Atul Samaiya (IN): standard fellowship (6 June - 1 July 2011)

Position: Consultant in Surgical Oncology at Jawaharlal Nehru Cancer Hospital & Research Center, Idgah hills Bhopal (MP), India
Host Unit/Institute: University of Sheffield (Royal Hallamshire Hospital and Northern General Hospital) , Sheffield Teaching Hospitals NHS Foundation Trust, UK
Learning Objectives: To learn the different techniques of breast oncoplasty; To learn nipple and areola sparing mastectomy and reconstruction; To observe clinic proceedings, patient’s interactions, counseling techniques and academic activities. By learning these procedures / activities, I will be able to perform more breast conservation surgery and serve the patients more efficiently at our centre, following the international norms in breast cancer patients care.

"It was a very good learning experiance and I learnt a whole range of breast oncoplstic techniques. It was nice to visit University of Sheffield (Royal Hallamshire Hospital) and interact with Breast Suregons, Plastic surgeons and Breast care nurse. Professor Reed and whole of his staff was very helping and supporting. This fellowship experiance is definitely going to help me and my hospital for better and complete care of breast cancer patients.

My sincere thanks to European Society of Surgical Oncology for awarding this fellowship."

Karol Polom (PL): standard training fellowship (27 April 2008 - 6 June 2009)

Position: Assistant surgeon at the Surgical Oncology and General Surgery Department of the Wielkopolska Cancer Centre, Poznan, Poland
Host Institute: Department of Surgery, Keio University Hospital, Tokio, Japan
Supervisor: Prof. Yuko Kitagawa
Learning Objectives: to observe and learn new techniques for minimally invasive oncology surgery at one of the leading international centres for the treatment of gastric cancer.

During my time at the Department of Surgery at Keio University in Tokyo, Japan, I had the opportunity to experience a different approach to cancer treatment in the gastro-oesophageal and hepatobiliary fields. I witnessed a wide range of novel techniques currently at the forefront of practice, including minimally invasive gastric cancer surgery, sentinel node biopsy, prone oesophagectomy and intra-operative radiotherapy for pancreatic cancer. I also had the opportunity to spent time in the laboratory assisting in a large clinical study headed by Dr. Hayashida on the BORIS gene in breast cancer. I hope we will soon be able to commence a cooperative study on new usages of indocyanine green in breast cancer. I also participated in many research and multidisciplinary meetings, and had a chance to exchange ideas on the subject of the role of SN metastases in pre-invasive breast cancer (ductal carcinoma in situ – DCIS) [1], and the role of lobular neoplasia in mammotomic biopsy [2], both being objectives of my recent work.

More attention is paid to quality of treatment in surgery at Keio University. Accuracy and precision have allowed for better therapeutic results in patients with rectal cancer through the routine use of total mesorectal excision (TME). The key to success in surgical treatment of neoplasms is the performance quality of the surgery. I hope that my lessons in Japan will lead to an improvement of my surgical skills.

Hard work, precision, as well as professional courtesy and kindness towards me are the marks of Prof. Y. Kitagawa and his entire team that will remain in my memory for a long time to come.

Summary of Experience

Minimally invasive gastric surgery:

Gastric cancer is still the most common malignant tumor in Japan. Due to gastroscopic screening, a large number of patients present with early stage neoplasms. Submucosal endoscopy of early stage gastric cancer is used to stage and grade the progression of the disease, and also as a treatment method of tumors involving only the gastric mucosa.

An important element of minimally invasive gastric surgery is combining effective oncologic treatment and the patient’s quality of life (QOL). Sentinel node biopsy (SNB) has been used for years in breast cancer and melanoma. SNB is used more frequently in gastrointestinal neoplasms [3,4], but this involves multidirectional lymphatic drainage and frequent skip metastases. Both laparoscopic function-preserving surgical procedures and SNBs are key in staging of neoplasms as regards minimally invasive gastric cancer surgery [3, 5, 6]. Intraoperative evaluation of the sentinel node (SN), including immunohistochemical examination, allows the surgeon to determine the necessity of lymph node resection. According to Kitagawa et al. [5], it is possible to perform function-preserving surgery of gastric cancers – such as pylorus preserving gastrectomy (PPG), segmental gastrectomy, partial gastrectomy, or limited proximal gastrectomy – in the case of negative SNB. Preservation of the pylorus prevents dumping syndrome and gastroesophageal reflux disease (GERD), two complications that can have significant impact on the patient’s QOL. To preserve the vascular supply to the pylorus, it is necessary to limit lymph node resection (lymph node numbers 5 and 6) along the right gastric artery and the right gastroepiploic artery. Limited resection of these lymph nodes can only be justified by a negative intraoperative SNB and departing from a classic D2 resection which Kitagawa et al. [3, 5, 6] report to be possible with laparoscopy-assisted distal gastrectomy (LADG) with resection (D1 + lymph node numbers 7, 8a, and 9). At Keio University, the SN is determined using two markers: technetium-99m labelled tin colloid delivered the day before surgical intervention, and indocyanine green (ICG) delivered just prior to surgery. Both markers are delivered to the submucosa gastroscopically [3,5]. Histochemical evaluation allows for the identification of micrometastases, occurring in approximately 23% of cases [3]. The complex lymphatic drainage of the region is responsible for skip metastases, which occur in 5-10% of cases and are found in a second compartment of lymph nodes even in early gastric cancers. In this situation also, SNB allows for careful analysis of the cases. The largest problem in selecting patients for SNB is the stage to which the disease has advanced – only patients with T1 tumors are good candidates for SNB. Patients with T2 tumors display a greater frequency of lymphatic vessel blockage by neoplastic cells, resulting in lymph flowing through other vessels to a false SN. For this reason, advanced gastric cancers and clinically positive lymph nodes are contraindications to SNB.

