En bloc resection of a pheochromocytoma metastatic to the spine for local tumor control and for treatment of chronic catecholamine release and related hypertension

Case report

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Resection of metastatic pheochromocytomas may be complicated by transient postoperative neurological deficits due to hypotension. The authors report the first case of en bloc excision of a spinal pheochromocytoma with associated long-term hypertensive management off all medication. Interestingly, this is the first case of transient hypotension following en bloc resection of pheochromocytoma associated with temporary hypotension-associated neurological decline that resolved completely after correction of hypotension postoperatively. A 23-year-old man with a prior adrenalectomy for pheochromocytoma presented with focal thoracic pain. He had a known T-10 vertebral body lesion for which he received chemotherapy and radiation therapy. Imaging demonstrated increased destruction of the T-10 vertebral body, which was concerning for tumor growth. The patient underwent angiographic embolization followed by single-stage posterior en bloc vertebrectomy with placement of a cage and posterior instrumentation and fusion without event. However, approximately 24 hours after surgery, the patient's systolic blood pressure was consistently no higher than 70 mm Hg. During this time, he began suffering from severe bilateral lower-extremity weakness. His systolic blood pressure increased with dopamine, and his strength immediately improved. The patient's oral regimen of adrenergic blockade was stopped, and he recovered without event. Since that time, the patient has been symptom free and requires no antihypertensive medication. The role of en bloc resection for metastatic lesions of the spine is controversial but may be warranted in cases of metastatic pheochromocytoma. En bloc resection avoids intralesional tumor resection and thus may help prevent complications of hypertensive crisis associated with hormonal secretion and extensive blood loss, which are not uncommon with pheochromocytoma resection surgeries. Additionally, the role of en bloc spondylectomy in this setting may allow for metabolic treatment as patients with actively secreting tumors may no longer require antiadrenergic medications.

Article Information

Address correspondence to: Daniel M. Sciubba, M.D., 600 North Wolfe Street, Meyer 5185, Baltimore, Maryland 21287. email: dsciubb1@jhmi.edu.

Please include this information when citing this paper: published online April 19, 2013; DOI: 10.3171/2013.3.SPINE12966.

© AANS, except where prohibited by US copyright law.

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Figures

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    Sagittal (upper) and axial (lower) CT scans of the thoracic spine demonstrating the extensive destruction of the T-10 vertebral body, pedicle, and posterior elements by this metastatic spinal pheochromocytoma.

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    Preoperative PET scan demonstrating increased uptake along the T-10 vertebra.

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    Preoperative angiogram demonstrating significant tumor blush at T-10 due to supply from the right T-9 and T-10 intersegmental arteries, as well as left T-10 intersegmental artery and left T-9 small radiculomedullary collaterals.

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    Postembolization angiogram demonstrating significant decrease in tumor blush.

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    Intraoperative image depicting the exposed spinal cord and pheochromocytoma tumor anteriorly. Silastic sheets have been placed along the anterior aspect of the vertebral body for resection.

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    Upper: Photomicrograph demonstrating healthy bone (left side) with tumor (right side). Lower: Photomicrograph demonstrating nests of round to oval tumor cells within a fibrovascular stroma. Many blood vessels can be seen abutting the tumor nests. H & E, original magnification ×40 (upper) and ×400 (lower).

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    Postoperative coronal (left) and sagittal (right) CT scans demonstrating solid osseous fusion and proper hardware position of the anterior cage at T-10 and posterolateral instrumentation and fusion from T-7 to L-1. No local recurrence can be seen at the vertebrectomy site.

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