A 38-year-old woman from rural Maharashtra presents with a 6-month history of episodic severe headaches, profuse sweating, and palpitations. Her blood pressure is 168/104 mmHg during the episode and 142/88 mmHg between episodes. She reports anxiety during attacks and has lost 4 kg despite good appetite. Fundoscopy shows grade II hypertensive retinopathy. Plasma free metanephrines are elevated at 4.2 times the upper limit of normal (reference

Question

A 38-year-old woman from rural Maharashtra presents with a 6-month history of episodic severe headaches, profuse sweating, and palpitations. Her blood pressure is 168/104 mmHg during the episode and 142/88 mmHg between episodes. She reports anxiety during attacks and has lost 4 kg despite good appetite. Fundoscopy shows grade II hypertensive retinopathy. Plasma free metanephrines are elevated at 4.2 times the upper limit of normal (reference <1.4 nmol/L). CT abdomen shows a 3.5 cm left adrenal mass with heterogeneous enhancement and areas of necrosis. What is the most appropriate next step in management?

Accepted Answer

C. Start immediate alpha-blockade with phenoxybenzamine followed by beta-blockade, then surgical resection. ## Diagnosis and Preoperative Preparation

**Key Point:** This patient has biochemically and radiologically confirmed pheochromocytoma. The elevated plasma free metanephrines (4.2× ULN) and imaging findings (left adrenal mass with heterogeneous enhancement and necrosis) establish the diagnosis. The critical next step is NOT further diagnostic confirmation but preoperative preparation to prevent intraoperative hypertensive crisis.

## Preoperative Medical Management Protocol

**High-Yield:** The standard preoperative regimen for pheochromocytoma is:

1. **Alpha-blockade first** — phenoxybenzamine 10 mg BD, titrated to 40–80 mg/day over 7–10 days
   - Achieves vasodilation and prevents catecholamine-induced vasoconstriction
   - Allows blood volume expansion (patients are typically volume-depleted)
   - Reduces risk of intraoperative hypertensive crisis

2. **Beta-blockade second** — propranolol 20–40 mg TDS (only AFTER adequate alpha-blockade)
   - Prevents reflex tachycardia from alpha-blockade
   - Never give beta-blockers alone — unopposed alpha-adrenergic effects cause severe hypertension

3. **Surgical resection** — after 7–14 days of preoperative preparation

**Clinical Pearl:** The sequence matters: alpha first, beta second. Giving beta-blockers before alpha-blockade is dangerous and is a common exam trap.

## Why Other Options Are Incorrect

| Option | Why Wrong |
|--------|----------|
| Amlodipine + lisinopril as first-line | These agents do not provide adequate catecholamine blockade and do not prevent intraoperative hypertensive crisis. Reassessment in 3 months delays definitive treatment of a hormonally active tumor. |
| 131I-MIBG scintigraphy before surgery | While MIBG is useful for staging metastatic disease, it is NOT a prerequisite for surgery in a patient with a solitary adrenal mass and no clinical evidence of metastases. Delaying surgery for staging is inappropriate when the primary tumor is resectable. |
| Fine-needle aspiration cytology | FNA is contraindicated in suspected pheochromocytoma because needle puncture can precipitate massive catecholamine release and life-threatening hypertensive crisis. Diagnosis is already confirmed biochemically and radiologically. |

**Mnemonic:** **ALPHA-BETA-SURGERY** — Always give Alpha-blockers first, then Beta-blockers, then proceed to Surgery.

Answer

A. Perform 131I-MIBG scintigraphy to assess for metastatic disease before surgery

Answer

B. Perform fine-needle aspiration cytology of the adrenal mass to confirm diagnosis

Answer

D. Initiate antihypertensive therapy with amlodipine and lisinopril, then reassess in 3 months

Explanation

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