Clinical case
Metastatic pheochromocytoma: An unusual case and its multidisciplinary management
Feocromocitoma metastásico: un caso inusual y su manejo multidisciplinar
J.M. Ruiz-Cánovasa,
, E.A. Achote-Reaa, T. Alonso-Gordoab, A. Martínez-Lorcac, M. Araujo-Castroa,d,
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Corresponding author
a Department of Endocrinology and Nutrition, Ramón y Cajal University Hospital, Madrid, Spain
b Department of Medical Oncology, Ramón y Cajal University Hospital, Madrid, Spain
c Department of Nuclear Medicine, Ramón y Cajal University Hospital, Madrid, Spain
d Ramón y Cajal Research Institute (IRYCIS), Madrid, Spain
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A. Rx de tórax y TC de tórax: infiltrados alveolares difusos bilaterales de predomino hiliar, así como derrame pleural bilateral y focos de vidrio deslustrado-engrosamiento de septos compatibles con edema agudo de pulmón. B. TC de abdomen: masa suprarrenal izquierda de gran tamaño (feocromocitoma). C. Cateterismo cardiaco con arterias coronarias normales. D. TC de cráneo: pérdida de diferenciación corticosubcortical y edema parietooccipital, troncoencefálico y cerebeloso sugestivos de áreas de isquemia-PRESS.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CASO 2. A. Rx tórax y TC de tórax con contraste iv. Corte axial y coronal: cardiomegalia, infiltrados alveolares difusos bilaterales de predomino hiliar, así como derrame pleural bilateral compatibles con edema agudo de pulmón. En cortes superiores de abdomen se visualiza masa suprarrenal izquierda de gran tamaño (feocromocitoma). B. PET-TC DOPA. Captación del radiotrazador en la masa suprarrenal izquierda descrita previamente. C. CardioRM 4 cámaras: dilatación biventricular compatible con miocardiopatía dilatada. D. RM de abdomen corte axial y gammagrafía con MIBG: ausencia de lesión suprarrenal izquierda y ausencia de captación de la misma tras la intervención quirúrgica (adrenalectomía izquierda).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.J. Vallejo Herrera, V. Vallejo Herrera, V. Márquez Pérez, F. Serrano Puche, I. Vegas Vegas" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M.J." "apellidos" => "Vallejo Herrera" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Vallejo Herrera" ] 2 => array:2 [ "nombre" => "V." "apellidos" => "Márquez Pérez" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Serrano Puche" ] 4 => array:2 [ "nombre" => "I." "apellidos" => "Vegas Vegas" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1889183724000722?idApp=UINPBA00004N" "url" => "/18891837/unassign/S1889183724000722/v1_202405210419/es/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical case</span>" "titulo" => "Metastatic pheochromocytoma: An unusual case and its multidisciplinary management" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.M. Ruiz-Cánovas, E.A. Achote-Rea, T. Alonso-Gordoa, A. Martínez-Lorca, M. Araujo-Castro" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Ruiz-Cánovas" "email" => array:1 [ 0 => "jruizcanovas@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.A." "apellidos" => "Achote-Rea" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "T." "apellidos" => "Alonso-Gordoa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Martínez-Lorca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:4 [ "nombre" => "M." "apellidos" => "Araujo-Castro" "email" => array:1 [ 0 => "marta.araujo@salud.madrid.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Endocrinology and Nutrition, Ramón y Cajal University Hospital, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Medical Oncology, Ramón y Cajal University Hospital, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Nuclear Medicine, Ramón y Cajal University Hospital, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Ramón y Cajal Research Institute (IRYCIS), Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding authors." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Feocromocitoma metastásico: un caso inusual y su manejo multidisciplinar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2407 "Ancho" => 2925 "Tamanyo" => 781828 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Complementary imaging tests. (A) Thoraco-abdominal-pelvic CT with contrast, biphasic study. (B and C) Thoracoabdominal [<span class="elsevierStyleSup">123</span>I]MIBG SPECT-CT: pulmonary and hepatic metastases and pathological retrocrural and retroperitoneal lymphadenopathies.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Metastatic pheochromocytomas are uncommon tumors. Among all patients with pheochromocytoma, approximately 10% have metastatic disease and five-year overall survival ranges between 34% and 60%, with some studies reporting 10-year overall survival rates of 25%. The unpredictable nature of pheochromocytomas, particularly their potential for late metastasis, poses ongoing challenges in patient management.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case presentation</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Chief complaints</span><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of an 80-year-old man with sporadic right pheochromocytoma who developed metastatic disease 6 years after the initial diagnosis of pheochromocytoma. The patient underwent total right adrenalectomy in June 2015 with biochemical cure criteria after surgery.