Alternative medicine and pheo

Happy holidays!

This is a long overdue topic suggested by a reader. I’ve been thinking about it for months. The reason for the long thinking process is mostly because I want to give alternative medicine in pheo management a fair and clear evaluation. Here are my opinions on alternative medicine.

Luckily, most patients with pheo do not need alternative medicine. For the majority of patients, preoperative preparation and surgical removal are sufficient and definitive management of pheo. We don’t have to invoke alternative medicine for them.

Patients may be interested in ways to prevent pheo recurrence if they have had pheo, or ways to prevent pheo emergence if they are carriers of mutations or have family members with pheo. As the exact molecular pathogenesis of pheo has not been worked out yet, there is no reliable knowledge on specific ways to prevent pheo recurrence or emergence. Patients and their family members should follow a healthy life style and appropriate surveillance.

Patients with metastatic pheo may have hard-to-control symptoms, develop adverse effects from treatment, or be resistant to therapies. For those patients, alternative medicine may have a role but the patients and their mainstream physicians need to be very cautious and act on good common sense. Alternative medicine won’t shrink the tumors or magically make the tumors disappear but it may make the patients feel somewhat better. The patients should let their mainstream doctors know that they are seeking alternative medicine or under alternative medicine treatment. The exact alternative medicine treatment should be known to the mainstream doctors and should not be outrageous or dangerous. The alternative medicine practitioner should not make grandiose claims about the regimen, should have a good reputation, and should know when to stop the regimen. I frankly don’t recommend alternative medicine to my patients in most situations.

Dr. Pheo

The story of Para and Poly: Are they related?

Polycythemia (Poly), a pathological increase of red blood cell count, is a well-recognized paraneoplastic syndrome. Many types of tumors are associated with polycythemia. The mechanism for the connection is generally thought to be tumor-elaborated erythropoietin (EPO), which stimulates red blood cell generation. Pheo and paraganglioma (Para) are both known to be associated with polycythemia. The polycythemia usually resolves after pheo or para resection. In some cases, the polycythemia can persist even after tumor resection, and in some others, polycythemia occurs long before pheo/para is diagnosed, suggesting that the polycythemia may not be necessarily caused by the pheo or para but they may have a common cause. Indeed, it was reported in 2009 that an inherited mutation in the gene PHD2 is associated with paraganglioma and polycythemia.

In this week’s New England Journal of Medicine, researchers at the National Institute of Health (NIH) reported two patients with paraganglioma and polycythemia who do not have PHD2 mutations. Both patients are female, 30- and 18-year-old respectively. The older patient also has somatostatinomas (duodenal or pancreatic neuroendocrine tumors secreting somatostatin). Through biochemical analysis, the NIH researchers found that the two patients have enhanced signaling of HIF2A (hypoxia-induced factor 2alpha, regulated by PHD2) in their paragangliomas. The researchers sequenced the tumor HIF2A gene and found 2 heterozygous mutations in it. Interestingly the two mutations are very closely spaced on the gene. Both mutations are activating; that is, the normal HIF2A function is heightened by the mutations. The patients’ parents do not have the mutations so the mutations are “somatic” (which occur by chance after the patients were conceived).

So now a novel cause of the syndrome of pheo/para and polycythemia has been discovered. And yes, Para and Poly are related. It is somewhat intriguing that inherited HIF2A mutations have not been found in patients with pheos in the past. It is also not clear how frequent the HIF2A somatic mutations are in the pheo/para tumors of all comers. From a practical point of view, we should screen for PHD2 and HIF2A mutations in patients with both pheo/para and polycythemia, especially if the polycythemia does not resolve after pheo/para resection, or is diagnosed long before the pheo/para is found. Novel treatment of these two disorders may now be possible. Keep tuned.

Dr. Pheo

P.S. Both Para and Poly are girl names. Para means "supreme". I don't know the origin of Poly. If you know girls named Poly, please ask them what it means. Thanks.

Small and very small pheos

As the readers may have guessed, I have been extremely busy (due to increased workload) in the last few months. That’s why I haven’t written anything in the last 4 months. I found some time at the Memorial Day weekend to write this post.  

An interesting study was published in May about small pheos. Small pheos are more commonly seen in these days. In the last year alone, at least 5 physician colleagues discussed with me about small pheos. There is no official definition of a “small” pheo but the authors call anything less than 3 cm in diameter as small. I actually agree with the authors in the 3 cm cutoff. In the past, I reviewed the literature on pheo-induced cardiomyopathy and noted all the tumors that cause cardiomyopathy are equal or larger than 3 cm. An inquisitive reader may wonder why doctors only use one dimension in describing tumor size. On one hand, doctors are lazy and one dimension is easier to remember; on the other hand, most pheos are nice and round. I have yet to see an odd-shaped pheo, say one resembling the shape of a cucumber. Of course you never know.

