2012 Japan Traveling Fellow reports on trip

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Figure 1. Sakurajima volcano.

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Figure 2. Dr. Grobmyer (front center) and Dr. Iwakuma of Kurume University (front right), join other members of the surgical oncology team at Kagoshima University Medical Center. Front left: Shoji Natsugoe, MD. Back row, left to right: Kosuke Kawagoe, MD; Munnetsugu Hirata, MD; Dr. Kijima; and Prof. Heiji Yoshinaka, MD, PhD.

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Figure 3. Expert Meeting in Breast Cancer, Kurume City, Japan. Left to right: Dr. Iwakuma; Dr. Grobmyer; Dr. Mitsuyama, and Dr. Toh.

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Figure 4. Professor Toi and Dr. Grobmyer at Kyoto University, Kyoto, Japan.

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Figure 5. Dr. Grobmyer (left) and Dr. Fukuma in Kamogawa.

Upon learning of my selection as the American College of Surgeons (ACS) 2012 Japan Traveling Fellow in October 2011, I began Japanese language lessons. This background not only facilitated my independent travel experiences in Japan, but also greatly strengthened my personal and scientific interaction with Japanese colleagues. This introduction to the Japanese language and customs proved to be an invaluable experience that other traveling fellows to Japan should consider pursuing.

Kagoshima University Medical and Dental Hospital

I arrived at Kagoshima International Airport on March 28. After arrival, I rode a bus for one-and-a-half hours through the most southern region of Japan to arrive in Kagoshima City. Kagoshima is also home to one of the largest active volcanoes in the world, Sakurajima (see Figure 1).

The next day, I visited the department of digestive surgery, breast, and thyroid surgery and the department of molecular frontier surgery at Kagoshima University Graduate School of Medical Sciences. Prof. Shoji Natsugoe, MD, chairman of the department of surgery greeted me and took me to the morning daily surgical case conference. For this conference, the physicians had prepared presentations in English. We discussed four cases, including a patient with insulinoma and several cases of locally advanced breast cancer (see Figure 2).

My host for the operating room (OR) day was Kosei Maemura, MD, who is a pancreatic surgeon at Kagoshima University Hospital. I observed a minimally invasive videoscopic thyroid lobectomy for a follicular neoplasm, an esophagectomy in a patient with a prior history of distal gastrectomy for gastric cancer, and a microwave-assisted hepatectomy for hepatocellular carcinoma.

I toured the surgical research laboratory in the afternoon. The department of surgery at Kogoshima University has a particular research interest in novel molecular markers for cancer and on circulating tumor cells in gastric cancer and other malignancies. We discussed potential applications of these markers as targets for nanotechnology-based anti-cancer strategies. I presented two lectures to the department faculty on Thursday afternoon: Technical Approaches to Prevention and Management of Complications following Surgery for Pancreatic Cancer, and Surgeon Directed Intra-operative Radiation for Breast Cancer with Low-Kilovoltage X-Rays.

I then attended a surgical case conference during which we reviewed cases of thyroid cancer and breast cancer and discussed some of the recent research in these areas from faculty members at Kagoshima University Hospital. We discussed the role of thyroglobulin in evaluation of indeterminate thyroid nodules as well as Kagoshima University Hospital’s experiences with transoral throidectomy. We discussed the indications and approaches to oncoplastic breast cancer surgery at Kagoshima University Hospital. My host for the OR on this day was Yuko Kijima, MD, PhD, who is an expert in oncoplastic breast surgery. I observed Dr. Kijima perform oncoplastic surgery for breast cancer, and I observed Akihiro Nakajo, MD, perform a transoral thyroidectomy for a follicular neoplasm.

Surgical oncology in Fukuoka Prefectue

I then traveled to Kurume City via the Shinkansen (Japan’s high-speed rail system) with Dr. Nobutaka Iwakuma from Kurume University and a former member of my laboratory group at the University of Florida. After a pleasant visit with the Iwakuma family,  I took a train to Kitakyushu Municipal Medical Center to visit Shoshu Mitsuyama, MD, president of Kitakyushu Municipal Medical Center. In the OR, I observed endoscopic surgery for early-stage breast cancer and a laparoscopic distal gastrectomy with lymphadenectomy for distal gastric cancer. I met with dermatologists at Kitakyushu Municipal Medical Center for a discussion about current treatments and surgical management of melanoma and other skin cancers. I was interested to learn about and discuss the very low incidence of malignant melanoma in Japan.

I then returned to Kurume City for the 2nd Expert Meeting in Breast Cancer (see Figure 3), where I gave an invited presentation titled Use of MRI for Guiding Breast Cancer Therapy. This session was followed by a reception attended by many faculty members and residents. Many residents and faculty whom I met had spent time in the U.S. as part of research or clinical training.

