Pheochromocytoma and Extra-adrenal Paraganglioma

Updates
Arthur S. Tischler, MD

Context.Advances in genetics and gene expression profiling have led to new ways of thinking about the pathobiology of pheochromocytoma and extra-adrenal paraganglioma. These developments are concurrent with the publication and dissemination of the 2004 World Health Organization bluebook on pathology and genetics of
endocrine tumors.
Objective.To summarize new information required by
pathologists for effective participation in patient management and research.
Data Sources.Literature review and primary material
from Tufts Medical Center.
Conclusions.The World Health Organization reserves
the term pheochromocytoma for tumors arising from chromaffin cells in the adrenal medulla. Closely related tumors
in extra-adrenal sympathetic and parasympathetic paraganglia are classified as extra-adrenal paragangliomas. A
pheochromocytoma is an intra-adrenal sympathetic paraganglioma. Although arbitrary, this nomenclature emphasizes important distinctive properties of intra-adrenal tu-

mors, including an often adrenergic phenotype, relatively

low rate of malignancy, and predilection to occur in particular hereditary syndromes. Malignancy is defined by
presence of metastases not local invasion. Occult germline
mutations characteristic of familial syndromes are now
found in more than 20% of patients with apparently sporadic tumors, bringing the percentage of tumors with a
known genetic basis close to 30%. In addition, tumor location and risk of malignancy vary with the underlying genetic defect. The 10 percent rule for pheochromocytoma/paraganglioma10% familial, 10% malignant, 10%
extra-adrenalis therefore no longer tenable. Current
roles of pathology are limited to diagnosing primary or
metastatic tumors and identifying features suggestive of
malignant potential or hereditary disease. Future roles may
involve more definitive assessment of malignancy, genotype-phenotype correlation, and identification of targets
for therapy.
(Arch Pathol Lab Med. 2008;132:12721284)

renal paragangliomas arise from chromaffin cells in sympathoadrenal and parasympathetic paraganglia, and A
phaeochromocytoma is an intra-adrenal sympathetic
paraganglioma. 1 Restricted use of the term pheochromocytoma is an arbitrary convention originated in 1950 by H.
T. Karsner, who wrote the first series of the Armed Forces
Institute of Pathology Atlas of Tumor Pathology fascicle, Tumors of the Adrenal. Karsner noted the previous application
of the term by other authors to various tumors in extraadrenal locations, including head and neck paragangliomas and even carcinoid tumors, and commented, The
confusion in terminology encumbers the exchange of experience which can be so constructive in fields where no
one pathologists experience is enough, adding An
agreement in nomenclature, even on an arbitrary basis, is
helpful. 2 Karsners original definition, which encompassed tumors in or near the adrenal, was refined in
the second series fascicle of 1985 to include only intraadrenal neoplasms. By then, the Armed Forces Institute of
Pathology fascicles had become the definitive vade mecum
for pathologists in the United States, and for them the arbitrary nomenclature became the norm. Pathologists in
other countries gradually adopted to the Armed Forces
Institute of Pathology definition.
Although the current nomenclature has its origin in an
arbitrary convention, special treatment of intra-adrenal
tumors can in fact be justified on the basis of several dis-

heochromocytomas and extra-adrenal paragangliomas

are tumors of neural crestderived endocrine cells or
organs, known as paraganglia, that exist throughout the
distribution of the sympathetic nervous system and along
supradiaphragmatic branches of the (parasympathetic) vagus and glossopharyngeal nerves during development or
in adult life. Prototypical sympathetic paraganglia are the
adrenal medulla and the organ of Zuckerkandl. The prototypical parasympathetic paraganglion is the carotid
body. Other paraganglia are microscopic and highly variable in location.
The current World Health Organization classification reserves the term pheochromocytoma for intra-adrenal tumors.
Similar tumors in other locations are defined as extra-adrenal paragangliomas, further coded according to their
anatomic site. According to the World Health Organization
Classification of Tumours, updated in 2004, Phaeochromocytomas . . . arise in the adrenal medulla and are derived
from chromaffin cells of neural crest origin, Extra-ad-

Accepted for publication March 11, 2008.

From the Department of Pathology, Tufts New England Medical Center, Boston, Mass.
The author has no relevant financial interest in the products or companies described in this article.
Reprints: Arthur S. Tischler, MD, Department of Pathology, Tufts Medical Center, 750 Washington St, Boston, MA 02111 (e-mail:
atischler@tufts-nemc.org).
1272 Arch Pathol Lab MedVol 132, August 2008

Pheochromocytoma and ParagangliomaTischler

Table 1.
Syndrome

Distributions of Tumors in Familial Paraganglioma Syndromes*

Gene
(Chromosome)

Tumor Distribution
Adrenal

Other Sympathetic

Parasympathetic

MEN2A and MEN2B

RET (10q11)

+/

VHL
VHL (3p25-26)

/
NF1
NF1 (17q11)

+/
+/
PGL1
SDHD (11q23)

PGL3
SDHC (1q21-23)
+/
+/

PGL4
SDHB (1p36)

* The table shows estimated distributions based on information in several references.1,4446 MEN indicates multiple endocrine neoplasia; ,
usual distribution of tumors; +/, rare; VHL, von Hippel-Lindau; NF1, neurofibromatosis type 1; PGL, paraganglioma; and +, less common.

