Peng Soon Koh

Liver cancer in Malaysia: Epidemiology and clinical presentation in a multiracial Asian population

Hepatocellular carcinoma (HCC) is an important cancer in Malaysia. This study aimed to determine the epidemiological characteristics and clinical presentations of patients in a multiracial population consisting of three major Asian races: Malays, Chinese and Indians.

Efficacy of radiofrequency ablation compared with transarterial chemoembolization for the treatment of recurrent hepatocellular carcinoma: a comparative survival analysis

BACKGROUND This study aims to assess if radiofrequency ablation (RFA) has any oncological superiority over transarterial chemoembolization (TACE) on post-hepatectomy recurrence. METHODOLOGY From 2002 to 2011, 60.15% of 823 patients developed recurrence after hepatectomy for Hepatocellular carcinoma (HCC). 102 patients with recurrence underwent RFA (n = 42) or TACE (n = 60) for tumor size ≤5 cm and number of lesion ≤3 when tumors were not resectable or transplantable. Those with renal impairment, portal vein thrombosis and poor liver reserve were excluded. Primary outcome was overall survival, which was determined using log-rank test and Kaplan Meier plots performed. Categorical data were analyzed using Chi-square test and continuous variable were analyzed using Mann-U Whitney test. RESULTS Demographics and primary tumor characteristics were similar in both groups (p > 0.05). Overall survival after initial hepatectomy and salvage treatment for recurrence was similar (p > 0.05) in both groups with 5-year OS after salvage treatment for RFA and TACE at 24.1% and 25.7%, respectively. For patients with second recurrence after salvage treatment, an interchangeable treatment strategy of RFA and TACE conferred a better survival outcome than a stand-alone treatment with RFA or TACE (p < 0.05). CONCLUSIONS RFA and TACE may be equally effective for intrahepatic recurrence after hepatectomy when tumor size is ≤5 cm and ≤3 lesion when re-resection or salvage transplantation is not considered feasible.

The friendly incidental portal vein thrombus in liver transplantation

Improved outcomes have been shown in liver transplantation (LT) with portal vein thrombosis (PVT). However, PVT is still discovered incidentally during surgery despite careful preoperative imaging. Data are limited comparing the outcomes of incidental PVT with PVT diagnosed via preoperative imaging before LT. This study aims to compare the overall outcomes of patients with PVT. From 2008 to 2012, 369 patients had LT, and 58 patients with PVT were identified. They were divided into those with non‐PVT (group 0; n = 311), preoperatively identified PVT (group 1; n = 28), and incidental PVT (group 2; n = 30). The demographics, characteristics, preoperative assessment, and postoperative outcomes were compared. A survival analysis was also performed. Baseline characteristics and preoperative evaluations of all 3 groups were comparable (P > 0.05) except for Model for End‐Stage Liver Disease score, tumor status, platelet levels, and serum bilirubin. A multivariate analysis only showed a high serum bilirubin level to be a predictor of PVT (P = 0.004; odds ratio, 3.395; 95% confidence interval, 1.467‐7.861). Postoperative outcomes were also comparable (P > 0.05). Compared to group 2, group 1 had more patients with a Yerdel classification of 3 or 4 with more extensive surgical intervention required (P = 0.02). The survival analysis in all 3 groups was comparable with 5‐year survival rate of 87.4%, 84.6%, and 91.8% in group 0, 1, and 2, respectively (P = 0.66). In conclusion, recipients with PVT undergoing LT can have similar outcomes as the non‐PVT patients even if PVTs were discovered incidentally. Discovery of incidental PVT only requires thrombectomy with no substantial change of treatment strategy, and the outcome is not adversely affected because most incidental PVTs are of a lower Yerdel grade. Preoperative imaging is useful to identify those with a higher Yerdel grade to allow planning of surgical strategy during transplantation. Liver Transpl 21:944‐952, 2015.

Education and imaging. Hepatobiliary and pancreatic: A huge liver paraganglioma.

