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INTRODUCTION
The Annual Meeting of the Thai Gynecologic Cancer Society (TGCS) was held between August 2–4, 2019 in the heart of beautiful Chiang Rai province in the uppermost part of northern Thailand. The theme of this year meeting was “Advance & Innovation in Gynecologic Oncology: Platform 5.0” aiming to provide updated information and discuss key issues in management of gynecologic cancers. Approximately 330 healthcare professionals including gynecologic oncologists, gynecologic oncology fellows, radiation oncologists, medical oncologists, general gynecologists, and specialized nurses from all regions of the country attended the meeting.
This report summarizes main scientific program topics and the society associated events.
OPENING AND PRESIDENTIAL ADDRESSES
In this session, Professor Jatupol Srisomboon, President of TGCS, addressed the impact of cervical cancer on the health of women in this region (Fig. 1A and B). He highlighted the effort of Thai gynecologic oncologists in preventing the disease by promoting widespread screening program incorporating cervical cytology and the coming human papillomavirus (HPV) testing along with early implementing HPV vaccination. He also outlined the development of surgical treatment of early-stage cervical cancer in Thailand. An emphasis was put on the process of development and modification of radical hysterectomy as a unique procedure central to gynecologic oncologists’ surgical armamentarium. It has been well accepted that early-stage (International Federation of Gynecology and Obstetrics stage IB–IIA) cervical cancer can be effectively treated either with primary radical hysterectomy and pelvic lymphadenectomy or pelvic radiation with 5-year survival rates of 80%–85% for stage IB and 50%–65% for stage IIA [1]. However, surgery provides a chance to preserve ovarian and vaginal function, which is particularly beneficial for young, reproductive age women [12]. Review of survival outcomes of 1,253 women with early-stage cervical cancer (stage IB1, 61%; stage IB2, 6.2%; and stage IIA, 8.5%) treated with radical hysterectomy and pelvic lymphadenectomy at Chiang Mai University over 12 years period from 1995–2006 revealed an estimated 10-year recurrence-free survival of 90%. Around 66% of the patients received no adjuvant treatment. Stage IB2/IIA, non-squamous cell carcinoma, pelvic node metastasis, and positive vaginal margins were factors associated with poor outcome. The most common long-term complication was lymphoedema and bladder dysfunction [3]. Nerve-sparing technique for radical hysterectomy has been adopted and modified with an attempt to minimize long-term morbidities associated with pelvic autonomic nerve damage during paracervical resection and, at the same time, to maintain favorable survival outcomes [45]. Tumor size, urinary tract infection, and individual surgeon's technique independently predict recovery of voiding function on day 7 post operation [6]. During this session on the issue of appropriateness of minimally invasive approach for radical hysterectomy, it was suggested that individual surgeon's technique and experience as well as survival outcomes would play important roles in decision making.
INVITED INTERNATIONAL SPEAKER SESSION
Dr. Tomoyasu Kato, Chief of the Gynecology Division at the National Cancer Center Hospital in Tokyo and a well-recognized pioneer in the technique of nerve-sparing radical hysterectomy, demonstrated anatomical foundation along with practical application of the technique based on previous researches [78]. Impressive step-by-step video presentation of the surgical technique was also shared and discussed widely with the participant gynecologic oncologists (Fig. 2).
INVITED SPEAKERS' SYMPOSIUM
1. Laparoscopic Approach to Cervical Cancer (LACC) trial: from their data to ours
Findings from the recently published LACC trial have a strong global impact on decision to offer laparoscopic approach for radical hysterectomy in early-stage cervical cancer patients [9]. In this much anticipated session, representatives from seven major gynecologic oncology centers that performed laparoscopic radical hysterectomy with pelvic lymphadenectomy for early-stage cervical cancer including Dr. Peerapong Inthasorn from Siriraj hospital, Dr. Apichai Vasuratna from King Chulalongkorn Memorial Hospital, Dr. Aranya Yantapant from Rajavithi Hospital, Dr. Nuttavut Kantathavorn from Chulabhorn Hospital, Dr. Supachai Raungkaewmanee from National Cancer Institute, Dr. Yuthasak Suphasynth from Songklanagarind Hospital, and Dr. Chailert Phongnarisorn from Maharaj Nakorn Chiang Mai Hospital gathered to share and discuss their case selection criteria, surgical protocols, techniques, results, and survival outcomes comparing to those of the LACC trial. Although the survival outcomes were not different between the open and the laparoscopic approaches in most centers, there appeared notable discrepancies among institutions regarding techniques and survival outcomes. A plan is in place to combine the data from these centers in order to increase the power to detect difference in important outcomes and to reach more meaningful conclusion.
