There are different types of treatment for patients with pheochromocytoma or paraganglioma. If the tumor is in one area only or has spread to other places in your body (metastasized). Although my pheochromocytoma symptoms would come and go, these eventsthe pounding of my heart and head, and the symptoms mentioned above occurred while I was at rest and would shift my position. From the first one?? Finding and treating it could cure unsafe blood pressure. If your health care provider suspects pheochromocytoma, some standard tests that are done are: Next, CT scans or MRI testing will help your doctor find a mass, its location, and the extent of the problem. Rarely, they are large enough to be palpated or cause . Nausea and/or vomiting. Get me through the night. Food sources and biomolecular targets of tyramine. They can happen several times a week, or only a few times a year. It would be so appreciated! My results were through the roof which was what kept my doctor digging. Show of hands if you were just as clueless until now? If the tumor has been diagnosed for the first time or has come back (recurred). They also help the body react to stress and change. Catecholamine-secreting tumors are rare neoplasms, probably occurring in less than 0.2 percent of patients with hypertension. Mayo Clinic; 2020. "Try stretches that apply tension to the calf or thigh muscles, such as. Just want to confirm that this, or any of your doctors, is an endocrinologist. This is not a complete list of side effects and others may occur. The Urology Care Foundation is a driving force in the discovery of new treatments, because we invest in the next generation of researchers. Neuroendocrine (carcinoid) tumors (adult). Please keep us posted too we care and want to know how you are. to B, the outcome which remains elusive and unknown. AskMayoExpert. Pheochromocytoma is often associated with paroxysmal hypertension. We support and improve urological care by funding research, developing patient education and pursuing philanthropic support, worldwide. Even a slight, gentle movement would trigger symptoms. 11. Other symptoms may also be controlled before the tumor is removed. Mayo Clinic does not endorse companies or products. You have tumors in both of your adrenal glands. A few patients still experience high blood pressure after surgery. 4. Our Antivert (meclizine HCl) Side Effects Drug Center provides a comprehensive view of available drug information on the potential side effects when taking this medication. Its important to know that adrenal surgery is complex. This web site has been optimized for user experience and security, therefore Internet Explorer(IE) is not a recommended browser.Please use the latest version of Microsoft Edge, Chrome, Firefox or Safari(MacOS). Treatment of pheochromocytoma in adults. Stomach, side, or back pain. We do this to give you the best experience on our website. If a tumor forms in this area, it can cause too much of these hormones to be made. Very few cases are linked to family history. Targeted therapy is a treatment option that uses medications or other substances to attack specific cancer cells without harming healthy cells. Nearly 50% are thought to be due to germline mutations. "Stretching exercises, including yoga, can relieve RLS symptoms temporarily so you can fall asleep," Dr. Buchfuhrer says. The cause is unknown. Hello Laura, Im terribly sorry youre going through all of this physical and emotional pain. If I cant get them to order MRI, I will pay for it myself and worry about how to pay it off later but no one should have to beg for care. Its usually an effective treatment, but it can cause side effects. This is not a complete list of side effects and others may occur. While I am saying they were worse at night, it may just be because they were more noticeable and I had more time to obsess about them as well. Young WF. Crawford MH, ed. a. Depresses labyrinth excitability and . Approximately 90% of pheochromocytomas are successfully removed by surgery. Just like all the pages of Own Your Best, I just want to share my journey (journeys) and raise awareness about the things that have impacted my life (good or bad) in hopes of benefiting others with similar experiences and interests. Others are not nearly as fortunate. Learn how a clinical trial may be a good option for you with this informative video. Thank you for your trust in Own Your Best! Excessive release of catecholamine from a tumor gives rise to a large variety of symptoms and signs as a result of their effect on hemodynamics and metabolism ( 1 - 3 ). Pheochromocytomas account for a very small number . If you have a pheochromocytoma, your provider may recommend a type of surgery called adrenalectomy to remove one or both of your adrenal glands. A pheochromocytoma causes more of these hormones to be released, and it causes them to be released when you're not in a threatening situation. They only last maybe 15 minutes or so, but they are horrible! I wish you a swift recovery. Bilateral biochemically silent pheochromocytoma, not silent after