A Sizeable Adrenal Ganglioneuroma: A Case Report

Abstract

Adrenal ganglioneuromas are mostly asymptomatic, although they may manifest with compressive local effects. We present a 27-year-old man with no medical history who was referred to the surgical oncology clinic due to the incidental finding of a left adrenal mass. The initial computed tomography (CT) abdomen revealed a large mass causing displacement of adjacent organs. A CT-guided biopsy was inconclusive, and further evaluation with an NM endo-adrenal (MIBG) medullary scan pointed to a possible diagnosis of pheochromocytoma. Laboratory tests showed normal levels of urinary metanephrine and normetanephrine. The patient's history revealed chronic abdominal pain, with no symptoms of hypertension, headache, palpitations, or sweating. Subsequently, the patient underwent a left adrenalectomy without complications. This case underscores the importance of a comprehensive approach in managing adrenal masses, particularly when dealing with non-specific symptoms, emphasizing the importance of timely diagnosis and appropriate treatment.

Keywords: adrenal mass; ganglioneuroma; hypertension; mibg; urinary metanephrine.

Figure 1. Both Schwann cells/stroma and ganglion cells are positive with synaptophysin immunostain.

Figure 2. Many mature ganglion cells seen having compact, eosinophilic cytoplasm with distinct cell borders, single eccentric nucleus and prominent nucleolus. In the background these are mixed with Schwann cells arranged in small intersecting fascicles.

Figure 3. The MIBG scan revealed a focal area of increased tracer uptake in the left upper abdomen, corresponding to a large hypodense lesion in the left upper quadrant with elevated tracer activity.

Figure 4. CT before surgical resection of the tumor.

Large mass present in the left upper abdominal quadrant, causing anterior and superior displacement of the spleen, anterior displacement of the pancreas and stomach, and inferior displacement of the left kidney. It measures approximately 15.9 x 11.8 x 13.5 cm. The left adrenal gland is not visualized. The mass appears to be separable from the spleen, pancreas and left kidney. The mass shows internal vascular structures in the arterial phase with an average density of 44 HU in the porto-venous phase.

Figure 5. CT after surgical resection of the tumor.

Kidneys are of normal enhancement with no stone, mass or hydronephrosis. Right adrenal is normal, while the left adrenal is resected with no obvious residual masses in the surgical bed.