washout tube to control tube (PTH W/C ratio) is calculated and considered positive if more than 2. Results: Total 16 patients (12 females and 4 males) underwent the PTH washout procedure. All patients had PHPT. Out of 16 patients, 13 had inconclusive Sestamibi scan while 3 patients didn’t have the scan due to pregnancy. PTH W/C ratio was positive in 13 patients (ruled in) and negative (ruled out) in 3 patients. All patients underwent parathyroid surgery. The operative findings and pathology report were consistent with PTH W/C ratio findings. i.e. parathyroid hypercellularity was found in all the 13 patients ruled in by PTH W/C ratio. Post-surgery, biochemical parameters normalized in all. Conclusion: PTH washout is an important tool in localizing parathyroid lesion in PHPT when Sestamibi scan cannot be done or if it is inconclusive. PTH W/C ratio can be performed with our novel method to accurately localize the PTH lesion and improve surgical outcome.

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SAT-202 Hypoglycemia Following Unilateral Pheochromocytoma Resection in the Immediate Post-Surgical Period

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.1499 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Raisa Ghosh ◽

Sanketkumar Dalwadi ◽

Hongxiu Luo

Keyword(s):

Lupus Erythematosus ◽

Elevated Serum ◽

Glucagon Secretion ◽

Serum Cortisol ◽

Surgical Pathology ◽

Surgical Removal ◽

High Dose ◽

Pathology Report ◽

Acth Stimulation ◽

Post Surgery

Abstract Introduction Hypoglycemia in the immediate post-resection period of unilateral pheochromocytoma is a potential complication but not very well recognized. Clinical Case A 47 year old female with past medical history of Hypertension, coronary artery disease, Myocardial infarction, Depression, Systemic lupus erythematosus presented to the hospital initially for elective robotic assisted Left adrenalectomy. CT scan showed a big left adrenal mass with normal right adrenal gland. It was clinically diagnosed as Pheochromocytoma as outpatient by primary internist. Biochemical studies showed elevated serum metanephrines and normetanephrines, and urine normetanephrine. Post-surgery (< 24 hours) patient had episodes of fasting hypoglycemia with blood glucose levels as low as 68 mg/dl, accompanied with neuroglycopenic symptoms like tremors, sweating and palpitations. High dose ACTH stimulation test was performed. Serum cortisol levels were tested as 5.1, 11.7 and 14.4 mcg/dl within 0, 30 minutes and 60 minutes of Cosyntropin 250 mcg IV injection. The patient was started on Prednisone 5 mg daily to prevent any further episodes, which was successful, and was stopped by the patient one week after discharge, without any more hypoglycemia episodes. Further endocrinology work up could not be done as the patient did not follow up. Post-surgical pathology showed a 7x 5.5 x4 cm mass, which was confirmed as pheochromocytoma histopathologically and immunohistochemically by positive chromogranin, synaptophysin and BCl2 and negative for calretinin and S100. Discussion and Conclusion The etiology of hypoglycemia after resection of unilateral pheochromocytoma can be explained by impaired glucagon secretion and decreased gluconeogenesis due to the suppression from higher catecholamine levels in the blood pre-operatively. The second mechanism is rebound insulin secretion from the pancreas due to sudden withdrawal of catecholamines. In our patient, the transient hypocortisolemia could be another reason. The lack of immunohistochemical evidence in post-surgical pathology report excluded cortisol- secreting tumor. Another rare situation, ACTH-secreting pheochromocytoma, has been reported but was not checked in the case. In a word, hypoglycemia is common after surgical removal of unilateral pheochromocytoma. Careful monitoring of patients’ glucose level in immediate post-resection period is essential to prevent transient hypoglycemia References 1.Akiba M, Kodaba T, Ito Y, Obara T, Fujimoto Y. Hypoglycemia induced by excessive rebound secretion of insulin after removal of pheochromocytoma. World J Surg; 14(3):317-24 2.Chen Y, Hodin RA, Pandolfi C, Ruan DT, McKenzie TJ. Hypoglycemia after resection of pheochromocytoma.Surgery;156(6): 1404-09

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Misdiagnosis of a Giant Uterine Leiomyosarcoma: Clinic and Image Challenges

Case Reports in Oncological Medicine ◽

10.1155/2017/3568328 ◽

2017 ◽

Vol 2017 ◽

pp. 1-4

Author(s):