A 48-year-old woman was investigated because of a 6-month history of pain in the upper abdomen and progressive abdominal distension. On examination, she had a large mass in the right upper quadrant that extended to the umbilicus. Routine blood tests including liver function tests and a serum level of alpha fetoprotein were within the reference range. A computerized tomography (CT) scan of the abdomen revealed a large mass in the right upper quadrant, approximately 12 ¥ 18 ¥ 18 cm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. A coronal view of the mass is shown in Figure 1. As a major liver resection was proposed, she underwent embolization of the right portal vein. A repeat CT scan did not demonstrate any reduction in the size of the tumor or hypertrophy of the left lobe of the liver. At laparotomy, she had a huge pedunculated mass arising from the inferior surface of segments 5 and 6 of the liver (Figure 2). Histological features were consistent with a paraganglioma and this was supported by immunohistochemical studies which showed positive staining for neuronspecific enolase, synaptophysin and glial fibrillary acidic protein. However, S100 was equivocal and immunohistochemical staining was negative for chromogranin, MNF 116, vimentin, actin and CD68. Paragangliomas are neoplasms of the sympatho-adrenal neuroendocrine system. The most common site for these neoplasms is the adrenal medulla (pheochromocytoma). Extra-adrenal paragangliomas are unusual and mostly follow the distribution of the sympathetic nervous system. Paragangliomas in abdominal organs are rare but have been reported in a number of sites including the bladder and gallbladder. Atypical features in the above case included the site of the tumor (liver) and the size of the tumor (many are relatively small). Clinical features of excess catecholamine secretion have been reported in 20–80% of patients. Only a minority undergo malignant change as determined by the development of metastases. Another notable feature in the above case was the presence of centripetal contrast enhancement that is normally thought to be a typical feature of a cavernous hemangioma.

Hepatobiliary and pancreatic:A huge liver paraganglioma

A 48-year-old woman was investigated because of a 6-month history of pain in the upper abdomen and progressive abdominal distension. On examination, she had a large mass in the right upper quadrant that extended to the umbilicus. Routine blood tests including liver function tests and a serum level of alpha fetoprotein were within the reference range. A computerized tomography (CT) scan of the abdomen revealed a large mass in the right upper quadrant, approximately 12 ¥ 18 ¥ 18 cm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. A coronal view of the mass is shown in Figure 1. As a major liver resection was proposed, she underwent embolization of the right portal vein. A repeat CT scan did not demonstrate any reduction in the size of the tumor or hypertrophy of the left lobe of the liver. At laparotomy, she had a huge pedunculated mass arising from the inferior surface of segments 5 and 6 of the liver (Figure 2). Histological features were consistent with a paraganglioma and this was supported by immunohistochemical studies which showed positive staining for neuronspecific enolase, synaptophysin and glial fibrillary acidic protein. However, S100 was equivocal and immunohistochemical staining was negative for chromogranin, MNF 116, vimentin, actin and CD68. Paragangliomas are neoplasms of the sympatho-adrenal neuroendocrine system. The most common site for these neoplasms is the adrenal medulla (pheochromocytoma). Extra-adrenal paragangliomas are unusual and mostly follow the distribution of the sympathetic nervous system. Paragangliomas in abdominal organs are rare but have been reported in a number of sites including the bladder and gallbladder. Atypical features in the above case included the site of the tumor (liver) and the size of the tumor (many are relatively small). Clinical features of excess catecholamine secretion have been reported in 20–80% of patients. Only a minority undergo malignant change as determined by the development of metastases. Another notable feature in the above case was the presence of centripetal contrast enhancement that is normally thought to be a typical feature of a cavernous hemangioma.

Jaundice and life‐threatening hemobilia: An uncommon presentation of choledochal cyst

Hemobilia with jaundice as a result of cholestasis and bleeding from choledochal cyst is uncommon. Ascertaining the diagnosis is often challenging and delayed diagnosis can lead to significant consequences due to hemodynamic instability, particularly in elderly patients. Although surgery remains the definitive treatment modality, interventional radiology for hemostasis has been increasingly recognized as an option. In this manuscript, we described two Malaysian cases of jaundice and hemobilia associated with choledochal cysts and the challenges related with clinical diagnosis and management.

Adult-to-adult living donor liver transplantation: Operative techniques to optimize the recipient's outcome

Adult-to-adult living donor liver transplantation (LDLT) is widely accepted today with good outcomes and safety reported worldwide for both donor and recipient. Nonetheless, it remained a highly demanding technical and complex surgery if undertaken. The last two decades have seen an increased in adult-to-adult LDLT following our first report of right lobe LDLT in overcoming graft size limitation in adults. In this article, we discussed the operative techniques and challenges of adult right lobe LDLT incorporating the middle hepatic vein, which is practiced in our center for the recipient operation. The various issues and challenges faced by the transplant surgeon in ensuring good recipient outcome are explored and discussed here as well. Hence, it is important to understand that a successful recipient operation is dependent of multifactorial events starting at the preoperative stage of planning, understanding the intraoperative technical challenges and the physiology of flow modulation that goes hand-in-hand with the operation. Therefore, one needs to arm oneself with all the possible knowledge in overcoming these technical challenges and the ability to be flexible and adaptable during LDLT by tailoring the needs of each patient individually.

Response to Wang et al. Re: How to choose and compare between radiofrequency ablation and transarterial chemoembolization for recurrent hepatocellular carcinoma?

