A case of metastasectomy following multiple courses of radionuclide therapy for distant metastatic pheochromocytoma.

Pheochromocytomas and paragangliomas (PPGLs) are neuroendocrine tumors derived from chromaffin cells that produce catecholamines. The primary treatment for PPGLs is surgical resection, and even in cases with distant metastases, metastasectomy may be considered. Other therapeutic options for distant metastatic disease include radionuclide therapy, such as 131I-metaiodobenzylguanidine (MIBG) and 177Lu-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid-(Tyr3)-octreotate (DOTATATE). However, clear evidence is lacking regarding which patients with distant metastases are the best candidates for metastasectomy or radionuclide therapy. Herein, we report a case of a 58-year-old man who underwent resection of a left pheochromocytoma 10 years prior and was admitted for treatment of recurrent metastases to the liver and peritoneum. Sequential 131I-MIBG and 177Lu-DOTATATE therapies were administered, which contributed to disease control and reduction of catecholamine levels but did not achieve a complete response. Subsequently, all metastatic lesions were successfully resected, leading to normalization of catecholamine secretion. This case suggests that metastasectomy may be preferable to radionuclide therapy in carefully selected patients with limited, resectable metastatic disease, despite the presence of distant and multiple metastases. Furthermore, it highlights the importance of periodic reassessment of resectability in patients with distant metastases, even when radionuclide therapy is initially selected, and consideration of metastasectomy once complete resection becomes feasible.