Jila Agah ◽

Sedighe Karimzadeh ◽

Fateme Moharrer Ahmadi

Keyword(s):

Abdominal Distension ◽

Gastrointestinal Disorder ◽

Cystic Mass ◽

Pathology Report ◽

Uterine Leiomyosarcoma ◽

Peripheral Tissues ◽

Chief Complaints ◽

Magnetic Resonance Imaging Mri ◽

Diagnostic Modalities ◽

Serous Cyst Adenoma

A 41-year-old woman (G3P2L2Ab1) was referred to gynecology clinic with chief complaints of abdominal distension and localized abdominal wall pruritus for three months. She was misdiagnosed with gastrointestinal disorder and ultimately had undergone imaging. Ultrasonography and computed tomography (CT) scan disclosed a huge solid-cystic mass originating from the ovary. On clinical examination the patient had no pain or tenderness and no gynecologic complaints. Laboratory tests showed normal tumor markers and hemoglobin at 8 g/dl. Laparotomy was carried out as diagnosis of ovarian serous cyst adenoma, but a huge tumor with attachment to uterus and ovaries and extension to pelvic floor, peripheral tissues of ureter, and upper abdomen was found. Hysterectomy with bilateral salpingooophorectomy was done. Pathology report demonstrated uterine leiomyosarcoma measuring 40 centimeters and weighing 10 kilograms. In conclusion, as pelvic masses even in a large size may present unspecific symptoms misdiagnosis may occur which lead to overgrowth, local invasion, or other complications. So, it is rather to suggest ultrasonography in patients with persistent abdominal or pelvic symptoms and if needed, more exact diagnostic modalities like magnetic resonance imaging (MRI) could be offered to avoid misdiagnosis and mismanagement.

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Clinical significance of circulating tumor cells and metabolic signatures in lung cancer after surgical removal

10.21203/rs.3.rs-17157/v1 ◽

2020 ◽

Author(s):

Dawei Yang ◽

Xiaofang Yang ◽

Yang Li ◽

Peige Zhao ◽

Rao Fu ◽

...

Keyword(s):

Lung Cancer ◽

Tumor Cells ◽

Circulating Tumor Cells ◽

Early Stage ◽

Effective Means ◽

Disease Recurrence ◽

Metabolic Changes ◽

Surgical Removal ◽

Targeted Metabolomics ◽

Post Surgery

Abstract Background Lung cancer (LC) remains the deadliest form of cancer globally. While surgery remains the optimal treatment strategy for individuals with early-stage LC, what the metabolic consequences are of such surgical intervention remains uncertain. Methods Negative enrichment-fluorescence in situ hybridization (NE-FISH) was used in an effort to detect circulating tumor cells (CTCs) in pre- and post-surgery peripheral blood samples from 51 LC patients. In addition, targeted metabolomics analyses, multivariate statistical analyses, and pathway analyses were used to explore surgery-associated metabolic changes. Results LC patients had significantly higher CTC counts relative to healthy controls with 66.67% of LC patients having at least 1 detected CTC. CTC counts were associated with clinical outcomes following surgery. In a targeted metabolomics analysis, we detected 34 amino acids, 164 lipids, and 24 fatty acids. When comparing LC patients before and after surgery to control patients, metabolic shifts were detected via PLS-DA and pathway analysis. Further surgery-associated metabolic changes were identified when comparing LA and LB groups. We identified SM 42:4, Ser, Sar, Gln, and LPC 18:0 for inclusion in a biomarker panel for early-stage LC detection based upon an AUC of 0.965 (95% CI = 0.900–1.000). This analysis revealed that SM 42:2, SM 35:1, PC (16:0/14:0), PC (14:0/16:1), Cer (d18:1/24:1), and SM 38:3 may offer diagnostic and prognostic benefits in LC. Conclusions These findings suggest that CTC detection and plasma metabolite profiling may be an effective means of diagnosing early-stage LC and identifying patients at risk for disease recurrence.

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Plasmalogen Deficiency and Overactive Fatty Acid Elongation Biomarkers in Serum of Breast Cancer Patients Pre- and Post-Surgery—New Insights on Diagnosis, Risk Assessment, and Disease Mechanisms

Cancers ◽

10.3390/cancers13164170 ◽

2021 ◽

Vol 13 (16) ◽

pp. 4170

Author(s):

Satomi Tomida ◽

Dayan B. Goodenowe ◽

Teruhide Koyama ◽

Etsuko Ozaki ◽

Nagato Kuriyama ◽

...