The rationale for our study when we first addressed this issue was the scarcity of data in the literature concerning treatment of recurrent hepatocellular carcinoma (HCC). As we all know, management of recurrent HCC could be challenging due to tumor factor and limited liver function reserve. Nonetheless, recent advances in transplantation, ablation or resection have rendered postoperative recurrence a treatable disease and previous studies from our center have also highlighted the possibility of long-term survival in these cohorts of patients. In our practice, there were selected patients who also received both RFA and TACE as well. The aim of this study, however, was not to act as a guide for selecting treatment for recurrent HCC, but to show that the outcome of TACE were similar to that of RFA in a selected group of patients, when tumour characteristics were comparable between the two treatment groups. RFA is regarded as a curative treatment option in our center, especially for oligo-nodular tumors due to the high success rate of complete tumor ablation whereas TACE were mainly used to control tumor growth and offered when multiple recurrences were developed. We postulated that the lack of difference in survival between the two treatment arms was that ablation is a local treatment that only targeted the macroscopic disease. Any occult intrahepatic recurrences would not be dealt with by this treatment strategy and this may explain why a combined treatment with RFA and TACE seemed to provide better oncological outcomes as shown in Fig. 4 of our article and other study. On patient selection, both groups were matched based on their tumour characteristics as outlined in our methodology. Both groups were comparable as there were not many significance despite what the authors pointed out. We used a p-value of <0.05 for any study of significance although the authors in their commentary have p-value of <0.10. Our univariate and multivariate analysis further proved that both groups were comparable and matched. As the conclusion of our study pointed out, TACE may be equally effective as RFA for intrahepatic recurrence after

Mediastinal hepatocellular carcinoma with unknown primary: an unusual and rare presentation.

This is an excerpt from the content Background Hepatocellular carcinoma (HCC) is a common cancer in Asia due to the high prevalence of hepatitis B and C infections in this region [1]. It often occurs in a cirrhotic liver as a sequalae of chronic hepatitis B and C infections as well as alcoholic liver or fatty liver disease. With improved treatment of HCC over the years, extrahepatic metastatic HCC are frequently reported, and its incidence is increasing [2]. Metastatic HCC has often been reported in common extrahepatic sites such as lungs, bones, lymph nodes and adrenals as a result of hematogenous or lymphatic spread as well as direct invasion of tumour tissue [3]. However, extrahepatic HCC presenting as a solitary mass is unusual when no primary liver tumour is detectable or identifiable. To our knowledge, there are numerous reports in the literature describing extrahepatic and metastatic HCC with no known primary occurring in various sites, but we report a rare case of mediastinal HCC with an unknown primary in a 46-yea ...

Hepatobiliary and Pancreatic: A huge liver paraganglioma: Education and Imaging

A 48-year-old woman was investigated because of a 6-month history of pain in the upper abdomen and progressive abdominal distension. On examination, she had a large mass in the right upper quadrant that extended to the umbilicus. Routine blood tests including liver function tests and a serum level of alpha fetoprotein were within the reference range. A computerized tomography (CT) scan of the abdomen revealed a large mass in the right upper quadrant, approximately 12 ¥ 18 ¥ 18 cm in size. There was contrast enhancement at the periphery of the mass consistent with a cavernous hemangioma. A coronal view of the mass is shown in Figure 1. As a major liver resection was proposed, she underwent embolization of the right portal vein. A repeat CT scan did not demonstrate any reduction in the size of the tumor or hypertrophy of the left lobe of the liver. At laparotomy, she had a huge pedunculated mass arising from the inferior surface of segments 5 and 6 of the liver (Figure 2). Histological features were consistent with a paraganglioma and this was supported by immunohistochemical studies which showed positive staining for neuronspecific enolase, synaptophysin and glial fibrillary acidic protein. However, S100 was equivocal and immunohistochemical staining was negative for chromogranin, MNF 116, vimentin, actin and CD68. Paragangliomas are neoplasms of the sympatho-adrenal neuroendocrine system. The most common site for these neoplasms is the adrenal medulla (pheochromocytoma). Extra-adrenal paragangliomas are unusual and mostly follow the distribution of the sympathetic nervous system. Paragangliomas in abdominal organs are rare but have been reported in a number of sites including the bladder and gallbladder. Atypical features in the above case included the site of the tumor (liver) and the size of the tumor (many are relatively small). Clinical features of excess catecholamine secretion have been reported in 20–80% of patients. Only a minority undergo malignant change as determined by the development of metastases. Another notable feature in the above case was the presence of centripetal contrast enhancement that is normally thought to be a typical feature of a cavernous hemangioma.