Thai Cholangiocarcinoma Workshop Report

Workshop in Cholangiocarcinoma: 

Sharing the Disease Burden in the UK and South East Asia

Khon Kaen University, Thailand – 12-14 March 2014 

 

Workshop Overview

imagesThis 3-day event was the first international cholangiocarcinoma workshop of its kind and was appropriately held in Khon Kaen, in the north east of Thailand, as this area has the highest reported incidence of cholangicarcinoma in the world.

The main purpose of the workshop was as a forum for the advancement of various aspects of cholangiocarcinoma research, including epidemiology, pathology, biology, molecular biology, diagnosis, prevention and treatment, and to share perspectives and experiences on CC amongst UK and Thai researchers.  It was hoped that new ideas for combating this devastating disease would be generated and that it would provide an opportunity for new and potential international research collaborations to be established.

There were over 100 registered participants coming from the UK and various parts of Thailand to share their research work and to establish links and, on the first day, there were more than 20 poster presentations from young (and not so young!) researchers, presenting an enormous range of work that is now underway.

10003643_10152842179033912_1781957720_oThe second day was ‘invited participant’ workshops, bringing together presentations and discussions from the major CC projects underway in the UK and Thailand, including biomarker, diagnosis, surgery, patient support and patient care workshops.  Helen Morement of AMMF, was a keynote speaker at the Patient Support workshop, presenting the work of the charity.  At each of the workshops there was the opportunity to discuss the lessons learned and the challenges that are faced.

The third and final day was a field trip to the rural areas of the north east Thailand, the area with the world’s highest incidence of CC, largely attributable to the consumption of raw river fish which is host to the liver fluke, Opisthorchis viverrini.  This field trip provided local and in-depth information on conditions in the area, leading to an understanding of the problems the Thai rural population face.

Helen Morement’s Report

AMMF's Helen Morement

AMMF’s Helen Morement

The invitation to attend this workshop and present the work of AMMF was a direct result of my meeting with the Thai cholangiocarcinoma delegation at Imperial College in London in the summer of 2013 when I was asked to present the work of the charity.

There is no doubt, cholangiocarcinoma is a global problem and, in order to move forward, we desperately need research and the improvements this will bring.  To achieve this we need access to higher numbers, to more samples, to effective research – collaboration with Thailand should enable this and, it is hoped, the results achieved in this way will then lead to improvements for the UK, Thailand and the world.

Helen Morement of AMMF with the Thai delegation and members of the Imperial College CC research team 06.06.13

Helen Morement of AMMF with the Thai delegation and members of the Imperial College CC research team 06.06.13

Professor Simon Taylor-Robinson of Imperial College London, with whom AMMF has had links going back over several years, has been instrumental in setting up a Thai collaboration, leading to the workshop, the first of its kind dedicated to cholangiocarcinoma.

To read more about the original meeting with the Thai delegation, click here

 

This is my personal report of an incredible 3 days in Thailand during March:

Day 1 – The venue for the first day was Srinagarind Hospital (Faculty of Medicine,  Khon Kaen University).  After a warm welcome on behalf of our Thai hosts from Associate Professor Charnchai Panthongviriyakul, there followed several major presentations on the work that is being carried out in the UK, and that is underway in Thailand.

I was particularly interested to hear Professor Narong Khuntikeo’s presentation.   I had met Prof Narong, a surgeon from Khon Kaen University, in London last summer when he told me that he had lost his grandfather, mother and father to CC and how, because he ate raw fish as a child, he knows he is at risk from CC too.  He is totally dedicated to helping those with the disease, and carries out an incredible number of surgical resections at Srinigarind hospital.  So it was good to hear him speak about the development of an ultrasound screening programme for early diagnosis and management of CC, amongst those considered to be at high risk in the endemic areas.

In rural areas, river fish are caught and eaten raw with herbs.

In rural areas, river fish are caught and eaten raw with herbs.

In rural areas, raw fish infested with the liver fluke, Opisthorchis viverrini, is eaten.  The liver fluke causes chronic inflamation of the biliary system and periductal fibrosis is also a risk – doctors are taught how to use the ultrasound equipment and read the results, a relatively simple, low cost way of detecting CC in its early stages.

 

 

Later, during the lunch break, Dr Bandit Thinkhamrop (from the Department of Biostatistics and Demography, Faculty of Public Health, KKU) introduced himself and I immediately recognized his name as he pops up now and then on AMMF’s Facebook page.  He is involved with the screening programme and posted the following on Facebook when I got back to the UK:

“So glad to meet you, Helen, in Thailand. We are just back from a district which is reportedly the place with the highest prevalence of CCA in Thailand. We performed ultrasound screening on 724 people who were selected by local primary care units as the risk population. Out of that, 30 people were suspected having CCA and were then referred for CT scan for confirmatory diagnosis.”