There are many challenges in the techniques of minimally invasive treatment of gastric cancers. In the case of cancers in the region of the gastric cardia, technical difficulties include the rigidity of the gamma camera probe, which can sometimes cause a shine-through effect and make it harder to localize all SNs. Another challenge is the presence of micrometastases and isolated neoplastic cells, and their significance in the clinical picture of gastric cancer, as well as recurrence of stomach cancer in the region of the lymph nodes. In Japan, there is a growing trend towards minimally invasive treatment of gastric cancer with preservation of maximum oncologic safety, with surgeons increasingly moving away from D3 lymphadenectomy, which has been the standard operative treatment of gastric cancer. Professor Kitagawa’s group, among others, has suggested future SNB with NOTES [8], or intraoperative evaluatoin of SNB with the use of real-time PCR (RT-PCR) to determine the presence of metastases at a molecular level [9], as well as in determining the patient’s prognosis and treatment plans by evaluating circulating tumor cells [10].

Prone position during esophagectomy and SNB of esophageal cancer:

Esophageal surgery in Keio hospital is undertaken thoracoscopically with the patient in the prone position, with anterograde abdominal laparoscopy and resection of neck lymph nodes according to the recomendations of Japan Esophageal Society [13]. Mini-invasive prone position thoracoscopic esophagectomy [14] has a lower rate of postoperative pulmonary complications, a shorter length of surgery, and a more rapid return to function for the patient. SNB is performed in patients with T1, or with T2 but clinically unenlarged lymph nodes cN0. In their paper, Takeuchi et al. pay particular attention to lymphatic drainage from lymph nodes in various locations [4]. In 25% patients with upper thoracic esophageal cancer, the SN was identified along the left gastric artery. Middle thoracic esophageal neoplasms have the most unpredictable lymphatic drainage, with up to 85% cases presenting with at least 1 SN out the second or third lymphatic compartment.

Intraoperative radiotherapy (IORT) of the pancreatic cancer and breast cancer:

IORT for pancreatic cancer has been in use for several years at the II Surgery Department of the University Hospital in Nagoya, under the direction of Prof. Akimasa Nakao. In the case of resectable cancer, IORT with 30 Gy through 8-10cm cones is employed. In nonresectable cancers, patients still receive 30 Gy, but through 6-8cm cones [22, 23]. Prof. Nakao has not observed any side effects of IORT. Patients with stage III disease, the IORT group had a statistically better survival rate (1 year survival of 44.6%, 2 year survival of 37.2%) than the non-IORT group (1 year survival of 23%, 2 year survival of 7.7%) [22]. Patients with stage IV resectable neoplasms, no benefits to IORT were observed. Similarly survivability data has been obtained for pancreatic cancer patients with metastases to both the liver and the peritoneum or just to the liver [23]. The group of patients that had an increased survival rate thanks to IORT was the group with metastases to just the peritoneum and no liver involvement. In nonresectable cancers, IORT appears to benefit patients in decreasing or even eliminating back pain. The university hospital in Nagoya is also a leader in the use of accelerated partial breast irradiation (APBI) in Asia at 19-21 Gy. One-step and final IORT to the site of lump removal in breast preserving mastectomy has been shown to be as effective as postoperative radiotherapy.

Acknowledgments:
I would like to thank the European Society of Surgical Oncology for granting me the travelling fellowship.
I would also like to thank Prof. Yuko Kitagawa, Head of the Surgery Department at the Keio University Hospital in Tokyo, for inviting me to visit Japan, as well as Prof. Akimasa Nakao, Head of II Surgery Department, Nagoya University School of Medicine, Nagoya for IORT lessons. Further thanks go out to Drs. Taizo Hibi, Norihito Wada, Takashi Endo, Hirotoshi Hasegawa, Hiroya Takeuchi, Masahiro Shinoda, and Minoru Tanabe for help with clinical practice, as well as Dr. Tetsu Hayashida for help with laboratory work. I also wish to acknowledge Dr. Margarita Lianeri for her assistance.

Read more:
Połom K. Observations on surgical approach to oncology in Japan- report of ESSO fellowship grant experience. (Japońskie doświadczenie w chirurgii onkologicznej. Raport ze stypendium naukowego ESSO (Europejskiego Towarzystwa Chirurgii Onkologicznej)). Nowotwory Journal of Oncology 2010;60(2):182-186.

References