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  Traveling Scholar Reports 2009 - 2010 (Part II)
  
 

The IGCS Traveling Scholars Program has supported a variety of international training opportunities for physicians and nurses outside of their usual environments. Activities from 2009 and 2010 are summarized below, based on reports from the award recipients. IGCS congratulates the recipients on their achievements, and extends gratitude to the host institutions and mentors who made these experiences possible..

See Reports Part I              This is Reports Part II

  
  Mr. Mohammed Elhoweris – SUDAN
London Regional Cytology Training Centre, London		  

I was incredibly honored to receive the IGCS Traveling Scholarship to attend the Gynaecological Cytology course at London Regional Cytology Training Centre (LRCTC) in Northwick Park Hospital, from 28th of September to 23rd of October 2009.

LRCTC is a leading centre for Cytology training in the UK and was founded by Dr. Elizabeth Hudson in 1979. The Centre is equipped with the latest teaching aids, including a multiheaded microscope for group discussion, and high quality microscopes.

The course covered all aspects of Gynaecological Cytology from sampling to reporting, including Interpretation of intraepithelial neoplasias- both histological and cytological in the female genital tract, management of women with abnormal smears, quality control, screening programme, health and safety, staining techniques, and reporting cervical cytology samples. The timetable of the four weeks scheduled 26 lectures, 19 microscopy sessions with multiheaded teaching microscope, 4 slide quiz and revisions , Cytology department visits, continuous assessment with MCQs, written questions, interpretive slides and group discussions.
The conversion from Conventional to Liquid Based Cytology (LBC) smears was completed in October 2008 in UK. The main advantages of LBC are a reduction in the rates of unsatisfactory smears, shorter time required for interpretation, and the ability to use the same sample for HPV testing. The course covered the techniques and the morphology of (ThinPrep) LBC cervical smears.

I received excellent training and knowledge: the training period was adequate, and the staff of LRCTC supported me in gaining great interpretive experience and diagnostic skills enabling me to recognize all abnormalities in Pap smears.

I would like to express my gratitude to the IGCS for giving me this unique opportunity and for financial support. I would also like to express my thanks to Ms. Erica Bard Riley for all her help and to Dr. Vesna Kesic for supporting my application. I remain indebted to the staff of London Cytology Training school, Mr. Ian Philips, Mr. David Smith, Mr. Mark Terry, Dr. Tanya Levine, Dr. Gillian Williams, and Mr. Ryan Togher.I am also grateful to have been in London with its exciting historical and cultural beauty.

I am grateful to my home institution in the Sudan University of Science and Technology for supporting my application and releasing me to attend the training. I hope this experience will help me to improve Gynecologic Cytology service, teaching and research in Sudan.
Dr. Rina Masadah (Indonesia)
UMC St. Radboud, Nijmegen, Netherlands

I am a medical specialist of Pathology in Hasanuddin University Makassar, Indonesia. I work in the Pathology Anatomy Laboratory Makassar, the biggest Pathology centre of the east part of Indonesia which serves around 25 million population. I participate in the diagnosis of pathology cases, around 10,000 cases per year, and mostly tumor cases. There are only 15 pathologists in my lab in Indonesia with limited facilities to support histopathological diagnosis of patients. That is why I am very grateful to have the IGCS Traveling Scholars Award to gain knowledge and skill in Pathology at UMC St Radboud, Nijmegen, The Netherlands from March to August 2010.

I would like to express my special thank to Dr. Johan Bulten, PhD at the Department of Pathology UMC St Radboud Nijmegen, who supervised and supported me in histopathology and cytology diagnosis, I learned many cases and new techniques in Pathology during my training. I also made research projects with Dr Johan Bulten and Professor Leon Massuger at the Oncology division Department of Gynecology UMC St Radboud. I revised 127 ovarian cancer case slides and did the immunohistochemistry scoring to look for alternative precursor lesion of ovarian cancer in the endometrium. I also did 180 endometrial cancer cases slides revision to look for another option type of endometrial cancer entities. Both of the projects will be presented in IGCS 13th Biennial Meeting in Prague October 2010.

