SAT-508 - Bilateral Adrenal Incidentalomas with Minimal Hormonal Activity Revealing Pheochromocytoma: A Diagnostic and Management Challenge

Background:
Adrenal incidentalomas are increasingly detected with widespread imaging, and bilateral lesions pose diagnostic and management challenges. Although biochemical evaluation is central to risk stratification, pheochromocytomas may rarely demonstrate minimal or atypical biochemical abnormalities, delaying diagnosis.

Clinical

Case:
A 62-year-old woman was incidentally found to have bilateral adrenal masses during abdominal imaging. Contrast-enhanced CT demonstrated a 3.3-cm HU 30 heterogeneous left adrenal mass with cystic and calcified components and a 2-cm HU 45 right adrenal lesion with similar imaging characteristics. Serial imaging over six months showed progressive left-sided growth, while the right-sided lesion remained stable, with minimal change on retrospective review dating back to 2007.

Comprehensive hormonal testing was unremarkable except for an isolated two-fold elevation in urinary dopamine levels, which was rendered insignificant and did not initially raise suspicion for pheochromocytoma. Due to radiologic concern and interval growth, the patient underwent robotic-assisted left adrenalectomy.

Histopathology confirmed pheochromocytoma. Postoperative staging, including whole-body MRI and PET-DOPA functional imaging, showed no metastatic disease; however, tracer uptake was noted in the remaining right adrenal gland. Subsequent genetic testing revealed a heterozygous SDHAF2 variant labeled as a VUS (variant of uncertain significance).

Conclusion:
This case highlights the diagnostic complexity of bilateral adrenal incidentalomas and demonstrates that pheochromocytoma may present with minimal biochemical abnormalities, including isolated dopamine elevation. Furthermore, the genetic result places the clinical team in a management dilemma: whether to recommend right-sided cortical-sparing adrenalectomy versus continued surveillance, given the lesion’s unchanged appearance on imaging over many years.

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