Pheochromocytomas larger than 6 cm or with invasive features require a specific surgical and perioperative strategy to achieve complete resection and reduce operative risk.
Large (greater than 6 cm) or invasive pheochromocytomas are managed with open resection to ensure complete tumor removal, prevent intraoperative tumor rupture, and avoid local recurrence.
For hormonally active tumors, perioperative management begins with a structured course of preoperative adrenergic blockade, with α-adrenergic receptor blockade as the first-line class of intervention, initiated over a defined period before surgery. Hemodynamic stabilization measures are added in the days before the procedure to address catecholamine-induced volume changes.
Full regimen, sequencing, and perioperative targets are in the complete protocol.Blood pressure below 130/80 mmHg seated and systolic above 90 mmHg standing; heart rate 60–70 bpm seated and 70–80 bpm standing.
DOI: 10.1210/jc.2014-1498
We recommend open resection for large (eg, >6 cm) or invasive pheochromocytomas to ensure complete tumor resection, prevent tumor rupture, and avoid local recurrence.
We recommend that all patients with a hormonally functional PPGL should undergo preoperative blockade to prevent perioperative cardiovascular complications.
We suggest α-adrenergic receptor blockers as the first choice.
We recommend preoperative medical treatment for 7 to 14 days to allow adequate time to normalize blood pressure and heart rate.
Treatment should also include a high-sodium diet and fluid intake to reverse catecholamine-induced blood volume contraction preoperatively to prevent severe hypotension after tumor removal.
Continuous administration of saline (1–2 L) is also helpful if started the evening before surgery.
Preoperative coadministration of β-adrenergic receptor blockers is indicated to control tachycardia only after administration of α-adrenergic receptor blockers.
Based on retrospective studies and institutional experience, a target blood pressure of less than 130/80 mm Hg while seated and greater than 90 mm Hg systolic while standing seems reasonable, with a target heart rate of 60–70 bpm seated and 70–80 bpm standing.
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