A silent pheochromocytoma with regional metastasis and negative germline testing

Biochemical silence does not imply benign pathology. Pheochromocytomas without catecholamine excess can still exhibit malignant potential, thereby highlighting the need for comprehensive testing in all cases. Discordant testing requires integrative assessment. Equivocal biochemical results should not preclude further evaluation or empiric preoperative blockade, especially when imaging features or clinical context raises suspicion. Tumor size is an unreliable risk surrogate. Even small adrenal lesions may harbor aggressive histopathology; risk stratification must incorporate pathology and molecular profiling. Genetic testing is indispensable but not definitive. Comprehensive germline testing informs prognosis and surveillance, yet negative results do not eliminate the possibility of malignant behavior. Long-term surveillance remains essential. High-risk features mandate sustained biochemical and imaging follow-up, regardless of tumor size, biochemical phenotype, or genetic background.