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STATEMENT OF OBJECTIVES
The Division of Surgical Oncology is one of the five clinical divisions in National Cancer Centre Singapore (NCCS). It provides surgical inputs in the multi-disciplinary management of cancers, and expertise in obtaining histological diagnosis and performing surgical ablation of solid tumours. The Division also has an academic focus, believing strongly in translational and clinical research in the various sub-specialty fields, and in the education of a future generation of doctors and academic surgeons.
DESCRIPTION OF OUR ROLES AND FUNCTIONS
The Division practices a consultant-led practice in sub-specialized field of Breast, Gastrointestinal & Sarcoma, Head & Neck, Hepato-pancreatic-biliary and Thoracic Surgical Oncology. All of our consultants are accredited by the SAB, and have obtained additional sub-specialty training in renowned international centres.
The core services and the measurable key performance indicators of the department are stipulated in the "Programme Leads" in Appendix I.
2. SCOPE 

2.1  Surgical Services

The Division of Surgical Oncology provides surgical care for many kinds of solid tumours. The signature surgical oncology services are Breast, Gastrointestinal Tract and Sarcoma, Hepatobiliary. Head & Neck and Thoracic Surgical Oncology.  Below is the introduction of various areas/ services:
Advanced Gastrointestinal and Sarcoma Surgical Oncology (AGISSO)
AGISSO specializes in Gastrointestinal Tumours, Pelvic and Peritoneal Cancers and Sarcomas. Through a multi-disciplinary and collaborative approach, surgical oncologists in this department provide holistic care to patients who suffer from these complex conditions. In addition, we perform diagnostic and therapeutic endoscopies and biopsies of suspected tumours.
Gastrointestinal and Peritoneal-based Tumours
Colorectal and gastric cancers are commonly seen in our patient population. They may be early staged and easily resectable, but may also be advanced, metastasizing to the liver, lung and peritoneum. Our department has offered cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) since 2001 and currently, has the most known extensive experience in Asia in CRS and HIPEC for patients with peritoneal-based tumours. Our multidisciplinary clinics offer a one-stop service for the evaluation and surgical management of these patients.

Advanced Pelvic Tumours
The pelvis is a small cavity in which many vital organs and structures are located. Due to its dependent location, many recurrent tumours of the abdomen and pelvis occur within the pelvis. Surgery for these patients is complicated, often involving multi-organ resection and should be undertaken by experienced surgeons. Our multidisciplinary clinics offer a one-stop service for the evaluation and surgical management of these patients, employing the expertise of a team of sub-specialists including gynae-oncologists and urologists for the benefit of the individual patient.
Sarcomas and Melanomas
Soft tissue sarcomas are a group of rare cancers that affect the soft tissues of the body. There are more than 70 different subtypes of soft tissue sarcomas and sarcoma-like growths. The more common sarcomas include liposarcomas, gastrointestinal stromal tumors (GIST) and leiyomyosarcomas. The mainstay of treatment is surgery with clear margins. Our department provides the surgical expertise in a coordinated multidisciplinary approach to the management of these tumours.
Melanomas are the most common malignant skin tumours. They often arise in the skin, but are also found in the eyes and mucous membranes. Surgery offers the best chance of cure and depending on the stage, often involves wide excision of the melanoma and sentinel lymph node biopsy or regional lymph node clearance. In advanced cases, isolated limb perfusion for limb salvage and surgery to relieve symptoms from metastases may be required. 
 Multidisciplinary Team Approach to Complex Tumours
The management of advanced and complex tumours is not routine to most surgeons. It requires a holistic approach and individualized care for each patient. To this end, surgeons in the advanced cancer team work closely to achieve the best outcomes for our patients. All cases of malignant tumors are discussed at multidisciplinary tumour boards comprising of surgical oncologists, medical oncologists, radiation oncologists, radiologists, nuclear medicine physicians and other allied health staff to ensure the appropriate treatment decisions are made.
Gastrointestinal Tumours and Sarcoma (Advanced Cancer Surgery) Clinics
Referral Criteria:
Suspicious lumps
Enlarged lymph nodes
Cancers of the gastrointestinal tract (oesophagus, stomach, small bowel, colon and rectum) presenting with:
• Change in bowel habits
• Peri-rectal bleeding/ black stools
• Difficulty in swallowing
• Loss of weight and/or appetite
• 
Peritoneal-based tumours
Sarcomas
Melanomas
Breast
The SingHealth Duke-NUS Breast Centre offers a comprehensive range of advanced surgical options, in particular – oncoplastic and reconstruction breast surgery, sentinel node lymph biopsy, minimally invasive surgery (eg: mammotome biopsy) and intraoperative radiotherapy for patients undergoing breast-conserving surgery.
Treatment is individualized for each patient, and every case of breast cancer is discussed at a weekly multidisciplinary conference to ensure the best treatment options are recommended.
Patients have access to warm, supportive care from the team of experts focused on breast cancer throughout their duration of treatment.

