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An incomplete treatment, such as repeated TACE without systemic treatment, might miss opportunities to prevent disease progression. All recurrences must be regarded as systemic disease, and our data support the efficacy of an aggressive combined treatment. The major limitations of this study are the retrospective design and the heterogeneous treatment http://www.selleckchem.com/products/pci-32765.html methods with regard to the local and systemic treatments. Due to the retrospective design of the study, the treatment method was not randomized to the patients and the treatment selection might have affected the survival rates. However, several factors partially compensate for these limitations. First, in 2007, we adopted a protocol in which sirolimus is administered after a diagnosis of recurrent HCC after LT. The use of sirolimus was not affected by the tumor extent, the site of recurrence, the time of the recurrence, or other variables. Patients who received sirolimus were not selected patients with lower tumor extent or better prognostic factors. Second, most of the patients began to receive sirolimus immediately after the diagnosis of HCC recurrence. Sirolimus was given immediately to the patients after a diagnosis of recurrence, so the patients receiving sirolimus were not the only survivors during the follow-up period. Third, all of our patients were followed up for more than a short duration; in this study, the duration of follow-up for all patients was longer than one?yr after the recurrence. In conclusion, HCC recurrence after LT presents with different clinical courses and patient survival rates, according to the recurrence time and site. A recurrence within six?months and initial multi-organ involvement were independent risk factors associated with early (