Traditionally, patients with pheo are treated with
medications to block the alpha adrenergic receptor (alpha blockade) before
surgical resection for longer than 2 weeks. alpha blockade has worked very well
in the past 50 years to prepare patients for surgery. On the other hand, whether
alpha blockade is really needed has been questioned for many years. Do we need
alpha blockade?
Indeed, there has not been a randomized clinical trial
comparing alpha blockade and another regimen without alpha blockade. Strictly
speaking, the answer to the question whether we need alpha blockage is unknown.
I believe in alpha blockade based on the long history of effective use,
successful personal experience, and some evidence that alpha blockade reverses
pheo-induced cardiomyopathy. In addition, I find 2 important flaws in the
arguments against alpha blockade.
Flaw 1: Other medications control blood pressure just as
well. As I explained in earlier posts, the goal of preoperative preparation is
not just to control blood pressure but to treat and prevent pheo-induced
cardiomyopathy. The most devastating complications of pheo are cardiovascular
catastrophes such as congestive heart failure, cardiac arrest, severe
arrhythmia, myocardial infarction, ventricular thrombosis, and stroke. Most
patients who present with those complications have no history of hypertension
but they are the ones who most need preoperative preparation.
Flaw 2: Nobody dies of pheo resection, regardless of the
preoperative preparation regimen. Perioperative mortality is the wrong
criterion for the success of pheo management. I have witnessed cases where
omission of preoperative alpha blockade in normotensive patients led to severe
postoperative complications and prolonged hospital stay. Postoperative length
of stay, complications, and quality of life are much more meaningful criteria
for the success of pheo medical management.
There is also a common issue in the arguments for and
against alpha blockade. Both sides seem to consider all the pheos and the
patients with pheo are the same. In reality, there is clear heterogeneity of
pheo and the patients with this tumor. A 2-cm incidentally identified pheo is
certainly different from a 7-cm one causing cardiac arrest. Likewise, a 30-year-old,
otherwise healthy patient is obviously different from an 80-year-old patient
with multiple comorbidities. Patients with low-risk pheo (< 3-cm) who are
otherwise healthy and non-pregnant may probably undergo adrenalectomy safely
without specific medical management. For the majority of patients with
intermediate- and high-risk pheo, alpha blockade is probably the best initial
treatment, until a randomized clinically trial demonstrates otherwise.
Dr. Pheo