Finally I would like to thank to IGCS for giving me this opportunity that indeed very useful for myself and for my host institution in Indonesia.
Dr. Kamlesh Mishra (India)
Royal Women’s Hospital, Sydney, Australia

I am extremely thankful to Prof Neville Hacker, Director of Gynecologic Oncology at Royal Women’s Hospital, Sydney for accepting me as a clinical observer for advanced training. I am also deeply indebted to IGCS for giving me a Traveling Scholarship to make my dream of working under such a respected doctor as Prof Hacker come true.

It was indeed a great opportunity to work with Profs Hacker, Friedlander, and Campean. I reached NSW on 19-Feb-2010. I was full of enthusiasm, but had butterflies in my stomach since I was going to meet a master of the subject and see him treating cancer patients in person, and whose book, “The Practical Gynecology Oncology, Forth Edition” I had followed to learn my basics in gynecologic oncology throughout my fellowship. The moment I met him, my all worries were allayed by his disarming smile and welcoming attitude. I was amazed by his thorough gentle and kind behaviour. He introduced me to everyone including faculty, administration, office bearers, nursing staff, colleagues, registrars and postgraduates. He took me on ward rounds and afternoon clinics the very first day, although it took some time to obtain permission for operation theatre entry.

I learned my initial gynaecological cancers skills at the Gujarat Cancer & Research Institute (GC&RI), Ahmedabad, Gujarat, during 2 years subspeciality fellowship with Profs Desai, Mankad, and Dave. Their perseverance, despite all odds in India for this subspecialty and the need of quality services to Gynecology cancer patients in a comprehensive manner, inspired me to pursue my future career in this area. It was definitely a difficult decision for me to change my career to dedicate exclusively to the subspeciality in a country where it is still not recognised by the medical board. I have all words of praise for my faculty members and Dr Uma Devi, honorary secretary of AGOI, for their sheer determination, continuous efforts and contribution to built this subspeciality. I was astonished to learn that Prof Hacker fondly remembers my institute, where he came to train my own mentors many years back.

When my IGCS application for travel to Sydney was accepted, I was very grateful. I found RHW, to be a true temple of learning for those who want to become gynaecologic cancer surgeons. I have no words to express my gratitude for his efforts to make my stay as comfortable and memorable as possible. During my training I attended surgical sessions, ward rounds, curative and preventive oncology clinics, weekly tumor boards and clinical meetings, teaching sessions and miscellaneous academic presentations. I was allowed access to a fully equipped library having journals and books on subjects of medicine with computers and internet. Besides making sure that I should be able to watch all kinds of surgical procedures like Wertheim Hysterectomy, primary debulking surgeries of ovarian cancers, he always clarified patiently all my doubts regarding patient management.

Besides radical surgeries, what impressed me most was his approach of conservative surgeries in vulvar cancers to decrease morbidity on one hand but to be aggressive in ovarian cancers on other hand. His effortless en block dissections in ovarian cancers with recto-sigmoid resection and end to end anastomosis were impressive. It gave me immense confidence to perform my surgeries independently. I feel privileged to be able to watch the pioneer, who suggested and proved the benefit of doing enlarged lymph node dissection in cervical cancer. He himself showed me how to do it. In fact I assisted in one of these difficult surgeries. I was fortunate to watch a case of bilateral gracillis myo-cutaneous graft in non-healing vaginal radio-necrosis. Though my wish to watch radical trachelectomy could not be realised, due to the lack of a suitable patient, his impressive individualised innovative surgical as well as clinical skills while treating patients were exemplary. I had an opportunity to watch him performing many anterior, posterior and hemi- vulvectomies too. I feel now confident to perform these procedures back in India. I saw numerous ladies in follow-up clinics with so much less psychosexual morbidity as compared to radical procedures, and without any compromise in overall survival.

After attending the various clinical teaching sessions, weekly tumor board, indoor patients management discussions in the presence of multidisciplinary specialists, all the nursing and other para-medical staff, showed me the value of transparency in cancer care, therefore to standardise treatment protocols with accountability. Being transparent and working in well-coordinated multi-disciplinary team in the leadership of a gynecologic oncologist, is the need of the hour to provide comprehensive quality care to gynecologic cancer patients in developing countries so our ladies, too, enjoy the optimum prognosis with good quality of life. I was given the opportunity to give a talk on “Gynecological cancers in India” and to work on a research project of unifocal vulvar melanoma, experience at RHW. I also attended Prof Michael Friedlander’s medical oncology clinics. Prof M Campean allowed me to watch him perform cold knife cone biopsies. Dr Katherine Clark, expert in palliative oncology, took all interests to teach me the needed basics and gave me valuable tips on palliative care in gynecologic cancer patients.