Head & Neck
The SingHealth-Duke-NUS Head and Neck Centre provide holistic care for patients with tumours of the head and neck region through a multi-disciplinary collaborative approach. A wide array of services, ranging from open resection surgery to minimally invasive robotic surgery, is available to patients who require them. To this end, the Centre comprises of head and neck surgeons, otorhinolaryngologists (ENT), plastics and reconstructive surgeons and allied health staff all working in unison to achieve the best outcome for patients.


 
Hepatobiliary
The HPB Surgical Oncology Service at NCCS operates within the Comprehensive Liver Cancer Clinic (CLCC) which is a one-stop multi-disciplinary program. The clinic brings together all the different specialists relevant to the management of HPB cancers to work around the patient. This facilitates multi-disciplinary discussion and care. For the patient, it also avoids multiple appointments with various specialists at different locations.
Surgical resection remains the modality of treatment that offers potential cure for HPB cancers that are amendable.  Currently available therapies also offer the opportunity of down-staging locally advanced HPB cancers to receive potentially curative surgical resection.
The specialists practicing at the CLCC include HPB surgeons, medical oncologists, radiation oncologist, interventional radiologist and nuclear medicine physicians.

We are dedicated to the diagnosis and treatment of:
1. Primary liver cancer (hepatocellular, peripheral cholangiocarcinoma)
2. Colon / rectal cancer that has spread to the liver
3. Neuroendocrine / carcinoid tumours and GIST that have spread to the liver
4. Gallbladder cancer
5. Bile duct cancer (central and distal cholangiocarcinoma)
6. Pancreatic cancers

Conditions Managed by HPB Surgical Oncology Service
• All suspected or proven tumours in the liver, gallbladder, biliary tree and pancreas:
– without or without previous treatments now seeking consultation regarding possible surgical, regional  or systemic therapy
– already been given a treatment plan or already treated but seeking a multi-disciplinary second opinion

• secondary liver tumour with a known or suspected primary tumour elsewhere
– e.g. colorectal, neuro-endocrine/carcinoid, GIST

 
Thoracic
Thoracic Surgery is a surgical specialty devoted to the treatment and diagnosis of pulmonary and other thoracic conditions. The main emphasis is on thoracic lesions which are suspected neoplasms.

Diseases treated include pulmonary, oesophageal, mediastinal, pericardial and pleural lesions, chest wall and sternum, both benign and malignant conditions.

The depth and breadth of our thoracic services means that patients have access to the leading-edge surgical and non-surgical techniques. This includes the minimally invasive surgeries, known as Video-assisted Thoracoscopic Surgery (VATS) that allow for quicker recovery. This type of surgery uses small incisions rather than one large incision. This minimally invasive approach provides excellent exposure of the lung.  It reduces surgical trauma, minimizes postoperative pain, allows earlier patient mobilization and hence decreases hospitalization. This resulted in overall better quality of life. The application of VATS in thoracic surgery has become a standard of care and has almost become a routine approach for most conditions, both benign and malignant conditions. Most lung cancer surgeries, for example lobectomy, are done via VATS.

It had been shown that, for most cancers, patients have fewer complications if they have surgery at a hospital that performs large numbers of these operations and performed by surgeons with expertise in the procedure.
 
We also work with oncologists, radiation oncologists, pathologists, and radiologists to provide a multidisciplinary comprehensive approach to therapy.  We have a unified approach to cancer care, with teams of doctors who work together to guide each patient through diagnosis, treatment and recovery.
 