Table 2.

Subtypes of von Hippel-Lindau (VHL)

Disease*
Major Tumor Distribution

VHL
Subtype

Pheochromocytoma Renal Cell

or Paraganglioma Carcinoma Hemangioblastoma

1
/

2A

2B

2C

* von Hippel-Lindau disease is subdivided into types 1 or 2 according to susceptibility to pheochromocytoma/paraganglioma, which is
determined by the nature of the underlying mutation. Truncating mutations and large deletions are associated with type 1, whereas missense mutations that presumably preserve a greater amount of function
are associated with type 2. Note that pheochromocytoma/paraganglioma develops in type 2C without other stigmata of VHL. / indicates
rare; , usual distribution of tumors; and , absent.

tinctive characteristics. Those include a lower rate of malignancy (5% overall vs 20% for extra-adrenal paragangliomas associated with the sympathetic nervous system3), an often adrenergic phenotype (extra-adrenal paragangliomas are almost always noradrenergic4), and a
proclivity to occur in association with particular genetic
disorders, particularly multiple endocrine neoplasia
(MEN) type 2 (MEN2).5 On the other hand, it can be reasonably argued that this classification may detract from
efforts to understand the pathobiology of tumors that,
overall, are more similar than different. Pheochromocytomas and extra-adrenal paragangliomas often have similar or identical morphology, share a mostly identical neuroendocrine phenotype, and sometimes have the same genetic predisposition.
Most pathologists agree in principle with the need for
consistency and accept the idea that the World Health Organization nomenclature, although imperfect, should be
adhered to. Nonetheless, even in recent publications precise and consistent nomenclature has been difficult to attain. Contributing factors include both lack of familiarity
with the World Health Organization nomenclature and resistance to its arbitrary distinctions. Extra-adrenal sympathetic paragangliomas are often still classified as pheochromocytomas, especially in papers written by clinicians,
and tumors site of origin is frequently not specified. Nomenclature preferences aside, the latter practice is particularly unfortunate because it obscures potential influences
of anatomical and functional context on tumor pathogenesis and phenotype.6 Salient distinctions between the normal adrenal medulla and extra-adrenal sympathetic paraganglia include denser innervation, an adrenergic versus
noradrenergic phenotype, an environment rich in adrenal
Arch Pathol Lab MedVol 132, August 2008

cortical steroids, and maturation much later in fetal and

postnatal development. Differences in maturation may be
particularly important in providing different developmental windows7 in which tumorigenic events can occur. Fortunately, the nomenclature stand-off is resolving as a result of cooperation between pathologists and clinicians
with a shared interest in pathobiology.
RECENT DEVELOPMENTS IN PHEOCHROMOCYTOMA
AND PARAGANGLIOMA RESEARCH
Recent advances in genetics, gene expression profiling,
and cell biology have led to new ways of thinking about
the pathobiology of pheochromocytoma and extra-adrenal
paraganglioma. Physicians have traditionally been taught
to remember the clinical properties of sympathetic paragangliomas according to the 10 percent rule10% familial, 10% malignant, 10% extra-adrenal. That rule is no
longer tenable. Occult germline mutations characteristic of
familial pheochromocytoma/paraganglioma syndromes
have recently been documented in more than 20% of patients presenting with apparently sporadic tumors,8,9
bringing the percentage of tumors with a known genetic
basis close to 30%. In addition, tumor location and risk of
malignancy vary according to the underlying genetic defect.
Hereditary disorders that are well known to be associated with development of pheochromocytomas/paragangliomas are MEN2A and MEN2B, von Hippel-Lindau
(VHL) disease, and neurofibromatosis type 1 (NF1) resulting, respectively, from mutations of the RET (Rearranged in Transfection) proto-oncogene and the VHL and
NF1 tumor suppressor genes (Table 1).1,9 von Hippel-Lindau disease is now divided into types 1 and 2, defined by
the absence or presence of susceptibility to pheochromocytomas/paragangliomas (Table 2).1 In addition, the list of
hereditary susceptibility disorders is now expanded to include familial paraganglioma (PGL) syndromes caused by
mutations of succinate dehydrogenase (SDH) genes SDHD
(PGLl), SDHC (PGL3), and SDHB (PGL4), which also appear to function as tumor suppressor genes10,11 (Table 1).
A novel aspect of PGLl is a mode of transmission that
involves genomic imprinting, that is, tumors occur only
after paternal transmission of the mutated gene.10,11 Finally, several kindreds susceptible to tumors harbor mutations that have still not been identified.12 Somatic mutations of the genes responsible for hereditary pheochromocytomas/paragangliomas are uncommon in tumors
that are truly sporadic.1316
Striking genotype-phenotype correlations exist for tumors in each of the familial pheochromocytoma/paraganglioma syndromes with respect to malignancy, distribuPheochromocytoma and ParagangliomaTischler 1273

