Suprarenal retroperitoneal liposarcoma with intracaval tumor thrombus: an imaging mimic of adrenocortical carcinoma Zsoka Vajtai a , Elena Korngold a , Jody E. Hooper b , Brett C. Sheppard c , Bryan R. Foster a , Fergus V. Coakley a, ⁎ a Department of Diagnostic Radiology, Oregon Health and Science University, Portland, OR 97239 b Department of Pathology, Oregon Health and Science University, Portland, OR 97239 c Department of Surgery, Oregon Health and Science University, Portland, OR 97239 abstract article info Article history: Received 8 April 2013 Received in revised form 11 July 2013 Accepted 23 August 2013 Keywords: Retroperitoneal liposarcoma Adrenocortical carcinoma PET/CT We report a 57-year-old previously healthy man who presented with dull right upper quadrant pain, weight loss, fatigue, and night sweats. Computed tomography demonstrated a large, heterogeneously enhancing, soft tissue mass with no macroscopic fat above the right kidney with tumor thrombus extending into the inferior vena cava and right atrium. Positron Emission Tomography scanning demonstrated intense Fluorodeox- yglucose avidity in the primary tumor and tumor thrombus. The presumptive radiological diagnosis was adrenocortical carcinoma, but surgical pathology revealed a dedifferentiated liposarcoma. We conclude that suprarenal retroperitoneal liposarcoma should be included in the differential diagnosis for an apparent adrenal mass with venous invasion. © 2014 Elsevier Inc. All rights reserved. 1. Introduction Intravenous tumor extension is a well-known feature of adreno- cortical carcinoma, occurring in approximately one third of cases [1], and accordingly, adrenocortical carcinoma is generally the primary diagnostic consideration for an adrenal mass with intravenous tumor thrombus seen at imaging. We recently encountered a patient in whom a right-sided suprarenal retroperitoneal liposarcoma with intracaval tumor thrombus mimicked an adrenocortical carcinoma at imaging. The purpose of this case presentation is to present the computed tomography (CT) and Positron Emission Tomography (PET) findings in this case so that the differential diagnosis for an apparent adrenal mass with venous invasion can be broadened to include retroperitoneal liposarcoma. 2. Case description A 57-year-old previously healthy man presented with dull right upper quadrant pain, weight loss, fatigue, and night sweats. Contrast- enhanced CT demonstrated a large, heterogeneously enhancing, soft tissue mass with no macroscopic fat content above the right kidney. The right adrenal gland was not visible separately from the mass. Tumor thrombus extended into the inferior vena cava and right atrium (Fig. 1). PET/CT scanning demonstrated intense Fluorodeox- yglucose (FDG) avidity in the primary tumor and in the tumor thrombus with standard uptake value of 21.2 (Fig. 2). No distant metastases were identified. The presumptive radiological diagnosis was adrenocortical carcinoma. En bloc surgical resection of the tumor was performed and entailed right adrenalectomy, right nephrectomy, resection of portion of the inferior vena cava, and a Segment 8 liver resection. Extension of tumor thrombus into the heart was removed by open atriotomy with the patient on cardiopulmonary bypass. Grossly, the surgical resection specimen consisted of a 16.5-cm heterogeneous tan-red to yellow mass with areas of necrosis, surrounding but distinct from the remnant adrenal gland and adherent to the superior portion of the kidney. The mass was also adherent to the undersurface of the liver, which necessitated a resection of hepatic Segment 8. Microscopically, the mass showed focal areas of adipose tissue with adipocytes of varying size and dark, atypical vacuolated nuclei, consistent with well-differentiated lipo- sarcoma. The majority of the tumor demonstrated increased cellular- ity with severe nuclear atypia, consistent with dedifferentiated liposarcoma. Invasion into large veins was present. Segment 8 of the liver showed a 2-cm nodule of adherent dedifferentiated liposarcoma. The final histopathological diagnosis was primary retroperitoneal dedifferentiated liposarcoma (Fig. 3). Tumor recurred in the inferior vena cava and right atrium 4 months after surgery, and the patient died of his disease within 6 months of initial diagnosis. 3. Discussion Most suprarenal masses with intravenous tumor thrombus are adrenocortical carcinomas. Other adrenal tumors that have Clinical Imaging 38 (2014) 75–77 ⁎ Corresponding author. Oregon Health and Science University, Portland, OR 97239. Tel.: +1 503 494 2333; fax: +1 503 494 4982. E-mail address: coakleyf@ohsu.edu (F.V. Coakley). Contents lists available at ScienceDirect Clinical Imaging journal homepage: http://www.clinicalimaging.org 0899-7071/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clinimag.2013.08.016