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Past medical history</span><p id="par0015" class="elsevierStylePara elsevierViewall">He has type 2 diabetes mellitus, dyslipidemia, arterial hypertension, permanent atrial fibrillation and autoimmune hypothyroidism. The patient had proper blood pressure (BP) control with 32<span class="elsevierStyleHsp" style=""></span>mg daily of candesartan and 10<span class="elsevierStyleHsp" style=""></span>mg daily of amlodipine.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Physical and laboratory examinations</span><p id="par0020" class="elsevierStylePara elsevierViewall">In August 2021, 74 months after the initial diagnosis of the pheochromocytoma, an annual review detected elevated chromogranin A levels (1212.0<span class="elsevierStyleHsp" style=""></span>ng/mL [upper limit of normality (ULN)<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>84.7]) with normal metanephrine levels. This elevated value was initially suspected that might be related with the use of proton pump inhibitors (Omeprazole). The patient was asymptomatic, without catecholaminergic paroxysms and with acceptable BP control. Thus, chromogranin A was repeated after cessation of omeprazole, confirming pathological values (1148.0<span class="elsevierStyleHsp" style=""></span>ng/mL), and the determination of metanephrines was found to be elevated in this second determination (2496<span class="elsevierStyleHsp" style=""></span>μg/24<span class="elsevierStyleHsp" style=""></span>h [ULN<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1000]).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Imaging examinations</span><p id="par0025" class="elsevierStylePara elsevierViewall">Given these findings, a contrast-enhanced thoraco-abdomin-pelvic CT scan was performed, where new-onset hypervascular lesions were described, consistent with metastatic lesions of hematogenous, nodal and peritoneal dissemination: bilateral pulmonary nodules (the dominant one in right upper lobe of 13<span class="elsevierStyleHsp" style=""></span>mm), hepatic of 11<span class="elsevierStyleHsp" style=""></span>mm in periphery of segment VI, implant in right prostatic cell of 23<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>22<span class="elsevierStyleHsp" style=""></span>mm, as well as adenopathies in right diaphragmatic crura of up to 27<span class="elsevierStyleHsp" style=""></span>mm, low retrocrural station (8<span class="elsevierStyleHsp" style=""></span>mm), previous retroperitoneal lymphadenectomy bed at interaortocaval level (40<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>37<span class="elsevierStyleHsp" style=""></span>mm), retrocaval (24<span class="elsevierStyleHsp" style=""></span>mm) and right lateroconal space (10<span class="elsevierStyleHsp" style=""></span>mm) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Subsequently, in October 2021, a thoracoabdominal SPECT-CT with metaiodobenzylguanidine-[<span class="elsevierStyleSup">123</span>I] MIBG was performed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B and C), displaying deposits in the surgical bed of right adrenalectomy in relation to recurrence of a chromaffin-like tumor with pulmonary and hepatic metastases and pathological retrocrural and retroperitoneal lymphadenopathies of the same nature.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Final diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Finally, after assessing functionality and initiating alpha-blocker treatment, the diagnosis of metastatic pheochromocytoma was performed and systematic therapy was planning.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><p id="par0040" class="elsevierStylePara elsevierViewall">Alpha-blocker treatment was started with 4<span class="elsevierStyleHsp" style=""></span>mg of doxazosin daily, achieving adequate target BP of less than 130/80<span class="elsevierStyleHsp" style=""></span>mmHg and heart rate 60–70<span class="elsevierStyleHsp" style=""></span>bpm seated and 70–80<span class="elsevierStyleHsp" style=""></span>bpm standing. High-sodium diet was established 2–3 days later to replenish intravascular volume.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In view of the diagnostic confirmation and distant extension, unresectable and progressive, systemic treatment with [<span class="elsevierStyleSup">131</span>I] MIBG was chosen since there was no contraindication due to excellent BP and heart rate control. A single dose of 6216MBq-(168<span class="elsevierStyleHsp" style=""></span>mCi) was administered in December 2021.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Outcome and follow-up</span><p id="par0050" class="elsevierStylePara elsevierViewall">Regarding chromogranin A levels, after this therapy, there was a slight decrease to 1148 units in February 2022. Subsequent measurements showed a decreasing trend: 508.5 units in May 2022, 378.8 in July 2022, 197.6 in January 2023, 284 in August 2023, and 252 units in October 2023. However, following treatment, 24-h urine methanephrines levels increased to 3713 units in February 2022. Thereafter, the levels fluctuated: 1470 units in May 2022, 4814 in July 2022, 2431 in January 2023, 3345 in August 2023, and 2399 units in October 2023.