tion, and function. Estimated rates of malignancy are quite

low for most of the known mutations, ranging from 1% to
10%. However, at least 50% of tumors with SDHB mutations are malignant.9 In addition, tumors with any of the
SDH mutations are often extra-adrenal, whereas those
with mutated RET are confined to the adrenal medulla or
immediate vicinity. SDH mutations are also suggested by
the combined occurrence of sympathetic and parasympathetic paragangliomas.
Gene expression profiling studies complemented by immunohistochemical and biochemical analyses have revealed different clusters of markers in tumors with specific
genetic backgrounds and in subsets of sporadic tumors.17,18
VHL, SDHB, or SDHD mutations are associated with a
transcription signature characterized by genes related to
hypoxia-driven transcription pathways. In contrast, the
signature of tumors with RET mutations is consistent with
increased activity of the Ras-mediated MAPK pathway.19
An additional distinctive characteristic of VHL tumors is
that they usually do not express phenylethanolamine
N-methyltransferase, the enzyme that synthesizes epinephrine from norepinephrine and are therefore noradrenergic even when intra-adrenal. Intra-adrenal tumors
with SDH mutations are also reported to be noradrenergic,20 whereas MEN2 and NF1 tumors in the adrenal typically produce both epinephrine and norepinephrine.17
The genotype-phenotype correlations in familial pheochromocytoma/paraganglioma syndromes and the high
prevalence of unsuspected hereditary disease have led to
gene-specific recommendations for genetic testing and
subsequent patient management.16,21,22 Tumor location,
presence of multiple tumors, presence of metastases, and
type of catecholamine produced are useful as guides in
deciding which genes to test. However, specific algorithms
differ somewhat according to institutional preference and
test availability. The most stringent recommendations favor genetic testing of all patients with apparently sporadic
tumors for RET, VHL, and SDH mutations to avoid being
misled by individual differences in presentation and penetrance, low penetrance of some mutations, de novo mutations, and imprinting of SDHD.22 Routine genetic testing
is not currently available for NF1 mutations because the
gene is extremely large and, in contrast to the other pheochromocytoma/paraganglioma susceptibility genes, does
not have discrete mutation hot spots leading to development of these tumors.23
ROLES OF PATHOLOGY IN MANAGEMENT OF
PHEOCHROMOCYTOMAS AND PARAGANGLIOMAS
The current roles of pathology in management of pheochromocytomas and extra-adrenal paragangliomas are
limited to diagnosis, documentation of malignant behavior, and recording of findings that may be clues to occult
hereditary disease. It is anticipated that future roles will
involve more definitive assessment of malignant potential,
genotype-phenotype correlation, and identification of targets for therapy.
Diagnosis
Pheochromocytomas and other paragangliomas show
enormous variability in cytology and histologic pattern
and must be distinguished from a variety of endocrine
and nonendocrine tumors. The classic pattern of zellballen formed by nests of uniform polygonal cells is often
not evident, and one may instead observe diffuse archi1274 Arch Pathol Lab MedVol 132, August 2008

