Tumor angiogenesis and outcome in osteosarcoma

Intratumoral angiogenesis quantified by microvessel density (MVD) has been shown to be a strong prognostic indicator in a number of malignant tumors. Its association with prognosis in bone sarcomas has been subject to less extensive research. The aim of this study was to investigate prognostic significance of angiogenesis in osteosarcoma. Thirty-nine patients with osteosarcoma were included in a retrospective immunohistochemical study. Sections from diagnostic biopsies were immunostained using anti-von Willebrand factor antibody and microvessels were counted at 400 x magnification on 3 microscopic fields per patient. MVD was correlated with overall and disease-free survival by Kaplan-Meier and log-rank analysis. Correlation between clinicopathological variables and the degree of angiogenesis was tested using a chi 2 test. Significant statistical difference was found regarding overall survival and disease-free survival between patients with high (> 32.3 vessels/field) and low (< or = 32.3 vessels/field) microvessel counts (log-rank test p = .0196 and p = .0147, respectively). The rate of metastasis was significantly higher in patients with high microvessel counts (p = .042). These findings strongly suggest that angiogenesis quantified by microvessel density is predictive of metastasis and poor prognosis in osteosarcoma.

Emerging and neglected zoonoses in transplant population

Zoonoses represent a problem of rising importance in the transplant population. A close relationship and changes between human, animal and environmental health (“One Health” concept) significantly influence the transmission and distribution of zoonotic diseases. The aim of this manuscript is to perform a narrative review of the published literature on emerging and neglected zoonoses in the transplant population. Many reports on donor-derived or naturally acquired (re-)emerging arboviral infections such as dengue, chikungunya, West Nile, tick-borne encephalitis and Zika virus infection have demonstrated atypical or more complicated clinical course in immunocompromised hosts. Hepatitis E virus has emerged as a serious problem after solid organ transplantation (SOT), leading to diverse extrahepatic manifestations and chronic hepatitis with unfavorable outcomes. Some neglected pathogens such as lymphocytic choriomeningitis virus can cause severe infection with multi-organ failure and high mortality. In addition, ehrlichiosis may be more severe with higher case-fatality rates in SOT recipients. Some unusual or severe presentations of borreliosis, anaplasmosis and rickettsioses were also reported among transplant patients. Moreover, toxoplasmosis as infectious complication is a well-recognized zoonosis in this population. Although rabies transmission through SOT transplantation has rarely been reported, it has become a notable problem in some countries. Since the spreading trends of zoonoses are likely to continue, the awareness, recognition and treatment of zoonotic infections among transplant professionals should be imperative.

Substitute ellipse of the permanent cavity in gelatin blocks and debridement of gunshot wounds

A new method in terminal ballistics is presented that allows precise numerical analysis of characteristics of the permanent cavity by computed tomography (CT). Shots were made with a Russian AK-74 assault rifle (5.45 mm) into gelatin used as a tissue simulant. CT scans were made of the gelatin blocks, transferred into digital format, and analyzed using computer software. CT scans of the permanent cavity are characterized by markedly irregular shapes, and an attempt was made to simplify these forms and to link them with surgical debridement of gunshot wounds. An assumption was made that the zone of debridement has the form of an ellipse. Using the information from the CT images, a substitute ellipse was constructed as an approximation of the a vital tissue surrounding the wound channel with the aim of approaching a more exact definition of the zone of necessary debridement of gunshot wounds.

The Role of Emerging and Neglected Viruses in the Etiology of Hepatitis

PURPOSE OF REVIEW

In this review, we present the overview of emerging and neglected viruses associated with liver involvement.

RECENT FINDINGS

Hepatitis E virus (HEV) emerged in the last two decades, causing hepatitis in many parts of the world. Moreover, liver involvement was also described in some emerging arboviral infections. Many reports showed dengue-associated liver injury; however, chikungunya, West Nile, tick-borne encephalitis, and Zika virus are rarely associated with clinically manifest liver disease. In addition, some neglected highly prevalent viruses such as adenoviruses and parvovirus B19 are capable of causing hepatitis in specific population groups. Anelloviruses (torque teno virus/torque teno mini virus/torque teno midi virus, SEN virus), human bocavirus, pegiviruses, and lymphocytic choriomeningitis virus have shown a little potential for causing hepatitis, but their role in the etiology of liver disease remains to be determined. In addition to the well-known hepatotropic viruses, many emerging and neglected viruses have been associated with liver diseases. The number of emerging zoonotic viruses has been increasingly recognized. While zoonotic potential of HEV is well documented, the recent identification of new hepatitis-related animal viruses such as HEV strains from rabbits and camels, non-primate hepaciviruses in domestic dogs and horses, as well as equine and porcine pegivirus highlights the possible zoonotic transmission in the context of "One Health." However, zoonotic potential and hepatotropism of animal hepatitis viruses remain to be determined.

