Large asymptomatic pheochromocytoma with incidental metastatic midgut carcinoid tumor

A 79-year-old asymptomatic woman was referred for a large adrenal incidentaloma found on imaging for painless hematuria. Computed tomography (CT) showed a hyperenhancing mass of the left adrenal gland with central necrosis, calcification, mass effect, and measuring 9.1 × 8.3 cm. Biochemical evaluation revealed markedly elevated 24-hour urine and plasma metanephrine and normetanephrine levels, strongly suggesting pheochromocytoma. On the morning of surgery, a dedicated adrenal-protocol CT confirmed the large left pheochromocytoma and incidentally detected a previously unrecognized partially calcified soft-tissue mass in the anterior mesentery. The patient underwent uncomplicated left laparoscopic, hand-port-assisted, transabdominal adrenalectomy. Using the same hand-port incision, the mesenteric mass was removed and frozen section analysis revealed mesenteric metastasis from midgut carcinoid tumor. The primary small bowel carcinoid tumor and mesentery were then resected en bloc, followed by primary intestinal anastomosis. She recovered well and was discharged after 48 hours. Final pathology confirmed pheochromocytoma coexisting with metastatic midgut carcinoid tumor. This case highlights the rare coexistence of 2 distinct neuroendocrine tumors, underscores the importance of careful review of imaging in patients with pheochromocytoma for unanticipated findings, and demonstrates the value of intraoperative frozen section analysis combined with a tailored, minimally invasive surgical approach.