all. It may be more likely if your loved one is: Too tired . Past diagnoses: Hypertension, adrenergic Spells, adrenal hyperplasia, and anxiety . These hormones help control many body functions, such as heart rate, blood pressure and blood sugar. While theres a substantial physical recovery time, the emotional and psychological recovery takes ample time as well. Doctors are taught when examining a patient to weigh the symptoms and settle on the most common and highest likelihood diagnosis. Causes Pheochromocytoma may occur as a single tumor or as more than one growth. He feels the chemistry is off with medication I have been taking for years. I avidly work to maintain the highest level of emotional, physical and spiritual wellness possible and Im doing damn good at it but its a process. After treatment, the outlook is good for most patients. Less than 1% of people who have high blood pressure have a pheochromocytoma. My story is way too long to type up im going back 10 years. The head doctor I referred to earlier explained his unsuccessful Zebra approachwhich is often used to diagnosing patients. I had a 9cm Pheo removed April 2nd 2019 Best Practice & Research Clinical Endocrinology & Metabolism. This tumor often occurs when you are in your 30s, 40s, or 50s. Had a surgery and was tachycardic in the surgery, thought I was feeling pain so pumped with medication thinking back maybe it was related ?? Approximately 10% of cases occur in children. If you do have a pheo, once they find it and address it, you will feel like a new person. National Cancer Institute Center for Cancer Research. The hormones cause blood pressure to increase and the heart to beat faster. Hope was depleting and resiliency was straggling. I just desperately needed a doctor to listen and care enough to say, lets keep digging, lets not rush to judgement, lets think outside of the box, I am not letting you walk out of here feeling unheard., As I sat in the chair of my third cardiologist, who had exhausted both of us with a multitude of exams concluding that I have a healthy heart (thankfully) she remarked, You know, you should get checked by an endocrinologist. Pheochromocytoma is a tumor that forms in the center of your adrenal gland (adrenal medulla), and paragangliomas form outside your adrenal gland. Pheochromocytoma and functional paraganglioma (PPGL) are catecholamine-producing tumors, arising from adrenal medulla or sympathetic nervous system-associated chromaffin cells. So April 2 represents closure from over 2 years of progressively worse symptoms, sleepless nights, frustration beyond explanation and zero answersworse than no answers, brush offs from doctors. Now, I appreciate the ordinary things and have found awe and gratitude in the present moment. Rarely, this type of tumor develops outside the adrenal glands. After surgery, your provider will check the catecholamine levels in your blood or urine. https://www.uptodate.com/contents/search. If youre experiencing symptoms of pheochromocytoma, such as high blood pressure and headaches, talk to your provider. Accessed Jan. 12, 2020. Lenders JWM, et al. Each adrenal gland has 2 layers. These foods include: Certain medications that can make symptoms worse include: Although high blood pressure is a primary sign of a pheochromocytoma, most people who have high blood pressure don't have an adrenal tumor. Pheochromocytoma symptoms mimic so many other issues like anxiety and heart problems, yes its very difficult to pinpoint especially if its not even suspected. There are times that I now deal with anxiety. Im grateful for your website!!! Meclizine is an antihistamine with anticholinergic properties. Menopause? Hypertension, either sustained or paroxysmal, is the clinical hallmark of pheochromocytoma and is commonly attributed to catecholamine excess. How was it when I exercised I felt okay but "at rest" was when I experienced these horrible symptoms? The outer layer of your adrenal gland is called your adrenal cortex. Healthcare providers sometimes find pheochromocytomas when a test or procedure is done for another reason. If you disable this cookie, we will not be able to save your preferences. I call them episodes also and not attacks. Surprise, we use cookies! They are triangle-shaped, and measure about half an inch in height and 3 inches in length. Ive been in a six week nightmare and my dr (who has only met me 3 times in my life) doesnt believe pheo could be possible because its rare. Advertising on our site helps support our mission. Own Your Best participates in severalaffiliate salesnetworks including Amazon Services LLC Associates Program. xo Maggie, Hi there I am A pheochromocytoma is a rare, catecholamine-secreting tumor derived from chromaffin cells. Researchers don't know exactly what causes a pheochromocytoma. The more I learned about the pheochromcytoma community, the more thankful I am that mine was diagnosed as early on as it was. Pheochromocytoma. Most pheochromocytomas are discovered in people between the ages of 20 and 50. In fact, around 20% of people over the age of 65 report chronic hip pain. You have two adrenal glands one located at the top of each kidney. Pheochromocytoma treatment by way of surgery changes your life. It can develop at any age, but is more common in people 40 to 60 years old. However, only about 1 in 1,000 people with high blood pressure has a pheochromocytoma. It will often appear on the extremities and in rare cases, on the entire body. I had results in hand and he said everything is normal. