NorepinephrinePredominant hormone from extra adrenal pheochromocytoma NorepinephrinePredominant hormone from Pheochromocytoma + MEN -> EpinephrinePlasma fractionated metanephrine - single most sensitive test24 hour urinary testsFractionated metanephrines - most sensitiveTotal metanephrines - most specificImagingAdrenal pheochromocytomaContrast CT and MRI - most sensitiveMIBG - most specificExtra-adrenal pheochromocytoma and paraganglioma - T2-weighted MRI with gadolinium contrastFNAC or NEEDLE BIOPSY & ANGIOGRAPHY - CONTRAINDICATED as it can trigger Bleeding or Hypertensive crisis.TreatmentSurgical removal of the tumor is the treatment of choice Preoperative preparationAlpha blocker therapy(phenoxybenzamine) should be given for atleast 7 days before surgeryLiberal salt intake and hydration - to avoid severe orthostasisBeta blockers (10 mg of propranolol three or four times per day) can then be addedMalignant pheochromocytomaPheochromocytoma with distant metastases are considered malignantThe first-line choice is nuclear medicine therapy for scintigraphically documented metastases, preferably with I-131-MIBG">