Adrenal medullary hyperplasia mimicking pheochromocytoma.

A 59-year-old woman, a known case of hypertension, was incidentally diagnosed with a large right-sided adrenal mass. Investigations for a functional adrenal lesion resulted in very high preoperative norepinephrine levels. A right adrenalectomy was performed. Histology showed adrenal medullary hyperplasia (AMH). AMH is a rare diagnosis and its incidence is poorly documented in the literature. This is a benign entity which resembles pheochromocytoma (PCC) in both clinical and biochemical manner. AMH is usually bilateral and may occur in isolation or in association with PCC. In fact, some authors consider it to be a precursor to PCC. Thus, these patients need long-term follow-up in view of the risk of development of PCC later.

La chirurgie d'épargne surrénalienne : du cortex à la médulla: Cortical sparing surgery: from cortex to medulla.

The 2017 Endocrine Society annual meeting included several communications and debates on the conservative adrenal surgery in bilateral hereditary pheochromocytomas (BHP), bilateral adrenal macronodular hyperplasia (BAMH) and primary hyperaldosteronism (PHA). The general principle is to preserve a part of the adrenal cortex to prevent the occurrence of a definitive adrenal insufficiency. In BHP, cortical sparing surgery allows more than 50% of patients to maintain normal corticotropic function at 10 years with a low recurrence rate (~ 10%). Since the adrenal medulla cannot be removed entirely, recurrence seems inevitable and long-term follow-up is essential. Individual risk of malignancy must be taken into account. In BAMH responsible for Cushing syndrome, unilateral adrenalectomy induces a normalization of urinary free cortisol in 92 to 100% of cases and even corticotropic insufficiency in 40 to 100% of cases. This is most often transient. Late recurrences of Cushing's syndrome may occur in 13 to 60% of cases. Prolonged patient monitoring is therefore essential. In PAH with lateralized aldosterone production, minimally invasive partial adrenal surgery, which consists of removing only the adrenal adenoma visualized at TDM, allows an improvement blood pressure in about 94% of patients. However, failure or recurrence may occur. Its place therefore remains marginal in the treatment of the lateralized PAHs.

Adrenal-derived stress hormones modulate ozone-induced lung injury and inflammation.

Ozone-induced systemic effects are modulated through activation of the neuro-hormonal stress response pathway. Adrenal demedullation (DEMED) or bilateral total adrenalectomy (ADREX) inhibits systemic and pulmonary effects of acute ozone exposure. To understand the influence of adrenal-derived stress hormones in mediating ozone-induced lung injury/inflammation, we assessed global gene expression (mRNA sequencing) and selected proteins in lung tissues from male Wistar-Kyoto rats that underwent DEMED, ADREX, or sham surgery (SHAM) prior to their exposure to air or ozone (1ppm), 4h/day for 1 or 2days. Ozone exposure significantly changed the expression of over 2300 genes in lungs of SHAM rats, and these changes were markedly reduced in DEMED and ADREX rats. SHAM surgery but not DEMED or ADREX resulted in activation of multiple ozone-responsive pathways, including glucocorticoid, acute phase response, NRF2, and PI3K-AKT. Predicted targets from sequencing data showed a similarity between transcriptional changes induced by ozone and adrenergic and steroidal modulation of effects in SHAM but not ADREX rats. Ozone-induced increases in lung Il6 in SHAM rats coincided with neutrophilic inflammation, but were diminished in DEMED and ADREX rats. Although ozone exposure in SHAM rats did not significantly alter mRNA expression of Ifnγ and Il-4, the IL-4 protein and ratio of IL-4 to IFNγ (IL-4/IFNγ) proteins increased suggesting a tendency for a Th2 response. This did not occur in ADREX and DEMED rats. We demonstrate that ozone-induced lung injury and neutrophilic inflammation require the presence of circulating epinephrine and corticosterone, which transcriptionally regulates signaling mechanisms involved in this response.

Adrenal Demedullation and Oxygen Supplementation Independently Increase Glucose-Stimulated Insulin Concentrations in Fetal Sheep With Intrauterine Growth Restriction.

