Pheochromocytoma Screening Before Surgery

Who Must Be Screened

All patients with adrenal masses >10 HU on non-contrast CT must be screened for pheochromocytoma with plasma or 24-hour urinary metanephrines, as recommended by the American College of Radiology 1
Patients with any signs or symptoms of catecholamine excess, such as headaches, sweating, palpitations, or hypertension, require screening regardless of imaging characteristics, according to the American Heart Association 1
Never perform adrenal biopsy without excluding pheochromocytoma first, as this can trigger life-threatening hypertensive crisis, as warned by the National Comprehensive Cancer Network 1, 2
All patients with MEN2A, MEN2B, or familial medullary thyroid carcinoma require pheochromocytoma screening before any planned surgery, regardless of age, as recommended by the American Thyroid Association 3, 4, 5
Biochemical screening with plasma free metanephrines and normetanephrines, or 24-hour urinary fractionated metanephrines, is mandatory for patients with genetic syndromes, according to the Endocrine Society 3

Plasma free metanephrines is the most sensitive and specific test for diagnosing pheochromocytoma, with a sensitivity of approximately 100% for both sporadic and familial pheochromocytomas, as reported by the American Association for Clinical Chemistry 1
Imaging should only follow biochemical confirmation—never perform imaging without biochemical testing first, as recommended by the Society of Nuclear Medicine and Molecular Imaging 3

Pre-operative alpha-adrenergic blockade is essential for patients with catecholamine-secreting pheochromocytomas to mitigate risk of intra-operative hypertensive crisis, as recommended by the American Society of Anesthesiologists 3
Pheochromocytomas should be removed first (with appropriate alpha-blockade) before any other planned surgery in MEN2 patients, according to the National Comprehensive Cancer Network 7

Any patient scheduled for adrenalectomy must have pheochromocytoma excluded preoperatively, even if the mass appears to be metastasis from another malignancy, as recommended by the American Urological Association 6