Phaeochromocytoma demonstrated by aortography

Acta Radiologica

ISSN: 0001-6926 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iaro20

Phaeochromocytoma demonstrated by
aortography

Lars R. Holsti

To cite this article: Lars R. Holsti (1962) Phaeochromocytoma demonstrated by aortography,
Acta Radiologica, 57:4, 259-263
To link to this article: http://dx.doi.org/10.3109/00016926209171753

Published online: 16 Dec 2010.

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Downloaded by [50.116.19.84] at 02:00 29 January 2016 FROM THE SURGICAL ROENTGENDIAGNOSTIC DEPARTMENT (DIRECTOR : DOCENT

R. KOHLER) AND SURGICAL CLINIC 11 (DIRECTOR: PROF. v. SEIRO), UNIVERSITY

CENTRAL HOSPITAL, HELSINKI, FINLAND.

PHAEOCHROMOCYTOMA DEMONSTRATED BY
AORTOGRAPHY
Report of two cases

LARSR. HOLSTI

Recent literature has laid stress on the diagnostic importance of aortography
in tumours of suprarenal origin (EDSMAN1957, AHLBACK 1958, GOODWIN1961).
Few cases however of phaeochromocytoma established by this method have
been verified histologically; a survey of the literature yielded only 15 cases
(DAHL-IVERSE1N957, EDSMAN1957, SUSSE & RADKE1957, ELFVIN1959,

GOODWIN1961, PYLE1961), in 2 of which the growths were bilateral (DAHL-
IVERSENP,YLE).Two further cases of this rare condition are now reported.

Case reports

Case 1. Male, aged 17, with four months’ history of right-sided blurring of vision and head-
aches, a blood pressure of 170/120, and hypertensive changes of grade III-IV in the ocular
fundi. The sight of the left eye had also deteriorated considerably and the patient was no
longer able to read. Ocular pressure: 50 bilaterally. The case had first been treated as one of
glaucoma.

On examination the blood pressure was found to have risen to 200/160 and electrocardio-
graphy demonstrated signs of slight left ventricular cardiac hypertrophy. There was increased
excretion of urinary catecholamines (400-1 200 ,ug in 24 hours), and a typical rapid fall in
blood pressure from ZOO/ 155 to 140/60 occurred following the intravenous injection of regitine.
Good renal function, urography normal. At retroperitoneal pneumography a plum-sized
mass was evident in the region of the left suprarenal gland.

Submitted for publication 1I December 1961.

259

260 LARS R. HOLSTI

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Fig. 1. Case 1. Aortograms. a) Arterial phase; tumor vessels from inferior suprarenal artery.
b) Capillary phase; contrast filling of phaeochromocytoma above hilum of kidney.

Aortography was performed with the catheter tip at the level of T h 12. As the catheter
was being inserted, the systolic blood pressure rose from 180 to 320 and the patient complained
of increasingly severe headache. The anesthetist, who was present throughout the examina-
tion, injected 5 mg regitine via a needle inserted in the cubital vein before the examination
was started. This produced a rapid fall in the systolic blood pressure to 160, and during the

injection of the contrast medium (40 ml Urografin 60 yo),for which a pressure syringe was

used, the blood pressure remained stable. The renal vessels appeared normal. During the
arterial phase, an artery arising from the left renal artery was seen to run upwards to the
upper pole of the kidney where it divided into two smaller branches and these in turn into
numerous small tumor vessels (Fig. la). No arteries arising from the aorta were seen running

to the suprarenal region. A tumor-like mass measuring 3 x 4 cm and lying close to the upper

pole of the kidney became filled during the nephrographic phase (Fig. Ib) ;it was completely
homogeneous at the end of the examination. Faint normal vasculature was seen on the right
side.

At operation (Prof. V. Seiro) 3 days later, a plum-sized, solid, smooth-walled and bluish
tumour arising from the median aspect of the left suprarenal gland was found. Suprarenal-
ectomy was performed and the tumour was removed. The cut surface of the tumour was light
grey in colour and displayed numerous petechiae. The histologic appearances were typical
of a benign phaeochromocytoma. The systolic blood pressure, which was 190 at the begin-
ning of the operation, rose temporarily to 240 and fell immediately after the excision of the
tumour to 105. The urinary catechol excretion decreased after the operation to 40 ,ug in 24
hours, the blood pressure was stabilised at 130/90, and the patient’s sight improved so that he
was again able to read.

PHAEOCHROMOCYTOMA DEMONSTRATED BY AORTOGRAPHY 26 1

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Fig. 2. Phaeochromocytoma in left renal hilum; arterial phase (a), capillary phase (b).

Case 2. Male, aged 18, with a ten months’ history of periodical tachycardia, sweating, vertigo
and fatigue. He had been examined on three occasions and found to have a blood pressure
ranging from 140/100 to 180/110. Urography, retroperitoneal pneumography, the histamine
test, and the urinary electrolyte values, were all normal. There was evidence, however of an
increased excretion of urinary catecholamines (165-750 ,ug in 24 hours).