tecture, spindle cells, admixtures of large and small cells,

and extreme cytologic atypia (Figure 1, A through F; Figure 2, A and B). Areas of ganglioneuroma or ganglioneuroblastoma (Figure 3, A and B) are occasionally admixed
with pheochromocytoma or paraganglioma in sympathoadrenal tumors (composite pheochromocytoma or paraganglioma). Parasympathetic paragangliomas often have
more pronounced zellballen (Figure 2, B) and somewhat
clearer cytoplasm than their sympathetic counterparts, but
overlap exists between the 2 types of tumor.
Specific considerations in differential diagnosis vary according to anatomic site and diagnostic strategies vary accordingly. In the adrenal gland, the principal differential
diagnosis is adrenal cortical adenoma or carcinoma. Elsewhere, possibilities include hepatic and hepatoid tumors,
alveolar soft part sarcoma, melanoma, glomus tumors and
other vascular neoplasms, and primary or metastatic carcinomas with endocrine or nonendocrine phenotype. It
should be noted that the term glomus tumor has in the past
been used as a synonym for paraganglioma in head and
neck locations and occasionally still crops up as such in
current publications. This use is unacceptable because it
leads to confusion with true glomus tumors, which are
derived from thermoregulatory myoarterial structures unrelated to paraganglia developmentally or functionally.
The ambiguous application of the same term to different
tumors is a vestige of 19th century nomenclature for head
and neck paraganglia (eg, the glomus caroticum, glomus jugulare, and glomus tympanicum).
Immunohistochemical staining procedures routinely
available in most pathology laboratories can now reliably
make the distinctions necessary for differential diagnosis,
provided they are applied judiciously and with appreciation of potential artefacts. The latter include technical artefacts such as enhancement of endogenous biotin staining
by heat-based antigen retrieval methods in staining protocols that use a biotin bridge,24 nonspecific staining of
some neuroendocrine cell types by serum,25 and cross-reactivities of commercially touted antibodies that are often
of dubious quality. Mitochondria often exhibit nonspecific
interactions with antibodies, as does lipofuscin in the adrenal cortex. Consequently, oncocytic tumors (eg, of the
adrenal cortex; Figure 4, A and B; Figure 5) can show very
convincing but nonspecific staining for a variety of antigens, or normal cortical cells can show spurious staining
for neuroendocrine markers. Although endogenous biotin
is often cited as a cause of nonspecific staining, in my
experience poorly validated primary antibodies or inadequate blocking of nonspecific staining is more often at
fault. Nonspecific staining by any given antibody is not
predictable. Moreover, no controls available in routine diagnostic immunohistochemistry are wholly adequate, including substitution of normal serum or immunoglobulin
G in place of primary antibody.
The single most specific and reliable generic neuroendocrine marker currently used in pathology practice is
chromogranin A (CgA), a major constituent of the matrix
of catecholamine-containing secretory granules.26 Immunoreactivity for CgA will readily distinguish pheochromocytomas and other paragangliomas from tumors that
are not neuroendocrine, such as those of the adrenal cortex. Staining of pheochromocytomas for CgA is usually
extensive, and the diagnosis should be made with caution
for tumors that show little or no staining. Distinction of
pheochromocytomas and paragangliomas from other neuPheochromocytoma and ParagangliomaTischler

Figure 1. Pheochromocytomas and extra-adrenal paragangliomas exhibit varied architectural and cytologic features. These figures illustrate a
small portion of the morphologic spectrum. The classic zellballen pattern in an adrenal tumor in A is often not present. B through E show
architectural variations including solid (B, E) and trabecular (D) growth patterns and prominent vascular channels (F) and stroma (C). Cytologic
variations include differences in cell size (exemplified by cells in A that are larger than normal chromaffin cells versus those in B that are smaller
than normal) and cytoplasmic staining that ranges from intensely basophilic (B) to clear (E) (hematoxylin-eosin, original magnifications 200 [A
through E] and 100 [F]).

roendocrine tumors that also express CgA is a process of

deduction that often involves panels of antibodies, for example, demonstration of immunoreactive tyrosine hydroxylase (TH; the rate-limiting enzyme in catecholamine biosynthesis) and exclusion of staining for keratin proteins
Arch Pathol Lab MedVol 132, August 2008

that are often expressed in pulmonary and gastrointestinal neuroendocrine tumors. This distinction is particularly
challenging when individual patients have both paragangliomas and carcinoid tumors (Figure 6, A through F; Figure 7, A through D), as can occur in NF1 or VHL disPheochromocytoma and ParagangliomaTischler 1275

Figure 2. Marked histologic variation is often noted within individual tumors. A is from a pheochromocytoma, and B is from a parasympathetic
paraganglioma (hematoxylin-eosin, original magnifications 100).
Figure 3. Composite pheochromocytoma with ganglioneuroblastoma. A (pheochromocytoma) and B (ganglioneuroblastoma) were from separate
areas of the same tumor. Either or both components may metastasize but do so infrequently compared with pediatric neuroblastic tumors and
often follow an indolent course1 (hematoxylin-eosin, original magnifications 200 [A] and 100 [B]).
Figure 4. Adrenal cortical oncocytoma and adjacent adrenal gland stained for synaptophysin with 2 different primary antibodies (A, antibody 1;
B, antibody 2), each diluted according to manufacturers specifications. Note that only adrenal medulla stains with antibody 2 (original magnifications 40).

1276 Arch Pathol Lab MedVol 132, August 2008

Pheochromocytoma and ParagangliomaTischler

Figure 5. Immunoblot with antibodies from Figure 4. Lane 1, normal

adrenal medulla; 2, normal cortex; 3, oncocytoma from Figure 4; 4
and 5, pheochromocytomas. Synaptophysin expression has been reported in adrenal cortex but is not detectable, at least in the same form
as in medulla, with the more specific antibody 2.