2. Nodal status in gynecologic cancer: trend in management
In this session, Dr. Suwanit Therasakvichya and Dr. Atthapon Jaishuen reviewed the importance of nodal metastasis, indications, and open/laparoscopic approaches to pelvic and para-aortic lymphadenectomy for patients with cervical, endometrial, and ovarian cancers. Related data from Siriraj Hospital were presented. Role of sentinel node biopsy was also discussed.
3. Management of vulvar cancer: basics and beyond
Vulvar cancer is considered an uncommon disease in Thailand. Dr. Prapaporn Suprasert and Dr. Kittipat Charoenkwan discussed surgical management of this disease. At Chiang Mai University, 15–20 patients with newly diagnosed vulvar cancer were treated annually. Approximately half of them were in early stage and were mostly treated with radical local excision plus groin node dissection with or without adjuvant radiation. Radical vulvectomy with advanced reconstructive technique in patients with extensive primary disease at the vulva was also demonstrated. In addition, role of sentinel node biopsy and treatment of vulvar Paget's disease were discussed.
4. Recent advance in radiotherapy for gynecologic cancers
Dr. Petch Alisanant emphasized the principle of radiotherapy, which is “to give the adequate radiation dose to control tumor and limit dose to adjacent normal tissue.” Modern external beam radiotherapy system including intensity-modulated radiotherapy, volumetric modulated arc therapy, CyberKnife, and tomotherapy as well as brachytherapy system particularly image-guided adaptive brachytherapy technique were presented.
5. Updated management of cancer of unknown primary
Cancers of unknown primary (CUP), which account for 2%–9% of all cancer patients, represent a heterogeneous group of metastatic tumors whose original sites are unable to be identified. Clinical presentations varied and can be categorized into subgroups based on prognosis, which is associated with chromosomal instability and molecular signatures. Comprehensive genomic profiling data from CUP tissue demonstrated clinically-relevant mutations in up to 85% of the patients with CUP, of which 15%–60% could benefit from available targeted therapy [1011121314]. Dr. Apiwat Aue-aungkul and Dr. Patrapim Sunpaweravong discussed clinical, pathological, molecular studies, and novel multidisciplinary management of this condition using precision medicine approach.
6. Advancement of hysteroscopy into the realm of endometrial cancer
Dr. Navamol Lekskul reviewed current role of hysteroscopy in the diagnosis of endometrial cancer with increased sensitivity as a result of the novel imaging systems that elucidate vascularity of the endometrium. Also, the concern over malignant cell spillage during the procedure due to the use of distension media and the importance of paying close attention to the pressure of fluid distension media were emphasized. Furthermore, the other benefits of hysteroscopy in injection of indocyanine green or technetium 99 m during sentinel lymph node mapping of para-aortic area and for resection of endometrium in combination with progestin therapy in fertility-sparing treatment of endometrial cancer were presented.
7. Liquid biopsy: a novel biomarker for gynecologic cancers
Liquid biopsy (also known as fluid biopsy) refers to the analysis of circulating tumor cell and circulating cell-free tumor DNA obtained from blood circulation or body fluids. It is considered a less invasive, easier, and more cost-effective technique for diagnosis, monitoring, and predicting response to treatment of many cancers compared to the available methods including tissue biopsy and imaging [15]. Although the technique has been approved for early detection in other cancers such as those originated in lung, breast, colon, and prostate gland, data on its utility in gynecologic cancers are still limited. Dr. Saranya Chanpanitkitchot discussed the possible future role of liquid biopsy as a biomarker for early detection and monitoring of gynecologic cancers especially ovarian cancer.
