Department of General Surgery, Duke Life Point Conemaugh Memorial Medical Center, Johnstown, PA, USA Corresponding Author: Karleigh R. Curfman, MD, Department of General Surgery, Conemaugh Memorial Medical Center, 1086 Franklin Street, Johnstown, PA, USA. Email: kcurfman@conemaugh.org The American Surgeon 00(0) 1–4 © The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0003134820945274 journals.sagepub.com/home/asu Functionally Silent, Giant Pheochromocytoma Presenting With Varicocele Karleigh R. Curfman, MD, Joseph A. Di Como, MD, Timothy R. Chung, DO, and Russell D. Dumire, MD Abstract Adrenal incidentalomas are a known entity that have been increasing in commonality with the advent of improved diagnostic and imaging techniques. There are a vast variety of causative pathologies to which this diagnosis can be attributed. Some of these pathologies are more common than others, while many remain extremely rare. One of the dis- tinct entities that is a unique cause of incidentalomas is the diagnosis presented herein: pheochromocytoma. Pheochromocytomas are often an exceptional subset of incidentalomas that can certainly play a major role in treatment and management plans. However, the exclusivity of a pheochromocytoma diagnosis alone is not where the uniqueness of this case rests. The uniqueness in this patient is paramount to report due to 2 additional significant factors. The first was that the patient was entirely asymptomatic aside from complaints related to scrotal swelling due to a varicocele, for which this presentation of pheochromocytoma has been scarcely reported in the literature. Second, the patient had a pathology proven diagnosis of pheochromocytoma, while lacking both symptoms and biochemical findings to support the diagnosis, making it truly a silent pheochromocytoma. Keywords pheochromocytoma, incidentaloma, varicocele SESC Annual Meeting Poster Paper Pheochromocytoma is a rare neuroendocrine tumor of the chromaffin cell origin often found in the adrenal gland; more specifically, approximately 90% occur in the abdomen, of which 90% of these occur within the adrenal gland. 1 There is a reported estimated incidence of pheochromocytoma at approximately 2-8 cases per 1 million people per year. 1 These tumors have been known to secrete catecholamines and other active pep- tides which can result in clinical symptoms. 1 Though not witnessed in the case presented within this report, the typical presenting symptoms can include hyperten- sion, tachycardia, sweating, and headache. 1 Additional symptoms that have been described are pallor, nausea, abdominal pain, and panic attacks. Given that pheo- chromocytomas are typically associated with hyperten- sion, the estimated incidence of pheochromocytoma in the hypertensive population is 0.2%. 1 Despite the evi- dence of uniqueness of this pathology at baseline, func- tionally silent pheochromocytomas, those presenting without outward signs of existence, have been proven to be even more unusual. With a reported incidence of pheochromocytomas at 0.0008% in the general popula- tion, silent pheochromocytomas will make up 8% of those reported, equivalent to 0.000064% of the popula- tion. 1 Recognition of the entity is often made via imag- ing, typically computed tomography (CT), and then confirmed with laboratory values, such as levels of metanephrines, normetanephrines, or catecholamines. 1 In active pheochromocytomas, medical management can play a significant role in treatment. 2 The aim of medical treatment is to reduce the potentially lethal abrupt changes in blood pressure that can occur with anesthesia and surgical manipulation, as well as the severe hypotension after surgical resection. 2 In silent