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array:24 [ "pii" => "S217357862200083X" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2022.08.008" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1499" "copyright" => "AEU" "copyrightAnyo" => "2022" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Actas Urol Esp. 2023;47:68-77" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210480622001371" "issn" => "02104806" "doi" => "10.1016/j.acuro.2022.05.008" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1499" "copyright" => "AEU" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Actas Urol Esp. 2023;47:68-77" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ARTÍCULO DE REVISIÓN</span>" "titulo" => "Manejo quirúrgico y posquirúrgico de paragangliomas abdominales y feocromocitomas" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "68" "paginaFinal" => "77" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Surgical and postsurgical management of abdominal paragangliomas and pheochromocytomas" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1225 "Ancho" => 2091 "Tamanyo" => 100712 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Algoritmo de tratamiento quirúrgico en paragangliomas abdominales.</p> <p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">* En casos seleccionados, se puede considerar la cirugía laparoscópica. Considerando que, con mayor frecuencia, el paraganglioma abdominal se asocia a mutaciones del complejo enzimático succinato deshidrogenasa B y a una mayor incidencia de enfermedad múltiple, recidiva y enfermedad metastásica que hacen de la linfadenectomía asociada una opción recomendable.</p> <p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">** Se considerará la extirpación o el tratamiento ablativo de las metástasis resecables si la condición general del paciente (ECOG o PS) lo permite.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Araujo-Castro, E. Pascual-Corrales, J. Lorca Álvaro, C. Mínguez Ojeda, H. Pian, I. Ruz-Caracuel, A. Sanjuanbenito Dehesa, A.B. Serrano Romero, T. Alonso-Gordoa, J. Molina-Cerrillo, V. Gómez Dos Santos" "autores" => array:11 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Araujo-Castro" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Pascual-Corrales" ] 2 => array:2 [ "nombre" => "J." 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"apellidos" => "Gómez Dos Santos" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S217357862200083X" "doi" => "10.1016/j.acuroe.2022.08.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357862200083X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480622001371?idApp=UINPBA00004N" "url" => "/02104806/0000004700000002/v1_202303021312/S0210480622001371/v1_202303021312/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173578622000890" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2022.08.014" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1497" "copyright" => "AEU" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Actas Urol Esp. 2023;47:78-86" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Buccal mucosa graft urethroplasty for bulbar urethral stricture: Outcomes andpredictive factors affecting success" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "78" "paginaFinal" => "86" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Uretroplastia con injerto de mucosa oral para la estenosis de uretra bulbar: resultados y factores predictivos asociados al éxito" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 998 "Ancho" => 1255 "Tamanyo" => 144910 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">1. Bulbar urethral stenosis, 2. buccal graft in corporeal bed, 3. postoperative 21 day retrograde urethrography (taken with a feeding catheter passed from the side of the Foley catheter), 4. postoperative 3 month retrograde urethrography.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Y. Güler" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Güler" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480622001358" "doi" => "10.1016/j.acuro.2022.04.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480622001358?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578622000890?idApp=UINPBA00004N" "url" => "/21735786/0000004700000002/v3_202310271248/S2173578622000890/v3_202310271248/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173578622000853" "issn" => "21735786" "doi" => "10.1016/j.acuroe.2022.08.010" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "1480" "copyright" => "AEU" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Actas Urol Esp. 2023;47:65-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Optimising the management of bone related effects of androgen deprivation therapy in prostate cancer in the non-castration resistant scenario" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "65" "paginaFinal" => "67" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Optimización del manejo de los efectos adversos óseos derivados de la terapia de privación de andrógenos en el escenario del cáncer de próstata no resistente a la castración" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. 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"apellidos" => "Moreno-Sierra" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210480622001048" "doi" => "10.1016/j.acuro.2022.04.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210480622001048?