 
2.2 Research

Advanced Gastrointestinal and Sarcoma Surgical Oncology (AGISSO)
Epidemiology of peritoneal-based malignancies and their treatment:
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in selected patients with peritoneal carcinomatosis. We have performed close to 200 HIPEC procedures thus far, which is the largest known experience in Asia. Our own institution's analysis has statistically shown that CRS and HIPEC be safely carried out in Asian patients with peritoneal carcinomatosis from ovarian, colorectal, appendiceal, mesothelioma, and primary peritoneal origins. Our research revolves around identifying the prognostic factors that determine the outcomes, as well as quality of life (QOL studies) and cost-benefit analysis. In addition, we have a basic science team working on the genetic profile of peritoneal tumours, identifying prognostic markers, carcinogenic pathways and novel therapeutic targets that can be used for peritoneal metastases from gastric and colorectal as well as of ovarian and primary peritoneal origin.   We study the molecular profiles of peritoneal carcinomatosis from different tumour histological types to examine if there is any commonality between them and to identify potential biomarkers and therapeutic targets.  Similarly, our postulation is that mucinous tumours of colorectal and ovarian origins share some characteristics in their profiles. We are also working, in collaboration with other researchers and clinicians, on the establishment of cell-line and xenograft models to better understand the biology of disease.
 Multidisciplinary management of sarcomas:
We are looking at clinical studies on our cohort of sarcoma patients and have published on our national centre’s experience with this diverse group of diseases. We have recently concluded a retrospective analysis which looked at validating the MSKCC prognostic nomogram and comparing it with other nomograms in terms of their predictive accuracy.  We also collaborate with Prof Teh Bin Tean on the molecular profiling of these cancers. Our current project seeks to determine the molecular signatures of well and de-differentiated liposarcomas that may allow us to determine the pathway of progressive dedifferentiation.

 
The GIST of the gastrointestinal stromal tumour project:
GISTs despite complete cytoreduction are associated with a 50% recurrence rate in 2 years. In trying to understand the biology of this disease, we collaborate with the medical oncologists and scientists to determine the molecular markers of relevance in GIST. In addition, our team has looked into the prospects of upfront surgery for the recurrent patient, as well as, the role and significance of multivisceral resection in patients with locally advanced GIST. Surgical management of melanomas:
Our institution has a fairly extensive experience with melanomas. Our studies include evaluating the prevalence of various histological types of melanoma presenting to our Asian society, trying to distinguish the difference between these melanomas with those that are more commonly seen in the Western population, and the role of surgical management of melanoma. One of the studies evaluates the extent of nodal dissection in patients with advanced lower limb melanomas with clinically palpable inguinal nodes. We seek to identify the clinicopathological or radiological factors that predict for pelvic nodal disease. We are currently also looking at our experience with isolated limb perfusion and reviewing the international literature on this topic.
Multidisciplinary approach to pelvic tumours & gastrointestinal cancers:
Pelvic tumours often comprise of cancers with colorectal, gynaecological and urological origins. Most of these locally advanced tumours require the collaboration of multidisciplinary teams and multvisceral resection of involved organs. Our studies evaluate the survival benefits of this aggressive surgical approach and identify the prognostic factors in these patients. We have also embarked on multi-institutional QOL studies for these patients.
Quality of life studies in peritoneal and pelvic cancers:
Prospective Quality of Life studies are ongoing for our peritoneal and pelvic cancer patients, and are carried out in 4 stages- pre-operative, 3 months, 6 as well as 12 months post-operative. The results of a QOL would greatly benefit the proposal of CRS & HIPEC, as well as pelvic exenterations as it helps allay concerns regarding quality of life deterioration post aggressive surgical therapy. Our studies show that our patients report a higher quality of life compared to outpatient cancer patients. We will continue to prospectively monitor our HIPEC as well as pelvic oncology patients up till 1 year post-surgery.