Prof Hacker’s impressive personality and untiring stamina with total commitment to serve cancer patients and train juniors, encourages positive energy in his surroundings. By training numerous doctors, especially those from developing countries, in this subspeciality Prof Hacker is a great teacher and support to newcomers in this field, and has made an impressive contribution to establish Gynaecologic Oncology in its appropriate respected place in many Asian and European countries.

My experience at RHW was an eye opener for my future in gynecologic oncology practice. I learned many new things in the management of gynecologic cancers that have made me wiser and more confident. Prof Hacker was extremely benevolent to teach and share all his experiences of surgical and clinical skills, although I think if I could have attended more of his teaching sessions (lectures). He is a great support to any new comer in this sub-speciality. His hunger to always continue to do something new, so quantity and quality of life could be improved, is remarkable. I had the opportunity to watch him interacting with cancer patients not only in his clinics, but also in wards and post operative area. In every area, I found something new to learn. He is a master of the subject in a true sense and is not only the cancer surgeon, but a guide to a future Gynecology oncologist. He has amazing leadership skills. Other consultants, Drs. Greg Robertson, Rhonda Farrell were also nice to me. I want to personally thank Ellen, Beth, Triss too, who were ready to help anytime I approached them. There was an excellent learning environment at RWH.

It was an opportunity to appreciate and to be part of the diversified cultural and traditional values of Australia. In all, my stay in Sydney was pleasant and full of excitement. The pollution-free lush green Australia and its exotic long coastal lines and beaches, were rare sights one can never forget. Other cities that I visited, Perth, Brisbane, Gold Coast and Canberra were equally beautiful. I enjoyed Australian styled Indian food a lot. Memories of Prof’s generous Indian dinners and discussions are still vivid, I am going to cherish them life-long.

Last but not the least I would personally thank Mrs Estelle Hacker, a lady of unbelievable talent, a great artist and still so humble and down-to-earth, a rare combination. When I saw portraits and sceneries made by her, I was left astonished and speechless for a moment; that in Australia, too, people could have such deep love and devotion to art. I have no words to describe her talent, I really have all my admiration to her. I never felt away from home, all because of Madam. Thank you to Erica Riley for her help, without which, this trip would have not been possible. I am sincerely grateful to Dr Michael Bookman for his kind and generous help rendered to me.

Presently I am working as Consultant Gynecologic Oncologist at Dharamshila Cancer & Research Centre, Delhi, India. I hope and wish to get more such opportunities from IGCS to hone my skill in my field.
Dr. Artem Stepanyan (Armenia)
University Hospital, Leuven, Belgium, EU and
Charles University and General Faculty Hospital, Prague Czech Republic

At Shengavit Medical Center, Yerevan, Armenia, we have been involved in a collaborative program in OB/GYN with AAMSC (Armenian American Medical Society of California) beginning in 2002. Through this program, our hospital is supplied with modern medical equipment including that related to endoscopy, anesthesiology and surgery. In addition, twice a year we are visited by Prof. Bedros Kojian (University Irvine, California USA), who gives master classes in operative gynecology (predominantly in vaginal surgery and video-endoscopic surgery). Thanks to this excellent support from our American colleagues we are able to provide a high standard of medical care to our patients. Unfortunately, GYN oncology is not involved in this program and the trainings abroad are the only opportunity to bring and keep up to date our activity in this field.

Division of Gynecological Oncology, Department of Obstetrics and Gynecology, University Hospitals of Catholic University Leuven, Belgium (20-May to 04-July): On the very first days of my stay in Leuven, Prof Vergote discussed with me the topics of interest in GYN oncology and together we composed a schedule designed to make my fellowship most effective and fruitful.