There are 3 main findings in the paper. First, about 1/3 of all pheos in the last 15 years are “small” (<3 cm). Second, small pheos do not usually cause hypertension or other classical pheo symptoms but some small pheos ironically cause hypertensive crisis during an unrelated surgical procedure. So if one has a small pheo and hypertension, the hypertension unlikely gets better after pheo removal. I recently had a patient with small pheo whose blood pressure actually got worse after pheo removal. Third, small pheos have typical appearance on CT/MRI but the biochemical test results can be borderline or in the cases of very small pheos (i.e. <1 cm), even normal. In my earlier posts, I emphasized that most borderline test results are false positive. That statement is still correct but I need to add some qualifications now. If an adrenal tumor is small but has typical pheo appearance on CT/MRI, and the test results are borderline, it has a good chance to be a real (small) pheo!

Pheo is a humbling tumor. The more I know about it, the more careful I become when I make a diagnosis. I begin to question myself whether I was absolutely right when I told my patients with normal biochemical test results “You don’t have pheo.” They might still have a very small pheo. Now I use a buzz phrase “clinically significant pheo.” I tell my patients if they likely or unlikely have a “clinically significant pheo” rather than if they have pheo or not. Nobody can say for sure whether a patient has a very small pheo. The good news is that very small pheos are clinically insignificant.

Dr. Pheo

A presidential tumor

I hope everyone has had a great holiday season. As the presidential campaign is gaining more steam, it is interesting to point out that pheo is a very presidential tumor.

President Dwight Eisenhower had severe, labile hypertension and multiple heart attacks and strokes. He died of congestive heart failure in 1969. Autopsy unexpectedly identified a 1.5-cm left adrenal pheo. Some notable physicians believe that the president’s pheo might have even contributed to his heart attack in 1955. The president had one of the best cardiologists (Dr. Paul Dudley White) as his personal physician and pheo was already well known as a cause of hypertension in the 1950’s. One may wonder why pheo was not thought of by the president’s medical team. Having seen quite a few patients with small pheos, I actually do not think the president’s pheo was clinically significant. Had the pheo been found and resected before his death, the president’s clinical course would not have been much different.

Steven Kubby sought to become the Libertarian Party’s nominee for president in 2008. Mr. Kubby is well known for his support of medical marijuana use. He has malignant pheo. He also had one of the best cardiologists (Dr. Vincent DeQuattro) as his doctor. Mr. Kubby received conventional treatment for malignant pheo, then he found marijuana. He claimed that marijuana solely controls his pheo symptoms and tumor growth. There is no medical literature on marijuana and pheo. Although marijuana can be used to increase quality of life in patients with severe malignant pheo, I am not aware of any mainstream doctors who prescribe it as the only treatment of malignant pheo.

All the information about the above two patients with pheo was gathered from public sources available to all.

Happy New Year!

Dr. Pheo

Report from ISP 2011 Part II

After chatting with the organizers, I realized that the primary reason to have the meeting in Disney Paris was financial—similar hotels in downtown Paris would cost twice as much. In addition, there is a grand chateau nearby that is undeniably French.

On 9/16, the lectures were mostly on progress in basic and clinical research. Regarding basic research, it seems rather clear that there are two “clusters” in pheo pathogenesis. The clusters concept is not entirely new (I wrote on the clusters before) but now the molecular details are worked out to a large extent. The scheme of pheo pathogenesis is a labyrinth of interconnected molecules. As I also do basic research myself, I am sometimes sarcastic about this kind of scheme. If everything affects everything else, how do we break the pathways? We need to figure out what the “driver” molecule is. But is there such a driver?

Some researchers reported the results of experimental targeted therapy in cell models, animal models, and in patients. The animal models are particularly intriguing and are real breakthroughs.

This meeting is very heavy on characterizing patients with SDH mutations and their individual mutations. The European countries are leading this effort. I have always wondered if SDH mutations are more common in Europe. In this meeting, I saw again some small countries reporting hundreds of patients with SDH mutations. I myself have not seen many patients in the US with clear familial paraganglioma syndromes. An alternative explanation is the difference in health care system. I cannot tell you how many patients I no longer follow due to their change of insurance plan. The national insurance system in Europe is a blessing to patients with rare and complicated diseases like pheo.

During the meeting, especially around 3 am when I was suddenly awake and trying unsuccessfully to go back to sleep, I reflected on the big picture of pheo patient care and where we should direct our research resource. I will elaborate my thoughts in later posts.

