482 SURGERY THE PRESENCE OF JUXTA- RENAL TUMOR in a patient with hypertension should raise the possibility of a pheochromocytoma. Appropriate α-blockade, β- blockade and volume re-expansion should be accomplished before surgical removal of pheo- chromocytomas. CASE REPORT A 49-year-old woman who underwent renal trans- plantation 3 years before admission was found to have an asymptomatic palpable right upper quadrant abdom- inal mass during a routine examination. Her medical history was significant for systemic lupus erythematosus with lupus nephritis and end-stage renal disease, hyper- tension for 3 years (which was controlled with 2 medica- tions), and borderline diabetes mellitus. She took cyclosporine, azathioprine, and prednisone for immunosuppression. She had no family history of hyper- tension or endocrine tumors. An abdominal ultrasound and computed tomogra- phy scan (Fig 1) both revealed a complex 15-cm cystic mass with septations and thick irregular walls in the right lobe of the liver, consistent with a biliary cystadenoma or biliary cystadenocarcinoma. There were no signs or symptoms to suggest a hepatic abscess. Laboratory data ruled out amoeba, and serology ruled out Echin ococcu s. A formal right hepatic lobectomy was performed. The 15 × 12 × 12-cm cystic mass (Fig 2) was fused to the infrahepatic inferior vena cava, necessitating removal of a small piece of the front wall of the infra- hepatic inferior vena cava with the cystic tumor. The right native kidney was densely adherent to the mass. The right adrenal gland was not identified but was thought to be within the hypervascular tissue removed with the specimen. During the procedure, the patient initially became hypertensive and was treated with labetalol while the cys- tic mass and the right hepatic lobe were being manipu- lated. After ligation of the short hepatic veins, the patient became hemodynamically unstable, with episodes of Pheochromocytoma presenting as a giant cystic tumor of the liver Justin S. Wu, MD, Shubhada N. Ahya, MD, Mark D. Reploeg, BS, Gary G. Singer, MD, Daniel C. Brennan, MD, Todd K. Howard, MD, and Jeffrey A. Lowell, MD, St Louis, Mo From the Washington University School of Medicine, Department of Surgery and Medicine (Renal Division), St Louis, Mo Accepted for publication October 16, 1999. Presented at the American College of Surgeons, Missouri Chapter, Lake of the Ozarks, MO, June 18, 1999. Reprint requests: Jeffrey A. Lowell, MD, Associate Professor of Surgery and Pediatrics, Washington University School of Medicine, 6107 Queeny Tower, 1 Barnes Hospital Plaza, St Louis, MO 63110-1093. Surgery 2000;128:482-4. Copyright © 2000 by Mosby, Inc. 0039-6060/ 2000/ $12.00 + 0 11/ 60/ 104113 Fig 1. Abdominal computed tomographic scan suggests a large right hepatic cystic mass. In this section we will feature outstanding photographs of clinical materials. These will be select- ed for their educational value, message, or possibly rarity. The images will be accompanied by brief case reports (limit 2 typed pages, 4 references). Our readers are invited to submit items for consideration.