In pregnancies complicated by placental insufficiency and intrauterine growth restriction (IUGR), fetal glucose and oxygen concentrations are reduced, whereas plasma norepinephrine and epinephrine concentrations are elevated throughout the final third of gestation. Here we study the effects of chronic hypoxemia and hypercatecholaminemia on ß-cell function in fetal sheep with placental insufficiency-induced IUGR that is produced by maternal hyperthermia. IUGR and control fetuses underwent a sham (intact) or bilateral adrenal demedullation (AD) surgical procedure at 0.65 gestation. As expected, AD-IUGR fetuses had lower norepinephrine concentrations than intact-IUGR fetuses despite being hypoxemic and hypoglycemic. Placental insufficiency reduced fetal weights, but the severity of IUGR was less with AD. Although basal plasma insulin concentrations were lower in intact-IUGR and AD-IUGR fetuses compared with intact-controls, glucose-stimulated insulin concentrations were greater in AD-IUGR fetuses compared with intact-IUGR fetuses. Interestingly, AD-controls had lower glucose- and arginine-stimulated insulin concentrations than intact-controls, but AD-IUGR and AD-control insulin responses were not different. To investigate chronic hypoxemia in the IUGR fetus, arterial oxygen tension was increased to normal levels by increasing the maternal inspired oxygen fraction. Oxygenation of IUGR fetuses enhanced glucose-stimulated insulin concentrations 3.3-fold in intact-IUGR and 1.7-fold in AD-IUGR fetuses but did not lower norepinephrine and epinephrine concentrations. Together these findings show that chronic hypoxemia and hypercatecholaminemia have distinct but complementary roles in the suppression of ß-cell responsiveness in IUGR fetuses.

Diverse proportion in composite pheochromocytoma-ganglioneuroma may induce varied clinical symptom: comparison of two cases.

Composite pheochromocytoma-ganglioneuroma is extremely rare. We described two cases of composite pheochromocytomas in the adrenal medullar. Case 1 was a 70-year-old male presenting with lower abdominal pain and normal blood electrolytes. Case 2 was a 48-year-old female with palpitation and back tenderness. Biochemical investigations showed hypocalcium, hypokalemia and high level of vma. The histological images and the immunohistochemical staining demonstrated the two cases composed of pheochromocytoma and ganglioneuromoma components. Ganglioneuroma component in case 2 accounted for more proportion than that in case 1. We speculated that the varied clinical symptoms were related with the diverse proportions in composite pheochromocytome-ganglioneuroma.

The effect of adrenal medullectomy on metabolic responses to chronic intermittent hypoxia.

Obstructive sleep apnea causes intermittent hypoxia (IH) and is associated with insulin resistance and type 2 diabetes. IH increases plasma catecholamine levels, which may increase insulin resistance and suppress insulin secretion. The objective of this study was to determine if adrenal medullectomy (MED) prevents metabolic dysfunction in IH. MED or sham surgery was performed in 60 male C57BL/6J mice, which were then exposed to IH or control conditions (intermittent air) for 6 weeks. IH increased plasma epinephrine and norepinephrine levels, increased fasting blood glucose and lowered basal and glucose-stimulated insulin secretion. MED decreased baseline epinephrine and prevented the IH induced increase in epinephrine, whereas the norepinephrine response remained intact. MED improved glucose tolerance in mice exposed to IH, attenuated the impairment in basal and glucose-stimulated insulin secretion, but did not prevent IH-induced fasting hyperglycemia or insulin resistance. We conclude that the epinephrine release from the adrenal medulla during IH suppresses insulin secretion causing hyperglycemia.

Epinephrine depletion exacerbates the fasting-induced protein breakdown in fast-twitch skeletal muscles.

The physiological role of epinephrine in the regulation of skeletal muscle protein metabolism under fasting is unknown. We examined the effects of plasma epinephrine depletion, induced by adrenodemedullation (ADMX), on muscle protein metabolism in fed and 2-day-fasted rats. In fed rats, ADMX for 10 days reduced muscle mass, the cross-sectional area of extensor digitorum longus (EDL) muscle fibers, and the phosphorylation levels of Akt. In addition, ADMX led to a compensatory increase in muscle sympathetic activity, as estimated by the rate of norepinephrine turnover; this increase was accompanied by high rates of muscle protein synthesis. In fasted rats, ADMX exacerbated fasting-induced proteolysis in EDL but did not affect the low rates of protein synthesis. Accordingly, ADMX activated lysosomal proteolysis and further increased the activity of the ubiquitin (Ub)-proteasome system (UPS). Moreover, expression of the atrophy-related Ub ligases atrogin-1 and MuRF1 and the autophagy-related genes LC3b and GABARAPl1 were upregulated in EDL muscles from ADMX-fasted rats compared with sham-fasted rats, and ADMX reduced cAMP levels and increased fasting-induced Akt dephosphorylation. Unlike that observed for EDL muscles, soleus muscle proteolysis and Akt phosphorylation levels were not affected by ADMX. In isolated EDL, epinephrine reduced the basal UPS activity and suppressed overall proteolysis and atrogin-1 and MuRF1 induction following fasting. These data suggest that epinephrine released from the adrenal medulla inhibits fasting-induced protein breakdown in fast-twitch skeletal muscles, and these antiproteolytic effects on the UPS and lysosomal system are apparently mediated through a cAMP-Akt-dependent pathway, which suppresses ubiquitination and autophagy.