Living donor liver transplantation for unresectable liver metastases from solid pseudo-papillary tumor of the pancreas: a case report

Solid pseudo-papillary tumors (SPT) are rare primary tumors of the pancreas that primarily affect young women. They are of borderline malignancy, and, unlike other pancreatic malignancies, the prognosis after resection is quite good. However, metastatic disease does occur; the liver is the most common site of tumor dissemination. Herein we have reported a case of a 20-year-old woman who presented with multiple, bilateral liver metastases at 3 years after distal pancreatectomy for SPT of the body and tail of the pancreas. The patient underwent living donor liver transplantation (LDLT) and is alive and disease-free at 24 months after surgery. In this report, we discuss the treatment of liver metastases from SPT, with an emphasis on the possible role of orthotopic liver transplantation (OLT).

How far along are we in revealing the connection between metformin and colorectal cancer?

Colorectal cancer (CRC) is among the most prevalent cancers worldwide, and its prevention and reduction of incidence is imperative. The presence of diabetes has been associated with a 30% increased risk of CRC, likely through the mechanism of hyperinsulinemia, which promotes tumorigenesis via the insulin receptor in the epithelium or by insulin-like growth factor pathways, inflammation, or adipokines, inducing cancer cell proliferation and cancer spread. Metformin, the first-line agent in treating type 2 diabetes, has a chemopreventive role in CRC development. Additionally, preclinical studies suggest synergistic effects of metformin with oxaliplatin in inhibiting in vitro models of colon cancer. Although preclinical studies on the post diagnostic use of metformin were promising and suggested its synergistic effects with chemotherapy, the data on the possible effects of metformin after surgery and other CRC treatment in the clinical setting are less conclusive, and randomized controlled trials are still lacking.

CT analysis of missile head injury

Between August 1991 and December 1992, CT was performed on 154 patients who had suffered missile head injury during the war in the Republic of Croatia. In 54% CT was performed 1-24 h after injury, and in 27% follow-up CT was also obtained. The wounds were penetrating, tangential or perforating (45%, 34% and 21%, respectively). Haemorrhage was the most frequent lesion in the brain (84%). Follow-up CT evolution of haemorrhage, oedema, cerebritis, abscess, secondary vascular lesions, necrosis, encephalomalacia and hydrocephalus. The most dynamic changes occurred 7-14 days after injury. In 14% of cases, deep cerebral lesions were found in the corpus callosum, septum pellucidum periventricular region and pons, although bone and shell fragments were in a different part of the brain parenchyma. Such lesions were found in penetrating injuries only. CT proved very useful for assessing the extent and type of lesions. Although different mechanisms of brain damage in missile head injury are known, here they are, to the best of our knowledge, shown for the first time by CT.

Angiogenesis and Ewing sarcoma--relationship to pulmonary metastasis and survival

BACKGROUND/PURPOSE

Intratumoral angiogenesis quantified by microvessel density (MVD) has been shown to be a strong prognostic indicator in a number of malignant tumors. Its association with prognosis in Ewing sarcoma has not been previously studied. The aim of our study was to investigate the relationship between angiogenesis and clinical outcome in Ewing sarcoma.

METHODS

Twenty-seven patients with Ewing sarcoma were included in a retrospective immunohistochemical study. Sections from diagnostic biopsies were immunostained using anti-von Willebrand factor antibody and microvessels were counted at 400x magnification on three microscopic fields per patient. Microvessel density was correlated with overall and disease-free survival as a continuous variable using univariate regression analysis and as a dichotomous variable by Kaplan-Meier and log-rank analysis. Correlation between clinicopathologic variables and the degree of angiogenesis was tested using chi(2) test.

RESULTS

Increasing MVD was not confirmed to be a poor prognostic factor in univariate analysis. Also, statistically significant difference was not found in overall survival or disease-free survival between patients with high (>31.6 vessels per field) and low (<or=31.6 vessels per field) microvessel counts. Finally, there was no difference regarding the metastatic rate between patients with high and low microvessel counts.

