Introduction: Pheochromocytoma is a catecholamine-secreting adrenal tumor associated with major perioperative hemodynamic instability. When concurrent major pelvic pathology requires surgery, operative planning becomes particularly challenging. We describe the successful single-stage management of pheochromocytoma and a giant uterine fibroid, highlighting the importance of multidisciplinary coordination and perioperative optimization. Case: A 49-year-old female with symptomatic uterine fibroid was found to have proliferative endometrium on a pipelle biopsy. Computed tomography (CT) abdomen incidentally detected a right adrenal mass alongside a large posterior uterine fibroid (11.9 × 17.4 × 14.6 cm). CT adrenal protocol demonstrated a heterogeneously enhancing right adrenal mass (6.9 × 6.9 × 9.6 cm) with high unenhanced attenuation. Biochemical evaluation revealed markedly elevated 24-hour urinary metanephrine (4.7× upper limit) and normetanephrine (2.4× upper limit). Following multidisciplinary discussions, a single-stage surgical approach was planned after careful assessment of feasibility and perioperative risk in view of the uncertain malignant potential of the pelvic mass and to minimize repeated exposure to anesthesia. Preoperative optimization included transitioning from terazosin to phenoxybenzamine, with subsequent addition of bisoprolol for hemodynamic control. The operative strategy prioritized pheochromocytoma resection first, given its potential for significant hemodynamic instability. Progression to hysterectomy was contingent upon achieving adequate intraoperative hemodynamic stability following adrenalectomy, with continuous reassessment by the anesthetic and surgical teams. Right adrenalectomy was performed first, followed by total abdominal hysterectomy with bilateral salpingooophorectomy. Significant hemodynamic lability occurred during tumor manipulation, with hypertensive surges managed using sodium nitroprusside and remifentanil infusions. Following adrenal vein ligation and tumor removal, hypotension was managed with noradrenaline and additional adrenaline support as required. Total operative time was approximately 6 hours. Postoperatively, transient noradrenaline support was required but was rapidly weaned as hemodynamic stability was achieved. Conclusion Single-stage adrenalectomy and major pelvic surgery can be safely performed in selected patients with pheochromocytoma when guided by meticulous preoperative optimization, clear intraoperative sequencing, and close multidisciplinary coordination.
Pheochromocytoma ; Adrenalectomy ; Leiomyoma ; Hysterectomy

Introduction: Adrenal incidentalomas are increasingly detected with the widespread use of imaging, whereby the large or heterogeneous lesions often raise concern for adrenocortical carcinoma (ACC). However, certain rare benign and infectious conditions may closely mimic malignant features, posing a diagnostic challenge. Case: A 64-year-old female with diabetes mellitus, hypertension, and dyslipidemia was noted to have progressively rising alkaline phosphatase during routine follow-up. She had non-specific gastrointestinal symptoms. A computed tomography abdomen pelvis showed a large, lobulated mass at the left flank, likely of adrenal origin. An adrenal protocol computed tomography revealed a large, heterogeneously enhancing left suprarenal mass measuring 10.7 × 10.3 × 10.7 cm, with a plain-phase attenuation of +81 Hounsfield Unit and absolute (28%) and relative (18%) washout. The right adrenal gland was normal, with no evidence of distant metastasis. Hormonal evaluation showed normal 24-hour urinary metanephrines, excluding pheochromocytoma. The overnight dexamethasone suppression test demonstrated cortisol of 89 nmol/L, suggestive of mild autonomous cortisol secretion, without clinical features of overt hypercortisolism. DHEA was low (0.371 µmol/L), and adrenocorticotropic hormone was suppressed (1.26 pg/mL). Evaluation for primary aldosteronism was not done due to the absence of resistant hypertension or hypokalemia. The gonadotropin profile was consistent with postmenopausal status (follicle-stimulating hormone (89 IU/L) and luteinizing hormone (28.9 IU/L) with low estradiol. The patient underwent open left adrenalectomy. Histopathology revealed an adrenal cavernous hemangioma with extensive hemorrhage and infarction, alongside necrotizing granulomatous inflammation with numerous intracellular fungal organisms and narrow-based budding yeast forms, highly suggestive of histoplasmosis, with no evidence of malignancy. She was subsequently comanaged with infectious disease team and commenced on intravenous amphotericin B. Conclusion This is a rare coexistence of an adrenal hemangioma and histoplasmosis, presenting as a large adrenal mass mimicking ACC. The limitations of imaging in differentiating benign from malignant adrenal lesions are revealed and emphasize the role of histopathological confirmation. Increased awareness of such entities can support the diagnosis and management.
Neoplasms