8. Cannabis (Gan-ja): relevant issues for gynecologic cancer patients
Dr. Sumonmal Manusirivithaya and Dr. Jintana Manorompatrasal discussed the role of cannabis in the management of patients with gynecologic cancers. Cannabis or Marijuana (known in Thailand more widely as Gan-Ja) has long been used for recreational and medical purposes. For cancer patients, cannabinoids have been claimed to be useful for management of common symptoms including chemotherapy induced nausea and vomiting (CINV) and pain. In addition, the agent may have a role in cancer treatment. However, benefits of cannabinoids in cancer patients except for CINV still cannot be confirmed [16]. Regarding CINV, systematic reviews showed that synthetic cannabinoids (nabilone and dronabinol) were significantly more effective than placebo and at least as effective as various conventional antiemetics (such as metoclopramide). However; comparing with serotonin receptor antagonists, they were similarly effective. Since cannabinoids have psychotropic effects that were not found with serotonin receptor antagonists, synthetic cannabinoids are not recommended as first-line or second-line antiemetics. However; cannabis may be useful for CINV that cannot be controlled by new standard antiemetics [1617].
9. Intraoperative tumor lysis syndrome (TLS) in a patient with advanced ovarian cancer
Dr. Malika Kengsakul and Dr. Karun Kengsakul discussed an interesting case with TLS. TLS is a potentially life-threatening oncological emergency resulting from massive cytolysis of malignant tumor cells which is commonly encountered in patients with hematological malignancies and rarely occurred in solid tumors. The condition leads to clinical complications such as seizures, acute renal failure, and cardiac arrhythmia. In this session, a case of spontaneous TLS that developed during tumor debulking surgery in patient with highly vascularized ovarian tumor was presented. The patient's symptoms and signs included marked sweating, sinus tachycardia, urine crystallization and impaired hemostasis. The operation was terminated after salpingo-oophorectomy and omentectomy. Laboratory investigations showed multiple electrolyte disturbances and acute kidney injury. The electrolyte abnormalities and progressive decline of kidney function did not respond to aggressive hydration and rasburicase. Eventually, the patient underwent hemodialysis on the next day. The major causes of death in patient with clinical TLS are hemorrhage and acute kidney injury. Moreover, it is associated with the higher treatment-related complication and costs. This case highlights the importance of early recognition and resuscitation when treating patients with TLS in high volume ovarian malignancy.
IDEAS FROM INTERNATIONAL MEETINGS AND CONFERENCES
In this session, TGCS's members, who have a chance to attend and present their research work in international meetings and conferences in the field of gynecologic oncology during the past year shared their experience and ideas obtained from those events.
GYNECOLOGIC ONCOLOGY FELLOWS' RESEARCH PRESENTATION
Twenty-three fellows who have just graduated fellowship training presented their research, submitted for board examination, in the oral presentation session, which is open to discussion by all congress attendees.
ADMINISTRATIVE AND SOCIAL EVENTS
1. TGCS business meeting and general election
Annual TGCS business meeting was held on August 3, 2019 to present the academic and social activities of the society carried out in the past year. The general election of the new administrative board members of TGCS was also held for the term 2020–2021.
2. Appreciation ceremony for retired senior TGCS members and TGCS Nite 2019
The TGCS Nite was a banquet that provided a good opportunity for TGCS members and congress attendees to express appreciation and pay respect to the senior members, who were going to retire in that year (Fig. 3A). Congratulations ceremony was organized for 23 doctors who have just graduated the gynecologic oncology fellowship training in 2019 (Fig. 3B and C). In addition, the banquet featured group performances by current gynecologic oncology fellows and attending oncologists from all institutions with a fellowship training program. The annual TGCS meeting was also the venue for alumni reunion of the 13 gynecologic oncology training centers in Thailand (Fig. 4). This pleasant social event was a great occasion to promote long-lasting friendship and future collaboration among all participants.
Fig. 3
(A) Appreciation ceremony for the retired senior Thai Gynecologic Cancer Society members (Dr. Chantawat Sheanakul from Bumrungrad International Hospital, Bangkok and Dr. Surawut Leelahakorn from Vajira Hospital, Navamindradhiraj University, Bangkok). (B, C) Congratulations ceremony for the 23 graduates in gynecologic oncology fellowship training.
Fig. 4
Gynecologic oncology teams & alumni reunion of some gynecologic oncology training centers. (A) King Chulalongkorn Memorial Hospital. (B) Ramathibodi Hospital. (C) Phramongkutklao Hospital. (D) Maharaj Nakorn Chiang Mai Hospital. (E) Siriraj Hospital.
The Annual Meeting of the TGCS 2020 will be held between August 7–9, 2020 in Phuket province, a rain-forested, mountainous island with the most popular beaches in the Andaman sea in southern Thailand.
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