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578622000853?idApp=UINPBA00004N" "url" => "/21735786/0000004700000002/v3_202310271248/S2173578622000853/v3_202310271248/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Surgical and postsurgical management of abdominal paragangliomas and pheochromocytomas" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "68" "paginaFinal" => "77" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Araujo-Castro, E. Pascual-Corrales, J. Lorca Álvaro, C. Mínguez Ojeda, H. Pian, I. Ruz-Caracuel, A. Sanjuanbenito Dehesa, A.B. Serrano Romero, T. Alonso-Gordoa, J. Molina-Cerrillo, V. Gómez Dos Santos" "autores" => array:11 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Araujo-Castro" "email" => array:1 [ 0 => "marta.araujo@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E." "apellidos" => "Pascual-Corrales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Lorca Álvaro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Mínguez Ojeda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "H." "apellidos" => "Pian" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "I." "apellidos" => "Ruz-Caracuel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "A." "apellidos" => "Sanjuanbenito Dehesa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 7 => array:3 [ "nombre" => "A.B." "apellidos" => "Serrano Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 8 => array:3 [ "nombre" => "T." "apellidos" => "Alonso-Gordoa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 9 => array:3 [ "nombre" => "J." "apellidos" => "Molina-Cerrillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 10 => array:3 [ "nombre" => "V." "apellidos" => "Gómez Dos Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Departamento de Endocrinología y Nutrición, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Urología, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de General y Cirugía Digestiva, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Anestesia, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento Médico Oncológico, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo quirúrgico y posquirúrgico de paragangliomas abdominales y feocromocitomas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1718 "Ancho" => 2925 "Tamanyo" => 194940 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgical treatment algorithm in pheochromocytomas.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">* Consider the retroperitoneal approach in case of previous abdominal surgery.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">** In selected cases, one-stage surgery with repositioning of the patient may be considered. Same approach considerations depending on the size of the lesion.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">*** Excision or ablative treatment of resectable metastases will be considered if the general situation of the patient (ECOG or PS) allows it.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Regarding adrenal “conservative” surgery, it has not been introduced in the hospital, but we believe that at this time it could be considered in the case of bilateral lesions or contralateral recurrence after previous adrenalectomy, and after its discussion in the endocrine tumour board.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pheochromocytomas and paragangliomas (PGLs) are rare neuroendocrine tumours arising from chromaffin cells of the adrenal medulla or neural crest progenitors located outside of the adrenal gland, respectively.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> PGLs can be located throughout the entire organism and are classified as sympathetic and parasympathetic depending on their origin. Pheochromocytomas and most PGLs of the thorax, abdomen, and pelvis are sympathetic.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently, there is consensus that α-adrenergic blockade should be initiated preoperatively<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> to reduce the risk of perioperative and intraoperative complications in catecholamine secreting tumours. Furthermore, the only curative treatment option of pheochromocytomas/PGLs is surgical resection. Surgery is a corner stone in control of hypersecretion and tumour growth.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The choice of surgical approach is determined based on several factors such as the location of the lesion, size, patient´s body habitus and the likelihood of malignancy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The basic principles in surgery for pheochromocytoma and abdominal PGL include early identification and ligation of the adrenal vein, minimal manipulation of the tumour to prevent tumour rupture or the release of catecholamines.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Surgery of pheochromocytoma and abdominal PGL performed by advanced laparoscopic surgeons and high-volume adrenal surgeons (4–6 adrenalectomies/year) have shown to improve surgical results.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this article, we detail our current protocol for the surgical and postsurgical management of abdominal PGLs and pheochromocytomas, with a special focus on the need of a multidisciplinary team for the management of these cases, and in centres with experience in this pathology.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The physicians involved in the management of patients with abdominal PGLs and pheochromocytomas of our hospital reviewed systematically current knowledge on the surgical management of abdominal PGLs and pheochromocytomas. The literature review used the online Entrez-PubMed facilities, including only publications in English and Spanish published from 2010 to 2021. After careful selection, more than 200 papers were reviewed, of which only 40 were used to elaborate the current protocol. The adrenal multidisciplinary team elaborated a first draft that was presented and perfected in a formal presentation with other doctors involved in the management of adrenal tumours. The protocol was subsequently approved by the Hospital Quality Unit. Our hospital meets criteria to be considered a referral centre having an experienced urologists and general surgeons with more than 150 adrenalectomies performed in the last 5 years, an average of 25–30 surgeries per year. The rate of intraoperative complications in the pheochromocytoma surgery is of 14% and of postoperative complications of 20%. The mortality rate in the last 5 years was of 0%. The median hospital stay was 5 days (range 3–13). Furthermore, this center participate in the multicentric national PHEO-RISK study that has included 162 adrenalectomies performed in 159 patients with pheochromocytomas.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Moreover, a previous study shows the current protocol for presurgical management and anesthetic management of pheochromocytomas and sympathetic PGLs.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical management of abdominal PGLs and pheochromocytomas</span><p id="par0025" class="elsevierStylePara elsevierViewall">Abdominal PGLs and pheochromocytomas represent the 80%–85% of all neuroendocrine chromaffin cells tumours.