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Background: The diagnostic workup of an adrenal mass should always rule out the possibility of an adrenal metastasis, especially in a patient followed-up for a known primitive cancer. Sometimes, however, the incidental finding of a bulky lesion in a cancer patient can lead to the unexpected diagnosis of metastasis from a second occult cancer. Here, we report the case of a voluminous, isolated left adrenal metastasis from unknown and persistently occult hepatocellular carcinoma (HCC), incidentally found during the follow-up for squamous carcinoma of the tongue., Case Description: A 72-year-old HBV/HCV-negative male patient with a history of alcohol abuse was referred to our hospital for gastric bleeding. Some weeks before, the patient was operated on for a locally advanced squamous cell carcinoma of the tongue, which required cervical lymph node neck dissection, temporary tracheostomy, jejunostomy, and plastic reconstruction. Subsequent diagnostic imaging revealed a left adrenal mass sized 9x15 cm with suspicious features. The hormonal workout was negative for pheochromocytoma and a hyperfunctioning adrenal lesion. The patient underwent laparotomic left adrenalectomy. The exploration of the liver was compatible with alcoholic cirrhosis and did not reveal any other palpable lesion. The adrenal mass histologically turned out to be a poorly differentiated G3 HCC. Subsequent radiological exams were unable to identify the primary liver lesion or any other neoplasms. Conversely, α-FP levels were initially high but reduced after treatment with sorafenib. After 2 years of follow-up, the patient is alive and well, albeit with evidence of locoregional inter-aortocaval lymphadenopathy. The primary HCC has never been identified, thus suggesting the hypothesis of a diffuse cirrhosis-like HCC., Conclusion: The suspicion of an adrenal metastasis in a patient with primary cancer with a low potential for adrenal metastatic spreading must raise the diagnostic suspect for another synchronous occult cancer beyond that for primary adrenal cancer. HCC can rarely first manifest as a metastatic adrenal lesion., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: The diagnosis of Hepatocellular Carcinoma (HCC) is usually established using noninvasive radiological imaging and tumor markers. The stage at diagnosis is a critical factor in the treatment, course and prognosis of HCC. Patients with Tumor Portal vein thrombus (PVT) are considered to have an advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately stage HCC. Fine-needle aspiration cytology (FNAC) of PVT is an effective procedure for diagnosing and staging HCC. We present a case where we used Ultrasound (USG) guided FNAC of a PVT to successfully diagnose and stage HCC in the absence of a well-defined liver mass on imaging. Case report: A 43-year-old Hepatitis B surface antigen positive male presented with a 3-month history of fatigue, jaundice and fever. On examination he had hepatomegaly. His liver function tests were elevated, but his alpha-fetoprotein was normal. USG and Computed Tomography (CT) showed a thrombus in the portal vein but failed to show a well-defined liver lesion. FNAC was taken from the PVT, which was positive for malignancy. He was offered palliative chemotherapy and a steroid for his pyrexia. He is on follow-up. Conclusion: FNAC is a safe, quick, easy and economical technique to diagnose and stage HCC in the presence of portal vein thrombus, especially in patients where the tumor is occult on imaging. It also affords an accurate method to differentiate between malignant and nonmalignant PVT, thereby aiding appropriate therapeutic decision making. [Arch Clin Exp Surg 2014; 3(2.000): 129-132]