Sukhum Bunyaratvej’s research while affiliated with Ramathibodi Hospital and other places

A case of hepatocellular adenoma (HCA) was described in a 26-year-old woman, who was a potential kidney donor for her father and denied taking the oral contraceptive pill. A hypervascular mass of 4.1 cm in largest dimension was detected in the liver segment V by computerized tomography and magnetic resonance imaging (MRI). The normal levels of liver enzymes, negative serum markers for hepatitis viruses, and non-elevated alpha- fetoprotein level were detected. The wedge resection of segment V was done with an uneventful clinical course. In Western countries, HCAs are known to occur in women in their reproductive periods. It may not be associated with oral contraceptive. Molecular biological studies disclosed three variants of HCAs, i.e., I) with mutation of HNF 1-alpha gene, II) with mutation of beta-catenin gene, and III) no mutation of the two genes. Histological correlations with the three variants as recommended by the Bordeaux group in 2007 could not be accomplished in the present study due to overlapping histological features between the variants I and III. The etiological factors of HCA are known to relate to the contraceptive pill usage in female and the anabolic-androgenic-steroid administration in male. In Thailand, the occurrence of HCA is expected to be only 0.3% of cases with hepatocellular carcinoma.

Human intestinal sarcocystosis is a zoonotic disease caused by two coccidians, i.e. Sarcocystis fusiformis (syn. S. bovihominis, S. hominis) due to consumption of raw infected beef and Sarcocystis meischeriana (syn. S. suihominis) due to consumption of infected raw pork. In 1987, survey of the macroscopic S. fusiformis cysts in market beef mainly from old water buffalos aged more than 15 years were commonly observed in Bangkok. In 2005, the macroscopic cyst was no longer seen in beef of cattle and water buffalo aged less than three years. The epidemiological investigation of Sarcocystis spp. infected meat in Bangkok and Lampang. Samples for each of the tongue and beef of cattle and water buffalo, pork from Bangkok markets and pork of domestic swine from some remote villages in various subprovinces (Ampurs) in Lampang were obtained for microscopic examination by H and E and selectively by PAS staining. The microscopic S. fusiformis cysts were seen in all five specimens of tongues and ten specimens of muscles of cattle and water buffalo obtained from fresh-food markets in Bangkok. Ten samples of pork from Bangkok markets revealed no coccidian infection. The microscopic S. meischeriana cysts were seen in three specimens of swine muscles collected from two subprovinces in Lampang. The present merozoites in coccidian cysts retrieved from beef and pork are similar to those previously observed in human intestine. This may histologically indicate an invasive sarcocystosis by both species leading to a condition presently known as chronic inflammation of undetermined etiology in man.

Combined hepatocellular and cholangiocarcinoma with sarcomatous transformation was first recognized in Ramathibodi Hospital in 2005. This variant of carcinoma has been increasingly reported particularly from Asian countries. Dedifferentiation of the epithelial component to various sarcomatous components is likely the underlying mechanism. The causative factors of hepatocarcinogenesis in Thailand include chronic viral hepatitis B or C, exposures to aflatoxin B1 and nitrosamine(s) and occasionally some certain nodular hepatocellular lesions due to arterial hyperperfusion. It is suggested that the recent change of the Thai peoples' life style to an increased consumption of fast foods containing food preservatives especially nitrate or nitrite, the nitrosamine precursor may allow heavy exposure(s) to the chemical carcinogen(s) i.e. nitrosamine(s) leading to sarcomatous transformation of the carcinoma.

Detect the early histological changes relating to human hepatocarcinogenesis in three nodular hepatocellular lesions. Three cases of dysplastic nodules and one of small hepatocellular carcinoma were obtained from the authors' surgical-pathology file during 2000-2005 for a histopathological study in relevance to the early changes during hepatocarcinogenesis by employing hematoxylin and eosin stain, as well as some immunohistochemical staining. One nodular hepatocellular lesion, diagnosed as a complex lesion of focal nodular hyperplasia contained a microscopic focus (1.5 mm in diameter) of combined hepatocellular and cholangiocarcinoma. The small dysplastic hepatocytes subjected to neoplastic transformation combined hepatocellular and cholangiocarcinoma and are the precursorial cells of hepatocellular carcinoma. Chronic viral hepatitis B or C, aflatoxin B, and nitrosamine(s), as well as some nodular hepatocellular lesions share distinct roles in the complex process of hepatocarcinogenesis pertaining to this Southeast Asian country.

Hepatotoxic effect related to Ganoderma lucidum (Lingzhi) mushroom powder was first described in a patient from Hong Kong in 2004. In 2005, the authors experienced a case of fatal fulminant hepatitis associated with such a preparation. Both patients had taken other therapeutic agents and traditionally boiled Lingzhi without any toxic effect. After switching to taking Lingzhi in powder form for 1-2 months, the hepatotoxic episode occurred in both patients. The toxic role of Lingzhi powder needs close monitoring in the future, especially in combination with other drugs.

Biliary fascioliasis was diagnosed in a woman from Angthong province, who presented herself with anorexia, weight loss, and jaundice for one month. Intraoperative retrograded cholangiopancreatography revealed a filling defect considered as a stone and bile sludge. By the sphincterotomy and balloon-extraction technique, one live fluke was removed and identified as Fasciola gigantica. A single dose of praziquantel, 25 mg/kg of body weight/day, was given although the postoperative stool examination revealed no Fasciola spp. egg. The patient was doing well after the fluke removal. According to a previous review, in this country, Ayutthaya is the southernmost province for the distribution of fascioliasis.

Two cases of hepatic fascioliasis due to Fasciola hepatica were retrieved from our surgical-pathology file since the hospital's foundation in 1969 up to 2005. The diagnosis of hepatic fascioliasis was based on detection of one live fluke in a large cystic lesion in the lobectomized liver specimen in one case and of deposited eggs in the large liver specimen obtained from open biopsy in the other Hepatic fascioliasis is rather rare and almost worldwide in distribution including Thailand. The diagnosis should be considered in the patient from endemic areas consisting of the northern, northeastern and upper-central regions of the country, with a history of ingesting fresh water plants or drinking untreated water and having fever right-upper-quadrant pain or intrahepatic cystic lesion(s) together with absolute peripheral blood eosinophilia.

Brunner 's gland adenoma is a very rare benign tumor of the duodenum. Only two cases of the adenoma have been in the file of the surgical pathology unit of Ramathibodi Hospital since 1992 and presented in this communication. The tumor is capable of producing a variety of clinical manifestations. Presently, endoscopic study plays an important role in both detection and diagnostic biopsy. Local excision, either by endoscopy or surgery is the main treatment in symptomatic cases. Ductal malignancy on top of Brunner's gland adenoma was described in one from estimated 200 recorded cases in the English literature since 1835.