Recently, the Department of Urology of Cancer Hospital of Fudan University successfully completed a case of adrenal pheochromocytoma resection + inferior vena cava tumor embolus removal + left nephrectomy + splenectomy. Let’s take a look at the story and the procedure! The patient, a 46-year-old male, was admitted to the hospital with “abdominal distension for 1 month and a mass in the right abdomen on physical examination”. His medical history was not detailed, and the final diagnosis was: left adrenal tumor with renal vein and inferior vena cava aneurysm embolism, hypertension grade II, diabetes mellitus, and diabetic retinopathy. CT film: After sufficient preoperative preparation (here is a small advertisement for our sister hospital: the Department of Vascular Surgery of Zhongshan Hospital of Fudan University, the patient was asked to ask colleagues of Zhongshan Hospital to put a vena cava filter before surgery, and the process went very smoothly. Without the help of Zhongshan Hospital colleagues, this operation could not have been successful), we entered the operating room with firm belief and determination to win. The procedure was as follows: 1.Take a median abdominal incision, enter the abdominal cavity, and explore the tumor and tumor embolus. 2.Turn the duodenum upward to fully expose the left renal vein and inferior vena cava and protect the inferior mesenteric vein in front of the tumor embolus. The left renal vein and the inferior vena cava are fully freed posteriorly to reach the level above the tumor embolus. The inferior vena cava is temporarily blocked using a Satinski clamp. The left renal vein is incised into the inferior vena cava, and the tumor plug is separated from the inferior vena cava. 5-0 sutures are used to close the inferior vena cava with a continuous suture of approximately 150 px. The satinski clamp is released and there is no active bleeding. The left renal artery was ligated along the left renal vein where the tumor embolus was located, and the left adrenal tumor blood supply vessels and thick veins were ligated one by one. The pancreas was protected and the tumor was freed from the posterior part of the pancreas. The splenic hilum was completely adhered to the tumor and could not be separated, so splenectomy was performed. The left kidney was fully freed and resected inferiorly and laterally. 5.Check the trauma carefully and introduce one thick drainage tube into the left lower abdomen. After the gauze and instruments were counted correctly, the incision was closed by layers. 6.The patient’s blood pressure and blood sugar returned to normal on the first day after surgery. (Intraoperatively, the patient’s blood pressure fluctuated drastically, with systolic blood pressure ranging from 100-310 mmHG, and at one time, the operation was interrupted to wait for the blood pressure to calm down. I would like to thank the anesthesiology teachers for riding the roller coaster with us all night, you suffered! (~.) After all this, what exactly is malignant adrenal pheochromocytoma? Here’s a simple explanation. The adrenal glands are paired retroperitoneal organs located within the perinephric fat, on the anterior and medial sides of the kidney. Pheochromocytes within the adrenal medulla are the main source of adrenaline in the body. The majority of pheochromocytomas occur in the adrenal gland, from which the name pheochromocytoma is derived. Approximately 10% of pheochromocytomas have malignant manifestations, however, it is not possible to distinguish benign from malignant pheochromocytomas by pathology alone. Therefore, we generally determine the benignity of pheochromocytomas based on whether the tumor is aggressive or metastatic. Malignant pheochromocytoma with inferior vena cava thrombosis is even rarer. In China, we can find single-digit case reports, and interestingly, most of them are right-sided adrenal pheochromocytoma with vena cava thrombosis. Even overseas, there are few reports of left-sided pheochromocytoma with tumor thrombus extending from the renal vein into the inferior vena cava as in the present case. If pheochromocytoma with vena cava thrombosis is suspected, adrenal tumor resection + vena cava thrombectomy is preferred. Depending on the depth of the thrombus, we sometimes need to use extracorporeal circulation techniques to safely complete the procedure. Therefore, preoperative CT and MRI examinations are particularly important. The 5-year survival rate of malignant pheochromocytoma has been reported to be around 36% in the literature. Malignant pheochromocytoma with concomitant metastases can be treated with chemotherapy in the regimen of cisplatin + vincristine + azurenzamide or cyclophosphamide + dacarbazine + vincristine, but the overall efficacy is not very satisfactory.