ease.2729 Excellent monoclonal antibodies are widely available for both CgA30 and TH. Although normal parasympathetic paraganglia express both TH and CgA, staining
for either or both of those markers tends to be weaker and
more variable in parasympathetic paragangliomas than in
their sympathoadrenal counterparts and TH may actually
be absent in some of those tumors4 (Figure 8, A through
C). Low expression of TH correlates with the fact that the
tumors were often classified as non-chromaffin paragangliomas in older literature.
Determination of Malignancy
According to the current World Health Organization
classification, malignancy of pheochromocytomas and
paragangliomas is defined by the presence of metastases1
not local invasion. Some pathologists challenge this convention, noting that other locally invasive tumors that have
minimal metastatic potential are nonetheless classified as
malignant (eg, basal cell carcinomas of the skin). The best
argument to the contrary is based on tumor biology. Despite its potential lethality, local invasion alone is a poor
predictor of metastases, and the absence of apparent inArch Pathol Lab MedVol 132, August 2008

vasion does not preclude development of metastases. The

2 types of aggressive behavior may therefore have different biologic underpinnings. Precise reporting and a consistent definition of malignancy are critical for assessing
criteria that in the future will better define risk from either
metastases or local invasion.
The most stringent definition of malignancy stipulates
that metastases must be to a site where paraganglionic
tissue is not normally present, for example, liver or bone
(Figure 9), to avoid confusion with multiple primary tumors. This concern is certainly valid and is particularly
applicable to clinical imaging studies. From the perspective of histopathology, if tumor is present within a clearly
identifiable lymph node, it is reasonable to classify that
tumor as malignant.
Determining whether a pheochromocytoma/paraganglioma is malignant before metastases have occurred is
more problematic, and there is currently no consensus that
it can reliably be done. An important obstacle to determining predictive criteria is the fact that pheochromocytomas/paragangliomas metastasize infrequently and often late. Consequently, it has been difficult to validate proposed criteria in large studies with adequate follow-up.
Most existing analyses are therefore retrospective. In addition, the clustering of gene expression profiles in tumors
with different underlying genetic predispositions31,32 suggests that any particular finding may carry different
weight in different patient cohorts. For example, extensive
local invasion might pose essentially no risk in an adequately excised tumor from a patient with MEN2A,
whereas even minimal invasion might be ominous in a
tumor with mutated SDHB. Because the prevalence of syndromic mutations varies geographically, studies reported
from different countries or regions might offer very different conclusions.
No single histologic feature is alone able to identify metastatic potential, including capsular or vascular invasion,
extreme cytologic atypia, or areas resembling pediatric
neuroblastoma. However, some evidence suggests that
multifactorial scoring systems can help to histopathologically discriminate tumors that pose a significant risk of
metastasis from those that do not. A seminal study by
Linnoila et al3 in 1990 examined multiple histologic and
nonhistologic parameters of 120 sympathoadrenal paragangliomas and developed a statistical model according
to which more than 70% of the tumors could be classified
correctly with more than 95% probability on the basis of
4 factors: extra-adrenal location, coarse nodularity, confluent necrosis, and absence of hyaline globules. Most malignant tumors had 2 or 3 of those features, whereas 89% of
benign tumors had 1 or none. Unfortunately, a number of
subsequent articles that deal with assessment of markers
for malignancy blur the distinction between intra-adrenal
and extra-adrenal tumors, so that the powerful independent predictive value of extra-adrenal location, clearly
demonstrated as the most powerful predictor (P .001)
in the Linnoila et al3 study, is obscured. Because extraadrenal location correlates with SDHB mutation and SDHB
mutation correlates with malignancy, it might be speculated that the pathology findings associated with malignancy point indirectly toward SDHB and that genetic testing for SDHB mutations33 might outweigh the predictive
value of current pathology criteria in many cases.
In 2002 Thompson34 proposed the PASS system (pheoPheochromocytoma and ParagangliomaTischler 1277

Figure 6. Pheochromocytoma (A, C, E) and lymph node (B, D, F) from a patient with pheochromocytoma and multiple lymph node metastases.
Tumor in the node is positive for chromogranin A (CgA) but negative for tyrosine hydroxylase (TH), indicating it is neuroendocrine but probably
not a pheochromocytoma (hematoxylin-eosin, original magnifications 20 [A and B]; CgA, original magnifications 100 [C and D]; and TH,
original magnifications 100 [E and F]).

chromocytoma of adrenal scaled score), specific to the adrenal gland, that scores multiple microscopic findings, including dependent and independent variables identified
by Linnoila et al, to arrive at a total score correlated with
metastatic potential. All tumors that metastasized had a
1278 Arch Pathol Lab MedVol 132, August 2008

score of greater than 4, but 17 of 50 with a score greater

than 4 had not metastasized in a follow-up period of approximately 5 years, and 1 with a score of more than 15
had not metastasized in approximately 28 years. In his
article, Thompson notes that the PASS score provides a
Pheochromocytoma and ParagangliomaTischler

Figure 7. Somatostatin-producing duodenal neuroendocrine tumor from the same patient as in Figure 6, proven to be the source of the lymph
node metastases. In contrast to pheochromocytomas, carcinoids are usually negative for tyrosine hydroxylase (TH) and often positive for cytokeratins
(hematoxylin-eosin, original magnification 100 [A]; cytokeratin 7, original magnification 100 [B]; TH, original magnification 100 [C]; and
somatostatin, original magnification 100 [D]).