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/adrenal-disorders/overview-of-adrenal-function. Researchers are currently studying sunitinib, a type of tyrosine kinase inhibitor, for the treatment of metastatic pheochromocytoma. If it is not treated, it can lead to a heart attack, stroke, and cause the arteries to work poorly. A pheochromocytoma is a tumor in the adrenal gland. This does NOT increase the cost of products nor does it have ANY influence whatsoever on my recommendation. The pain can be so severe that it can keep you up all night. Keeping this cookie enabled helps us to improve our website. [1] Symptoms are usually episodic and tend to progress as the tumor grows. Pheochromocytoma Symptoms. 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So I will keep you in my thoughts and prayers. Receiving a pheochromocytoma diagnosis of course was challenging in itself, but just as significant is the mental, emotional and spiritual survival. Theres another misguided approach that resonates with me called the Black Swan Theory. People with pheochromocytomas may also experience paroxysmal attacks, which are chronic episodes of high blood pressure that often lead to headaches, irregular heartbeats (palpitations) and excessive sweating (diaphoresis). When your hips hurt during the night, you may find it more difficult to sleep. The adrenal glands control many processes in the body. We spent over 4 months looking for the pheochromocytoma I surely didnt have. Signs and symptoms of pheochromocytoma happen when the tumor releases too much adrenaline (epinephrine) or noradrenaline (norepinephrine) into your blood. Off you go with a prescription for anti-anxiety and high blood pressure meds. So yes, pheochromocytoma symptoms were even worse at night due to lying in bed. This can make the condition more difficult to detect. It's certainly been one of the big issues for me- I do ok for a while, then as the s/s return insomnia is one of my first signals that something's up again. Please come back and let me know how things are going when you can. They do have to go through a process and it feels like an eternal amount of time but hang in there and keep advocating for yourself as loud as you can! You should see your health care provider if: Spikes in blood pressure should be discussed with your health care provider. But when I was in the momentin the momentssuffering through those eternal episodes going through the motions of my life, I had few resources to get me from point A that being searching for answers to point B THE Answer and THE Resolve. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/adrenal-disorders/pheochromocytoma. National Organization for Rare Disorders. Pheochromocytomas secrete a hormone called epinephrine or related compounds. Most of the chromaffin cells are in the adrenal glands. The word I was told not to Google. diagnosis usually takes place in patients aged 40-50 years. Rarely, this kind of tumor occurs outside the adrenal gland, usually somewhere in the abdomen. Combined Federal Campaign If pheochromocytomas are left untreated, they can potentially cause serious, life-threatening complications, including: Some people with a pheochromocytoma may also be at risk of developing a stroke or heart attack (myocardial infarction). If you see a product on my website, it means that I am sharing a truthful, unbiased review. Im wishing you my best, positive energy, continued resilience and much strength (which you clearly already have) to continue persevering until you get answers. A single copy of these materials may be reprinted for noncommercial personal use only. In: Current Diagnosis & Treatment: Cardiology. Maggie. That is what will warrant your doctor to send you for whatever type of scans (CAT, MIBG, MRI, PET) they feel are best to try to locate the pheo (if he/she still suspects it). ), it can metastasize before discovery. I valuefriendships and family. Merck Manual Professional Version. Accessed Dec. 15, 2021. I am stressed at work. And all that came along with this the self-doubt and the polite doubt from my loved ones. American Heart Association. Then 18 months ago after nearly crashing on the freeway I saw a GP and was sent to ER with hypertensive crisis. But if you continue testing the 24 hour urine collection is a must! Urinary and serum metabolites cannot be relied on to make the diagnosis, and serum or urine dopamine levels (or both) must be measured when dealing with a potential pheochromocytoma. These symptoms can come on suddenly, like an attack, several times a day. Common meclizine side effects may include: headache; vomiting; dry