 
Breast
DSO’s Breast Surgeons engage in clinical, translational and lab-based research on topics related to breast surgery and breast cancer. They collaborate closely with the multidisciplinary breast cancer research team within NCCS and beyond.
One such collaboration is with the Saw Swee Hock School of Public Health titled The Singapore Breast Cancer Cohort Project. It aims to identify all patients diagnoses/treated at public hospitals in Singapore, evaluate important genetic and environmental risk factors in breast cancer and identify new genetic prognostic markers in the disease.
On the surgical front, precise characterization of axillary sentinel node locations and their relative predictive values is described and being explored by our surgeons. Potentially, a novel predictive model may reduce the need for axillary nodal dissection for patients needing a mastectomy for breast cancer. Prospective trials for new tracer techniques in sentinel node biopsies are also underway.
As the only institution in Singapore with an intraoperative radiation therapy device (Intrabeam), we provide intraoperative radiation therapy (IORT) as a clinical service. We also add to the current knowledge by having 2 ongoing clinical trials that explore the safety of IORT in extended indications, including its role in treating DCIS.
We work closely on various projects with the scientists in our NCCS labs, exploring the tumour microenvironment of breast cancer and developing cell lines that may shed light on predictive markers in neoadjuvant therapies for the breast. Recent successful work on fibroepithelial lesions identified a recurrent mutation within fibroadenomata, associated with dysregulated estrogen signaling, also found in uterine fibroids suggests a common genetic basis of these 2 benign tumours common in women. Sequencing of fibroadenomas and a range of phyllodes tumours demonstrated common mutations, providing insights into the molecular pathogenesis of breast fibroepithelial tumors, with potential clinical implications.

 
Head & Neck
DSO’s Head and Neck team is involved in a number of research programs that study various clinical and translation aspects of head and cancer prognostication and therapeutics.
Clinical research is achieved through the establishment and enrichment of good clinical databases to answer specific clinical questions and dilemmas in head and neck oncology. Currently, an online database has been created to track outcomes of all head and neck oncology patients capturing the various treatment modalities that they receive sub-stratified by tumour subtype, stage and grade using the capabilities afforded by the REDCAP (Research Electronic Data Capture) relational database system. This system serves as the electronic platform via which cases are presented during the head and neck multidisciplinary tumour boards. Joint decisions are entered and recorded real-time at the meetings into the database for future research projects and audit purposes.
The team is also carrying out an in-depth Quality of Life (QOL) project aims to identify patients who require more intensive rehabilitation than what is currently offered. The team of doctors, nurses and allied health professionals gather to address problems in complex cases which require multi-disciplinary care. This allows the team to have a better understanding of the possible challenges faced by patients during recovery and better tailor the pre/post treatment support.
The Cancer Therapeutics Research Laboratory’s (led by PI Dr Gopal Iyer) theme is identification of prognostic markers, novel therapeutic targets and modification of conventional therapy for head and neck cancers, through individualization of treatment modalities. The lab has established primary cell line and stem cell models for testing of targeted compounds specific to head and neck cancers. The aim is to translate this knowledge into clinical trials and patient specific outcome in the near future.
 
Hepatobiliary
The DSO’s HPB team is heavily involved in clinically-driven basic and clinical studies that aim to interrogate the molecular and mechanistic basis of liver cancer, improve patient diagnosis and prognosis and develop novel therapies for HPB diseases by bringing discoveries from the bench to the bedside that can be translated to the next effective therapy. The HPB discipline has vast experiences in conducting multicentre clinical trials and has spearheaded numerous investigator-initiated multicentre HCC clinical trials leveraging on the Asia-Pacific Hepatocellular Carcinoma (AHCC) trials group which has over 40 sites in 17 different countries.
Thoracic Surgery
Thoracic Surgery is a surgical specialty devoted to the treatment and diagnosis of pulmonary and thoracic diseases amenable to surgical approach, in the following areas: lung, pleura, mediastinum, chest wall and diaphragm.
This specialty maintains an important collaboration with respiratory medicine and works in liaison with other specialties such as Oncology, Critical Care Medicine, Imaging and General Surgery, also providing support for all medical and surgical specialties.
With the increasing incidences of lung cancer and adoption of minimally invasive approaches in approaching the thoracic cavity, we have set up the Lung Cancer Database. With the information we can analyse the surgical results and outcome of the patients and help us in further improvement.

 
2.3 Education

Overview
The National Cancer Centre Singapore is committed to providing the most effective outcome to patients through our multidisciplinary and holistic approach. The Division of Surgical Oncology contributes beyond surgical inputs and believes that academia is equally important in providing integrated care to patients and continually improving our clinical services. Our academic focus adopts a highly collaborative, “bench-to-bedside” approach towards education and learning.

Educational Collaborations
The Division of Surgical Oncology grooms future generations of doctors by collaborating actively with National University of Singapore Yong Loo Lin School of Medicine and Duke-NUS Graduate Medical School.
Students undergo carefully planned and structured programs to ensure progressive clinical training and exposure throughout their medical course. The programs are designed to expose students to general surgical conditions, to equip students with skills necessary to contribute as a responsive and safe member of the surgical team, to help students integrate and translate factual textbook knowledge into practice and apply them in clinical situations, and to expose students to medical oncology in inpatient and outpatient settings such that they may ultimately, enter clinical life confidently and be able to contribute as a valuable member of the healthcare team.