Dr. Pheo

Report from ISP 2011 Part I

The 3rd International Symposium on Pheochromocytoma (called “ISP 2011” by the organizers) is being held in a Disneyland Hotel outside Paris. I am here attending this meeting. It is a 4-day meeting but most academic activities are concentrated on Sept 15 and 16.

The specific Disneyland hotel is kind of an odd choice of venue for an American attendee like me. I would pick a downtown Paris hotel on the left bank. Apparently my European colleagues are tired of Paris and prefer a place on a theme park. The hotel is full of little cute girls and boys dressed in Disney costumes, or pestering their parents to buy them a set or 2 of. The hotel is so serious about the Disney theme that you see Monsieur Mickey everywhere, including on shower curtain. At one moment today, I felt I was at home until someone said Bonjour to me. And a bottle of coke costs 3.5 Euros.

The meeting itself is simply fantastic so far. Today’s lectures and posters are actually very educational to me even though I believe I knew a few things about pheo before the meeting (I indeed presented a poster on pheo clinical care). Really great is the discussion with colleagues. All the big shots on pheo are here, including most doctors I recommended as pheo experts in a post 2 years ago. I am pleased to say that we share similar experience and opinions on many controversial issues. Patient support groups also have a prominent presentation.

The following is an incomplete list of new things I learned today:
1. Practical half-life of plasma metanephrines is longer than most people thought. Plasma metanephrines can linger for one month after complete pheo resection.
2. Most attendees agree on the importance of preoperative preparation even when the patient does not have hypertension at the time of diagnosis.
3. First-hand accounts of the discovery processes of the novel pheo genes TMEM127, SDHAF2, and MAX, by the discoverers themselves.
4. The 3 novel genes, however fascinating for studying pheo pathogenesis, probably have limited value in clinical care for most patients.
5. Apart from family history and clinical predictors, pheo markers and pheo tissue staining can also predict specific mutations.
6. No real progress in pathological diagnosis of malignant pheo. Basically even an expert pathologist cannot accurately tell if a primary pheo is benign or malignant.
7. Surgical indications of head and neck paragangliomas.
8. Still there are no commercial labs that can do plasma methoxytyramine in the US.
9. More and more people realize that pheo causes heart damage. I have observed that for many years and it is nice to see people now agree.
10. Some new vagaries of pheo. For example, cardiomyopathy can have a waxing-and-waning course even after phenoxybenzamine.

To be continued…

Dr. Pheo

"Pheo interest group"

As pheo is a rare disease, it is no surprise that many doctors have little experience on pheo. Ideally patients with suspected pheo should be seen at large centers with extensive experience such as Mayo Clinic or National Institute of Health. On the other hand, most patients with suspected pheo do not actually have pheo and the management of pheo is not that complicated in most cases. Having traveled long distances, many patients with suspected pheo would feel that they probably could have saved the trip if their primary doctors had simply communicated with the experts in large centers about their conditions. A recent paper addresses the above situation somewhat, albeit indirectly.

In this paper, doctors at one center examined whether a "pheo interest group" could improve the diagnosis and treatment of pheo. The pheo interest group is nothing more than a group of doctors with a common interest in this rare disease. A few of the doctors have a large personal experience with pheo. The doctors compared the diagnostic accuracy and management of pheo before and after the formation of the pheo interest group and found that the quality of care improved after the group formation.

It might be expected that quality of care of course would be higher if the patients were seen by pheo specialists. This paper, however, shows that the pheo specialists do not have to see the patients directly. A phone call or email exchange between the primary doctor and a pheo specialist often does the job. The pheo specialist would review the clinical history, lab test, and imaging results (if available) provided by the primary doctor and arrive at a conclusion. The specialist only communicates with the primary doctor, without seeing the patient. The medical responsibility still rests in the primary doctor's hands. The primary doctor chooses to adopt the opinions of the specialist or not. As alluded in this paper, most primary doctors would adopt those opinions after they have had positive experience with the pheo specialists.

The moral: an inexperienced doctor should seek help from pheo specialists for diagnosis and management of pheo. Will the specialists be happy to answer the questions from non-specialists? They should. Take me as an example. I have been approached by doctors in my practice area and from remote places for pheo-related questions. I am happy to answer them. First of all, these questions are not very frequent so do not cost a lot of time. Second, I often learn new things on pheo from my colleagues who have questions in pheo. Last, it is rewarding for me to help my colleagues and patients (indirectly). I always make sure to emphasize that my opinions are "friendly" and non-binding. It is the primary doctor's responsibility to decide what to do.

Dr. Pheo