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Nearly 5% of patients with adrenal incidentalomas prove to have a pheochromocytoma and approximately 40% of these patients have germline mutations.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The decision on the type of surgical approach depends mainly on the aetiology of the lesion, size, likelihood of malignancy and patient´s body habitus. The optimal approach is also based on the experience and preference of the surgeon. At present, laparoscopic surgery is considered the gold standard approach for pheochromocytomas.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However, the level of competence for the open approach must be maintained in case of both the need for reconversion and the primary indication. <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a> indicate the surgical treatment algorithm of our Urology and General Surgery services for pheochromocytomas and abdominal PGLs. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the main approaches for abdominal PGL and pheochromocytoma surgery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Laparoscopic adrenalectomy</span><p id="par0035" class="elsevierStylePara elsevierViewall">In hands of experienced surgeons, laparoscopy can be performed safely while preserving the principles of oncological surgery, with similar results to open surgery. The basic principles during surgery are to prevent direct manipulation or application of pressure to the tumour in order to avoid rupture of the tumour capsule.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Laparoscopic adrenalectomy has even been proposed in selected cases of potentially malignant or locally aggressive pheochromocytomas and PGLs in experienced centres, with oncological results that are equivalent to the open approach, while providing advantages in terms of patient morbidity.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Laparoscopy offers better visualization of the adrenal gland and faster access to the adrenal vein, further reducing the risk of catecholamine release. However, some studies have suggested that intra-abdominal insufflation during laparoscopy alone may cause an increase in serum catecholamines.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> This fact can be minimized by slow and progressive inflation and the use of low intra-abdominal pressures.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Tumour size has been a basic consideration in laparoscopic adrenalectomy. In this way, the Endocrine Surgery Society guidelines suggest open surgery in tumours greater than 6 cm due to initial doubts regarding the possibility of obtaining safe oncological margins and the increased perceived risk of capsular rupture.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,12</span></a> However, some observational, controlled studies.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–14</span></a> that have compared both open and laparoscopic approaches did not show differences in the rate of recurrence and equivalent perioperative outcomes between both approaches. Therefore, laparoscopic resection of large pheochromocytomas requires previous experience, and potentially malignant tumours should not be considered as an absolute contraindication for laparoscopic excision, as long as oncological principles should be strictly followed avoiding capsular rupture. There is agreement that potentially malignant tumours larger than 10 cm or those with possible infiltration of adjacent organs should be approached by open surgery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Transperitoneal and retroperitoneal laparoscopic surgery</span><p id="par0045" class="elsevierStylePara elsevierViewall">The lateral transperitoneal laparoscopic approach is currently the most widely used for unilateral adrenalectomy due to the familiarity of the intra-abdominal anatomy and the large working space. However, the retroperitoneal approach provides direct access to the adrenal tumour, avoiding possible injury to the intra-abdominal organs. Both approaches have shown similar efficacy and safety for small tumours.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The transperitoneal laparoscopic approach has been widely used for adrenal tumours of all sizes due to excellent anatomical exposure.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The patient is placed in the lateral decubitus position, and the table is flexed to maximize the space between the costal margin and the iliac crest. Full lateral decubitus makes repositioning for bilateral tumours difficult. The workspace in retroperitoneal approach is more limited than in the transperitoneal approach. It requires important surgeon experience being potentially more difficult for larger masses or obese patients with increased retroperitoneal fat.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The patient location is more lateral position than transperitoneal approach. The surgical table is slightly flexed to open the space between the costal margin and the iliac crest.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The most frequent causes of conversion to open surgery are the difficulty in controlling bleeding or the need to secure the oncological margins. The incidence of deep vein thrombosis in laparoscopic adrenalectomy can reach up to 4% of patients, therefore antithrombotic prophylaxis should be considered according to clinical thromboprophylaxis guidelines.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Robotic adrenalectomy</span><p id="par0060" class="elsevierStylePara elsevierViewall">Robotic adrenalectomy has similar results to laparoscopic adrenalectomy. Some authors argue that robotic surgery is useful for larger tumours and bilateral and partial adrenalectomies as it provides additional degrees of freedom of movement for the surgeon. However, the costs associated with the robotic surgery are greater than conventional laparoscopy.