Diagnostic Approach to Pheochromocytoma

Imaging Recommendations

The American College of Radiology recommends using nonionic contrast agents for CT scans in patients with suspected pheochromocytoma, as they appear safe and do not increase the risk of hypertensive crisis 1
Small pheochromocytomas or those in atypical locations may be missed on conventional CT imaging without proper arterial phase assessment 2
For biochemically confirmed pheochromocytoma with negative initial CT imaging, consider extending imaging to include chest and neck 2

Functional imaging with 123I-MIBG scintigraphy, 18F-FDOPA PET, or 18F-FDG PET provides higher sensitivity for detecting small or atypically located tumors 2
In patients with established pheochromocytoma, FDG-PET appears superior to MIBG for detecting malignant tumors, particularly in patients with SDHB mutation 1

Biochemical confirmation with plasma free metanephrines or 24-hour urinary fractionated metanephrines should always precede imaging for suspected pheochromocytoma 2, 3
Fine needle biopsy of suspected pheochromocytoma is contraindicated due to risk of hypertensive crisis 1, 3