threshold for risk but does not quantitate the risk above
that threshold, and he further notes that a score of 3 or
less does not guarantee that a patient will not at some
point develop metastases. There is currently no agreement
on the utility or reproducibility of a PASS score. Calculation of a score or reporting each of its components is optional, but a high score should not be considered equivalent to a diagnosis of malignancy.
Immunohistochemistry has been used as an ancillary
technique for assessment of malignant potential, with
mixed results. The marker most consistently reported to be
correlated with malignancy is labeling index of tumor cells
stained for the proliferation marker Ki-67, which is performed on paraffin sections using monoclonal antibody
MIB-1.3537 However, in some studies MIB-1 labeling does
not correlate with malignancy. Studies of MIB-1 labeling
show a striking lack of methodologic consistency, and many
papers do not provide sufficient methodologic detail to permit replication. Although many pathologists now include
an assessment of MIB-1 labeling in diagnostic reporting of
pheochromocytomas/paragangliomas, there is currently no
prospect of standardization, and reporting of a Ki-67 index
remains optional. Increasingly, numerous additional markArch Pathol Lab MedVol 132, August 2008

ers are reported to correlate with malignancy.9,35,38 However,

their usefulness is still limited to research. As is the case
for morphologic characteristics, it has not been ruled out
that different immunohistochemical marker profiles carry
different weights in tumors with different genetic backgrounds. For example, hypoxia-sensitive markers reported
to be associated with malignancy, such as vascular endothelial growth factor and HIF1, also characterize pheochromocytomas/paragangliomas in patients with VHL disease,31,32 and those tumors are usually benign.9
A 2005 scoring system proposed by Kimura et al36 for
both pheochromocytomas and extra-adrenal sympathetic
paragangliomas combines histologic, immunohistochemical, and biochemical characteristics to arrive at a score reported to predict both the metastatic potential of tumors
and the prognosis for patients with tumors that metastasize. An interesting aspect of the system is scoring of
whether a tumor is adrenergic or noradrenergic, thereby
anticipating incorporation of this element into patient
management algorithms later proposed by clinicians.21
Anatomic site in this system is indirectly given additional
weight because extra-adrenal paragangliomas are almost
invariably noradrenergic.
Pheochromocytoma and ParagangliomaTischler 1279

syndromes. In general, a finding of multicentric tumors is

suggestive of familial disease. In the adrenal gland, familial disease may be manifest as multiple pheochromocytomas and/or diffuse and nodular hyperplasia. These
changes should be carefully searched for and their presence or absence should be documented. They are most
likely to occur in MEN2 but are often subtle or absent in
MEN2 and are usually absent in other syndromes.
Adrenal medullary hyperplasia is usually detected by
gross examination of the specimen. Adrenal medullary tissue is gray, in contrast to the brown zona reticularis of the
cortex, and is normally concentrated in the head and body
of the gland. Hyperplasia is suggested when medulla extends into the alae or tail and is often confirmed by subtle
nodularity seen grossly or microscopically (Figure 10; Figure 11, A and B). In the absence of diffuse hyperplasia,
separate small nodules are sometimes found widely separated by apparently normal medulla (Figure 11, B). A
practical approach to search for these changes is to
breadloaf the entire fresh adrenal into thin slices, allow
the slices to adhere to a dry paper towel, and immerse the
towel flat in fixative. This approach provides complete sections without retraction artefact.
Some evidence suggests that microscopic findings may
also provide clues to underlying genotypes. Pheochromocytomas that occur in patients with VHL disease have
been reported to exhibit distinctive features consisting of
a thick vascular capsule, myxoid and hyalinized stroma,
small cells with clear or amphophilic cytoplasm, intermixed small vessels, and absence of hyaline globules.39
These changes are not always present and it not known
whether they correlate with specific VHL mutations. They
may also overlap with findings in other familial or sporadic pheochromocytomas. In addition, the residual vascular scaffold of collapsed normal adrenal medulla adjacent to a pheochromocytoma may resemble a thick vascular capsule. Immunohistochemical staining for phenylethanolamine N-methyltransferase, the enzyme that
synthesizes epinephrine from norepinephrine, may be a
useful ancillary technique because pheochromocytomas in
VHL disease are usually noradrenergic32 and, therefore,
phenylethanolamine N-methyltransferase negative (Figure
12, A through C). A caveat, however, is that high-quality
monoclonal antibodies such as those long-available for
CgA or TH are not yet available for phenylethanolamine
N-methyltransferase.

