Sae Byeol Choi, et al. DISCUSSION A liver transplantation is a treatment option for selected HCC patients with cirrhosis. For those patients with recur- rent HCC and poor liver function, a liver transplantation may be a choice to prolong their lives.7 The recurrence of HCC after a liver transplantation has been reported to be about 10%.8 Some authors reported that the recurrences oc- curring within one year of the liver transplantation are mainly extrahepatic.9 The two cases in this report demonstrated ex- trahepatic HCC recurrence within one year after a liver transplantation. Although early tumor recurrence is depen- dent upon many factors, namely vascular invasion and the number and size of the tumor, the influence of the post- transplant immunosuppression in a dysfunctional immune system cannot be excluded as contributing to the accelera- tion of the recurrence. Although it is known that the phar- macologic immunosuppression required after a transplanta- tion can accelerate tumor growth, the possible influence of different immunosuppressive schedules on HCC recurrence after a liver transplantation has been poorly investigated un- til recently.10 There is no consensus on the treatment of recurrent HCC following a liver transplantation, and treatment of the recur- rent tumor is not always effective. Moreover, early recur- rence shows a short survival period; however, in recent years, treatment has been more aggressive in an effort to improve survival.11 Several therapeutic modalities have been pro- posed such as surgical resection, TACE, percutaneous etha- nol injection therapy, and radiation therapy. Aggressive management of extrahepatic metastatic lesions have achiev- ed improved outcome.12,13 The adrenal gland is the second most common site of metastasis from HCC.6 In those cases, an adrenalectomy is considered to be the treatment of choice. However, the sur- vival benefit and disease control effect of an adrenalectomy in the case 1 patient is questionable. It may be better to closely observe the patient and provide systemic chemo- therapy or TACE rather than to perform a surgical resec- tion. In a clinical situation, a surgical resection should be carefully considered for a patient with good performance and no intrahepatic recurrence. Surgery for adrenal metas- tasis from HCC may be indicated not only for patients without evidence of an intrahepatic or extrahepatic lesion, but also for patients with a well-controlled intrahepatic or extrahepatic lesion to increase survival.14 In the cases of solitary splenic metastasis of HCC, it is also difficult to predict the prognosis. Because metastatic splenic tumors are usually detected as a part of disseminat- ed hematogenous metastasis with multi-organ involvement, isolated splenic metastasis is exceedingly rare.14 The surviv- al benefit of a splenectomy for a solitary metastatic splenic tumor is unknown and the disease control effect will be evaluated. However, with more aggressive management of metastatic tumors, the increase to perform splenectomy as a treatment of solitary splenic metastasis during the past de- cade might be expected to continue.15 In conclusion, the survival benefit of surgical resection in the management of isolated extrahepatic metastases of HCC is questionable due to its rarity. Surgical resection is a treatment option with low morbidity that may offer a chance for long-term survival in selected patients without poor prognostic factors and whose intrahepatic tumors are con- trolled. Surgical treatment can be an option to treat extrahe- patic solitary metastasis from HCC. ACKNOWLEDGEMENTS This study was supported by a grant of the Korea Health- care technology R&D Project, Ministry for Health, Welfare & Family Affairs, Republic of Korea (A084120). REFERENCES 1. Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Boz- zetti F, et al. Liver transplantation for the treatment of small hepa- tocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693-9. 2. Yao FY, Ferrell L, Bass NM, Watson JJ, Bacchetti P, Venook A, et al. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepa- tology 2001;33:1394-403. 3. Schwartz M. Liver transplantation for hepatocellular carcinoma. Gastroenterology 2004;127(5 Suppl 1):S268-76. 4. Katyal S, Oliver JH 3rd, Peterson MS, Ferris JV, Carr BS, Baron RL. Extrahepatic metastases of hepatocellular carcinoma. Radiol- ogy 2000;216:698-703. 5. Castroagudín JF, González-Quintela A, Martínez J, Tomé S, Forteza J, Varo E. 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