Clinical decision making in small non-functioning VHL-related incidentalomas

• Published in: Endocrine Connections Vol. 9; no. 8; pp. 834 - 844
• Main Authors: Därr, Roland, Kater, Jonas, Sekula, Peggy, Bausch, Birke, Krauss, Tobias, Bode, Christoph, Walz, Gerd, Neumann, Hartmut P, Zschiedrich, Stefan
• Format: Journal Article
• Language: English
• Published: Bristol Bioscientifica Ltd 01.08.2020; Bioscientifica
• Subjects: adrenal; endocrine cancers; neuroendocrinology; rare diseases/syndromes; neuroendocrinology; rare diseases/syndromes; adrenal; endocrine cancers
• ISSN: 2049-3614; 2049-3614
• DOI: 10.1530/EC-20-0208

The optimal treatment strategy for patients with small non-functioning VHL-related incidentalomas is unclear. We searched the Freiburg VHL registry for patients with radiologic evidence of pheochromocytoma/paraganglioma (PHEO/PGL). In total, 176 patients with single, multiple, and recurrent tumours were identified (1.84 tumours/patient, range 1–8). Mean age at diagnosis was 32 ± 16 years. Seventy-four percent of tumours were localised to the adrenals. Mean tumour diameter was 2.42 ± 2.27 cm, 46% were <1.5 cm. 24% of tumours were biochemically inactive. Inactive tumours were significantly smaller than active PHEO/PGL at diagnosis (4.16 ± 2.80 cm vs 1.43 ± 0.45 cm; P < 0.025) and before surgery (4.89 ± 3.47 cm vs 1.36 ± 0.43 cm; P < 0.02). Disease was stable in 67% of 21 patients with evaluable tumours ≤1.5 cm according to RECIST and progressed in 7. Time till surgery in these patients was 29.5 ± 20.0 months. A total of 155 patients underwent surgery. PHEO/PGL was histologically excluded in 4 and proven in 151. Of these, one had additional metastatic disease, one harboured another tumour of a different type, and in 2 a second surgery for suspected disease recurrence did not confirm PHEO/PGL. Logistic regression analysis revealed 50% probability for a positive/negative biochemical test result at 1.8 cm tumour diameter. Values of a novel symptom score were positively correlated with tumour size (Rs = 0.46, P < 0.0001) and together with a positive biochemistry a linear size predictor (P < 0.01). Results support standardised clinical assessment and measurement of tumour size and metanephrines in VHL patients with non-functioning incidentalomas <1.5 cm at one year following diagnosis and at individualised intervals thereafter depending on evolving growth dynamics, secretory activity and symptomatology.