Figure 8. Vagal paraganglioma from a patient with multiple parasympathetic paragangliomas. In contrast to sympathoadrenal tumors, head
and neck paragangliomas are sometimes only focally positive for
chromogranin A (CgA) and can be negative for tyrosine hydroxylase
(TH)4 as in this example (hematoxylin-eosin, original magnification
200 [A]; CgA, original magnification 200 [B]; and TH, original magnification 200 [C]).
Figure 9. Paraganglioma metastatic to bone. The pale staining, ovoid
to spindled cells can mimic or be mimicked by a variety of other tumors (hematoxylin-eosin, original magnification 20).

Identification of Occult Hereditary Disease

Pathology plays an important role in identifying clues
that may lead to identification of patients with previously
undetected familial pheochromocytoma/paraganglioma
1280 Arch Pathol Lab MedVol 132, August 2008

A PRACTICAL SUMMARY
Recent advances in genetics and gene expression profiling have dramatically increased our understanding of
the previously mysterious combinations of tumors in hereditary pheochromocytoma/paraganglioma syndromes.
Studies of familial syndromes, especially VHL and familial PGL syndromes resulting from SDH mutations, have
provided a platform from which to explore both familial
and sporadic tumors. Understanding of genotypephenotype correlations is important for both pathology and
clinical management.
Despite these breakthroughs, the current practice of pathology with respect to these tumors is still based on careful gross examination of specimens and histologic study
based principally on hematoxylin-eosin sections. Because
pheochromocytomas and extra-adrenal paragangliomas
often metastasize late and their behavior is unpredictable,
patients require long-term follow-up. These tumors should
Pheochromocytoma and ParagangliomaTischler

Figure 10. Classic, moderately severe adrenal medullary changes in

multiple endocrine neoplasia type 2A. Diffusely expanded gray medulla contains multiple poorly defined nodules. The sharply circumscribed nodule on top is a small pheochromocytoma. Two large pheochromocytomas were present in the opposite adrenal.
Figure 11. Subtle changes in adrenals from 2 multiple endocrine neoplasia type 2A patients. A shows slightly expanded medulla with 3
discrete nodules (3 arrows). B shows no definite abnormality except
for a single minute nodule (single arrow). However, a pheochromocytoma was present at the opposite end of the gland, with no intervening abnormalities (original magnifications 1).

therefore never be signed out as histologically benign.

They should also not be signed out as malignant unless
there is unequivocal documentation of metastasis to
lymph nodes or distant sites. Care must be taken to avoid
interpreting separate primary tumors as lymph nodes. Local invasion should be documented and does have some
correlation with metastatic potential, at least if it is extenArch Pathol Lab MedVol 132, August 2008

Figure 12. Pheochromocytoma from a patient with von Hippel-Lindau (VHL) disease. The tumor is characterized by small nests of cells
with prominent interspersed capillaries. Although it is positive for tyrosine hydroxylase (TH), absence of staining for phenylethanolamine
N-methyltransferase (PNMT) confirms the noradrenergic phenotype. A
rim of residual normal adrenal medulla at left in C serves as a positive
control for the PNMT stain (hematoxylin-eosin, original magnification
200 [A]; TH, original magnification 200 [B]; and PNMT, original
magnification 200 [C]).

Pheochromocytoma and ParagangliomaTischler 1281

Table 3.

Synoptic Reporting Template for Pheochromocytoma and Paraganglioma*

Gross description
Nature of specimen
Nature of surgery
Weight of specimen
Dimensions of specimen
Coarse nodularity
Adrenal capsule
Excision complete
Uninvolved adrenal
Other tissues included (define)
Microscopic description
Predominant cell type
Hyaline globules
Mitotic count (20 HPF 400)
Confluent necrosis
Vascular invasion
Capsular invasion
Infiltration into surrounding tissues
Sustentacular cells
Other components
Uninvolved adrenal identified
Medullary hyperplasia

Right adrenalectomy
Open
g

Yes
Intact
Yes
Identified

Large
Yes

mm
No

No

No

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Ganglioneuroma
Yes
No
Yes
No

Left adrenalectomy

Other (define)

Laparoscopic

Not known

Breached

Not identified

Not applicable

Small

Not assessed
Neuroblastoma
Not applicable
Not assessed

Ganglioneuroblastoma
Not applicable

Comments:
* Used with the kind permission of the Royal College of Pathologists, www.rcpath.org (accessed February 5, 2008). HPF indicates high-power
field.

