The Endocrine Society Clinical Practice Guideline on Phaeochomocytoma and Paraganglioma (PPGL) recommends phlebotomy for plasma-free metanephrines (PMets) with patients fasted and supine using appropriately defined reference intervals. Studies have shown higher diagnostic sensitivities using these criteria. Further, with seated-sampling protocols, for result interpretation, reference intervals that do not compromise diagnostic sensitivity should be employed.
To determine the impact on diagnostic performance and financial cost of using supine reference intervals for result interpretation with our current PMets fasted/seated-sampling protocol.
We conducted a retrospective cohort study of patients who underwent screening for PPGL using PMets from 2009-2014 at Galway University Hospitals (GUH). PMets were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Supine thresholds for plasma NMN and MN set at 610pmol/L and 310pmol/L respectively were used.
A total of 183 patients were evaluated. Mean age of participants was 53.4 (±16.3) years. Five of 183 (2.7%) patients had histologically confirmed PPGL (males, n=4). Using seated reference intervals for PMets, diagnostic sensitivity and specificity was 100% and 98.9% respectively with two false positive cases. Application of reference intervals established in subjects supine and fasted to this cohort gave diagnostic sensitivity of 100% with specificity of 74.7%. Financial analysis of each pre-testing strategy demonstrated cost-equivalence (€147.27/patient).
Our cost analysis, together with the evidence that fasted/supine-sampling for PMets offers more reliable exclusion of PPGL mandates changing our current practice. This study highlights the important advantages of standardised diagnostic protocols for PMets to ensure the highest diagnostic accuracy for investigation of PPGL.