CONCLUSIONS

Our results did not confirm increasing angiogenesis quantified by MVD to be predictive of prognosis or pulmonary metastasis in Ewing sarcoma. The diffuse pattern of distribution of microvessels found in Ewing sarcoma may be responsible for the observed lack of prognostic significance of angiogenesis. Future work is required to assess the prognostic importance of MVD in this disease.

Liver transplantation and aging

An increase in the average life expectancy, paralleled by a demographic shift in the population with end-stage liver disease lies behind the rising demand for liver transplantation (LT) among the elderly. Some of the most common indications for LT including hepatocellular carcinoma, alcohol-related liver disease, chronic hepatitis C and non-alcoholic fatty liver disease tend to affect older patients. Transplant professionals are faced with an increasing demand for LT among elderly patients in an age of organ shortage and it is important that risk and benefits are carefully weighed in order to achieve the optimum use of precious liver grafts.

Liver transplantation for benign liver tumors

Benign liver tumors are common lesions that are usually asymptomatic and are often found incidentally due to recent advances in imaging techniques and their widespread use. Although most of these tumors can be managed conservatively or treated by surgical resection, liver transplantation (LT) is the only treatment option in selected patients. LT is usually indicated in patients that present with life-threatening complications, when the lesions are diffuse in the hepatic parenchyma or when malignant transformation cannot be ruled out. However, due to the significant postoperative morbidity of the procedure, scarcity of available donor liver grafts, and the benign course of the disease, the indications for LT are still not standardized. Hepatic adenoma and adenomatosis, hepatic hemangioma, and hepatic epithelioid hemangioendothelioma are among the most common benign liver tumors treated by LT. This article reviews the role of LT in patients with benign liver tumors. The indications for LT and long-term outcomes of LT are presented.

Hepatitis E Virus in Croatia in the "One-Health" Context

Hepatitis E virus (HEV) is the most common cause of viral hepatitis globally. The first human case of autochthonous HEV infection in Croatia was reported in 2012, with the undefined zoonotic transmission of HEV genotype 3. This narrative review comprehensively addresses the current knowledge on the HEV epidemiology in humans and animals in Croatia. Published studies showed the presence of HEV antibodies in different population groups, such as chronic patients, healthcare professionals, voluntary blood donors and professionally exposed and pregnant women. The highest seroprevalence in humans was found in patients on hemodialysis in a study conducted in 2018 (27.9%). Apart from humans, different studies have confirmed the infection in pigs, wild boars and a mouse, indicating the interspecies transmission of HEV due to direct or indirect contact or as a foodborne infection. Continued periodical surveys in humans and animals are needed to identify the possible changes in the epidemiology of HEV infections.

War injuries of the talus

Twenty-eight patients with war fractures of the talus were reviewed to determine the incidence of infection and late functional results. The average age of our patients was 37.5 years. Twenty-one injuries were explosive fractures that resulted from shell fragments or mines; seven fractures resulted from gunshot missiles. Seven patients had isolated talus injuries, whereas 21 patients had associated fractures of other bones of the foot or lower leg. All patients were initially treated with debridement, tetanus immunization, intravenous antibiotics, and stabilization, either with cast immobilization or an external fixator. Five days after injury, wound cultures were positive in 25 of 28 feet. Infection was eventually eradicated in all patients, allowing for soft tissue coverage. One patient eventually required a below-knee amputation. The patients were reviewed for functional outcome at 36 to 60 months after injury. Most patients reported a certain degree of residual complaints. The overall result can be considered excellent in only one patient.

An infected wound in a patient with necrotising fasciitis

This case study describes the management of a patient with rheumatoid arthritis and diabetes mellitus who presented with necrotising fasciitis

Borderline resectable pancreatic cancer and vascular resections in the era of neoadjuvant therapy

While pancreatic cancer is still characterized by early systemic spread and poor outcomes, the treatment of this disease has changed significantly in recent years due to major advancements in systemic therapy and advanced surgical techniques. Broader use of effective neoadjuvant approaches combined with aggressive surgical operations within a multidisciplinary setting has improved outcomes. Borderline resectable pancreatic cancer is characterized by tumor vascular invasion, and is a setting where the combination of potent neoadjuvant chemotherapy and aggressive surgical methods, including vascular resections and reconstructions, shows its full potential. Hopefully, this will lead to improved local control and curative treatment in a number of patients with this aggressive malignancy.

