After confirming a pheochromocytoma, what are the essential next steps before surgical resection?

• A. Immediate surgical resection
• B. Tumor localization with imaging, initiate alpha-blockade and volume repletion
• C. Begin chemotherapy
• D. Start high-dose steroids

Answer: (C)

Preoperative optimization of a pheochromocytoma centers on controlling catecholamine effects and planning for safe surgery. After confirming the diagnosis and localizing the tumor with imaging, the key step is to start alpha-adrenergic blockade to prevent dangerous blood pressure surges when the tumor is manipulated during surgery. This blockade is begun before surgery and continued, with careful titration, to achieve stable blood pressure and symptom control. Once alpha blockade is underway, volume repletion is important because longstanding catecholamine excess can shrink the intravascular volume; correcting this helps prevent severe hypotension after tumor removal.

Beta-blockade, if needed for persistent tachycardia, should be added only after alpha blockade to avoid unopposed alpha stimulation and dangerous hypertension. Surgery is performed once the patient is adequately prepped. Chemotherapy is not the standard preoperative step for localized disease and is reserved for malignant or unresectable cases. High-dose steroids do not play a role in routine preoperative management of pheochromocytoma.