The staff pathologists and residents were enthusiastic and eager to learn. During the coffee breaks, we were inundated by questions especially pertaining to the implementation of the 2016 WHO Classification. We were also shown cases as JPEGs of hematoxylin/eosin- stained slides on a pathologist’s laptop as well as actual glass slides under a multihead microscope. Many of these cases were challenging especially in the absence of the usual battery of immunohistochemical stains and advanced MRI sequences that we are accustomed to in North America. The difficulty of making an informed and precise diagnosis, in the absence of complete adjunct clinical and pathological information, was acutely obvious. At the same time, we also experienced first- hand the collegiality of the pathology group, amongst the staff pathologists and trainees as well as the need to extract as much information from the H/E section as possible.
During the multihead microscope session, we reviewed cases ranging from pilocytic astrocytoma to primary CNS lymphoma. Certainly, there was a variety of brain tumors similar to that seen in Vancouver. There were also many cases that could benefit from additional immunohistochemical and genomic workup including IDH1 R132H, ATRX, and H3F3A K27M testing as well as 1p19q co-deletion testing. These are the molecular adjuncts proposed in the most recent WHO Classification and should be integrated into the “glass- based” diagnosis. On the other hand, one can argue that the need for additional molecular information is only necessary when they alter management decision. For example, the inclusion of patients with diffuse midline glioma with H3F3A K27M mutation in a EZH2 inhibitor trial. A survey of management paradigm for low and high grade glioma in Vietnam revealed a fairly standardized algorithm whereas resection and radiological followup is used for LGG and ionizing radiotherapy following surgical resection is typical for glioblastoma. There is no apparent difference in management between molecular astrocytic (IDH- mutant, 1p19q- retained) and oligodendroglial (IDH- mutant, 1p19q- codeleted) tumours whereas this information is essential in the management of LGG patients in North America. The lack of IDH1 R132H and ATRX IHC testing, not to mention 1p19q FISH or loss of heterozygosity testing, makes this a process that relies purely on histomorphological yet analog metrics. In the absence of 1p19q information, the combination of stereotypical histology and supporting IDH1 R132H/ATRX IHC findings are adequate for a “NOS” classification. This is not sufficient for a de facto molecular diagnosis of oligodendroglioma, IDH- mutant, 1p19q- codeleted associated with the best clinical outcome; however, “NOS” is associated with an intermediate outcome better than IDH- mutant astrocytoma but inferior to genuine molecular oligodendroglioma (IDH- mutant, 1p19q- codeleted). We were very motivated to help to establish these IHC assays and 1p19q- FISH test and provided unstained LGG slides for the optimization of these assays and informed them of the CIQC initiative to assist with ongoing quality assurance of IHC testings.
HCMC was an amazing experience. We met motivated, smart, and dedicated clinicians, pathologists, and trainees. We made many friends. We were deeply impressed by the kindness, warmth and hospitality of the Vietnamese people. We also became aware of how fortunate we are to practice neuropathology in North America. Access to pre-operative imaging and antibodies has significantly enhanced the precision and clinical impact of brain tumour diagnosis. Despite these deficiencies, the desire and drive to learn and to do the best for patients remain. This trip highlighted the need to reach out to countries with less resources and expertise to improve the practice and training in pathology. Telepathology is the logical choice to maintain case exchange between Vancouver and HCMC. Whereas the trip this fall was helpful, we believe that the long term and sustainable solution is to provide additional training for a Vietnamese pathology resident interested in neuropathology. This plan is underway and when funding for a 2 year fellowship training program has been secured, UMP will select the most dedicated Faculty to take up this training with UBC Pathology.
Our teaching experience in Vietnam was analogous to crossing the road in HCMC. It was hectic, busy, and at times overwhelming; however, we learned to “go with the flow”, to place our trust on others and also to make our intentions clear and known. This strategy worked in both crossing the road full of scooters and our inaugural effort of neuropathology teaching in Vietnam.
Although there was very little time for sightseeing during our short time in HCMC, we managed to briefly visit a few landmarks of the city. The Central Post Office (Fig--), is an example of French colonial architecture designed by Gustave Eiffel, who also designed the Eiffel Tower in Paris. It is remarkably well preserved and still used as the city’s main post office. Prominently displayed at the far end of the building is a large portrait of Ho Chi Minh, the Vietnamese leader with a national following who ended the French colonial rule, united the country and established the Democratic Republic of Vietnam. The HCMC Municipal Theater (Opera House), a beautiful, well preserved 800-seat building is another example of French colonial architecture built in 1898 (Fig--). Unforgettable is the visit to the War Remnants Museum. Graphic photographs, exhibits and American military equipment are a testimony to the brutal 8 year war (1964-1972) launched by the United States, who used maximum military effort in order to defeat a nationalist revolutionary movement in a small country and failed. The horrific photographs of death and executions of Vietnamese civilians and the effects of napalm bombs are as shocking as the graphic photographs of birth defects due to prenatal exposure to “Agent Orange”, a defoliant that was sprayed by planes to destroy trees and other plants. It is estimated that 500,000 children were born with birth defects and 4.8 million people were exposed to it. The museum conveys the suffering, but also the resilience of the Vietnamese people and makes an extraordinary statement in support of peace and against war and the devastation of human life.This trip would not have been possible without the tireless advocacy of Hanh Huynh at UBC, who has dedicated his life to improving medical education in his native country, of Antony Nezic & Kelly Wong at the Canadian Chamber of Commerce Vietnam, Dr. Tuan, UMP President, thousands of donors of the Terry Fox Run Vietnam, Victor Ling and Stephen Herst at TFRI, as well as Mike Allard at UBC Pathology who are all instrumental to the current and ongoing success of this initiative.ß