Recurrent hemangioendothelioma in a pediatric patient: report and review of the literature.

The most common adrenal tumor in the pediatric population is a benign hemangioma. Adrenal hemangioendotheliomas are extremely rare variants of the hemangioma which are characterized by the presence of multiple anastomosing vascular spaces lined by endothelial cells, and have indeterminant biologic behavior. We report a unique case in a pediatric patient with Beckwith-Wiedemann syndrome which was complicated by a recurrence of the lesion.

The utility of cortical-sparing adrenalectomy in pheochromocytomas associated with genetic syndromes.

Management of pediatric patients with pheochromocytomas associated with genetic syndromes, such as Von Hippel-Lindau (VHL) disease, is complex owing to the need for continuous surveillance, high rates of recurrence, multiple operations during childhood, and the possibility of lifelong exogenous steroid replacement. We report the successful treatment of two siblings with VHL who underwent a total of six cortical-sparing procedures without requiring steroid therapy.

Sympathetic innervation of the splanchnic region mediates the beneficial hemodynamic effects of 8-OH-DPAT in hemorrhagic shock.

Administration of the 5-HT(1A) receptor agonist, 8-OH-DPAT, improves cardiovascular hemodynamics and tissue oxygenation in conscious rats subjected to hypovolemic shock. This effect is mediated by sympathetic-dependent increases in venous tone. To determine the role of splanchnic nerves in this response, effects of 8-OH-DPAT (30 nmol/kg iv) were measured following fixed-arterial blood pressure hemorrhagic shock (i.e., maintenance of 50 mmHg arterial pressure for 25 min) in rats subjected to bilateral splanchnic nerve denervation (SD). Splanchnic denervation decreased baseline venous tone as measured by mean circulatory filling pressure (MCFP) and accelerated the onset of hypotension during blood loss. Splanchnic denervation did not affect the immediate pressor effect of 8-OH-DPAT but did reverse the drug's lasting pressor effect, as well as its ability to increase MCFP and improve metabolic acidosis. Like SD, adrenal demedullation (ADMX) lowered baseline MCFP and accelerated the hypotensive response to blood withdrawal but also reduced the volume of blood withdrawal required to maintain arterial blood pressure at 50 mmHg. 8-OH-DPAT raised MCFP early after administration in ADMX rats, but the response did not persist throughout the posthemorrhage period. In a fixed-volume hemorrhage model, 8-OH-DPAT continued to raise blood pressure in ADMX rats. However, it produced only a transient and variable rise in MCFP compared with sham-operated animals. The data indicate that 8-OH-DPAT increases venoconstriction and improves acid-base balance in hypovolemic rats through activation of splanchnic nerves. This effect is due, in part, to activation of the adrenal medulla.

Neural and humoral control of regional vascular beds via A1 adenosine receptors located in the nucleus tractus solitarii.