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> A recent randomized controlled trial comparing robotic versus laparoscopic adrenalectomy for pheochromocytoma<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> described some advantages of robotic adrenalectomy, including shorter median operative time (92.5 vs 122.5 min, P = 0.007) and significant lower blood loss and operative time compared with the conventional laparoscopic group (P < 0.05). A recent metaanalysis concluded that he robotic adrenalectomy for pheochromocytoma achieve better outcomes over laparoscopic approach in terms of safety and efficacy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Single-Site Laparoscopy (LESS. Laparoendoscopic Single-Site)</span><p id="par0065" class="elsevierStylePara elsevierViewall">LESS is a laparoscopic technique that uses a single skin incision. It offers a better cosmetic result and a short convalescence, but it turns out to be more technically demanding due to the loss of triangulation of the instruments. Nevertheless, a systematic review and meta-analysis of LESS versus conventional adrenalectomy<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> could not show a difference in estimated blood loss or length of hospital stay, but surprisingly neither in cosmetic results, recovery time, or laparoscopic port-related complications.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Open surgery</span><p id="par0070" class="elsevierStylePara elsevierViewall">Open surgery or laparotomy is chosen when faced with a high risk of metastatic disease (eg, SDHB mutations) or for multifocal lesions where a laparoscopic approach may not be feasible.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> Nevertheless, although the patient has a SDHB mutation, if there is no evidence of metastatic disease or infiltrative disease in the CT or MR, laparoscopic resection may be chosen (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Although the reoperation is not a contraindication due to the minimally invasive approach, it may be a better indication for open surgery. Although, there is no precise threshold for the tumour diameter to indicate open approach, it is generally recommended for tumours over 6 cm without malignancy or malignancy with no local invasion.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,23</span></a> Open resection is also usually recommended for abdominal paragangliomas as they are more likely to be malignant and are frequently found in areas difficult for laparoscopic resection, but laparoscopic resection can be performed for small, non-invasive paragangliomas in surgically favourable locations.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Open surgery is usually performed using a transperitoneal anterior approach. The lateral extraperitoneal approach is a good choice for obese patients.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Cortical preservation surgery or partial adrenalectomy</span><p id="par0075" class="elsevierStylePara elsevierViewall">Partial adrenalectomy would be acceptable in cases of benign lesions with high rates of multifocality and bilaterality and recurrence are expected, such as in VHL and MEN 2 syndromes. A recent study even has suggested to consider partial adrenalectomy in all patients with hereditary pheochromocytoma.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The VHL and MEN 2 syndromes have a high probability (40–50% in VHL; >50% in MEN 2) of developing bilateral pheochromocytomas, either synchronously or metachronous, while the probability of metastasis is very low.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In bilateral pheochromocytomas, removal of the tumour alone versus the entire adrenal gland remains controversial. Cortical sparing surgery was introduced into practice in 1999, although it remains a relatively underused procedure. A recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> concluded that cortical preservation during adrenalectomy may reduce the need for steroid replacement therapy (23% of patients with cortical preservation developed adrenal insufficiency) and carries a low risk of recurrence (in 8–10% of patients, mostly in patients with VHL and MEN 2), based mainly on retrospective studies and limited sample size. The surgical goal is to leave enough adrenal cortex, about 30%, with an adrenal vein preserved in situ to prevent adrenal insufficiency and consequently steroid replacement therapy for life.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Cortical sparing adrenalectomy can be performed openly or minimally invasive.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Although there is a wide variation regarding the technical aspects of this complex procedure, there is agreement on some points. Before mobilization and devascularization of the gland, intraoperative ultrasound is recommended to define the anatomy of the pheochromocytoma in relation to normal adrenal gland and adrenal vein. This will optimize surgical planning and allow the surgeon to de-vascularize only the portion of the adrenal to being resected. Additionally, ultrasound will help exclude additional ipsilateral pheochromocytomas. Both transperitoneal and retroperitoneal approaches have been described, being safe and feasible techniques. The same can be said regarding robotic partial adrenalectomy whose results are pretty similar to conventional laparoscopy.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Surgery of metastatic pheochromocytomas and PGLs</span><p id="par0085" class="elsevierStylePara elsevierViewall">It is estimated that approximately 10% of pheochromocytomas and 25% of PGLs are metastatic. Nevertheless, rates of malignancy vary depending on the genetic context and the anatomical site of origin (for example, 2–4% jugulotympanic, 4−6% carotid body or 10–19% vagal tumours).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,28</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">All cases should be discussed in a multidisciplinary reference team specializing in complex cases of pheochromocytoma/PGL with the aim of optimize the treatment.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> All patients with a hormonally functional secreting pheochromocytoma/PGL should undergo preprocedural blockade for 7–14 days before procedure, including for surgery and for most localized and systemic therapies to prevent periprocedural cardiovascular complications. Regarding surgery, when complete resection is possible, it may be beneficial; however, when resection will leave residual metastatic disease, the benefits may be less clear. Nevertheless, surgical debulking should be considered in patients with metastatic disease with good overall health and without evidence of massive multiple metastases. Resection of the primary lesion in metastatic disease has some potential benefits: i) in those patients with functional tumours, an improvement in symptoms related to catecholamine excess is expected with the reduction in tumour burden and ii) it has been shown to improve overall survival.