Keyword(s):

Breast Cancer ◽

Fatty Acid ◽

Surgical Removal ◽

Fatty Acid Elongation ◽

Breast Cancer Patients ◽

Case Control Studies ◽

Post Surgery ◽

Lipid Species ◽

Ethanolamine Plasmalogen ◽

Accurate Mass Spectrometry

The polyunsaturated fatty acid (PUFA) elongase, ELOVL5, is upregulated in breast cancer (BC) vs. adjacent normal tissue. We performed a comprehensive lipid metabolomic analysis of serum using high-resolution accurate mass spectrometry from two case-control studies that included non-BC, BC subjects pre-surgery, and BC subjects one-month post-surgery to determine if the metabolic signatures of over-active fatty acid elongation and other lipid changes could be detected in BC vs. non-BC subjects: study 1 (n = 48: non-BC, n = 69: pre-surgery BC); study 2 (blinded validation: n = 121: non-BC, n = 62: pre-surgery BC, n = 31: one month post-surgery). The ratio of the ELOVL5 precursor, linoleic acid (18:2) to a non-ELOVL5 precursor, oleic acid (18:1) was evaluated in multiple lipid pools (phosphatidylethanolamine (PtdEtn), phosphatidylcholine (PtdCho), lyso-PtdCho, and free fatty acids). This ratio was lower in pre-surgery BC subjects in all pools in both studies (p < 0.001). At one-month post-surgery, the 18:2/18:1 ratios increased vs. pre-surgery and were no longer different from non-BC subjects (p > 0.05 expect for lyso-PtdCho). In contrast to the elongation biomarkers, docosahexaenoic acid (22:6n-3) containing ethanolamine plasmalogen (EtnPls) species were observed to be further decreased in BC subjects one-month post-surgery vs. pre-surgery levels (p < 0.001). These results are consistent with the hypothesis that ELOVL5 is upregulated in BC tissue, which would result in the selective depletion of 18:2 vs. 18:1 containing lipid species. Surgical removal of the tumor removes the overactive ELOVL5 effect on serum lipids. In contrast, the low EtnPls levels do not appear to be caused by BC tumor activity and may be pre-existent and a possible risk factor for BC. These results indicate that it may be possible to screen for both breast cancer risk and breast cancer activity using a simple blood test.

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Case report of the successful removal of a haemangioma of the left ventricle in a paediatric patient

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2020-3-132-137 ◽

2020 ◽

Vol 24 (3) ◽

pp. 132

Author(s):

U. G. Kolbik ◽

A. V. Gorustovich ◽

Yu. I. Linnik ◽

M. M. Shved ◽

V. V. Drozdovskaya ◽

...

Keyword(s):

Surgical Treatment ◽

Paediatric Patient ◽

Conflict Of Interest ◽

Recovery Period ◽

Final Diagnosis ◽

Surgical Removal ◽

Capillary Haemangioma ◽

Cardiac Tumours ◽

Post Surgery ◽

Choice Of Treatment

This publication presents the clinical observation in a paediatric patient with haemangioma of the left stomach. The effectiveness of surgical treatment of this disease is also noted. We assess the challenges in diagnosis and the choice of treatment of this pathology in children and the effectiveness of surgical treatment disease. Primary cardiac tumours are rare; vascular tumours and haemangiomas are rarer. The clinical picture of heart haemangioma is non-specific and varies as per its location and size. Echocardiography is the main diagnostic method for this disease. However, in most cases of preoperative diagnostic examination, the pre-surgery diagnosis is not confirmed. The final diagnosis of capillary haemangioma is established following immunohistochemical staining of the surgical material. Thus far, owing to the rare occurrence, a generally accepted tactic for the treatment of such patients with vascular heart tumours has not been developed. This clinical case describes our experience of treating a rare pathology in children with unusual localisation as well as the rapid successful surgical removal of the tumour without complications and with a favourable post-surgery recovery period.Received 14 May 2020. Revised 15 June 2020. Accepted 26 June 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributions Literature review: U.G. Kolbik, A.V. Gorustovich, Y.I. Linnik Illustrations: U.G. Kolbik, I.V. Sakharov, V.V. Drozdovskaya Drafting the article: U.G. Kolbik, A.V. Gorustovich, I.V. Sakharov Critical revision of the article: I.V. Sakharov, M.M. Shved, Yu.I. Linnik Surgical treatment: A.V. Gorustovich, M.M. Shved, U.G. Kolbik Final approval of the version to be published: U.G. Kolbik, A.V. Gorustovich, Yu.I. Linnik, M.M. Shved, V.V. Drozdovskaya, I.V. Sakharov, K.V. Drozdovski