Table 4. Summary of Association of Directors of

Anatomic and Surgical Pathology Recommendations
for Reporting of Extra-adrenal Paragangliomas*
Anatomic site of tumor pathologic diagnosis (terminology based
on anatomic site, eg, urinary bladder paraganglioma)
Type of resection
Tumor size (
cm
cm
cm) and weight (
g)
Gross description (external and cut surfaces)
Microscopic description (including presence and quantitation of
mitotic figures)
Margins of resection (free of tumor, or tumor present at margins)
Presence and approximate extent of necrosis
Presence or absence of invasion (vessels, adjacent tissues or organs)
Unusual pathologic features
Special studies
* Excerpted from Lack et al,43 provided as a checklist at http://
www.adasp.org/ (accessed February 5, 2008). Reprinted from Human
Pathology with permission from Elsevier.

sive.3 However, by itself it is a poor predictor. In the classic

1990 study by Linnoila et al,3 30 of 120 sympathetic paragangliomas had metastasized but only 2 of those also
showed extensive local invasion, whereas 2 additional tumors with extensive local invasion showed no evidence of
metastasis.
In addition to local invasion, other features correlated
with malignancy in large series3,34,36 should be noted. The
listing of potentially unfavorable findings will presumably
flag a tumor for some type of follow-up, but the nature of
the required follow-up remains unclear. Most pathologists
do not currently use any formal scoring system in routine
practice, for reasons including the lack of prospective validation, poor concordance in recognizing some of the
scored parameters, and a high false-positive rate evident
from the fact that many tumors with high scores apparently never metastasize.3 If a numerical score is assigned
it must be emphasized that a high score does not consti1282 Arch Pathol Lab MedVol 132, August 2008

tute a diagnosis of malignancy either for clinical or research purposes.

To optimize reporting of information required for care
of patients with cancer, guidelines and templates for reporting of malignant tumors are provided by the College
of American Pathologists (www.cap.org) and the Association of Directors of Anatomic and Surgical Pathology
(ADASP) (www.ADASP.org) in the United States and the
Royal College of Pathologists (www.rcpath.org) in the
United Kingdom. Those recommendations are available in
pathology journals39,40 and textbooks, as well as on the organizations Web sites. The College of American Pathologists and the ADASP checklists are based on staging criteria in the American Joint Committee on Cancer 2002
staging manual and incorporate elements required by the
American College of Surgery Commission on Cancer,
which accredits cancer centers in the United States. Strictly
speaking, most pheochromocytomas and extra-adrenal
paragangliomas do not require template reporting because they are not malignant. However, the templates
available for these tumors incorporate major elements of
the various proposed scoring systems and therefore serve
as useful checklists of features that should be noted, while
leaving flexibility to add additional elements. Most elements listed are generic descriptors required in all tumor
reporting (size, weight, necrosis, mitotic activity, and vascular or capsular invasion), but some are not necessarily
highly correlated with the behavior of pheochromocytomas or extra-adrenal paragangliomas. For example, tumor
size and weight may show some correlation with metastatic potential but not as independent variables.35 The adrenal checklist currently proposed for use in the United
Kingdom (Table 3) is somewhat more detailed than that
provided by ADASP, whereas ADASP provides a separate
paraganglioma checklist not available on the Royal College Web site (Table 4). As noted on the ADASP Web site,
. . . ADASP realizes that specimens and practices vary
Pheochromocytoma and ParagangliomaTischler

References

Figure 13. Parasympathetic paraganglioma embolized prior to surgery. Arrow indicates foreign material in blood vessel. Most tumor cell
nuclei are pyknotic, and frank necrosis is present at lower right. Confluent necrosis in embolized tumors is not a worrisome feature (original
magnification 4).

and it will not be possible to report these elements in every case.

Quality pathology reporting starts with the approach to
the gross specimen. Sampling should be liberal and
should represent all morphologically variant areas of a tumor, the tumor capsule, and the interface with adjacent
soft tissue. A general guideline of at least one section per
centimeter of tumor is suggested, as for many types of
tumor. In principle, surfaces should be inked prior to sectioning to assess margins. However, laparoscopy is now
the method of choice for resecting pheochromocytomas,
and adrenals are often lacerated during laparoscopic removal. Routine inking is not a substitute for thoughtful
gross assessment and can be confusing if ink is daubed
onto lacerated surfaces. An additional potential source of
confusion is that paragangliomas, particularly of the head
and neck, are frequently embolized by clinicians prior to
surgery to reduce operative bleeding, thereby creating
gross or microscopic areas of necrosis that should not be
interpreted as tumor necrosis. Foreign material used for
this purpose can usually be identified in tumor blood vessels (Figure 13).
An exciting prospect is that pathologists in the near future might play a role in management of malignant pheochromocytomas/paragangliomas by immunohistochemically identifying proteins for targeted therapy, as is already routine for a number of other malignancies. One
immediate possibility is targeting of heat shock proteins41
using drugs that are already in clinical trials.42 There is
presently little discussion of how sections should be used
for immunohistochemistry or other ancillary studies. If the
appearance of a tumor varies from slide to slide, as is
often the case, should all of the slides be stained for each
marker studied? If a tumor is large, should staining be
performed on sections representing both the center and
the periphery? Although the logical answer to both questions is yes, that approach may be precluded by constraints of cost and time. These issues remain to be resolved both in the design of protocols for clinical studies
and in clinical practice.
I thank James F. Powers, PhD, for assistance with preparation
of this article and for performing the immunoblot study shown
in Figure 5.
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Pheochromocytoma and ParagangliomaTischler