CASE REPORT Case 1 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 mea- sured at 87.96 IU/mL. After a treatment with two cycles of intrahepatic arterial cisplatin and systemic 5-FU chemo- therapy, 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 Ta- A B Sae Byeol Choi, et al. crolimus 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, plate- let 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 adrenalecto- my with retroperitoneal approach in April 2007. A multi- nodular grayish-brown, soft-to-friable solid mass was gross- ly noted. It was well demarcated, measuring 5 × 3.5 cm in size. Tumor emboli were present in the blood vessels con- necting to the mass (Fig. 1B). The pathological examination demonstrated metastatic HCC without metastatic lymph nodes retrieved from around the aorta and the left renal ves- sels (Fig. 1C). There were no immediate complications dur- ing recovery. Immunosuppressive therapy (Tacrolimus) continued following the adrenalectomy. However, a follow-up CT scan taken two months after the adrenalectomy revealed innumerable intrahepatic arteri- al enhancing nodules consistent with HCC. There were no recurrent lesions at the site of the adrenalectomy. The pa- tient received systemic adriamycin chemotherapy with sub- sequent transarterial chemoembolization. The intrahepatic recurrent tumors were not controlled, although chemothera- py was performed. The patient expired 16 months after the adrenalectomy due to liver failure. Case 2 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 in- creased to 54.53 IU/mL. He was treated with TACE how- ever; the remaining viable tumor was still detected with an increase in size. Then the patient underwent a cadaver do- nor liver transplantation in November 2006 in China. He thereafter took Tacrolimus for immunosuppression. Four C Fig. 1. A CT scan reveals a newly-developed solitary left adrenal mass, which was 3.5 × 2.3 cm in size, homogenous, and well-demarcated, sug- gesting HCC metastasis (A). Pathologic specimen following adrenalectomy (B) and microscopic exam, Hematoxylin & Eosin stain, ×100 (C). 200 Yonsei Med J http://www.eymj.org Volume 52 Number 1 January 2011