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Context: Adrenal incidentalomas are commonly nonfunctional and can be diagnosed with imaging and biochemical testing. However, detection of rare causes of adrenal incidentalomas like metastatic adrenal tumors can makes its’ diagnosis very challenging due to vast majority of uncommon primary tumors. Consideration of biopsy for diagnosis and the awareness of rare primary tumors that can metastasize to adrenals is essential to prevent unnecessary adrenalectomies. Our case illustrates one such rare case where bilateral adrenal mass was the initial presentation of obscure retroperitoneal primary NSGCT (Non seminomatous germ cell tumor). Case Description: We present a case of a 34-year-old male with acute abdominal pain found to have huge bilateral adrenal masses. The left adrenal gland was markedly enlarged to 11 x 9 x 5 cm and the right adrenal gland was 6.5 x 3.4 x 7.7 cm. Multiple enlarged and centrally necrotic retroperitoneal lymph nodes (maximum 2.6 x 4.2 x 5.4 cm) along with iliac and inguinal lymphadenopathy were noted. The incidentalomas were proven to be biochemically nonfunctional and extensive imaging and further lab work up ruled out lymphoma, mycobacterial or fungal infection, infiltrative diseases. He then underwent a core biopsy of the left adrenal mass which showed predominantly necrotic tissue, acute inflammatory cells with histiocytes, and rare atypical cells without evidence of malignancy. Repeat core biopsy of left adrenal mass was unrevealing. He finally underwent a core biopsy of a large 4cm retroperitoneal lymph node which ultimately revealed NSGCT. Scrotal ultrasound showed testicular microlithiasis without any testicular mass. He had a very low testosterone level of 21 (241-827 ng/dL) and an a mildly elevated b-hCG (beta human chorionic gonadotropin) of 134 (0-1mIU/ml). A retroperitoneal primary NSGCT with metastasis to the adrenal glands was the most likely diagnosis (visceral metastasis) - Stage III (pTxN3M1S1). He was started on bleomycin, etoposide and cisplatin (BEP) chemotherapy. Conclusion: Rapidly progressing adrenal masses in young males should prompt consideration for metastatic germ cell tumors as a possible cause, even with near normal tumor markers such as alpha-fetoprotein (AFP) and beta human chorionic gonadotropin (B-HCG). Confirmation of the metastatic tumor, via histopathology, is required to avoid unnecessary adrenalectomy.

SAT-218 Metastatic Non Seminomatous Germ Cell Tumor Masquerading as Bilateral Adrenal Masses