On April 3, I visited Kurume University Medical Center (KUMC) with Dr. Iwakuma. After being welcomed by department of surgery chairman Prof. Kazuo Shirouzu, MD, we visited the OR to watch a lumpectomy and axillary lymphadenectomy for breast cancer, performed by Uhi Toh, MD. I had discussions with KUMC surgeons about differences in the U.S. and Japan regarding margins of excision for breast cancer and re-excisions. I also observed a low anterior resection for large low rectal cancer performed by Dr. Shirouzu as well as laparoscopic total gastrectomy. In the afternoon, we visited the laboratory to discuss collaborative research in cancer nanotechnology and toured the breast cancer clinic.

Breast Cancer Research at Kyoto University

The following day, I traveled to Kyoto via the Shinkansen. Prof. Masakazu Toi, MD, chairman of the breast cancer department at Kyoto University, greeted me and gave me a tour of the university (see Figure 4). We discussed ongoing breast cancer research at Kyoto University, particularly with respect to the role of carbonic anydrase in lymph node metastases in breast cancer, a common interest in both of our breast cancer research groups. Following this exchange, we attended a presentation by Tomoharu Sugie, MD, on his work with the use of intraoperative fluorescence guided surgery developed at Kyoto University. We discussed the future plans for this work as well as the development of new nanomaterials for fluorescent intraoperative imaging under development by our group at the University of Florida. In the evening, I attended the breast cancer tumor board of Kyoto University. There was a discussion regarding management of many newly diagnosed patients. Particular attention was given to the selection of patients for neo-adjuvant therapy and the role of preoperative axillary nodal evaluation.

After visiting the OR the following morning and at the suggestion of the faculty at Kyoto University, I visited numerous famous sites in Kyoto, including Nijo Castle, Ryoanji Temple, Sanjusangendo, and The Golden Pavilion.

On April 6, I observed Dr. Sugie performing a modified radical mastectomy in a patient following neo-adjuvant chemotherapy. In the afternoon, I also visited the pathology lab and the breast cancer research labs. I presented a lecture titled Intra-operative Radiation Therapy for Breast Cancer to the clinical and research teams at Kyoto University and had dinner with the breast cancer team and Dr. Toi at a Pontocho restaurant.

Next, I went to Tokyo to visit friends who took me to Aoyama Cemetery, which is famous for cherry blossoms in the spring.

Endoscopic Breast Surgery in Kamogawa

On April 8, I arrived at Kamogawa in Chiba Prefecture to visit Kameda Medical Center. My host in Kamogawa was Eisuke Fukuma, MD, chairman of the breast center at Kameda Medical Center. Kamogawa was the closest point that I visited during this trip to the center of the tragic tsunami that struck Japan in 2011. I learned from Dr. Fukuma much about the impact of the tsunami on this region and people of Japan.

I toured the breast clinic and hospital at Kameda Medical Center and met with Takaaki Kameda, MD, the hospital’s chairman of the board and chief executive officer. We discussed similarities and differences in Japan and U.S. surgical care. In the afternoon, I attended the OR to observe a minimally invasive mastectomy with sentinel node biopsy performed by Dr. Fukuma.

I attended a multidisciplinary breast conference at Kameda Medical Center and visited the ORs to observe four cases of endoscopic breast surgery and gave a lecture on applications of nanotechnology for solving clinical problems in breast cancer (see Figure 5).

Japan Surgical Society Annual Meeting

On April 11, I travelled to Chiba for the Japan Surgical Society (JSS) meeting. At this meeting, I attended a poster presentation by Dr. Iwakuma on nanoparticle delivery to cancer resulting from ongoing collaborations between Kurume University and the University of Florida. I also attended the award ceremony for the travelling international fellows.

I presented a paper at the JSS annual meeting titled Applications of Nanotechnology for Solving Clinical Problems in Breast Cancer. This session was chaired by Prof. Kyoichi Takaori, MD, FACS, from Kyoto University. I also met with Prof. Noriaki Ohuchi, MD, dean of the graduate school of medicine at Tohoku University. Professor Ohuchi is a leader in cancer nanotechnology in Japan, and we discussed translational efforts in cancer nanotechnology in Japan and the U.S. On April 14, I departed Japan and returned to the U.S.

I am extraordinarily grateful for the opportunity to exchange scientific and clinical information with former and many newly acquainted colleagues in Japan. I am very grateful for the hospitality extended to me by so many people in Japan during my visit. It was very interesting to learn how much we in the U.S. have in common with our Japanese surgical colleagues. I look forward to applying some of the knowledge gained during my visit to Japan to my surgical oncology practice in the U.S.

As a result of my trip, I look forward to many future productive years of scientific collaboration and friendship with surgical colleagues in Japan. I thank the American College of Surgeons and the Japan Surgical Society for this unique opportunity.

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