Preoperative Management of Catecholamine-Secreting Adrenal Tumors

Introduction to Alpha-Blockade

The European Society for Medical Oncology recommends administering terazosin, an alpha-1 blocker, preoperatively to prevent life-threatening hypertensive crises and arrhythmias caused by massive catecholamine release during surgical manipulation of catecholamine-secreting adrenal tumors (pheochromocytomas) 1, 2, 3
The American Heart Association suggests that alpha-blockade must be established before surgery to prevent catastrophic hemodynamic instability 1, 2, 3

The Endocrine Society states that not all adrenal adenomas require alpha-blockade — only those producing norepinephrine or epinephrine (pheochromocytomas) 4
Adenomas secreting only cortisol, aldosterone, or non-functional adenomas do not require alpha-blockade 1, 2

The European Heart Journal explains that terazosin prevents hypertensive response by occupying alpha-1 receptors, preventing the hypertensive response when catecholamines are released during tumor manipulation 5
The American College of Cardiology recommends that alpha-blockade must be initiated at least 10-14 days before surgery to allow adequate receptor blockade and volume expansion 1, 2, 3

The European Society of Cardiology suggests that supine blood pressure should be <130/80 mmHg and standing systolic blood pressure should be preferably >90 mmHg to avoid orthostatic hypotension 1, 2, 3
The American Heart Association recommends that terazosin dosing should be titrated to achieve adequate alpha-blockade, with a longer half-life than prazosin allowing once-daily dosing 1, 2, 3

The American College of Cardiology warns that never administering beta-blockers before establishing alpha-blockade can cause unopposed alpha-stimulation and severe hypertension 1, 2, 3
The European Society for Medical Oncology states that beta-blockers should only be added after adequate alpha-blockade if tachyarrhythmias develop 1, 2, 3

The European Heart Journal recommends adding calcium channel blockers (nifedipine slow-release) as second-line if target blood pressure is not achieved with alpha-blockade alone 1, 2, 3
The American Heart Association suggests considering metyrosine (inhibits catecholamine synthesis) where available 1, 2, 3

The Lancet Diabetes and Endocrinology states that alpha-blockade is unnecessary and potentially harmful in cases of purely dopamine-secreting adenomas 4
The Endocrine Society recommends monitoring for hypotension rather than hypertensive crisis in these cases 4

The American College of Cardiology recommends treating intraoperative hypertension with IV phentolamine, magnesium sulfate, calcium channel blockers, or nitroprusside 1, 2, 3
The European Society for Medical Oncology suggests anticipating profound hypotension due to sudden catecholamine withdrawal and pre-existing peripheral hypovolemia after tumor removal 1, 2, 3

The European Society for Medical Oncology recommends that complete surgical excision (R0 resection) is the only curative treatment for adrenal tumors and should be performed as soon as the patient is medically optimized 6, 7
The American Urological Association suggests that the decision pathway depends on hormonal status assessment, which must be done first, including screening for pheochromocytoma with plasma or urine metanephrines 8, 7
The National Comprehensive Cancer Network recommends measuring serum cortisol after 1 mg dexamethasone suppression test to evaluate for cortisol-secreting adenoma 8
The Endocrine Society suggests checking plasma aldosterone and renin activity if hyperaldosteronism is suspected 9

The European Association of Urology recommends that laparoscopic adrenalectomy is the gold standard for tumors <5-6 cm without invasion 6, 8
The Society of Surgical Oncology suggests that open adrenalectomy is mandatory for masses >5 cm, irregular morphology, heterogeneity, local invasion, or suspected adrenocortical carcinoma (ACC) 6, 8
The American College of Radiology recommends that CT features suggesting malignancy include: size >4 cm, heterogeneity, irregular margins, lipid-poor appearance, poor contrast washout, and evidence of invasion or necrosis 8, 9

The American Heart Association recommends initiating alpha-adrenergic blockade (phenoxybenzamine 10 mg twice daily or doxazosin) for 10-14 days before surgery for pheochromocytoma 6, 7
The Endocrine Society suggests administering hydrocortisone 150 mg/day during surgery and postoperatively to prevent adrenal crisis for cortisol-secreting tumors 6, 9

The American Urological Association warns that never performing biopsy on a suspected pheochromocytoma can precipitate fatal hypertensive crisis 8, 7
The European Society for Medical Oncology advises against delaying surgery for chemotherapy in resectable disease, as this worsens recurrence rates and survival 6
The Society of Surgical Oncology recommends that laparoscopic approach is contraindicated for ACC >5 cm due to significantly higher recurrence rates and carcinomatosis with minimally invasive approaches 8

The European Society for Medical Oncology recommends that adjuvant mitotane should be considered after complete resection of ACC to delay or prevent recurrence 6
The American Society for Radiation Oncology suggests that adjuvant radiotherapy is indicated for incomplete (R1) or uncertain (Rx) resection margins 6