ESMO 2018: The Surgical Approach for Malignant Pheochromocytoma / Paraganglioma

Munich, Germany ( Dr. Martin Walz gave the surgical perspective on how to treat pheochromocytoma and paraganglioma. Pheochromocytoma was always believed to be the 10% tumor, meaning that all rare subtypes of the tumor were thought to be prevalent in approximately 10% of cases. However, real-world data from Dr. Walz’s institution demonstrate different numbers. Approximately 15% of these tumors are bilateral, 5% are pediatric, 35% have some genetic component, 15% are extra-gonadal, and the percentage of malignant tumors is not clear.

These tumors can be seen using various advanced PET imaging techniques, including MRI, PET-CT, and PET-MRI (Figure 1).

UroToday ESMO2018 Pheochromocytoma in the various imaging modalities
Figure 1 – Pheochromocytoma in the various imaging modalities:

Dr. Walz did not go into the extensive process of diagnosing these tumors due to interests of time. Instead, he focused on reporting some surgical cases he was involved in and even showed some interesting videos of previous procedure that he has performed, both laparoscopically and robotically.

He summarized his talk, stating that for unilateral pheochromocytoma, the optimal treatment is surgical removal. When there are bilateral tumors, partial adrenalectomy should be attempted, at least at one side, in an attempt to avoid forcing the patient to take lifelong hormonal replacements. For a large paraganglioma, as seen in figure 2, surgical extirpation is recommended as well. This treatment is also recommended for multiple chromaffin tumors, recurrent pheochromocytoma, and for recurrent paraganglioma.

UroToday ESMO2018 Large Paraganglioma
Figure 2 -Large Paraganglioma:

When the recurrent pheochromocytoma is accompanied by multiple metastases, there is no point in surgery at this time. In contrast, in chromaffin tumors with only some visualized metastases, it is possible to attempt a mastectomy along with the removal of the primary tumor.

Dr. Walz then described in short, his surgical technique, which is usually attempted with minimally invasive techniques, with either the robot or laparoscopic surgery. Minimally invasive techniques are being used more often worldwide for these tumors, and this modality seems to be an effective and safe technique.  Dr. Walz commonly uses the posterior retroperitoneal approach, where the patient lies on his abdomen, because the approach to the tumor is the fastest and most simple, according to him.

Dr. Walz believes that the renal vessels represent a line, where above it the surgery should be done in a retroperitoneoscopic approach, and below these vessels, the procedure should be done laparoscopically. Following this simple rule will make the surgery technically easier for the surgeon.

Presented by: Martin Walz, MD, Professor, The Essen-Mitte Clinic, Essen, Germany

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 European Society for Medical Oncology Congress (#ESMO18), October 19-23,  2018, Munich Germany