Terminal ballistics of the Russian AK 74 assault rifle: two wounded patients and experimental findings

OBJECTIVE

To study the effects of the Russian AK 74 assault rifle missile (5.45 x 39 mm) on an experimental model and on two wounded patients.

DESIGN

Experimental and clinical study.

SETTING

Brodarski Institute, Marine Research and Special Technologies, Zagreb, Croatia, and General Hospital, Karlovac, Karlovac, Croatia.

MATERIALS AND PATIENTS

Twenty gelatin blocks used as tissue stimulants and two patients with gunshot wounds caused by AK 74 assault rifle missiles.

INTERVENTIONS

After being fired at, gelatin blocks were filmed with a high-speed television camera and radiographs were made of the blocks. Wounds of our patients were treated with minimal excision and drainage.

MAIN OUTCOME MEASURES

The correlation between the wound profile method and our experimental model, and the correlation between the wound profile method and the wounds of the patients we treated.

RESULTS

Bullets were not found to deform or fragment in tissue stimulant. The bullet path through the gelatin block was found to differ from the path predicted according to the wound profile method.

CONCLUSION

Gelatin disruption in the initial 8 to 11 cm of the bullet path is minimal. Even the highest-velocity military missiles, like the AK 74 5.45 x 39 mm bullet, may cause only minimal tissue disruption in this initial part of tissue penetration.

Treatment of War Injuries of the Shoulder with External Fixators

In this retrospective study, 18 patients with war injuries of the shoulder were reviewed to evaluate the technical problems associated with external fixation and to analyze the incidence of infection and late functional results. The average patient age was 28.5 years. All patients were male. Thirteen patients had explosive wounds, whereas five wounds were caused by gunshot missiles. All injuries were extensive in terms of bone and soft tissue defects. Six patients presented with complex injuries involving neurovascular structures. Sixteen patients were treated with external fixation. Application of the proximal pins of the external fixator through the humeral head was possible in eight patients, the scapula served as the site of proximal fixation in four patients, only the clavicle was available for placement of pins in two patients, and both the scapula and the clavicle had to be pinned to achieve proximal stabilization in two patients. In two patients, fixation was not possible and early amputation was performed. Infection was eventually eradicated in all patients, allowing for adequate soft tissue coverage of the wounds. Analysis of functional results at an average of 6 years after the injury showed a considerable degree of functional deficit in most patients.

Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case report

BACKGROUND

Refractory ascites is a rare complication following orthotopic liver transplantation (OLT). The broad spectrum of differential diagnosis often leads to delay in diagnosis. Therapy depends on recognition and treatment of the underlying cause. Constrictive pericarditis is a condition characterized by clinical signs of right-sided heart failure. In the advanced stages of the disease, hepatic congestion leads to formation of ascites. In patients after OLT, cardiac etiology of ascites is easily overlooked and it requires a high degree of clinical suspicion.

CASE SUMMARY

We report a case of a 55-year-old man who presented with a refractory ascites three months after liver transplantation for alcoholic cirrhosis. Prior to transplantation the patient had a minimal amount of ascites. The transplant procedure and the early postoperative course were uneventful. Standard post-transplant work up failed to reveal any typical cause of refractory post-transplant ascites. The function of the graft was good. Apart from atrial fibrillation, cardiac status was normal. Eighteen months post transplantation the patient developed dyspnea and severe fatigue with peripheral edema. Ascites was still prominent. The presenting signs of right-sided heart failure were highly suggestive of cardiac etiology. Diagnostic paracentesis was suggestive of cardiac ascites, and further cardiac evaluation showed typical signs of constrictive pericarditis. Pericardiectomy was performed followed by complete resolution of ascites. On the follow-up the patient remained symptom-free with no signs of recurrent ascites and with normal function of the liver graft.

CONCLUSION

Refractory ascites following liver transplantation is a rare complication with many possible causes. Broad differential diagnosis needs to be considered.

Pre- and intraoperative predictors of acute kidney injury after liver transplantation

BACKGROUND

Acute kidney injury (AKI) after liver transplantation (LT) is a frequent and multifactorial event related to increased morbidity and mortality. Risk factors for AKI after LT still need to be clarified.

AIM

To identify the predictors of acute kidney injury after liver transplantation.