Our previous studies showed that stimulation of adenosine A(1) receptors located in the nucleus of the solitary tract (NTS) exerts counteracting effects on the iliac vascular bed: activation of the adrenal medulla and ß-adrenergic vasodilation vs. sympathetic and vasopressinergic vasoconstriction. Because NTS A(1) adenosine receptors inhibit baroreflex transmission in the NTS and contribute to the pressor component of the HDR, we hypothesized that these receptors also contribute to the redistribution of blood from the visceral to the muscle vasculature via prevailing sympathetic and vasopressinergic vasoconstriction in the visceral (renal and mesenteric) vascular beds and prevailing ß-adrenergic vasodilation in the somatic (iliac) vasculature. To test this hypothesis, we compared the A(1) adenosine-receptor-mediated effects of each vasoactive factor triggered by NTS A(1) adenosine receptor stimulation [N(6)-cyclopentyladenosine (CPA), 330 pmol in 50 nl] on the regional vascular responses in urethane/chloralose-anesthetized rats. The single-factor effects were separated using adrenalectomy, ß-adrenergic blockade, V(1) vasopressin receptor blockade, and sinoaortic denervation. In intact animals, initial vasodilation was followed by large, sustained vasoconstriction with smaller responses observed in renal vs. mesenteric and iliac vascular beds. The initial ß-adrenergic vasodilation prevailed in the iliac vs. mesenteric and renal vasculature. The large and sustained vasopressinergic vasoconstriction was similar in all vascular beds. Small sympathetic vasoconstriction was observed only in the iliac vasculature in this setting. We conclude that, although A(1) adenosine-receptor-mediated ß-adrenergic vasodilation may contribute to the redistribution of blood from the visceral to the muscle vasculature, this effect is overridden by sympathetic and vasopressinergic vasoconstriction.

Brain cyclooxygenase and prostanoid TP receptors are involved in centrally administered epibatidine-induced secretion of noradrenaline and adrenaline from the adrenal medulla in rats.

Plasma adrenaline mainly originates from adrenaline-containing cells in the adrenal medulla, whereas plasma noradrenaline reflects not only the release from sympathetic nerves but also the secretion from noradrenaline-containing cells in the adrenal medulla. The present study was undertaken to examine the mechanisms involved in centrally administered epibatidine (a potent agonist of nicotinic acethylcholine receptors)-induced elevation of plasma catecholamines with regard to the brain prostanoid. Intracerebroventricularly (i.c.v.) administered epibatidine (1, 5 and 10 nmol/animal) effectively elevated plasma noradrenaline and adrenaline. The epibatidine (5 nmol/animal, i.c.v.)-induced elevation of both catecholamines was attenuated by hexamethonium (an antagonist of nicotinic acethylcholine receptors) (0.9 and 1.8 micromol/animal, i.c.v.), indomethacin (an inhibitor of cyclooxygenase) (0.6 and 1.2 micromol/animal, i.c.v.) and (+)-S-145 (an antagonist of prostanoid TP receptors) (0.6 and 1.3 micromol/animal, i.c.v.), and abolished by acute bilateral adrenalectomy. On the other hand, intravenously administered epibatidine (5 nmol/animal) was largely ineffective on the plasma levels of catecholamines, and intravenous pretreatment with hexamethonium (1.8 micromol/animal) had no effect on the epibatidine (5 nmol/animal, i.c.v.)-induced elevation of both catecholamines. These results suggest that centrally administered epibatidine activates the brain nicotinic acethylcholine receptors, thereby evoking the secretion of noradrenaline and adrenaline from the adrenal medulla by brain cyclooxygenase- and prostanoid TP receptor-mediated mechanisms in rats.

Abordaje laparoscópico transperitoneal de feocromocitomas y paragangliomas / Transperitoneal laparsoscopic surgery for pheochromocytomas and paragangliomas

Los feocromocitomas adrenales y extra-adrenales o paragangliomas funcionantes constituyen una causa inusual de hipertensión arterial pasible de ser tratada mediante el tratamiento laparoscópico...El abordaje laparoscópico de feocromacitomas adrenales funcionantes constituye un método seguro y efectivo, siendo considerado actualmente el procedimiento de elección. Los avances de los métodos por imágenes de localización pre-operatoria y el continuo desarrollo quirúrgico laparoscópico permitirán, en un futuro no muy lejano, imponer el acceso laparascópico también como vía de elección en feocromocitomas extra-adrenales o paragangliomas. La alta incidencia de bilateralidad y compromiso extraadrenal justifica, a nuestro entender, la triple evaluación imagenológica (TAC-RMN-Centellografía MIBG) en todos los pacientes.