Since the major goal of my visit was surgery of advanced ovarian cancer, Leuven was an ideal place for improvement. Twice or thrice a week I had an opportunity to observe or assist in ovarian cancer debulking surgery cases. Along with the lower and middle abdominal debulking which is properly established in most of GYN oncological centers, here I could see the upper abdominal surgery (diaphragmatic stripping and resection, splenectomies, distal pancreatic and multiorgan resections etc.) which is the most challenging and a relatively new field in surgical gynecological oncology. On the other hand, I could also observe or assist in other procedures performed for cervical endometrial and vulvar cancer. During the procedures Profs Vergote and Amant patiently answered all my numerous questions in detail so I could learn many tips and tricks at the hands of great masters. Moreover, I was introduced to the basics of robotic surgery which is a well established and frequently used technique in the department.

Every Wednesday was breast surgery day. I was able to observe and assist in radical mastectomies, breast sparing and oncoplastic procedures, sentinel node technique etc.

Tumor boards were a very important part of the training. All members of the department along with the radiation oncologists and pathologists, participated in those meetings and every case was discussed in detail with viewing of CT, MRI, PET, PET/CT images and pathology slides. It was a great opportunity not only to become familiar with the clinical approaches in certain institutions, but also to see how the clinical trials were designed.

Along with the treatment activities I had one day weekly in the diagnostics department mostly in breast radiology. Thanks to the extremely kind and professional staff (Dr. Van Ongeval, Dr. Van Steen, charging nurse – Ann), I had an opportunity not only to discuss numerous mammographic slides and to observe breast ultrasound, but I had a separate examination room with US machine and with all the necessary facilities to enable me to perform hundreds of US guided biopsies. It was a great improvement because I've gained not only knowledge but very useful skills as well. My mentors were very concerned about efficacy of the training and possibility of implementation in Yerevan. So, at the end of training, I was presented with a set of biopsy guns and a very nice book about Belgium with the signatures and warm wishes from the members of department.

In parallel Prof. Vergote kindly arranged for me a one month hands on training in video-endoscopic surgery at the Center of Surgical Technologies. The basic exercises were performed on the endotrainer. Surgical procedures were performed on the POP (pulsating organ perfusion) trainer and animal model. Although I had a laparoscopic background, this training was very useful especially in the scope of suturing and knot tying skills improvement. As an example, on the first days of training my laparoscopic suturing/knot tying score was 4-5 minutes whereas at the end it was 90±5 sec.

The second part of my fellowship was shifted to Oncogynecological Center of Department of Obstetrics and Gynecology of Charles University, Prague Czech Republic (06-Jul to 12-Aug): This was a familiar department for me as I spent five weeks there in 2008. During my last visit I was trained in extremely radical modifications of procedures performed in this department (radical hysterectomy, para-aortic lymphadenectomy, debulking surgery) and ultrasound staging of gynecological malignancies. On returning to Yerevan I’ve implemented those new modifications in the practice of our Hospital. But as usually happens, during this activity numerous questions related to some technical details arose. Therefore, the second visit was very important for getting answers to those questions.

From the very first day of my visit I was actively engaged in the work of the department. Since the major goal of the fellowship was improvement in radical surgery my visit to Prague was of great importance. Thanks to extremely kind and friendly relationship of Prof Cibula and his staff I could assist almost all procedures performed in the department (1-3 cases daily). Along with the OR, one day per week I spent in the ultrasound department observing US staging of gynecological cancer. It was very important for me because CT/MRI are not routine imaging methods in my country. Tumor boards were also very useful and informative. Every time there was somebody from the department who kindly translated all discussions so I could gain maximal information from the meeting. I’ve find not only highest level of gynecological oncology but also very good friends and an excellent possibility to built long lasting collaboration.

In Conclusion: Tremendous – this expression fits best as a description of this fellowship. In a very short time I was able to make a huge step forward in my specialty, gaining knowledge and skills which will be implemented in our country and I’m sure will save many lives. This is an excellent example of people staying above the economic and political issues and sharing of priceless pearls of professional knowledge. So here I would like to express my infinite gratitude to IGCS and Erica Riley for the support which became the basis of this fellowship. To Professors Ignace Vergote, Frederic Amant and Patric Nevin. To Doctors Van Ongeval and Van Steen. To my trainer in endoscopic surgery – Ann Lissens. To the brilliant surgeon, excellent teacher and my great friend Prof. David Cibula and his team: Jiri Swarovski, Jiri Slama, Michael Zikan, Daniela Fisherova, David Pavlista and Ivana Pinkalova.