Ultrasound screening 724 people sounds an amazing task, but to have found 30 who may have CC is certainly an incredible result, as this may save their lives.

Amongst the other presentations, I was especially interested to hear Dr Shahid Khan (Imperial College London) speak about the epidemiology of CC, and his concerns that changes in the way extra- and intrahepatic CC are now classified may be skewing statistics incorrectly to show that intrahepatic CC is increasing markedly.  (For more about this, ‘Rising trends in cholangiocarcinoma: Is the ICD classification system misleading us?’ click here )

And good to see the AMMF logo on Dr Khan’s slide presentation to acknowledge the support we have given his research work.

In fact, AMMF’s contribution to CC research was mentioned several times in various presentations and was particularly acknowledged by Dr Khan, Dr Chris Wadsworth, and Dr Abigail Zabron.  Extremely heartening!

Learning to work with the lotus flower ...

Learning to work with the lotus flower …

During the afternoon, there was a brief but wonderful interlude when a few of us elected to visit the Saeng-Thip and Aim-Im projects.  Here we learned about the thoughtful and gentle end-of-life care for patients, and how student nurses are taught loving kindness and gentleness through working with the most delicate of flowers to produce incredible arrangements and garlands. A wonderful atmosphere of peace and calm – but much laughter, too, especially at my attempts to deal with a lotus flower! We were treated to beautifully presented afternoon tea, Thai style, and I left laden with flowers and gifts from the ever-smiling Thai ladies.

The special 'good luck' thread being tied to my wrist by 'Big Thai Mama', who runs the projects.. And, as is traditional when having the thread tied, my arm is being supported by the wonderfully kind and helpful Duangsamorn.

The special ‘good luck’ thread being tied to my wrist by ‘Big Thai Mama’, who runs the projects.. And, as is traditional when having the thread tied, my arm is being supported by the wonderfully kind and helpful Duangsamorn.

Beautifully presented afternoon tea, Thai style

Beautifully presented afternoon tea, Thai style

 
The ladies of the Saeng-Thip and Aim-Im projects

The ladies of the Saeng-Thip and Aim-Im project

Special sets used during end-of-life care

Special ‘sets’ used during    end-of-life care

 

A guided hospital tour followed, which included a visit to the ITU, where two CC patients were recovering from resection (astounding that we were allowed to go in to this area), and to see the MRI scanner in operation.

The Gala Reception - traditional Thai music and dancing

The Gala Reception – with traditional Thai music and dancing

A packed day – but not over yet!  Back to the hotel with 20 minutes to change for the Gala Reception.

We, the honoured overseas delegates, were regally entertained with traditional Thai music and graceful dancers, and by a rendition of a traditional Thai melody played by the surgeon Professor Narong on a set of Thai pipes (looked like overgrown Pan pipes)!

Several speeches were given during the evening, including my one of thanks to the Thai organizers and hosts and the distribution of lapel pin gifts from AMMF.

Surgeon Professor Narong plays for us on the traditional Thai pipes

Surgeon Professor Narong plays for us on the traditional Thai pipes

 

 

 

 

 

 

And so ended, exhaustedly, the first day!

Day 2 and the specific workshops covering Biomarkers, Diagnosis, Surgery, Patient Support and Patient Care.

Day 2 at the Workshop

Day 2 at the Workshop

With presentations taking place in three different rooms on the 2nd day some, unfortunately, had to be missed.  This was so difficult, as I really wanted to be at all of them!

However, I chose to go first to the Diagnosis Workshop, to hear presentations from Professor Adrian Lim on the state-of–the-art Microbubble Ultrasound which, as he explained,  has an accurate diagnostic capability which rivals that of CT and MRI techniques – and it’s quick and cost effective, too.

This was followed by Professor Richard Syms explaining the current situation with the MRI imaging device with miniature internal coils.  Prof Syms is an engineer, and he has been working for some time on this device with Dr Chris Wadsworth at Imperial – work AMMF has been interested in and has supported.  The device is showing great promise, but there are difficulties to overcome, re testing and the expense involved in developing this further.  AMMF has been in contact with Prof Syms about this since our return.

Then on to the Biomarkers Workshop to hear Dr Abigail Zabron present the current situation with her work, and with that of Dr Simon Ralphs, on biomarkers for CC – again work AMMF has supported.  Dr Zabron explained that advances have begun to delineate the many implicated pathways, but that progress is frustratingly slow and as yet, have not translated into improved patient outcome.  However, analyses of patient biofluids have begun to identify novel biomarkers which may improve diagnostic efficacy.  But, there is much more work to be done.