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> If curative surgical resection cannot be performed, debulking surgery can still be considered, as it may improve the efficacy of other treatment options such as targeted radiation therapy.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Postoperative biochemical response is more common in patients with disease confined to the abdomen than those with extra-abdominal disease. If we accept that there is a benefit to resection of the primary PGL/pheochromocytoma, the open approach is of choice, although laparoscopic resection should be performed when complete resection with an intact capsule can be achieved. Surgery includes locoregional lymphadenectomy at the time of laparotomy, in addition to resection of the primary tumour. As a general recommendation, lymph node dissection should be considered for larger or locally invasive tumours, or when preoperative imaging or intraoperative exploration suggest node involvement.</p></span></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Postsurgical management</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Post-surgical anesthetic treatment</span><p id="par0095" class="elsevierStylePara elsevierViewall">Although immediate postoperative care in an intensive care unit is not necessary in most patients, admission to a postanaesthetic recovery unit is advisable during the first 24 h after surgery.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Some risk factors of postoperative complications after resection of a pheochromocytoma have been described, such as body mass index, ischemic heart disease, tumour size, intraoperative hemodynamic instability and the use of crystalloid-colloids in the preoperative period. The most frequent postoperative complications are:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Hyperglycaemia-hypoglycaemia:</span></span> Pheochromocytoma patients are usually hyperglycemic due to suppression of insulin release from pancreatic β cells and increased glycogenolysis. The treatment is carried out with insulin according to the blood glucose levels. Tumour resection results in hyperinsulinemia with subsequent hypoglycaemia, which may appear in up to 15%–20% of operated patients. In this case, the treatment will be carried out with the contribution of glucose. It is advisable to monitor blood glucose levels every 4−6 h in the first postoperative days. So, plasma glucose levels should be monitored closely for the first 48 h after surgery.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,31</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Prolonged drowsiness:</span></span> It usually occurs in the first 48 h after surgery. It is favoured by prolonged ά adrenergic blockade. It is necessary to be cautious with the added administration of drugs that promote respiratory depression, especially opiates.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Hypertension:</span></span> 30% of patients remain hypertensive after tumour resection due to the storage of high levels of catecholamines in the nerve endings. Sometimes the cause of hypertension is also hypervolemia in relation to excessive fluids been administered, or the recovery of autonomic reflexes, inadvertent ligation of the renal artery or the persistence of the tumour. Hypertension usually returns to normal a week after surgery. The drugs of choice are esmolol or ά-blockers. Paroxysmal arterial hypertension occurs in 27–38%<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> of patients operated on for pheochromocytoma and is more frequent in cases of familial hypertension and in older patients.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Persistent arterial hypotension</span></span><a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a><span class="elsevierStyleBold">:</span> It is usually due to blood loss, impaired vascular compliance, or residual effects of preoperative adrenergic blockade. The treatment will be carried out depending on which we think is the cause that originates it.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">e)</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Heart failure and acute lung edema</span></span>: they are due to both the excess volume administered and an effect and β adrenergic effect.</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Evaluation of pathological anatomy results</span><p id="par0125" class="elsevierStylePara elsevierViewall">The specimen should be sent to the Surgical Pathology department in the shortest possible time after surgical removal, to minimize cold ischemia time. Shipping fresh allows freezing samples to be taken, before fixation, for the Biobank or for genetic studies in the cases deemed convenient.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The piece should be measured and weighed (in cases with abundant surrounding adipose tissue, the tumour will be reweighed once this adipose tissue has been removed). The specimen must be oriented, and the surface marked with ink to correctly identify the surgical margin. Subsequently, cross sections will be made. Fixation in formalin should be carried out for 24 h.</p><p id="par0135" class="elsevierStylePara elsevierViewall">During the grossing, special attention should be paid to foci of necrosis and haemorrhage that can be macroscopically identified. In addition, abundant tissue from the surrounding tumour-parenchyma interface should be included to histologically assess the parameters of capsular invasion, infiltration of adipose tissue, and vascular invasion. All macroscopically differentiable areas should be included.