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Systemic therapy has meant for the patient: maintenance of ability to carry out work of light or sedentary nature, ambulatory but restricted in physically strenuous activities (ECOG 1), adequate BP control without paroxysms with 4<span class="elsevierStyleHsp" style=""></span>mg of doxazosin per day, radiological stability in control CT scans (last performed in August 2023), without significant variations in the levels of metanephrines, but a slightly reduction in chromogranin levels (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">This clinical case highlights the importance of long-term follow-up with biochemical monitoring as a vital tool for the early diagnosis of tumor recurrence of patients with pheochromocytomas, having a positive impact on the prognosis of an entity with a median onset of metastasis after initial diagnosis of 5.5 years (range 0.3–53.4 years) and a median age of onset of 39 years (range 7–83 years).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The reported rates of recurrence (local and metastatic together) widely range between 6 and 22%, which have been independently associated with the presence of <span class="elsevierStyleItalic">succinate dehydrogenase B (SDHB</span>) pathogenic variant, higher levels of urinary normetanephrine and a larger tumor size.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> Also, this degree of extension seems to be associated with the elevation of 3-methoxytyramine and metanephrines.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Although risk factors related to recurrence have been described, patients with a low probability of metastatic disease, as in this case (sporadic pheochromocytoma in an 80-year-old male with no other risk factors) may eventually develop the disease. Hence, the current recommendation is a lifelong follow-up in all patients with pheochromocytomas.</p><p id="par0075" class="elsevierStylePara elsevierViewall">It also emphasizes the value of chromogranin A as a sensitive parameter of recurrence, which can precede the increase of metanephrines in an asymptomatic patient and underlines the importance of the coordination of the different departments involved in the management of these patients,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a> ensuring individualized therapeutic adaptation for each patient according to scientific evidence and their preferences, prioritizing their quality of life and continuous care.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The focus should be placed on the evaluation from the outset on the rate of evolution of the malignant disease, tumor aggressiveness, control of catecholamine-dependent symptoms, those associated with the mass effect of the tumor itself and the overall tumor burden. Given the absence of painful bone metastases or metastases that threatened structural function, local treatment with external radiotherapy or thermoablation was not offered, nor was a surgical approach to reduce tumor burden. Radiofrequency ablation was not considered for the 11<span class="elsevierStyleHsp" style=""></span>mm hypervascular hepatic nodule.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Following this multimodal approach, attending tumor extension and unresectability, systemic therapy with [<span class="elsevierStyleSup">131</span>I] MIBG was chosen, as an option for only approximately 60% of cases,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> documenting median overall and metastatic pheochromocytoma-specific survival rates of 24.6 and 33.7 years, respectively.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The rates of complete response, partial response, stable disease, and progressive disease achieved by [<span class="elsevierStyleSup">131</span>I] MIBG are 3%, 27%, 52%, 18%, respectively, and the overall effectiveness is 82%.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusion</span><p id="par0095" class="elsevierStylePara elsevierViewall">This case serves as a poignant reminder of the unpredictable nature of pheochromocytomas and the importance of ongoing, individualized monitoring. The success of systemic therapy in this instance highlights the potential for improved survival rates and quality of life when tailored treatments are employed. The lessons learned from this case contribute valuable insights for future patient management strategies and emphasize the need for a holistic and interdisciplinary approach to care.