A 71-year-old man with HCV hepatitis was diagnosed with HCC in 2002. He was treated with radiofrequency ablation and transarterial chemoembolization (TACE) for the HCC at another hospital. When he was referred to our hospital in December 2005, a CT scan demonstrated innumerable tiny intrahepatic HCC nodules. He belonged to Child-Pugh class A, and the alpha-fetoprotein (AFP) level was measured at 87.96 IU/mL. After a treatment with two cycles of intrahepatic arterial cisplatin and systemic 5-FU chemotherapy, he underwent a cadaver donor liver transplantation in March 2006 in China, although he met neither Milan nor UCSF criteria. He took Pegylated interferon alpha and Tacrolimus after the liver transplantation.

Eleven months post-transplantation, a CT scan revealed a solitary left adrenal mass, 3.5 × 2.3 cm in size, without any other recurrent lesions (Fig. 1A). The laboratory values showed hemoglobin of 10.2 g/dL, WBC of 3,270/µL, platelet count of 119,000/µL, albumin of 4.5 g/dL, AST/ ALT of 32/15 IU/L, total bilirubin of 0.5 mg/dL, prothrombin time of 10.7 sec, and AFP of 6.02 IU/mL. The patient was in a good performance status and underwent a left adrenalectomy with retroperitoneal approach in April 2007. A multinodular grayish-brown, soft-to-friable solid mass was grossly noted. It was well demarcated, measuring 5 × 3.5 cm in size. Tumor emboli were present in the blood vessels connecting to the mass (Fig. 1B). The pathological examination demonstrated metastatic HCC without metastatic lymph nodes retrieved from around the aorta and the left renal vessels (Fig. 1C). There were no immediate complications during recovery. Immunosuppressive therapy (Tacrolimus) continued following the adrenalectomy.

However, a follow-up CT scan taken two months after the adrenalectomy revealed innumerable intrahepatic arterial enhancing nodules consistent with HCC. There were no recurrent lesions at the site of the adrenalectomy. The patient received systemic adriamycin chemotherapy with subsequent transarterial chemoembolization. The intrahepatic recurrent tumors were not controlled, although chemotherapy was performed. The patient expired 16 months after the adrenalectomy due to liver failure.

A 63-year-old man who was a carrier of HBV for 30 years was admitted for a ruptured HCC located in segments VIII of the liver in August 2004. He belonged to Child-Pugh class A. He was treated three consecutive times with TACE. The patient then underwent a central bisectionectomy in February 2005 due to a remaining viable tumor (Fig. 2A). The tumor was 5.7-cm in diameter and the resection margin was tumor-free with a distance of 3.5 cm (Fig. 2B). It was compatible with HCC and was composed of 60% necrosis due to TACE. Vascular invasion was not found. Sixteen months after the operation, another 1.5 cm-sized recurrent HCC on segment VII was found, and the AFP level increased to 54.53 IU/mL. He was treated with TACE however; the remaining viable tumor was still detected with an increase in size. Then the patient underwent a cadaver donor liver transplantation in November 2006 in China. He thereafter took Tacrolimus for immunosuppression. Four months after the liver transplantation, a newly-developed 3 cm-sized heterogeneous mass was found in the hilum of the spleen (Fig. 3A and B). The laboratory values showed hemoglobin of 10.7 g/dL, WBC of 3400/µL, platelet count of 146,000/µL, albumin of 4.4 g/dL, AST/ ALT of 18/9 IU/L, total bilirubin of 0.4 mg/dL, prothrombin time of 11.0 sec, and AFP of 2.15 IU/mL. The patient was closely observed for three months, and a splenectomy was performed in July 2007 due to a mass growth without evidence of intrahepatic recurrence or distant metastasis. A well-defined, white, solid mass measuring 6 × 5 × 4.5 cm was found. It was partially encapsulated and was pathologically compatible with metastatic HCC (Fig. 3C and D). Because the lesion invaded the perisplenic space, the patient received radiation therapy on the splenectomy site following an uneventful postoperative recovery. The radiation dosage was 50.4 Gy. The patient demonstrated no evidence of recurrence for 15 months. The patient received only adjuvant radiation therapy without any other treatment modality. However, a follow-up CT scan taken 15 months after the splenectomy demonstrated two nodular lesions in segment VI of the liver compatible with HCCs. He then received TACE for 4 times. However, he was in the progressive disease status and was expired 29 months after the splenectomy.