Adrenal Incidentaloma in a 72-year-old Male with History of Prior Exploratory Laparotomy

Background: Adrenal incidentalomas are adrenal masses greater than 1 centimeter in diameter that have been found unexpectedly on radiographic imaging. Theses incidentalomas are found on 2.3% of abdominal radiographic images. The differential diagnosis of an adrenal mass is broad and includes adenoma, myelolipoma, cyst, lipoma, pheochromocytoma, adrenal cancer, metastatic cancer, hyperplasia, and tuberculosis. Case information: A 72-year-old Caucasian male presents for evaluation of a left adrenal mass that has increased in size over the past year. The mass was found on a CT scan showing a left adrenal mass with heterogenous enhancements with small low-density areas that could be cystic or necrotic. The patient did not present with any signs or symptoms. The patient has a history of hyperlipidemia, diabetes mellitus, hypertension, and is a hepatitis C carrier. He has allergies to penicillin, does not drink, and has a 10-pack year smoking history despite quitting 5 years ago. The patient's labs show elevated glucose at 137, elevated hemoglobin A1c at 5.8 and a decreased HDL at 37. All his other labs were within normal limits. He has a surgical history of exploratory laparotomy for a perforated gastric ulcer, appendectomy, and right finger amputation. A 24-hour urine study was done to measure the patients total metanephrines. His total metanephrine level was 305 mcg/24 hours which is in the normal range for the patient's age. Due to the increasing size a robotic left adrenalectomy was the treatment decided upon between the patient and physician. The increased risk of conversion to an open operation due to prior exploratory laparotomy was thoroughly discussed. Due to difficulty dissection, visual impediment, and proximity of the mass to the splenic artery and vein, the procedure is converted to an open surgery. The pathology report for the left adrenal mass reveals a 7 by 4.5 by 4 cm lesion positive for pheochromocytoma. The mass stains positive for chromogranin, synaptophysin and pancytokeratin while staining negative for GATA 3, inhibin and S100. The mass also shows a high potential for malignancy with 2+ periadrenal adipose tissue, 2+ necrosis, 2+ cellular spindling, 1+ capsular invasion, and 1+ vascular invasion. Conclusion: This patient and his case illustrate a distinct presentation of pheochromocytoma in an atypical age group, with no accompanying signs or symptoms.