CASE REPORT Resection of Adrenal Metastasis Invading Left Renal Vein Following Living Donor Liver Transplantation for Hepatocellular Carcinoma Volkan Ince 1 & Ersin Gundogan 1 & Kerem Tolan 1 & Cuneyt Kayaalp 1 & Sezai Yilmaz 1 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Introduction Hepatocellular carcinoma (HCC) is the fifth most common type of cancer in the world, and it is the most common cancer of the liver parenchyma. It is seen more common in males and in the underdeveloped countries; it takes the second place among the fatal cancers in this gender. Various treatment mo- dalities such as liver resection, liver transplantation, radiofre- quency ablation (RFA), percutaneous alcohol or acetic acid ablation, transarterial chemoembolization (TACE), cryoablation, radiation therapy, and systemic chemotherapy can be used. Liver transplantation which is the preferred treat- ment for both the chronic liver disease and the localized HCC seems to be advantageous in terms of removing both the HCC and the underlying cirrhotic liver. However, post-transplant recurrence is one of the biggest problems in these patients. In 10–20% of the patients the recurrence of the HCC occurs in the lung, bone, lymph nodes, and adrenal glands, and when it happens, it significantly reduces the survival of the patients [1]. Although the overall prognosis is poor, the locoregional therapies and the surgical excision can be used for the treat- ment of the recurrent HCC in some selected patients [2–5]. Solitary metastasis without any evidence of other organ in- volvement is the most preferred indication for surgical resec- tion. The presence of multiple organ metastases or metastasis invading adjacent organs is not well-described criteria for the resection of the metastasis. Here, we described such an HCC recurrence in the left adrenal gland invading the left renal vein and its outcome after surgical resection. Case A 61-year-old male patient admitted to our hospital with an HCC and cirrhosis due to hepatitis B virus (HBV) a year ago. Apart from having a prior thyroidectomy and an HBV infec- tion, he did not have any other disease. Radiological imaging revealed that the liver was nodular in appearance and a mass of approximately 25 cm was detected in the liver. The level of alpha-fetoprotein (AFP) was 187 ng/ml at admission. A living donor liver transplantation was performed in this Child B patient with MELD score of 6. He had no extrahepatic disease but the tumor was beyond the Milan criteria. The patient was discharged on postoperative day 17 after an uneventful course. Pathology report demonstrated a 24 × 17 × 13 cm size, poor differentiated HCC and the presence of microvascular inva- sion. The patient was followed up regularly after the surgery. Contrast-enhanced computed tomography (CT) on the 12th month, a 4-cm necrotic mass in the left adrenal gland invading the left renal vein was discovered (Figs. 1 and 2). Positron emission tomography (PET) was taken for the correlation and also for the additional HCC focus scanning. Fluorodeoxyglucose (FDG) uptake was high (SUV max: 7) for the adrenal mass and the AFP level was 275 ng/ml. There were pulmonary lesions in the PET but they did not get path- ological uptakes and did not accept metastasis. With these findings, the mass was thought to be a recurrent HCC without any additional focus; the patient was decided for metastasis excision. The recurrent mass was removed en-block with the left kidney and the left adrenal gland together with the left renal vein which was invaded by the tumor (Fig. 3). There was a chylous acid drainage which was then gradually de- creased and disappeared on postoperative day five. He was discharged on the 12th day without any problem. The control AFP value was 59 ng/ml before discharge. The mass was reported as an HCC metastasis and the renal vein macro tumor thrombosis. In the 4th month, multiple pulmonary masses were detected and accepted as metastasis after PET confirma- tion. Sorafenib was started and he died 6 months after * Volkan Ince volkanince@outlook.com 1 Department of Surgery, Liver Transplantation Institute, Inonu University School of Medicine, 44280 Malatya, Turkey Journal of Gastrointestinal Cancer https://doi.org/10.1007/s12029-019-00252-7