METHODS

The frequency and pre- and intraoperative predictors of AKI within the first 7 d after LT were evaluated in adult liver transplant candidates in a single LT center in Croatia. AKI was defined according to the Kidney Disease: Improving Global Outcomes criteria.

RESULTS

Out of 205 patients (mean age 57 ± 10 years; 73.7% males, 52.7% with alcohol-related liver disease) 93 (45.36%) developed AKI, and the majority of them (58.06%) had stage 1. Only 5.38% of patients required renal replacement therapy after LT. The majority of patients (82.8%) developed AKI within the first two days after the procedure. Multivariate logistic regression identified pre-LT body mass index (OR = 1.1, 95%CI: 1.05-1.24) and red blood cell transfusion (OR = 1.66, 95%CI: 1.09-2.53) as independent predictors of early post-LT AKI occurrence. 30-d survival after LT was significantly better for patients without AKI (P = 0.01).

CONCLUSION

Early AKI after LT is a frequent event that negatively impacts short-term survival. The pathogenesis of AKI is multifactorial, but pre-LT BMI and intraoperative volume shifts are major contributors.

Calyceal plication with pyeloplasty in the treatment of giant hydronephrosis in children

The relief of obstruction alone is frequently not sufficient to ensure renal salvage in giant hydronephrosis. We report on our experience with plication of the renal calyces used as an adjunct to dismembered pyeloplasty in patients with giant hydronephrosis. We describe the operative technique and outcomes in ten children after a follow-up period of six months. Ten patients (six girls and four boys) with a mean age of 8.1 years (range 2-14 years) with giant hydronephrosis caused by primary ureteropelvic junction obstruction underwent a dismembered pyeloplasty followed by plication of the dilated renal calyces. The preoperative evaluation included an excretory urography, ultrasonography, 99mTc-DMSA and 99mTc-DTPA scans. The same tests were repeated six months after the operation to evaluate the outcomes. There were no intraoperative or postoperative complications. Excretory urography and ultrasonography performed six months after the operation demonstrated a significant improvement of the morphology of the operated kidneys. The kidneys shrunk in diameter from a mean of 149.5 mm (range 89-224 mm) to 93.6 mm (range 68-121 mm) and the mean diameter of the calyces was reduced from 26.9 mm (range 15-42 mm) to 14.7 mm (range 10-24 mm). Renal 99mTc-DTPA scans showed improved perfusion and renal function after surgery, with the mean elimination rate decreasing from 22.41 min (range 17.84 - 28.22 min) to 11.7 min (range 8.16-13.76 mm). 99mTc-DMSA scans demonstrated no new scars and no deterioration of renal parenchyma after surgery. We believe that plication of the renal calyces is the method of choice to be used as an adjunct to the Anderson-Hynes pyeloplasty in the treatment of paediatric patients with giant hydronephrosis.

Simultaneous Orthotopic Liver Transplantation With Abdominal Aortic Aneurysm Repair: A Case Report

The simultaneous occurrence of an abdominal aortic aneurysm and liver cirrhosis needing surgical treatment is extremely rare. There is still controversy regarding the timing of abdominal aortic aneurysm repair and liver transplantation and regarding optimal treatment of the aneurysm. Here, we describe a 70-year-old white male patient who presented with end-stage liver disease secondary to chronic hepatitis C with a solitary hepatocellular carcinoma measuring 5.5 cm in diameter in the right liver lobe. A pretransplant work-up resulted in discovery of a 6.7-cm abdominal aortic aneurysm. The decision was made to perform orthotopic liver transplantation with simultaneous aneurysm repair. The patient was initially explored through a median laparotomy. The liver transplant was performed first with the graft prepared on the back table using a standard procedure. The liver graft was transplanted using a "piggy-back" technique with end-to-side caval and end-to-end portal vein anastomosis. The arterial anastomosis was performed with an end-to-end anastomosis between the donor's proper hepatic artery and the recipient's common hepatic artery. The bile duct anastomosis was performed with an end-to-end anastomosis. A midline incision was extended to the pubis. After proximal and distal vascular control of the infrarenal aorta, resection of the abdominal aortic aneurysm was performed followed by reconstruction with an InterVascular 22-mm prosthesis using 3.0 Prolene in a running fashion. Eight days after surgery, the patient was discharged and remained well during the 2-year follow-up. Although rare, in a patient with end-stage liver disease and abdominal aortic aneurysm, a simultaneous liver transplantation and aneurysm repair procedure represents the safest treatment solution.