Fellowships and Observerships
The Division of Surgical Oncology also actively promotes cross-border knowledge exchange by hosting professional oncology training programmes for overseas medical doctors. These also serve as platforms for the exchange of ideas between the overseas medical doctors and their counterparts in Singapore.
Fellowships are offered across each of the sub-specialties to train oncologists and doctors to work in multidisciplinary teams, and to provide comprehensive tertiary multidisciplinary care for patients with breast malignancies, head and neck malignancies, hepato-pancreato-biliary malignancies, and advanced gastrointestinal malignancies and sarcomas.
Hands-off observerships and short term attachments are also offered by the Division to strengthen the visiting physicians’ clinical knowledge in surgical oncology and help acculturate and provide insight to NCCS’s holistic approach to the management of cancer.


Research and Educational Events
The Division also aims to provide platforms to promote and enhance learning through the hosting of conferences and symposiums. These provide an avenue for the exchange of information, as clinicians and researchers are able to present and discuss their work through interactive case discussions and in-depth analysis of clinical cases. Through these, we ensure that the Division remains up-to-date with the latest developments in the field of oncology, and hope to bring the local and regional medical community together to establish collaborations for research in this rapidly moving field to accelerate the advancement of oncological care in Singapore and the region.


2.4 Other services

The following are additional Sub-specialty or Specialised Clinical Privileges that is under the purview of the Division of Surgical Oncology: MRI guided biopsies of the breast, sentinel node biopsy, mammotome, minimally invasive thorascopic procedure, MIS/robotic head and neck surgery, Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS+ HIPEC), sarcoma and melanoma surgeries (including isolated limb perfusion).These require additional privileging supported by the Head of Department.

Additionally, other procedures that require selected medical instrumentation (e.g. surgical lasers, robotics), or procedures new to the hospital, or not routinely carried out in other hospitals, or procedures that require back-up by other discipline and those require new and untried medical equipment will have to be given the appropriate approvals by the Chairman of Medical Board, NCCS or SGH


2.5 Outpatient Services

The outpatient services are conducted at the National Cancer Centre Singapore. We register an average of 24,961 outpatient visits annually. We see an average of 350 new cases per month with surgical oncology services being available every day of the week.

2.6  Inpatient Services & Credentialing

Our inpatients are admitted into either the Singapore General Hospital (SGH) or the National Heart Centre (NHC) wards under the purview of the Department of General Surgery, SGH and Department of Cardiothoracic Surgery, NHC. Surgeons in the DSO are visiting consultants under these departments. Likewise, their credentialing and privileging falls under these two departments. The credentialing of staff follows the core and specific sub-specialty competency requirements as stipulated by these departments.  Surgical audits are performed at these two institutions. Therefore, the surgical morbidity and mortality audits are done at these respective departments, that is weekly at the Department of General Surgery, SGH and monthly at the Department of Cardiothoracic Surgery, NHC.
Additionally, some operations are performed in the single operating theatre at the NCCS. On average, 150 operations are performed monthly consisting of minor to medium operations. While majority of the cases are day procedures, there are operations where admissions are planned. Some of our consultants are also visiting consultants to KKWCH, KTPH etc.

2.7 Surgical Audits

The  following  parameters  are  tracked  routinely  by  the  NCCS  performance indicators staff in addition to the regular surgical audits described above.

1. Surgical Site Infection Rates by dedicated Infection Control Staff
2. Unplanned admission to hospital after elective operations/procedures like endoscopies
3. Timeliness of appointment scheduling, clinic waiting times etc.

2.8 Endoscopy Services

We perform endoscopic procedures at our outpatient endoscopy suite, for screening as well as diagnosis. All endoscopists are accredited.


2.9 Visiting Consultants

Within the division, we have visiting consultants from various hospitals in Singapore.  Majority of them are from the Singapore General Hospital.  They serve to provide additional surgical oncology support given the established services there. Their services include Neurologic, Colorectal, Urologic and Gynaecologic.  In addition, we also have the Anaesthesiologists who support the surgical procedures and operations within the NCCS Operating Theatre.
Presently, DSO has about 87 active visiting consultants.  Their services are renewed annually or biennially.