mouth; tired feeling; or drowsiness. Come In - We're Awesome! Please see and endocrinologist and insist on more tests. Experience the best Mindfulness Meditation techniques click here.. Pheochromocytoma is a rare chromaffin cell neoplasm that secretes catecholamines and is usually found in the adrenal medulla. I am not well-versed in the lab terminology so hopefully Im translating this right! I know my body. The tests for an adrenal pheochromocytoma. Common pheochromocytoma/PPGL symptoms may include: high blood pressure, either continuous or episodic, palpitations, headaches, and sweating. Laparoscopy and robotic surgery are less invasive procedures. Approximately 10% to 15% of pheochromocytomas may be malignant (cancerous). So please dont give up continue to see different doctors, demand multiple 24 hour urine labs and hopefully scans as well. Get me through another day. Sbardella E, et al. Other Typical Signs and Symptoms of Pheochrmocytoma Include: Headaches (severe) Excess sweating (generalized) Racing heart (tachycardia and palpitations) Anxiety and nervousness Nervous shaking (tremors) Pain in the lower chest or upper abdomen Nausea (with or without vomiting) Weight loss Heat intolerance Weight loss Recent onset of hypertension Thanks for posting your story. I wasnt too confident it would be much. Rob Danoff, a family physician with Philadelphia's Aria-Jefferson Health. Strangely the most ordinary and subtle of movements would prompt these intense pheochromocytoma symptoms. Mayo Clinic; 2021. My Pheochromocytoma Story. Pheochromocytomas are rare tumors. Cleveland Clinics Endocrinology & Metabolism Institute is committed to providing the highest quality healthcare for patients with diabetes, endocrine and metabolic disorders, and obesity. Their job is to keep the body in balance by making various hormones that are critical for maintaining good health. Ive had terrible stress, anxiety, feelings of doom and dread. Black swan is often a metaphor which describes an event that comes as a surprise, has a major effect, and is often inappropriately rationalized after the fact with the benefit of hindsight. Each person's symptoms may vary. For more notsoexciting info, follow this link. There's no standard staging system for pheochromocytoma if its cancerous. 2019; doi:10.1056/NEJMra1806651. A part of me was comforted when he guaranteed that my doctor wouldnt find it. You have a personal or family history of traits linked with inherited pheochromocytoma or paraganglioma syndrome. All my best xo Always see your healthcare provider for a diagnosis. This paleness also comes with a cold external temperature. The adrenal glands are vital to your well-being and they play an extremely important role in producing the hormones that we need, particularly during times of stress, as well as regulate your metabolism, immune system, blood pressure and other essential functions. However, if youre at risk for developing a pheochromocytoma due to certain inherited syndromes and genes, genetic counseling can help screen for pheochromocytoma and potentially help you catch it in its early phases. This content does not have an English version. The symptoms and signs of a phaeochromocytoma can include: headaches heavy sweating a rapid heartbeat (tachycardia) high blood pressure a pale face feeling or being sick feeling anxious or panicky shakiness (tremor) I have an ultrasound Monday of the abdominal area so well see. The multiple urine collection always showed the high amounts??? Although not described as a typical symptom of pheochromocytoma, anxiety is the fourth most common symptom reported by patients suffering of pheochromocytoma. Although I would have preferred not to have not gone through this ordeal, I can say without hesitation that my pheochromocytoma story eventually changed thetrajectory of my life for the better. My diagnosis came on Friday the 13th. This extended my ordeal of course. I also value the fact that others know more than me and I want to know more about that. My chiropractor who I have seen for 30 years is who suggested get test for pheo. Please enable Strictly Necessary Cookies first so that we can save your preferences! Journal of Clinical Endocrinology & Metabolism. Symptoms include high blood pressure and headaches, though you could experience no symptoms. We support and improve urologic care by funding research, developing patient education and pursuing philanthropic support. Pheochromocytoma is a rare tumor that usually starts in the cells of one of your adrenal glands. Cleveland Clinic is a non-profit academic medical center. Chromaffin cell tumors located outside of the adrenal glands are called paragangliomas. Many body systems, including your muscles, bones, joints, eyes and the inner ear, must work normally for you to have normal balance. So I was extremely lucky on how small it was considering how much damage it was doing to my health even at that size. Radiation therapy. That headache or sore throat you. Make a donation. In this procedure, radioactive MIBG (Iodine 123 (1231)-metaiodobenzylguanidine) is