PMC8121102_01
CT scan of 20 cm large left adrenocortical carcinoma (*) with segment 8 liver metastasis ( ). The segment 7 tumor is not shown on this reconstruction (A). Necrosis on CT after liver TAE (  ) and embolization of the previously bleeding primary tumor (**) (B). Abscess from the necrotic tumor reaching the thigh (+) (C). Drains in the abscess (arrows); the descending part is already resolved (D, E).
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Abdominal contrast-enhanced computed tomography (CT) showed a 20 cm subdiaphragmatic retroperitoneal tumor together with two metastases in segment 7 (29x21 mm) and segment 8 (52x43 mm) of the liver ( Figure 1A ). The CT documented a large necrotic mass occupying the tumor region ( Figure 1B ). April 2017, however, a septic condition developed with a large intra-peritumoral abscess descending down to the left thigh through the femoral canal ( Figure 1C ). A left iliac venous thrombosis was also documented. Being too risky to be operated acutely, ultrasound-guided drainage of both the femoral ( Figure 1D ) and retroperitoneal regions ( Figure 1E ) was performed, prehabilitation continued, and therapeutic LMWH was again administered. The patient was stabilized and with repeated irrigations through the drains, the femoral abscess disappeared ( Figure 1D ), and the thrombosis resolved.
Timeline of case.
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The timeline of the case with the most important therapeutic and diagnostic procedures is shown in  Figure 2 .
Embolization of the S8 tumor through the right replaced hepatic artery was achieved with 0.1mm PVA particles (A). Embolization of the primary tumor through the left inferior phrenic artery was performed by 0.2mm PVA particles (B). CT, celiac trunk; SA, splenic artery; CHA, common hepatic artery; GDA, gastroduodenal artery; *, dominant suprarenal artery from left inferior phrenic artery.
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To affect tumor growth, palliative superselective trans-arterial embolization of both liver metastases was performed with 2 mL 0.1mm PVA particles through the replaced right hepatic artery arising from the superior mesenteric artery ( Figure 3A ). To control bleeding, hyperacute trans-arterial embolization of the primary tumor was performed with 1 mL 0.2mm PVA particles through the previously mapped dominant left suprarenal artery arising from the left inferior phrenic artery ( Figure 3B ).
Surgical removal of the necrotic primary tumor together with the left kidney after resolution of the descending abscess. The left renal vein is clamped.
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After 6 weeks, surgical re-exploration was performed in June 2017, and the large retroperitoneal mass was successfully resected together with the left kidney (R0) ( Figure 4 ).