Diagnostic Challenges of Abdominal Tumors Without Typical Imaging Features: From Misdiagnosis of Pancreatic Cystadenoma to Adrenal Pheochromocytoma and the Intraoperative Response.

BACKGROUND Pheochromocytoma is a rare neuroendocrine tumor. Some patients are asymptomatic, and misdiagnosis is common, especially when it lacks typical imaging features. In asymptomatic patients misdiagnosed with pheochromocytoma, hemodynamic instability often occurs during surgical procedures, posing significant challenges to surgeons and anesthesiologists. This case report presents a patient who was misdiagnosed as having a pancreatic cystadenoma prior to surgery, aiming to explore the intraoperative decision-making and considerations for such cases. CASE REPORT A 48-year-old woman with abdominal pain was preoperatively diagnosed with pancreatic cystadenoma by imaging. Laparoscopic surgery was performed following standard procedures, including patient positioning, stomach suspension, tumor search, and tissue dissection. The surgery lasted 156 min, with minimal blood loss (50 mL). Intraoperative hemodynamic instability occurred, and the final histopathological report confirmed the tumor as a pheochromocytoma. The patient was monitored in the intensive care unit (ICU) after surgery and was discharged on the 8th postoperative day, without complications. CONCLUSIONS Clinicians should be aware of the limitations of imaging. When dealing with abdominal tumors lacking typical features, especially those located in the adrenal gland or para-adrenal region, a high suspicion for asymptomatic pheochromocytoma is necessary. In the event of intraoperative hemodynamic instability, a high degree of suspicion for pheochromocytoma is needed. Moreover, it is crucial to strengthen multidisciplinary collaboration and emphasize the optimization of preoperative laboratory tests and examinations to compensate for the limitations of imaging studies. Surgeons need to be prepared for unexpected findings during surgery and adjust the surgical plan according to local anatomy to improve surgical safety and success rates.