title: Hemodynamic instability during resection of pheochromocytoma in MEN versus non-MEN patients.
abstract: OBJECTIVE
  Hemodynamic (HD) instability still underlies difficulties during pheochromocytoma resection. Little is known about HD instability in patients with multiple endocrine neoplasia (MEN) type 2-related pheochromocytoma. Our aim was to assess differences in HD during pheochromocytoma resection between MEN2 and non-MEN patients. In addition, we sought to identify risk factors for intraoperative HD instability.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  A total of 22 MEN2 and 34 non-MEN patients underwent 61 pheochromocytoma resections at the University Medical Center Utrecht between 2000 and 2010. All MEN2-related pheochromocytomas were diagnosed by annual screening. HD instability was assessed by measuring the frequency of hypotensive (mean arterial blood pressure (MABP) <60  mmHg) and/or hypertensive (systolic arterial blood pressure (SABP) >200  mmHg) episodes.
  
  
  RESULTS
  Compared with non-MEN patients, MEN2 patients were younger at diagnosis, had less symptoms, lower hormone levels, and smaller tumors. Intraoperatively, MEN2 patients had a similar frequency of hypertensive episodes (1.3 vs 1.9, P=0.162, 95% confidence interval (CI): -6.7 to 35.4) and a similar maximum SABP (200 vs 220  mmHg, P=0.180, 95% CI: -9.7 to 50.5). However, MEN2 patients experienced less frequent (1.04 vs 2.6, P=0.003, 95% CI: 0.57 to 2.6) and less severe hypotensive episodes after tumor resection (lowest MABP: 52.5 vs 45.6  mmHg, P=0.015, 95% CI: -12.6 to 1.16). Tumor size was an independent risk factor for HD instability for the total group after multivariate analysis.
  
  
  CONCLUSIONS
  MEN2 patients with pheochromocytoma, despite their smaller tumors, do not distinguish themselves from non-MEN patients in terms of hypertensive episodes during pheochromocytoma resection. Therefore, pretreatment with α- and β-blockade remains the standard of care in MEN2-related as well as in non-MEN-related pheochromocytomas.
authors.affiliation: Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Hp.nr. G04.228, Heidelberglaan 100, 3584CX Utrecht, The Netherlands. a.scholten-5@umcutrecht.nl
authors.forename: Anouk
authors.initials: A
authors.lastname: Scholten
authors.forename: Menno R
authors.initials: MR
authors.lastname: Vriens
authors.forename: Geert Jan E
authors.initials: GJ
authors.lastname: Cromheecke
authors.forename: Inne H M
authors.initials: IH
authors.lastname: Borel Rinkes
authors.forename: Gerlof D
authors.initials: GD
authors.lastname: Valk
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000473:pathology / Q000503:physiopathology* / Q000601:surgery*; D058668:Adrenergic alpha-1 Receptor Antagonists / Q000627:therapeutic use; D058671:Adrenergic beta-1 Receptor Antagonists / Q000627:therapeutic use; D000328:Adult; D001794:Blood Pressure; D015331:Cohort Studies; D017292:Doxazosin / Q000627:therapeutic use; D005260:Female; D006439:Hemodynamics; D006801:Humans; D006973:Hypertension / Q000209:etiology; D007431:Intraoperative Complications / Q000209:etiology; D008297:Male; D008790:Metoprolol / Q000627:therapeutic use; D008875:Middle Aged; D018813:Multiple Endocrine Neoplasia Type 2a / Q000150:complications / Q000503:physiopathology* / Q000601:surgery*; D010673:Pheochromocytoma / Q000473:pathology / Q000503:physiopathology* / Q000601:surgery*; D012189:Retrospective Studies
chemical_list: D058668:Adrenergic alpha-1 Receptor Antagonists; D058671:Adrenergic beta-1 Receptor Antagonists; D008790:Metoprolol; D017292:Doxazosin