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interests</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres2251748" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1883916" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2251747" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1883915" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case presentation" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Chief complaints" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Past medical history" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Physical and laboratory examinations" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Imaging examinations" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Final diagnosis" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Treatment" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Outcome and follow-up" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-07-07" "fechaAceptado" => "2024-09-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1883916" "palabras" => array:3 [ 0 => "Metastatic pheochromocytoma" 1 => "Metaiodobenzylguanidine" 2 => "Chromogranin A" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1883915" "palabras" => array:3 [ 0 => "Feocromocitoma metastásico" 1 => "Metayodobenzilguanidina" 2 => "Cromogranina A" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe the case of an 80-year-old man with sporadic right pheochromocytoma who developed metastatic disease six years after initial diagnosis. Despite adequate blood pressure control and initial biochemical cure criteria after surgery, elevated chromogranin A levels were detected during routine screening, which anticipated elevated 24-h urine metanephrines. Subsequent imaging tests revealed metastatic lesions in the lungs, liver, prostate and lymph nodes. The patient underwent systemic treatment with [131I] MIBG, which resulted in a decrease in chromogranin A levels, achieving radiological and clinical stability. This case highlights the importance of long-term follow-up and biochemical monitoring for early detection of tumor recurrence in patients with pheochromocytoma, emphasizing the need for individualized treatment strategies and interdisciplinary care.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se describe el caso de un hombre de 80 años con feocromocitoma derecho esporádico que desarrolló enfermedad metastásica seis años después del diagnóstico inicial. A pesar de un adecuado control de la presión arterial y de los criterios iniciales de curación bioquímica tras la cirugía, se detectaron niveles elevados de cromogranina A durante una revisión rutinaria, que anticiparon la elevación de metanefrinas en orina de 24 horas. Las pruebas de imagen posteriores revelaron lesiones metastásicas en los pulmones, el hígado, la próstata y los ganglios linfáticos. El paciente fue sometido a tratamiento sistémico con [<span class="elsevierStyleSup">131</span>I] MIBG, lo que produjo una disminución de los niveles de cromogranina A, logrando, asimsimo, estabilidad clínica y radiológica. Este caso subraya la importancia del seguimiento a largo plazo y la monitorización bioquímica para la detección precoz de la recurrencia tumoral en pacientes con feocromocitoma, enfatizando la necesidad de estrategias de tratamiento individualizadas y atención interdisciplinaria.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2407 "Ancho" => 2925 "Tamanyo" => 781828 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Complementary imaging tests. (A) Thoraco-abdominal-pelvic CT with contrast, biphasic study. (B and C) Thoracoabdominal [<span class="elsevierStyleSup">123</span>I]MIBG SPECT-CT: pulmonary and hepatic metastases and pathological retrocrural and retroperitoneal lymphadenopathies.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \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">Chromogranin A \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">24-h urine methanephrines \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">Aug/Oct-21 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1212 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2496 \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">Feb-22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1148 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3713 \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">May-22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">508.5 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1470 \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">Jul-22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">378.8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4814 \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">Jan-23 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">197.6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2431 \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">Aug-23 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">284 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3345 \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">Oct-23 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">252 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2399 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3671054.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Biochemical monitoring since tumor recurrence.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Young WF. 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