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In the microscopic evaluation of the tumour, the histological parameters necessary to perform include the PASS<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> prognostic scales in pheochromocytoma and GAPP<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> in pheochromocytoma and PGL<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> (<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>). Currently, the existence of malignant pheochromocytomas and PGLs is not readily recognized on the pathology specimen but a risk of metastasis is assigned to each tumour, unless the patient already has metastatic deposits in nonchromaffin tissue sites such as bone, liver or lymph nodes. Based on a recent meta-analysis with 809 pheochromocytomas, a score greater than 4 has a low positive predictive value of metastasis (31%) but a score less than 4 has a high negative predictive value of metastasis (99%).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The GAPP scale requires knowing the metabolites produced by the tumour and the final score is transformed into a grade on a scale of three. The higher the grade, the greater the risk of metastasis.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Additionally, immunohistochemistry for SDH-B is performed for two purposes. The first purpose is to screen for mutations in the SDH-B, SDH-C and SDH-D genes. Immunohistochemical loss of SDH-B has been associated with mutations in these genes, showing in the original series a sensitivity of 100% (95% CI 87–100) and a specificity of 84% (95% CI 60–97).<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> The second aim is to use it as a predictor of metastasis, since patients with mutations in the SDH genes have a higher risk of metastasis and of presenting multicentric pheochromocytomas / PGLs.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> In fact, there is a modified GAPP scale that includes the result of immunohistochemistry for SDH-B.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Postoperative hormonal evaluation</span><p id="par0150" class="elsevierStylePara elsevierViewall">Metanephrine levels in plasma or urine should be measured between 2 and 6 weeks after surgery in patients who had elevated levels before the intervention.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a> In patients operated of metanephrine-producing tumours, the presence of elevated postoperative metanephrine levels strongly suggests persistent disease. In these cases, imaging tests are needed to confirm the presence of residual catecholamine secreting tissue and locate it.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In those patients with normal preoperative levels of metanephrines and high preoperative levels of chromogranin A, it is advisable to analyse plasma levels of chromogranin A 2–6 weeks after surgery since in these cases they can serve as an alternative biochemical marker.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">It is advisable during follow-up to perform annual biochemical tests for lifetime with measurement of metanephrines in plasma or urine to detect local or metastatic recurrence or new tumours.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Postoperative radiological evaluation or other tests</span><p id="par0165" class="elsevierStylePara elsevierViewall">An imaging test is recommended 3 months after surgery in the following cases<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>: i) patients operated for pheochromocytoma and PGL who have elevated levels of metanephrines in the postoperative period; ii) patients in whom metanephrine levels were normal before surgery and iii) patients in whom metanephrine levels were not measured before surgery.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The best imaging technique or optimal time interval for periodic follow-up images is unknown.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Imaging tests are recommended every 1–2 years in patients undergoing surgery for pheochromocytoma or biochemically inactive PGL to detect local or metastatic recurrences or new tumours.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In addition, imaging tests are the only follow-up option in those cases in which there are no reliable biochemical markers that are mainly useful in patients with head and neck PGLs.</p><p id="par0175" class="elsevierStylePara elsevierViewall">In the case of hereditary pheochromocytomas and PGLs, a personalized follow-up is advised, taking into account the different genotype-phenotype presentations.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In patients with SDHx mutations, thoracoabdominopelvic CT and head and neck magnetic resonance angiography (MRI) should be performed. However, to avoid ionizing radiation, it is also advisable to perform MRI to detect biochemically silent tumours and reserve imaging modalities by CT and nuclear medicine to better characterize the tumours detected.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,7</span></a></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">Surgery represents the treatment of choice of most abdominal PGLs and pheochromocytomas. For the proper selection of the surgical approach, the location and size of the tumour and the patient´s body habit and the likelihood of malignancy should be considered. Moreover, a proper presurgical evaluation and treatment with alpha- and beta-adrenergic blockade should be performed to reduce the risk of perioperative and intraoperative complications. Optimal postsurgical evaluation, including hemodynamic, pathological, hormonal, and radiological evaluation, should be performed by a multidisciplinary team specializing in PGL/pheochromocytoma management.