Authors: Merchant A, et al.
Cureus 17(10): e95754. DOI: 10.7759/cureus.95754
Summary
A 77-year-old man with a 17 cm right retroperitoneal mass presumed to be adrenocortical carcinoma (ACC) underwent open adrenalectomy. Preop endocrine work-up (plasma metanephrines, aldosterone/renin, morning cortisol) was non-functional, but imaging showed a large heterogeneous, hypervascular lesion displacing the right kidney, favoring malignancy. Intraoperatively the tumor was unusually vascular; estimated blood loss was ~800 mL and norepinephrine was required. In PACU he developed refractory hypotension despite fluids and vasopressors. Concern for hemorrhage prompted urgent re-exploration, which revealed no active bleeding. He was rewarmed and stabilized in ICU, extubated on postoperative day 1, and discharged on day 7. Final pathology: benign adrenal cavernous hemangioma with thrombosis/infarction. The authors highlight how these rare, hypervascular adrenal lesions mimic ACC and how postoperative hypotension may reflect hypovolemia/vasodilation rather than surgical bleeding. They argue that early perioperative point-of-care ultrasound (POCUS)—focused echo (ventricular filling/function), IVC assessment, and FAST—can rapidly differentiate shock states and potentially avert unnecessary re-operation.
What You Should Know
• Cavernous hemangioma of the adrenal is rare and can closely mimic ACC on CT/MRI; nonfunctioning endocrine labs do not exclude a large vascular tumor.
• Post-resection hypotension may stem from relative hypovolemia, vasodilation, hypothermia, or myocardial dysfunction—not just hemorrhage.