Seroprevalence of SARS-CoV-2 in Croatian solid-organ transplant recipients

INTRODUCTION

The data on the coronavirus disease (COVID-19) in solid-organ transplant recipients (SOTRs) in Croatia is unknown. The aim of this study was to analyze the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Croatian SOTRs.

MATERIALS AND METHODS

From 7 September to 27 November 2020 (beginning of the second COVID-19 pandemic wave), a cross-sectional screening for COVID-19 was performed in the adult outpatient liver (LTRs; N = 280) and kidney transplant recipients (KTRs; N = 232). Serum samples were initially tested for SARS-CoV-2 IgG antibodies using a commercial enzyme-linked immunosorbent assay (ELISA; Vircell Microbiologists, Granada, Spain). All positive samples were confirmed using a virus neutralization test (VNT). Data on risk exposure and COVID-19 related symptoms were collected using a questionnaire.

RESULTS

The transplanted cohort's seroprevalence detected by ELISA and VNT was 20.1% and 3.1%, respectively. Neutralizing (NT) antibodies developed in 15.6% of anti-SARS-CoV-2 ELISA IgG positive SOTRs. The difference in seropositivity rates between LTRs and KTRs was not statistically significant (ELISA 21.1% vs. 19.0%, P = 0.554; VNT 3.6% vs. 2.6%, P = 0.082). Overall VNT positivity rates were higher in patients who reported participation in large community events (5.9% vs. 1.0%; P = 0.027) as well as in patients who reported COVID-19 related symptoms in the past six months. In addition, symptomatic VNT positive patients showed significantly higher (P = 0.031) NT antibody titers (median 128, interquartile range (IQR) = 32-128) compared to asymptomatic patients (median 16, IQR = 16-48).

CONCLUSIONS

This study showed that 15.6% of anti-SARS-CoV-2 ELISA positive Croatian SOTRs developed NT antibodies indicating protective immunity. Further studies are needed to determine the dynamic of NT antibodies and COVID-19 immunity duration in immunocompromised populations such as LTRs and KTRs.

Successful separation of xypho-omphalopagus conjoined twins with extrauterine twin-twin transfusion syndrome: a case report

Conjoined twining is a rare medical phenomenon, with an overall prevalence of 1.47 per 100 000 births. This report describes a successful separation of xypho-omphalopagus conjoined twins complicated by unbalanced blood shunting through the porto-systemic anastomoses within the shared liver parenchyma. Significant extrauterine twin-twin transfusion syndrome caused by unbalanced shunting is an extremely rare, and probably under-recognized, hemodynamic complication in conjoined twins necessitating urgent separation. Progressive deterioration with a poor outcome can be prevented if the condition is recognized in a timely manner.

Adrenalectomy for Bilateral Metachronous Adrenal Recurrence of Hepatocellular Carcinoma After Liver Transplant: A Case Report

Hepatocellular carcinoma is the fifth most common cancer in the world and the third leading cause of cancer-related death. It is currently one of the leading indications for liver transplant, with selected 5-year survival rates after liver transplant of about 70%. Despite excellent results of liver transplant for hepatocellular carcinoma, a number of patients develop metastases after transplant, and multifocal metastatic disease is the most frequent cause of death. In a large autopsy series of patients with hepatocellular carcinoma, adrenal glands were the third most common site of extrahepatic metastasis after lungs and bones. However, isolated metastatic disease in the adrenal glands is rare, and isolated metachronous bilateral metastasis is an even rarer occurrence. Only few reports have been published of metachronous bilateral metastasis of hepatocellular carinoma after liver transplant treated with bilateral adrenalectomy. We describe a case of a 56-year-old man who underwent liver transplant for hepatocellular carcinoma in a cirrhotic liver. Two years after liver tranplant, regular follow-up revealed metastatic disease in the left adrenal gland. Preoperative imaging showed no other metastasis, and he underwent an uneventful left adrenalectomy. A year after surgery, he presented with right flank pain and tenderness. Imaging showed hemorrhage and tumor involvement of the right adrenal gland, and he underwent right adrenalectomy. Two years after surgery, he is alive and well with no signs of disease recurrence. Apparently, in the absence of intrahepatic or other metastases, bilateral metachronous recurrence of hepatocellular carcinoma after liver tranplant can be a good surgical indication with acceptable long-term survival.