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1999075" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1713360" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1713362" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1999074" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1713361" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Surgical management of abdominal PGLs and pheochromocytomas" "secciones" => array:4 [ 0 => array:3 [ "identificador" => "sec0020" "titulo" => "Laparoscopic adrenalectomy" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Transperitoneal and retroperitoneal laparoscopic surgery" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Robotic adrenalectomy" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Single-Site Laparoscopy (LESS. Laparoendoscopic Single-Site)" ] ] ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Open surgery" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Cortical preservation surgery or partial adrenalectomy" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Surgery of metastatic pheochromocytomas and PGLs" ] ] ] ] ] 7 => array:3 [ "identificador" => "sec0055" "titulo" => "Postsurgical management" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Post-surgical anesthetic treatment" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Evaluation of pathological anatomy results" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Postoperative hormonal evaluation" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Postoperative radiological evaluation or other tests" ] ] ] 8 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "xack698649" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-05-19" "fechaAceptado" => "2022-05-30" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1713360" "palabras" => array:4 [ 0 => "Pheochromocytomas" 1 => "Abdominal paragangliomas" 2 => "Laparoscopic surgery" 3 => "Partial adrenalectomy" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1713362" "palabras" => array:2 [ 0 => "PGL" 1 => "SDHB" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1713361" "palabras" => array:4 [ 0 => "Feocromocitomas" 1 => "Paragangliomas abdominales" 2 => "Cirugía laparoscópica" 3 => "Suprarrenalectomía parcial" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">To describe our current protocol for surgical and postsurgical management of abdominal paragangliomas (PGLs) and pheochromocytomas, with a special focus on multidisciplinary management in centres with experience.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">The physicians involved in the management of patients with abdominal PGLs and pheochromocytomas of our hospital reviewed systematically current knowledge on the surgical management of abdominal PGLs and pheochromocytomas.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Currently, surgery is considered the treatment of choice for abdominal PGLs and pheochromocytomas. The choice of surgical approach is determined based on the location of the lesion, size, patient́s body habitus and the likelihood of malignancy. Laparoscopic surgery is usually considered the gold standard approach for pheochromocytomas, but open access should be considered in invasive and/or potentially malignant tumours >8–10 cm and for abdominal PGLs. Postsurgical management of pheochromocytomas and PGLs includes close hemodynamic monitoring and treatment of postsurgical complications, the pathological study of the surgical specimen, reassessment of hormonal and/or radiological status and planning of follow-up based on the risk of recurrence and malignancy.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Surgery represents the treatment of choice of most abdominal PGLs and pheochromocytomas. Optimal postsurgical evaluation, including hemodynamic, pathological, hormonal, and radiological evaluation, should be performed by a multidisciplinary team specializing in PGL/pheochromocytoma management.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Describir nuestro protocolo actual para el manejo quirúrgico y posquirúrgico de los paragangliomas abdominales (PGL) y los feocromocitomas, con especial atención en el manejo multidisciplinar en centros con experiencia.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Los facultativos implicados en el tratamiento de pacientes con PGL abdominales y feocromocitomas de nuestro hospital revisaron sistemáticamente la bibliografía actual sobre el tratamiento quirúrgico de los PGL abdominales y feocromocitomas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">La cirugía se considera el tratamiento de primera elección para los PGL abdominales y feocromocitomas. La decisión sobre el abordaje quirúrgico se basa en la localización y el tamaño de la lesión, la constitución corporal del paciente y la probabilidad estimada de malignidad. La cirugía laparoscópica suele considerarse el método de referencia para los feocromocitomas, pero el abordaje abierto debe considerarse en los tumores invasivos y/o potencialmente malignos de más de 8–10 cm y en los PGL abdominales. El tratamiento posquirúrgico de los feocromocitomas y los PGL incluye una monitorización hemodinámica estrecha y el tratamiento de las complicaciones posoperatorias, el estudio patológico de la muestra quirúrgica, la reevaluación del estado hormonal y/o radiológico y la planificación del seguimiento en función del riesgo de recurrencia y de malignidad.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">La cirugía representa el tratamiento de elección de la mayoría de los PGL abdominales y feocromocitomas. La evaluación posoperatoria óptima, que incluye la evaluación hemodinámica, patológica, hormonal y radiológica, debe ser realizada por un equipo multidisciplinar especializado en el tratamiento de PGL/feocromocitomas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1718 "Ancho" => 2925 "Tamanyo" => 194940 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgical treatment algorithm in pheochromocytomas.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">* Consider the retroperitoneal approach in case of previous abdominal surgery.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">** In selected cases, one-stage surgery with repositioning of the patient may be considered. Same approach considerations depending on the size of the lesion.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">*** Excision or ablative treatment of resectable metastases will be considered if the general situation of the patient (ECOG or PS) allows it.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Regarding adrenal “conservative” surgery, it has not been introduced in the hospital, but we believe that at this time it could be considered in the case of bilateral lesions or contralateral recurrence after previous adrenalectomy, and after its discussion in the endocrine tumour board.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1226 "Ancho" => 2091 "Tamanyo" => 95156 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Surgical treatment algorithm in abdominal paragangliomas.