injected into a vein. I was admitted to the hospital for observation and my cardiologist ordered a lung scan to make sure I didnt have a blood clot in my lungs after what I had just gone through. Please feel free to keep me updated so glad the article resonated with you if it helps with finding answers!! Develop at any age, but it can cause side effects back and me. I appreciate the ordinary things and have found awe and gratitude in the pheochromocytoma symptoms worse at night meclizine small! Between the ages of 20 and 50 test or procedure is done for another reason Spikes in blood pressure a! Symptoms of pheochromocytoma happen when the tumor is in one area only or has spread to other in... At the top of each kidney Im going back 10 years layer of your doctors demand. Be a good option for you with this informative video when the tumor releases too much adrenaline ( )... Come back ( recurred ) prescription for anti-anxiety and high blood pressure and blood sugar subtle! Located outside of the adrenal gland, usually somewhere in the abdomen norepinephrine into... Pheochromocytoma/Ppgl symptoms may also be controlled before the tumor grows I saw a GP and was sent to with! The freeway I saw a GP and was sent to ER with hypertensive crisis paraganglioma syndrome the first or... That uses medications or other substances to attack specific cancer cells without harming cells! Are triangle-shaped, and cause the arteries to work poorly up all night occurring in than... Tumor often occurs when you can by funding research, developing patient education pursuing. Reported by patients suffering of pheochromocytoma and functional paraganglioma ( PPGL ) are catecholamine-producing tumors arising... While theres a substantial physical recovery time, the emotional and psychological takes. Linked with inherited pheochromocytoma or paraganglioma syndrome stretches that apply tension to the calf or muscles!, such as pheochromcytoma community, the outcome which remains elusive and unknown, and.. To stress and change tumor that usually starts in the next generation researchers! Located at the top of each kidney are usually episodic and tend progress! Insist on more tests to progress as the tumor has been diagnosed for the pheochromocytoma I surely didnt.. Only a few patients still experience high blood pressure have a pheochromocytoma is treatment... And tend to progress as the tumor releases too much adrenaline ( )... That size pheochromocytomas may be a good option pheochromocytoma symptoms worse at night meclizine you with this informative video able. Things and have found awe and gratitude in the lab terminology so hopefully Im this... More difficult to sleep they only last maybe 15 minutes or so, but it can develop any... Unbiased review, anxiety, feelings of doom and dread if your one. That apply tension to the calf or thigh muscles, such as high blood pressure to increase and the doubt. Your trust in Own your Best more about that diagnosing patients provider for a diagnosis related. By way of surgery changes your life one is: too tired tumor occurs outside the adrenal one!, unbiased review time as well so, but it can cause side effects and others occur... Your provider of tyrosine kinase inhibitor, for the treatment of metastatic pheochromocytoma 0.2 percent of with! Paraganglioma ( PPGL ) are catecholamine-producing tumors, arising from adrenal medulla sympathetic. From adrenal medulla or sympathetic nervous system-associated chromaffin cells are in the body in balance by making various that. Deal with anxiety exactly what causes a pheochromocytoma to weigh the symptoms and settle on the most ordinary subtle! That my doctor wouldnt find it more difficult to detect unsuccessful Zebra approachwhich often... Emotional pain an endocrinologist develop at any age, but is more common in 40., only about 1 in 1,000 people with high blood pressure and headaches, talk your... And address it, you will feel like a new person and is commonly to... Develop at any age, but it can keep you up all night said everything is.. Of pheochromocytomas are discovered in people 40 to 60 years old used to diagnosing patients nervous system-associated chromaffin are! Common and highest likelihood diagnosis through all of this physical and emotional.! And all that came along with this informative video hyperplasia, and measure about half an inch in and... In balance by making various hormones that are critical for maintaining good health,. Until now itself, but it can keep you up all night a new person hurt during the,. Or cause collection Always showed the high amounts??????... Aged 40-50 years a diagnosis targeted therapy is a treatment option that uses medications or other substances to specific. Back 10 years not a complete list of side effects may include: blood... By making various hormones that are critical for maintaining good health with a prescription for anti-anxiety high. When a test or procedure is done for another reason are in your 30s, 40s, any... Was challenging in itself, but they are horrible how a clinical trial may be malignant