A 38-year-old woman from South India presents with episodic headaches, profuse sweating, and palpitations for 6 months. Plasma free metanephrines are elevated (noradrenaline 850 pg/mL, adrenaline 120 pg/mL). CT abdomen shows a 3.5 cm left adrenal mass. All of the following are appropriate next steps in management EXCEPT:

Explanation

## Preoperative Management of Pheochromocytoma ### Critical Principle: Alpha-Blockade First **Key Point:** Immediate surgical resection **without preoperative alpha-blockade is contraindicated** and carries high risk of intraoperative hypertensive crisis, arrhythmias, and cardiovascular collapse. **High-Yield:** The **mandatory preoperative sequence** is: 1. **Alpha-blockade** (phenoxybenzamine or doxazosin) — goal: control hypertension, prevent catecholamine surge 2. **Wait 7–14 days** for alpha-blockade to take effect 3. **Beta-blockade** (propranolol or atenolol) — only AFTER alpha-blockade is established, to prevent unopposed alpha-mediated hypertension 4. **Volume expansion** if hypotensive 5. **Then proceed to surgery** **Clinical Pearl:** Beta-blockade **before** alpha-blockade is dangerous — it causes unopposed alpha-adrenergic vasoconstriction, worsening hypertension and risking myocardial infarction or stroke. This is a **classic exam trap**. ### Appropriate Preoperative Steps | Step | Rationale | |------|----------| | **Genetic testing** | ~30–40% of pheochromocytomas are hereditary; SDH, VHL, RET (MEN 2), NF1 mutations must be excluded. Age <40 is a strong indicator for genetic screening. | | **Functional imaging (PET-CT or MIBG)** | Excludes metastatic disease, extra-adrenal paragangliomas, and bilateral tumors before surgery. Guides surgical planning. | | **Alpha-blockade** | Prevents intraoperative catecholamine release and hypertensive crisis. Phenoxybenzamine (irreversible non-selective alpha antagonist) is preferred; doxazosin (selective α1 antagonist) is an alternative. | | **Beta-blockade (after alpha)** | Prevents reflex tachycardia and arrhythmias once alpha-blockade is established. | **Mnemonic for Preop Sequence — "Alpha First, Beta Second":** Always establish alpha-blockade before beta-blockade to avoid unopposed alpha effects. ### Why Immediate Surgery Is Wrong **Warning:** Pheochromocytoma surgery **without preoperative pharmacological preparation** is associated with: - Intraoperative hypertensive crisis (BP >250/150 mmHg) - Myocardial infarction - Stroke - Arrhythmias (including ventricular fibrillation) - Mortality rate up to 5% if unprepared vs. <1% if properly prepared [cite:Harrison 21e Ch 397; Endocrine Society Clinical Practice Guidelines for Pheochromocytoma (2014)]