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">* In selected cases, laparoscopic surgery may be considered. Considering that, more frequently, abdominal paraganglioma is associated with Succinate Dehydrogenase B mutations and a higher incidence of multiple disease, recurrence and metastatic disease that make associated lymphadenectomy recommended.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">** Excision or ablative treatment of resectable metastases will be considered if the general situation of the patient (ECOG or PS) allows it.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">LESS: Laparoendoscopic Single-Site; PGL: paraganglioma.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Approach \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indications \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Advantages \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Disadvantages \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transperitoneal laparoscopic aproach</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PGLs/pheochromocytoma <6−8 cm</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Compared to open surgery: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Controversy regarding its role in large adrenal masses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Lower surgical and postsurgical morbidity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Risk of capsule rupture</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Equal success and recurrence rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Shorter hospital stay \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retroperitoneal laparoscopic approach</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same indications that transperitoneal approach \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The same as transperitoneal approach</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reduced operative space \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgeon decision \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Technically difficult in the obese patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Open surgery</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pheochromocytoma/PGLs >6−8 cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Safer control of large adrenal masses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increased surgical and perioperative morbidity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retroperitoneal PGL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Possibility of additional extensive retroperitoneal lymphadenectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in hospital stay \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Robotic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same indications as laparoscopic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same as laparoscopic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cost increase \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Less</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same indications as laparoscopic surgery</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Same as laparoscopic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Technical difficulty</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Better cosmetic results \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3319338.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Surgical approaches in pheochromocytoma and abdominal paragangliomas.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Histological pattern: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Zellballen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Large or irregular cell nests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Pseudorosettes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cellularity: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Low (<150 cells per field 400x) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Moderate (150−200 cells per field 400x) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- High (>250 cells per field 400x) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presence of comedonecrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular or capsular invasion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ki67 labelling index: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- <1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- 1−3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- >3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catecholamine type: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Epinephrine type \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Norepinephrine type (norepinephrine +/- dopamine) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Non-functioning type \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grading: well differentiated (0−2), moderately differentiated (3−6) and poorly differentiated (7−10).</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The higher the grade, the greater the risk of metastasis.</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3319340.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">GAPP SCALE (Grading of Adrenal Pheocromocytoma and Paraganglioma).<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Large nests or diffuse growth (>10% of tumor volumen) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central or confluent tumor necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High cellularity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cellular monotony \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumor cell spindling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mitotic figures >3/10 High Power Fields \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atypical mitotic figure(s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extension into adipose tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular invasion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Capsular invasion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Profound nuclear pleomorfism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nuclear hyperchromasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; 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