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Effects of Lactobacillus reuteri-containing lozenges on healing after surgical removal of mandibular third molars: a randomised controlled trial

Beneficial Microbes ◽

10.3920/bm2018.0168 ◽

2019 ◽

Vol 10 (6) ◽

pp. 653-659

Author(s):

D.-Å. Wälivaara ◽

I. Sjögren ◽

N. Gerasimcik ◽

T. Yucel-Lindberg ◽

S. Twetman ◽

...

Keyword(s):

Wound Healing ◽

Lactobacillus Reuteri ◽

Controlled Trial ◽

Test Group ◽

Subjective Perception ◽

Surgical Removal ◽

Third Molars ◽

Post Surgery ◽

Surgical Extraction ◽

Mandibular Third Molars

We investigated the effect of probiotic supplements on oral wound healing, swelling, pain and discomfort after surgical removal of mandibular third molars. A second aim was to evaluate if the intervention could influence the concentrations of oxytocin in saliva. Sixty-four consecutive volunteers (18-34 years) were enrolled to a double-blind randomised placebo-controlled trial with two parallel arms. Following surgery, the patients were asked to take three lozenges per day containing two strains of Lactobacillus reuteri (DSM 17938 and ATCC PTA 5289) or placebo for two weeks. The clinical healing and extra-oral swelling were scored two weeks post-operatively. Samples of wound exudate were cultivated for the presence of Staphylococcus aureus and β-haemolytic streptococci. Salivary oxytocin concentrations were analysed from pre- and post-surgery samples using ELISA technique. Compliance and the subjective perception of swelling, pain and discomfort were reported daily through visual analogue scales in a logbook. All patients except three completed the protocol and the postoperative course was uneventful in most cases. Minor extra-oral swellings were noted in five patients, but none required antibiotic treatment. At the 2-week follow-up, there were no significant differences in clinical wound healing index, extra-oral swelling, bacterial growth or salivary oxytocin levels between the groups. The self-reported data unveiled, however, a significantly reduced sense of swelling, in particular during the second week after surgery in the probiotic test group (P<0.05). Likewise, significantly fewer nights with disturbed sleep and fewer days with sick-leave from work were reported among the participants in the test group (P<0.05). No differences were found in the post-operative use of analgesics. In conclusion, we found no significant influence of probiotic supplements on objective wound healing after surgical extraction of impacted mandibular third molars. However, since the patients’ perceived significant post-operative ameliorations, further studies are needed to explore the patient’s value of the intervention.

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Clinical significance of circulating tumor cells and metabolic signatures in lung cancer after surgical removal

10.21203/rs.3.rs-17157/v2 ◽

2020 ◽

Author(s):

Dawei Yang ◽

Xiaofang Yang ◽

Yang Li ◽

Peige Zhao ◽

Rao Fu ◽

...

Keyword(s):

Lung Cancer ◽

Tumor Cells ◽

Circulating Tumor Cells ◽

Early Stage ◽

Effective Means ◽

Disease Recurrence ◽

Metabolic Changes ◽

Surgical Removal ◽

Targeted Metabolomics ◽

Post Surgery

Abstract Background: Lung cancer (LC) remains the deadliest form of cancer globally. While surgery remains the optimal treatment strategy for individuals with early-stage LC, what the metabolic consequences are of such surgical intervention remains uncertain. Methods: Negative enrichment-fluorescence in situ hybridization (NE-FISH) was used in an effort to detect circulating tumor cells (CTCs) in pre- and post-surgery peripheral blood samples from 51 LC patients. In addition, targeted metabolomics analyses, multivariate statistical analyses, and pathway analyses were used to explore surgery-associated metabolic changes. Results: LC patients had significantly higher CTC counts relative to healthy controls with 66.67% of LC patients having at least 1 detected CTC before surgery. CTC counts were associated with clinical outcomes following surgery. In a targeted metabolomics analysis, we detected 34 amino acids, 147 lipids, and 24 fatty acids. When comparing LC patients before and after surgery to control patients, metabolic shifts were detected via PLS-DA and pathway analysis. Further surgery-associated metabolic changes were identified when comparing LA (LC patients after surgery) and LB (LC patients before surgery) groups. We identified SM 42:4, Ser, Sar, Gln, and LPC 18:0 for inclusion in a biomarker panel for early-stage LC detection based upon an AUC of 0.965 (95% CI = 0.900–1.000). This analysis revealed that SM 42:2, SM 35:1, PC (16:0/14:0), PC (14:0/16:1), Cer (d18:1/24:1), and SM 38:3 may offer diagnostic and prognostic benefits in LC. Conclusions: These findings suggest that CTC detection and plasma metabolite profiling may be an effective means of diagnosing early-stage LC and identifying patients at risk for disease recurrence.

