Bone tumors in Singapore


Possibly the best known orthopaedic oncologist in Singapore, in the last 15 years or so A/Prof Saminathan Suresh Nathan and his team had been responsible for putting on the global academic map the significant contribution of his and his mentor's work in musculoskeletal oncology and limb salvage surgery (Figure 1) involving the care of patients with bone tumors and cancers and those of the soft tissues around bones and joints. Through numerous grants, workshops, seminars, meetings and international representation, the unique pairing of Singapore representing an Asian Medical Hub and facing the dual problem of dealing with a rare condition in a small population has resulted in truly unique solutions to problems. These solutions have received critical attention globally and the respect of workers in the field - not uncommonly adapting these techniques for more extensive use in their own countries through fellowship programs that were officially established famously by Prof Suresh in 2007.



Figure 1. While bone tumors have been managed by orthopedists in Singapore as part of their general practice, it was really only consolidated with E/Prof RWH Pho in the seventies (a, lower left). This mantle was handed to A/Prof Saminathan Suresh Nathan in 2005 who became the inaugural chief of the musculoskeletal oncology unit of the National University Health System and Current Chief of the Sarcoma Service of the National University Cancer Institute of Singapore. International acclaim achieved by this unit is regularly cemented with the sponsorship of a tumor surgeon in Singapore biannually in the form of the RWH Pho Lectureship (b). Today Prof Suresh heads a number of initiatives in passing the mantle of academic leadership to the next generation of promising  future doctor's and scientists (c).

History

The history of bone tumor management can be claimed by many. In general however, the credit has been given to Ralph Marcove in the late sixties in the Memorial Sloan-Kettering Cancer Centre. Dr Marcove as related by his mentees Dr John Henry Healey and Dr Patrick Boland the chief and senior attending of the orthopaedic service respectively, was a brilliant man who somehow 'felt' the nature of tumors. This is a remarkable feat considering the time in which Dr Marcove practiced where modern scientific method had not become established. Dr Marcove by all accounts instinctively treated tumors and was responsible for all manner of tumorous interventions including cryosurgery. Being Jewish with a strong sense of service to his community he would be sought out by Israelites with bone cancers who could not be seen to enter the afterlife incomplete for all eternity due to an amputation. Hence limb salvage had its basis in religious sentiment. To this day, these sentiments remain strong in members of the Judeo-Islamic faith.

Meanwhile, in Singapore, there was one young Robert  WH Pho, who would rather have spent his days frolicking under the New Guinea sun. It was deigned that the future Prof Pho should come to Singapore after training as an orthopaedic surgeon skilled in all manner of subspecialties (he performed the first hip replacement in Singapore) although his eventual fame was established in microvascular reconstructions in tumors. The University Unit of Orthopaedics moved to their new premises in Kent Ridge in 1984 and Prof Pho stayed behind for a time to manage the skeleton team as the satellite university head of department. Since the seventies, Prof Pho's tireless work in musculoskeletal oncology gained steady recognition culminating in the hosting of the 7th International Symposium of Limb Salvage Surgeons in Singapore in 1993 (Figure 2).



Figure 2. Singapore has been involved in musculoskeletal oncology research for the last 40 years beginning with development of techniques in surgery (a) as this paper on vascularised joint transfers attests (Pho, 1979). Presently, we investigate molecular basis of disease as in this study recently published (Nathan SS, 2011) that suggests that micro-environmental differences in the tumor may cause drug resistance (b). Present clinical research (Nathan SS, 2009) investigates the best siting of of procedures for a given problem (c). In 2012, on review (Nathan SS, 2012) of the national survival data it was conclusively determined that treatment in Singapore resulted in a superior survival rate of patients with osteosarcoma comparable to the best centres in the United States (d).

Prof Suresh therefore came into the picture being truly fortunate to benefit from this rich history. Working with Prof Pho since the nineties he quickly established himself as a prolific researcher in stem cell research and skilled surgeon in arthroplasty under the tutelage of Prof Lee Eng Hin and Prof K Satkunanantham in the late nineties. Given the obvious history that the Memorial Sloan-Kettering Cancer represented, the young Dr Suresh developed a significant reputation for himself winning multiple academic and research awards and received the notice of Dr John H Healey. He was hired as a fellow there in 2003 to 2005. He is presently considered an important figure in the field with his many novel contributions (Figure 3). He served as President of the Asia Pacific Musculoskeletal Tumor Society (APMSTS) from 2014 to 2016 and is the inaugurating speaker for the Yoshio Ogihara Lectureship for the 12th APMSTS in Jaipur India in 2018 with the topic "My brush with the contradictions in orthopaedic oncology we take for granted" - a lecture based on his insightful and highly regarded research conducted over decades (Figure 4).


Figure 3. The University Unit of Orthopaedics moved to their new premises in Kent Ridge in 1984. Since the seventies, Prof Pho's tireless work in musculoskeletal oncology gained steady recognition culminating in the hosting of the 7th International Symposium of Limb Salvage Surgeons in Singapore in 1993. With the return of Prof Suresh in 2005 from his 2-year fellowship in the Memorial Sloan-Kettering cancer centre, a unique service in musculoskeletal oncology was established that provided unparalleled care, research and education in the region. This resulted in a strong consolidation of all such cases in the University Unit since 2007 (dark blue bar).


Figure 4. The award being presented by Han Soo-Kim (Korea), Thomas Baad-Hansen (Denmark) and Sahachart Piputkul (Thailand) on completion of the oration on October 7th 2018 entitled "My brush with the contradictions in orthopaedic oncology that we take for granted".


The future

Prof Pho and Suresh have left behind a legacy of education, research and healthcare that will be felt in the years to come. Listed here are the fellows formerly trained by Prof Suresh Nathan (Figure 5). They are namely:

1.    Dr Praveen Kumar, India, 2005

2.    Dr Ayan Ray, India, 2006

3.    Dr Amarjit Singh, India 2007

4.    Dr Edwin Guerzon, Philippines 2008

5.    Dr Sumit Jain, India 2009

6.    Dr Miguel Go, Phillipines 2009

7.    Dr Kiran Oblampalli, India 2009

8.    Dr Jikku Hannibal, India 2010

9.    Dr Kishore, India 2011

10. Dr Ratnakar K Rao, 2011

11. Dr Feroze Ragaman, 2012

While in the past it was perhaps the least popular of orthopaedic sub-specialties, in recent times more impressionable trainees have stepped up to the mantle (Figure 5). Still others who may have shown initial interest but have decided not to pursue the specialty at the level it deserves have been mavens in bringing the attention of the work of musculoskeletal oncologists to these patients. The future holds promise for the patients who must go through these trying times.



Figure 5. The future is now in the hands of the many fellows that Prof Suresh and his team have trained. This enduring legacy bodes well for unfortunate patients with bone tumors in the region who until recently would either face amputation or death.