At aortography, the same precautionary measures were taken as in the first case, but neither

catheterization nor the injection of contrast medium (40 ml Urografin 60 yo)with a pres-

sure syringe caused elevation of blood pressure. No regitine was therefore administered. The
right suprarenal gland appeared to be regular during the nephrographic phase. No increase
in the density of the contrast medium was evident at the normal site of the left suprarenal
gland but an opacity due to contrast medium appeared close to the hilum of the left kidney
in the nephrographic phase; this was misinterpreted as an early venous phase.

At operation (Docent M. Turunenj 5 days later the left suprarenal gland was found to lie
close to the hilum of the kidney. A large cherry-sized tumour was attached to the medial mar-
gin of the suprarenal gland and, together with a part of the gland, was resected. The tumour
was found histologically to be a typical phaeochromocytoma. At re-appraisal of the arterio-
grams after operation a ‘cluster’ of pathologic vessels, obviously arising from the middle supra-
renal artery, was evident in the region of the hilum of the left kidney (Fig. 2a). The opacity
mentioned (Fig. 2bj was seen at the same site in the nephrographic phase. The change was
thus caused by the phaeochromocytoma.

Discussion

The aortograms of both of the cases were characterised by rich vascularity
and tumour vessels, features which are typical of the majority of the other

262 LARS R. HOLSTI

Downloaded by [50.116.19.84] at 02:00 29 January 2016 cases reported in the literature. T h e two avascular phaeochromocytomas
described by EDSMAN(1957) are more uncommon.

A considerable elevation of the blood pressure occurred during the catheteriza-
tion in the first case. Precautions had been taken, however, and the immediate
injection of regitine rapidly lowered the blood pressure which then remained
stable during the actual examination. The same precautions were observed in
the second case, but the blood pressure did not change during the procedure.
Both AMUNDSEeNt coll. (1956) and EDSMAN(1957) have reported a hyperten-
sive attack during aortography but, as in our Case 1, no more serious sequelae
occurred. O n the other hand, the literature describes two hypertensive crises
after translumbar aortography, both of which terminated fatally (KOONCE
et coll. 1952, SALTZet coll. 1956). I n both these cases autopsy revealed a hemor-
rhage in the retroperitoneal space. SALTZet coll. considered adrenaline shock
in their case to have been the cause of death. A third of all active phaeochromo-
cytomas secrete adrenaline as well as noradrenaline (VON EULER& STROM1957).
It is known that patients with a phaeochromocytoma may die after a minor
operative procedure (ARANOW1950). Aortography should therefore be per-
formed in these patients in such a way that they are subjected to as little stress
as possible and irritation of the active phaeochromocytoma avoided. Trans-
lumbar aortography should give place to catheterization, but not to selective
renal angiography. The patient may be examined under narcosis, as was done
by PYLE;regitine may be administered prophylactically, as by GOODWIN;
or regitine may be kept in readiness for injection as by the present author. A
precautionary measure that has been found useful is for the anesthetist to be
present during the examination to control the blood pressure and general
condition of the patient. I n addition GOODWINinjected procaine intra-aortally
to avoid spasms. The patient must be sedated. The forestalling of complications
during the examination is all important and must always be given careful
thought and consideration.

Addendum

Since completion of the manuscript the author has had the opportunity of
studying three further cases in which phaeochromocytoma was localised pre-
operatively by aortography. One of the cases was malignant.

SUMMARY

Two cases of phaeochromocytoma were demonstrated by percutaneous femoral aortography.
Insertion of the catheter caused a hypertensive attack in one of the cases and was managed
by the immediate intravenous injection of regitine. The risks of aortography in phaeochromo-
cytoma and the necessary precautionary measures are briefly discussed.

PHAEOCHROMOCYTOMA DEMONSTRATED BY AORTOGRAPHY 263

ZUSAMMENFASSUNG

Mit perkutaner femoraler Aortographie sind 2 Falle von Phaeochromocytom nachgewiesen
worden. Die Einf-&rung des Katheters verursachte in einem der Falle eine Blutdrucksteige-
rung; diese wurde mit unmittelbarer intravenoser Injektion von Regitine behandelt. Das
Risiko einer Aortographie bei Phaeochromocytomen und die notwendigen Vorsichtsmass-
nahmen werden kurz besprochen.

RESUMC

Deux cas de phtochromocytome ont C t t diagnostiquts par aortographie fkmorale percu-
tante. L’introduction du cathCter a provoquk une crise d’hypertension dans un cas, traitte
par injection intraveineuse immtdiate de rkgitine. L’auteur examine brikvement les dangers
de l’aortographie dans le phCochromocytome et les prkcautions nCcessaires.

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