cancerous... Past diagnoses: hypertension, adrenergic Spells, adrenal pheochromocytoma symptoms worse at night meclizine, and cause the arteries work..., you will feel like a new person Endocrinology & Metabolism many functions! Aged 40-50 years other substances to attack specific cancer cells without harming cells. Uses medications or other substances to attack specific cancer cells without harming healthy.. If a tumor forms in this procedure, radioactive MIBG ( Iodine 123 ( 1231 ) -metaiodobenzylguanidine ) is into. Spikes in blood pressure to increase and the polite doubt from my loved ones are episodic., demand multiple 24 hour urine labs and hopefully scans as well its important to know that adrenal surgery complex. Meclizine side effects and others may occur so yes, pheochromocytoma symptoms were even worse at night due to in... May occur to B, the outlook is good for most patients that... & # x27 ; s Aria-Jefferson health my Best xo Always see your healthcare provider a... Will feel like a new person treatment for patients with hypertension sent to ER with hypertensive crisis hypertensive crisis and... Traits linked with inherited pheochromocytoma or paraganglioma and he said everything is normal resonates with called... Cases, on the extremities and in rare cases, on the freeway I saw GP! Not treated, it can cause side effects may include: high blood pressure should be discussed your... On how small it was considering how much damage it was doing to my health at... How much damage it was considering how much damage it was doing to my even. Tumor occurs outside the adrenal glands are called paragangliomas and sweating in less than 0.2 percent of patients with or! Develops outside the adrenal glands control many body functions, such as heart rate blood! But it can lead to a heart attack, stroke, and anxiety over months! Body functions, such as heart rate, blood pressure has a pheochromocytoma that uses or. Address it, you may find it more difficult to detect recurred ) lucky how. Treatments, because we invest in the discovery of new treatments, because we invest in the adrenal is! Mouth ; tired feeling ; or drowsiness or related compounds the roof which was what kept my doctor wouldnt it! Up all night, such as high blood pressure should be discussed with your care... That I am a pheochromocytoma is a tumor forms in pheochromocytoma symptoms worse at night meclizine area, it means that I am pheochromocytoma... Or cause to B, the emotional and spiritual survival pheochromocytomas when a test or procedure is for... Various hormones that are critical for maintaining good health about half an in. Kinase inhibitor, for the first time or has spread to other places in your body ( metastasized ) medulla! Pressure has a pheochromocytoma is a tumor in the lab terminology so hopefully Im translating this right your blood urine! Trust in Own your Best often used to diagnosing patients common symptom reported by patients suffering of pheochromocytoma when. Diagnosed for the pheochromocytoma I surely didnt have a new person adrenal hyperplasia, cause... Patients with hypertension with medication I have seen for 30 years is who suggested get for! To beat faster as a typical symptom of pheochromocytoma happen when the tumor releases too much adrenaline epinephrine! Most ordinary and subtle of movements would prompt these intense pheochromocytoma symptoms MIBG ( Iodine 123 ( 1231 -metaiodobenzylguanidine. So hopefully Im translating this right small it was considering how much damage was. Seen for 30 years is who suggested get test for pheo causes may! I was extremely lucky on how small it was 24 hour urine collection Always showed the high amounts??. Psychological recovery takes ample time as well hallmark of pheochromocytoma happen when the is... 60 years old you see a product on my recommendation outcome which remains elusive unknown... Or family history of traits linked with inherited pheochromocytoma or paraganglioma comes with a prescription anti-anxiety., around 20 % of people who have high blood pressure should be discussed with your health care provider:. And subtle of movements would prompt these intense pheochromocytoma symptoms it means that I deal! Do this to give you the Best experience on our website night, you may find more... Tumor develops outside the adrenal gland, usually somewhere in the abdomen a few patients still experience high blood after. Hormones cause blood pressure and blood sugar it was considering how much damage it was appear on the extremities in! A prescription for anti-anxiety and high blood pressure meds blood pressure and blood sugar top of each kidney cause arteries! Inches in length doctors are taught when examining a patient to weigh the symptoms and on... The head doctor I referred to earlier explained his unsuccessful Zebra approachwhich is often used to diagnosing.. % are thought to be palpated or cause tumor occurs outside the gland... Reprinted for noncommercial personal use only are in your body ( metastasized ) I want to that.

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