AMMF's Presentation at the Thai CC Workshop

AMMF’s slide presentation at the Thai CC Workshop

The afternoon choice had to be the Patient Support Workshop – not least because this was the one at which I had been invited to present the work of AMMF!  The presentation was well received, with many questions asked afterwards by members of the new CCA Foundation in Thailand  – which has only recently been established and is seeking the best ways to bring about much needed social awareness of CC.

To view the slides used in the AMMF presentation, click here

British Council and Thailand Research Fund Workshop

British Council and Thailand Research Fund Workshop

 

 

For the complete Workshop programme:

click here

 

 

 

 

 

Day 3 and the Field Trip  It was another early start.  As we left Khon Kaen we were driven northwards along the Friendship Highway (aka Freeedom Highway) – an impressively large road leading out into rural Thailand* – through Udon Thani,  to Nong Khai and the Mekong River, where the road links with the Thai-Lao Friendship Bridge to Laos.

We were passing through rural areas with the highest concentration of cholangiocarcinoma in the world.  To the left and right were numerous rice fields, complete with water buffalo – which is where the snails that start the liver fluke cycle (snail – fish – man) are present in their thousands.

UK CC researchers and specialists field trip - at the Mekong River

UK CC researchers and specialists at Nong Khai – with the Mekong River behind

Just over two hours later, we arrived in Nong Khai for lunch and a welcome drink – the heat was exhausting, 95˚F plus and so humid – a walk along the bank of the Mekong River looking across to Vientiane in Laos, and a stroll through a typical market, filled with stalls selling incomprehensible items of incredible variety, and with people bringing small amounts of produce from their home or village to sell – we were worlds away from Tesco or Aldi …

There was an abundance of the river fish on sale – but here, unlike in the markets of Khon Kaen where live fish and pickled raw fish was on sale, at least it was cooked and so, presumably safe.  Not that any of us took that chance!

At Ban Chiang - the architectural excavation site

At Ban Chiang – the architectural excavation site

 

Back on the road with a brief stop at the impressive Ban Chiang archaeological excavation site, a final dinner, Thai style, just outside Khon Kaen – and the 3-day Thai workshop came to an end.

 

 

* Snippet of history: USAID (The U.S. Agency for International Development) helped to build the Friendship Highway from Bangkok through the northeast of Thailand to the Laos border. And Udon was a front-line facility of the United States Air Force (USAF) during the Vietnam War from 1964 through 1975 – a thriving area during those years, of course, quiet and seemingly deserted now.

Final thoughts …

What an extraordinary experience. From the minute I arrived in Khon Kaen, more than a little jaded after a 22 hour journey, I was treated with incredible kindness and respect by all our Thai hosts – presented with flowers and gifts at every turn. I have learned much, met many wonderful people, and have many new leads in both the UK and Thailand to follow up.

I am very grateful to everyone at Imperial College who has been so supportive to AMMF, to our wonderful Thai hosts, and to The British Council who funded this event

I can honestly say that I was incredibly moved several times during this visit – not only because I found it so hard to feel worthy of the amazing respect that I was shown, but also because, seeing so many dedicated people focusing on one subject, at last it really seems as though cholangiocarcinoma is well and truly on the agenda.

Helen Morement 

Comments from Imperial College news report on the Workshop:

iclogoProfessor Simon Taylor-Robinson of Imperial’s Wellcome Centre for Global Health Research (WCGHR) said, “It was a great honour to visit KKU and I hope this will be a long lasting relationship.  We hope that this will be the first of many exchanges through the Wellcome Global Centre and Imperial’s Institute of Global Health and Innovation.”

Professor Pisake Lumbiganon, Dean of the Faculty of Medicine at Khon Kaen University said “This workshop has been a very successful scientific meeting. We are certain that the imagesexperiences and knowledge shared among researchers from the UK and Thailand will lead to potential future research projects that will finally benefit people from all parts of the world. We are very much looking forward to future fruitful collaborations between our two institutions”.

 

To read the Imperial news report in full, click here

 

March 2014

 

Professor Paiboon Sithithawarn of Khon Kaen University Faculty of Medicine

Professor Paiboon Sithithaworn of Khon Kaen University Faculty of Medicine

 

May 2014 – We are delighted that Professor Paiboon Sithithaworn has contributed an article on cholangiocarcinoma in Thailand for our occasional “Specialist Viewpoint” series.  To read this article, click here

 

 

 

 

 

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