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Re-assessment of surgical breast cancer quality indicators by the Florida Initiative for Quality Cancer Care (FIQCC) consortium.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.27_suppl.84 ◽

2012 ◽

Vol 30 (27_suppl) ◽

pp. 84-84

Author(s):

Christine Laronga ◽

Jhanelle Elaine Gray ◽

Erin Siegel ◽

Ji-Hyun Lee ◽

William J. Fulp ◽

...

Keyword(s):

Breast Cancer ◽

Quality Improvement ◽

Quality Indicators ◽

Performance Indicators ◽

Cancer Care ◽

Axillary Node ◽

Axillary Node Dissection ◽

Pathology Report ◽

Node Dissection ◽

Post Surgery

84 Background: In 2006, the FIQCC (comprised of 11 practice sites) initiated a comprehensive review of quality of care specific to breast cancer based on QOPI/NCCN/ACOS and panel consensus quality indicators. Feedback on indicator performance was provided to participating practices in 2007 to encourage quality improvement efforts. Re-assessment of adherence to the same performance indicators was conducted in 2009. Methods: Chart reviews were conducted for breast cancer patients (pts) seen by a medical oncologist at FIQCC sites in 2006(n=602) and 2009(n=636) Quality indicators included: 1) presence/completeness of pathology report; 2) documentation of surgery type; 3) documentation of sentinel lymph node biopsy (SLNB) and if SLNB positive documentation of a complete axillary node dissection; and 4) mammogram usage post surgery. Statistical comparisons of 2006 and 2009 data were performed using the Pearson chi-square exact test based on Monte Carlo estimation. Results: The median age of pts (99% female) was 60 years (range 24-94). Compared to 2006 data, improvements were made in specimen orientation (69%-2006, 78%-2009; p=0.001) and inking of margins (89%-2006, 96%-2009; p=<0.001). In clinical node negative N0 pts, SLNB was performed in 87%, up from 82%-2006 (p=0.035). Of the pts with a metastatic SLNB, 86% went on to have a complete axillary node dissection, but not statistically significant compared to 79% in 2006 (p=0.10). Compliance continues to be highly variable across practice sites with obtaining a mammogram within 14 months of surgery (79%) (p=0.002); but the range narrowed: 26%-98% (2006) and 56%-92% (2009). Significant variances also continued in 2009 across practice sites for margin orientation (p<0.001), inking of the margins (p=0.04), and performance of SLNB (p<0.001). Conclusions: The FIQCC identified quality improvement needs in multiple aspects of breast cancer care. Improvements in margin orientation/inking, use of SLNB and follow-up mammograms after definitive surgery made over the course of this initiative speak to the benefits of continual re-assessment of adherence to performance indicators to guide quality improvement.

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Comparison of Wound Healing Using Envelope and Triangular Flap for Impacted Mandibular Third Molar Surgery

10.53350/pjmhs2115102811 ◽

2021 ◽

Vol 15 (10) ◽

pp. 2811-2813

Author(s):

Atiq ur Rahman ◽

Muhammad Junaid Hashmi ◽

Muhammad Shairaz Sadiq ◽

Fareed Ahmad ◽

Muhammad Anwaar Alam ◽

...