Abordaje laparoscópico transperitoneal de feocromocitomas y paragangliomas / Transperitoneal laparsoscopic surgery for pheochromocytomas and paragangliomas

Los feocromocitomas adrenales y extra-adrenales o paragangliomas funcionantes constituyen una causa inusual de hipertensión arterial pasible de ser tratada mediante el tratamiento laparoscópico...El abordaje laparoscópico de feocromacitomas adrenales funcionantes constituye un método seguro y efectivo, siendo considerado actualmente el procedimiento de elección. Los avances de los métodos por imágenes de localización pre-operatoria y el continuo desarrollo quirúrgico laparoscópico permitirán, en un futuro no muy lejano, imponer el acceso laparascópico también como vía de elección en feocromocitomas extra-adrenales o paragangliomas. La alta incidencia de bilateralidad y compromiso extraadrenal justifica, a nuestro entender, la triple evaluación imagenológica (TAC-RMN-Centellografía MIBG) en todos los pacientes.(AU)

Salsolinol and the peripheral sympathetic activity: the effects of hypophysectomy, adrenalectomy and adrenal medullectomy.

The endogenous isoquinoline salsolinol (SALS) is a recently identified prolactin (PRL) releasing factor, a selective and potent stimulator of PRL secretion both in vivo and in vitro. SALS decreased the peripheral tissue dopamine (DA) level dose dependently, consequently increased the NE/DA ratio, indicating reduced release of newly formed norepinephrine (NE) from sympathetic terminals. The aim of our study was to investigate the effect of adrenal medullectomy (MEDX), adrenalectomy (ADX) and hypophysectomy (HYPOX) on the action of SALS on the PRL secretion, and on the catecholamine concentration of the selected sympathetically innervated peripheral tissues (atrium, spleen, etc). The experiments were done in male rats of 200-300 g body weight kept in air conditioned room with regular lighting. We used high-pressure liquid chromatography with electrochemical detection (HPLC-EC) for measurement of NE and DA concentrations, and radioimmunoassay for prolactin measurement. In MEDX as well as in ADX rats, SALS (25 mg/kg i.p.) was able to reduce DA level and increase the NE/DA ratio. The changes of prolactin secretion (increase by SALS) were not affected either by ADX or MEDX. Therefore the presence of the adrenal gland is not required for the changes of prolactin secretion, nor for the reduction of peripheral sympathetic activity induced by SALS. Investigating the possible effect of pituitary hormones on the peripheral sympathetic system, the action of SALS has been tested in HYPOX rats. We have found that the effect of SALS on peripheral sympathetic terminals is not affected by HYPOX, consequently the role of pituitary hormones in the effect of SALS on the peripheral catecholamine metabolism may be excluded.

Effect of sympathectomy and demedullation on increased myenteric and dorsal vagal complex Fos-like immunoreactivity by cholecystokinin-8.

Chemical sympathectomy with daily, intraperitoneal (IP) injections of guanethidine sulfate to adult rats, attenuated myenteric, but not dorsal vagal complex (DVC) Fos-like immunoreactivity (Fos-LI) by cholecystokinin-8 (CCK). This technique destroys only 60-70% of the sympathetic neurons, and spares the hormonal source of catecholamines, the adrenal medulla. The goal of the current study is to evaluate the effect of complete sympathectomy or destroying 100% of the sympathetic neurons by injecting guanethidine to 1-day-old pups (40 mg/kg daily for 5 weeks), and surgically removing the adrenal medulla. In the DVC, demedullation and sympathectomy-demedullation increased Fos-LI by CCK in the area postrema and nucleus of the solitary tract, but sympathectomy-demedullation increased it only in the area postrema. In the myenteric plexus, sympathectomy increased this response in the duodenum, and demedullation increased it in the duodenum and jejunum. On the other hand, sympathectomy-demedullation attenuated myenteric Fos-LI in the jejunum. These results indicate that catecholamines may play an inhibitory role on the activation of the DVC neurons by CCK. In the myenteric neurons, however, catecholamines may have both inhibitory and excitatory roles depending on the level of the intestine e.g., duodenum vs. jejunum. This may also indicate that CCK activates the enteric neurons by different mechanisms or through different pathways.

Combined adrenal myelolipoma and medullary hyperplasia.

OBJECTIVE: A patient is reported with hypertension due to combined medullary adrenal hyperplasia and myelolipoma. METHODS: A 52-year-old woman with long-standing hypertension was evaluated for an incidentally discovered large tumor of the left adrenal. Left adrenalectomy was performed for a presumptive clinical diagnosis of pheochromocytoma. RESULTS: Histopathologic examination revealed a mixed tumor consisting of a large myelolipoma with infiltrating foci of adrenal medulla. CONCLUSIONS: A patient is described with hypertension, myelolipoma and adrenal medullary hyperplasia; following adrenalectomy, however, blood pressure and biochemical abnormalities normalized.