Biochemically Silent Pheochromocytoma Presenting with Hypertensive Crisis During Surgery

ABSTRACT Objective: Pheochromocytomas (PHEOs) are tumors of the adrenal medulla, and paragangliomas (PARAs) are tumors of the sympathetic, or parasympathetic chain. Adrenal PHEOs and sympathetic PARAs commonly secrete catecholamines. Elevated plasma free metanephrines or 24-hour urinary fractionated metanephrines are the gold standards to diagnose a secreting PHEO or PARA, and if secreting, pretreatment with alpha-blockade is indicated to reduce morbidity and mortality associated with anesthesia and surgery. However, if the tumor is nonsecreting, alpha-blockade is generally not recommended. Methods: We present a case of a 65-year-old man who presented with an incidentally noted 1.9-cm right adrenal nodule. Workup showed this to be a nonsecreting adrenal mass, with normal plasma free metanephrines. However, he experienced a hypertensive crisis at the time of induction of anesthesia when he presented for elective repair of an abdominal aortic aneurysm. He was stabilized and treated with alpha-blockade. After adequate alpha-blockade, he underwent uneventful resection of the adrenal mass, followed by successful repair of his abdominal aortic aneurysm. Results: Final pathology confirmed it to be a PHEO. Conclusion: This is a unique case of a biochemically silent adrenal mass that behaved clinically like a secreting PHEO, requiring medical therapy with alpha-blockers for stabilization prior to resection. Abbreviations: AAA = abdominal aortic aneurysm; CI = confidence interval; CT = computed tomography; HU = Hounsfield units; PARA = paraganglioma; PHEO = pheochromocytoma; VMA = vanillylmandelic acid