2 Case Reports in Medicine Figure 1: T1-weighted abdominal MRI in the axial plane demon- strating bilateral multiple renal masses of varying sizes and MR signal intensities. Figure 2: T2-weighted MR image in the coronal plane demonstrat- ing bilateral, adrenal masses and renal cysts. The large adrenal mass on the right side has almost completely replaced the adrenal tissue. were within normal limits. Ultrasound (US) and abdominal magnetic resonance imaging (MRI) were performed to understand the nature of a recent, blunt, nonspeciﬁc upper abdominal pain and revealed 3 small, solid masses in the right kidney measuring between 1 and 4 cm and 5 masses in the left kidney measuring between 1 and 3 cm in size. All were suggestive of renal cell carcinomas (RCCs) (Figure 1). An 8 cm solid mass completely replaced the right adrenal gland, while there were 5 small masses on the left side, all consistent with pheochromocytomas (Figure 2). The paracaval mass, measuring 4 cm in size, could be not only an enlarged lymph node but also a paraganglioma. The imaging ﬁndings of the cystic mass at the uncinate process of pancreas were suggestive of a neuroendocrine tumor (Figure 3). All other radiologic studies, including spinal and cerebral MRI, were normal. Serum and urine biochemical workup (including cortisol and vanilmandelic acid measurements) revealed normal ﬁndings regarding the functional status of the adrenal masses. The patient was diagnosed as VHL disease and a staged surgical approach was recommended based on the radiologic ﬁndings. In the ﬁrst stage, through a subcostal anterior transperitoneal approach, right adrenalectomy, resection of the paracaval mass, and enucleation for the 9 small solid renal masses were performed. Intraoperative frozen Figure 3: Arterial phase T1-weighted image in the axial plane fol- lowing intravenous contrast depicts hypervascular adrenal masses on both sides and an approximately 3 cm hypervascular mass in the uncinate process of the pancreas consistent with a neuroendocrine tumor. section ﬁndings were inconclusive about the actual biologic behaviour of the mass located in the uncinate process of the pancreas. Additionally, two other smaller pancreatic masses were palpated during the operation. Given the young age of the patient, we decided to perform a Whipple procedure to remove these pancreatic lesions. Pathologic diagnoses were Fuhrman grade 1, cystic clear-cell renal cell carcinoma (RCC) for only 1 of the renal masses (the rest were reported to be benign nodules), a pheochromocytoma (8 cm in maximal diameter) in the right adrenal completely destroying the gland architecture, a paraganglioma (2 cm in maximal diameter), and benign, well-diﬀerentiated neuroendocrine tumors of the pancreas. The postoperative period was uneventful so the second stage was performed within 6 weeks. This time, through an intercostal extraperitoneal approach, 5 pheochromocytomas (largest of which was measuring 5 cm in maximal diameter) were removed in cortex-sparing fashion and 4 Fuhrman grade 2, cystic clear-cell RCCs were enucleated. Postoperative course was uneventful without any complications. After a followup of 1,5 years, the patient developed a left 1 cm renal mass, which was histologically proven by ultrasound- guided percutaneous biopsy to be a RCC and was treated by percutaneous, ultrasound-guided radiofrequency ablation. Pancreatic and adrenal functions were normal throughout the follow-up period and never necessitated any replacement therapy. Blood cortisol level (blood sample taken at 8 : 00 in the morning) was 21 µg/dL upon his last control visit. There was no adrenal or extra-adrenal pheochromocytoma recurrence being detected to date (Figure 4). 3. Discussion Adrenal incidentalomas are unsuspected adrenal masses greater than 1 cm in diameter, identiﬁed on cross-sectional imaging performed for unrelated causes. The frequency of adrenal incidentalomas is relatively high, with contemporary imaging series reporting an incidence of approximately 5% [1]. Approximately 20% of adrenal incidentalomas are found to be potential surgical lesions. Generally, large size (≥4 cm), hormonal activity, and radiologic ﬁndings suspicious of