Keyword(s):

Wound Healing ◽

Maxillofacial Surgery ◽

Third Molar ◽

Surgical Removal ◽

Post Surgery ◽

Triangular Flap ◽

Impacted Mandibular Third Molar ◽

Mandibular Third Molar ◽

Significant Difference

Objective: To compare the wound healing with triangular flap versus envelope flap techniques among patients undergoing surgical removal of the impacted mandibular third molar (IMTM). Study Design: An open label randomized controlled trial. Place and Duration of the Study: The Department of Oral & Maxillofacial Surgery, Bakhtawar Amin Medical and Dental College, Multan from January 2021 to June 2021. Material and Methods: A total of 70 patients (35 in each group) of both genders aged 20 to 50 years requiring surgical removal of IMTM were included. Patients were asked to follow up on third and seventh day while observations regarding wound healing and pain were noted on 7th day among all cases completing the final follow up. Chi square was applied to compare data between both study groups taking p-value below 0.05 as significant. Results: In a total of 70 patients, there were 42 (60.0%) female and 28 (40.0%) female. Majority of the patients, 36 (51.4%) were above 30 years of age while mean age was noted to be 32.4+9.1 years. Sixty two patients completed the follow up so they were included in the final analysis for the assessment of wound healing and pain. Overall, wound healing was observed to be in 55/62 (88.7%) patients while wound healing was found to be 30/32 (93.8%) patients in envelope flap group in comparison to 25/30 (83.3%) in triangular flap group (p=0.1953). Overall, there was no statistically significant difference in between both study group with regards to evaluation of pain (p=0.3271) Conclusion: Both envelop flap and triangular flap techniques resulted in similar outcomes regarding wound healing among patients undergoing surgical removal of IMTM. Both flap techniques resulted in relatively similar degrees of post-surgery pain. Keywords: Third molar, pain, wound healing.

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Asymptomatic Pheochromocytoma With Delayed Resection Due to Covid-19 and Persistent Postoperative Hypertension

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.235 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A117-A117

Author(s):

Trisha Menon ◽

Avani G Sinha

Keyword(s):

Breast Cancer ◽

Adrenal Mass ◽

Asymptomatic Patient ◽

Tracer Uptake ◽

Uncontrolled Hypertension ◽

Beta Blockade ◽

Surgical Removal ◽

Pathology Report ◽

Postoperative Hypertension ◽

Plasma Metanephrines

Abstract Background: Pheochromocytoma is promptly treated by surgical removal and usually results in resolution of hypertension. This case discusses an asymptomatic patient with two new malignancies-breast cancer and pheochromocytoma- who had positive outcomes despite delayed resection of pheochromocytoma due to COVID-19, but with a persistence of postoperative hypertension. Clinical Case: A 60 year old woman with newly diagnosed breast cancer presented for workup of an adrenal mass found on PET scan. An abdominal contrast CT-scan demonstrated a left 3.2 cm indeterminant adrenal mass. Initial laboratory testing demonstrated positive 24 hour urine metanephrines (metanephrine 951 mcg/24hr, n < 400 mcg/24hr for HTN and normetanephrine 1302 mcg/24hr, n < 900 mcg/24h for HTN) and plasma metanephrines (normetanephrine 826 pg/mL, n < 145 pg/mL and metanephrine 391 pg/mL, n < 62 pgmL), suggestive of pheochromocytoma. An MIBG scintigraphy showed tracer uptake in the left adrenal gland, suspicious for pheochromocytoma. The patient was started on alpha then beta blockade with plan for removal, but due to the COVID-19 pandemic, surgery was delayed. In the interim, breast cancer therapy was adjusted to avoid complications or symptoms from the possible pheochromocytoma. The patient had always been asymptomatic, even during the physical and emotional stress of cancer and chemotherapy. She only had a diagnosis of uncontrolled hypertension for four years prior to presentation, treated with Valsartan-Hydrochlorothiazide, with average systolic BP of 140–180, and diastolic BP of 80–100. With the addition of Doxazosin and Metoprolol, the patient’s BP improved, with all readings < 120/90. A left adrenalectomy was performed nearly six months after initial presentation, with final pathology report demonstrating moderately differentiated pheochromocytoma, with clean surgical margins. The patient remained hypertensive for months after the procedure, with initial systolic (SBP) readings of 150–160, and diastolic (DBP) readings of 90–100. However, follow up plasma metanephrine levels were normal (normetanephrine 165 pg/mL n < 191.8 pg/mL and metanephrine 22.1 pg/mL n < 88 pg/mL). The patient was then started on Amlodipine and Valsartan, with most recent SBP readings in the 130s. Conclusion: This case demonstrated a clinically asymptomatic patient with persistent postoperative hypertension and normal plasma metanephrines, which has been demonstrated only in a minority of patients. Additionally, pheochromocytoma needs to be promptly removed if possible; this case demonstrated successful resection and clinical course despite the delay for this urgent surgery due to COVID-19.

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